Timing of aneurysm surgery: the International Cooperative Study revisited in the era of endovascular coiling.

OBJECTIVE

The International Cooperative Study on the Timing of Aneurysm Surgery demonstrated that subarachnoid hemorrhage (SAH) patients who underwent surgery on post-hemorrhage days 4-10 had worse outcomes than patients treated on days 0-3 and days 11-14. Based on these findings, it was concluded that patients who present with SAH on days 4-10 should have aneurysm surgery delayed until after day 10. Since the study, coiling has become a treatment option and it is unclear whether these results apply to this new treatment modality. Our institution is a regional referral center for SAH, and patients are transferred at different time points after hemorrhage. We wanted to determine whether patients that arrive on days 4-10 were safe to undergo coiling immediately rather than waiting until after day 10.

METHODS

We reviewed 119 consecutive SAH patients who underwent coiling between January 2006 and June 2008. Factors of age, gender, Hunt-Hess grade, Fisher score, aneurysm size and aneurysm location were included in a regression analysis to determine the effect of day of coiling on clinical outcome at discharge.

RESULTS

Of 119 study patients, 86% had coiling on post-hemorrhage days 0-3, and 12% on days 4-10. Patients in these cohorts did not differ in any demographic factors. Age and Hunt-Hess grade were the only predictors of mortality (age p=0.0001, Hunt-Hess p=0.0110) and poor outcome, defined as death or discharge to a skilled nursing facility (age p=0.0001, Hunt-Hess p=0.0001). Day of coiling had no effect on mortality (p=0.5731) or poor outcome (p=0.1861).

CONCLUSIONS

Coiling of ruptured aneurysms can be performed safely on patients who arrive on post-hemorrhage days 4-10, and treatment need not be delayed after day 10, as the results of the Timing of Aneurysm Surgery Study initially suggested.