1University of Michigan Medical School, and.
2Department of Neurosurgery, University of Michigan, Ann Arbor, Michigan.
J Neurosurg. 2018 May;128(5):1297-1303. doi: 10.3171/2017.2.JNS163017. Epub 2017 Jul 21.
OBJECTIVE Recent observational data suggest that ultra-early treatment of ruptured aneurysms prevents rebleeding, thus improving clinical outcomes. However, advances in critical care management of patients with ruptured aneurysms may reduce the rate of rebleeding in comparison with earlier trials, such as the International Cooperative Study on the Timing of Aneurysm Surgery. The objective of the present study was to determine if an ultra-early aneurysm repair protocol will or will not significantly reduce the number of incidents of rebleeding following aneurysmal subarachnoid hemorrhage (SAH). METHODS A retrospective analysis of data from a prospectively collected cohort of patients with SAH was performed. Rebleeding was diagnosed as new or expanded hemorrhage on CT, which was determined by independent review conducted by multiple physicians. Preventability of rebleeding by ultra-early aneurysm clipping or coiling was also independently reviewed. Standard statistics were used to determine statistically significant differences between the demographic characteristics of those with rebleeding compared with those without. RESULTS Of 317 patients with aneurysmal SAH, 24 (7.6%, 95% CI 4.7-10.5) experienced rebleeding at any time point following initial aneurysm rupture. Only 1/24 (4.2%, 95% CI -3.8 to 12.2) incidents of rebleeding could have been prevented by a 24-hour ultra-early aneurysm repair protocol. The other 23 incidents could not have been prevented for the following reasons: rebleeding prior to admission to the authors' institution (14/23, 60.9%); initial diagnostic angiography negative for aneurysm (4/23, 17.4%); postoperative rebleeding (2/23, 8.7%); patient unable to undergo operation due to medical instability (2/23, 8.7%); intraoperative rebleeding (1/23, 4.3%). CONCLUSIONS At a single tertiary academic center, the overall rebleeding rate was 7.6% (95% CI 4.7-10.5) for those presenting with ruptured aneurysms. Implementation of a 24-hour ultra-early aneurysm repair protocol would only result in, at most, a 0.3% (95% CI -0.3 to 0.9) reduction in the incidence of rebleeding.
最近的观察性数据表明，超早期治疗破裂的动脉瘤可以防止再出血，从而改善临床结局。然而，与国际破裂动脉瘤手术时机合作研究等早期试验相比，对破裂动脉瘤患者的重症监护管理的进步可能会降低再出血的发生率。本研究的目的是确定超早期动脉瘤修复方案是否会显著降低蛛网膜下腔出血（SAH）后再出血的发生率。
对前瞻性收集的一组 SAH 患者的数据进行回顾性分析。再出血的诊断标准为 CT 上新出现或扩大的出血，由多位医生进行独立的回顾性评估。通过独立评估，确定超早期夹闭或栓塞动脉瘤是否可以预防再出血。采用标准统计学方法比较再出血组与无再出血组患者的人口统计学特征。
在 317 例蛛网膜下腔出血患者中，24 例（7.6%，95%CI4.7%至 10.5%）在初始动脉瘤破裂后任何时间点发生再出血。只有 1/24（4.2%，95%CI-3.8%至 12.2%）的再出血事件可以通过 24 小时超早期动脉瘤修复方案预防。其余 23 个事件无法预防，原因如下：在入组作者单位前再出血（14/23，60.9%）；初始诊断性血管造影未见动脉瘤（4/23，17.4%）；术后再出血（2/23，8.7%）；患者因病情不稳定无法手术（2/23，8.7%）；术中再出血（1/23，4.3%）。
在单一的三级学术中心，破裂动脉瘤患者的总体再出血率为 7.6%（95%CI4.7%至 10.5%）。实施 24 小时超早期动脉瘤修复方案最多可使再出血的发生率降低 0.3%（95%CI-0.3%至 0.9%）。
