Department of Neurosurgery, Oslo University Hospital, Rikshospitalet, P.B. 0454, 0424, Nydalen, Oslo, Norway.
Institute of Clinical Medicine, University of Oslo, P.B. 1072, 0316, Blindern, Oslo, Norway.
Acta Neurochir (Wien). 2021 Mar;163(3):771-781. doi: 10.1007/s00701-020-04673-3. Epub 2021 Jan 6.
Mortality and morbidity of aneurysmal subarachnoid haemorrhage (aSAH) remain high, and prognosis is influenced by multiple non-modifiable factors such as aSAH severity. By analysing the chronology of aSAH management, we aim at identifying modifiable factors with emphasis on the occurrence of rebleeds in a setting with 24/7 surgical and endovascular availability of aneurysm repair and routine administration of tranexamic acid.
Retrospective analysis of institutional quality registry data of aSAH cases admitted into neurosurgical care during the time period 01 January 2013-31 December 2017. We registered time and mode of aneurysm repair, haemorrhage patterns, course of treatment, mortality and functional outcome. Rebleeding was scored along the entire timeline from ictus to discharge from the primary stay.
We included 544 patients (368, 67.6% female), aged 58 ± 14 years (range 1-95 years). Aneurysm repair was performed in 486/544 (89.3%) patients at median 7.4 h after arrival and within 3, 6, 12 and 24 h in 26.8%, 44.7%, 73.0% and 96.1%, respectively. There were circadian variations in time to repair and in rebleeds. Rebleeding prior to aneurysm repair occurred in 9.7% and increased with aSAH severity and often in conjunction with patient relocations or interventions. Rebleeds occurred more often during surgical repair outside regular working hours, whereas rebleeds after repair (1.8%) were linked to endovascular repair.
The risk of rebleed is imminent throughout the entire timeline of aSAH management even with ultra-early aneurysm repair. Several modifiable factors can be linked to the occurrence of rebleeds and they should be identified and optimised within neurosurgical departments.
尽管对颅内破裂动脉瘤（aSAH）的治疗已经取得了显著进展，但是其死亡率和发病率仍然居高不下，且预后还受到包括动脉瘤破裂严重程度在内的多种不可改变的因素的影响。通过分析 aSAH 管理的时间顺序，我们旨在确定可改变的因素，重点是在 24/7 均可进行手术和血管内动脉瘤修复，以及常规使用氨甲环酸的情况下，识别再出血的发生。
对 2013 年 1 月 1 日至 2017 年 12 月 31 日期间收入神经外科治疗的 aSAH 病例的机构质量登记数据进行回顾性分析。我们登记了动脉瘤修复的时间和方式、出血模式、治疗过程、死亡率和功能结局。再出血沿着从发病到初次住院出院的整个时间线进行评分。
我们纳入了 544 例患者（368 例，女性占 67.6%），年龄为 58 ± 14 岁（1-95 岁）。486/544 例（89.3%）患者在到达后的中位数 7.4 小时内进行了动脉瘤修复，分别在 3、6、12 和 24 小时内进行修复的比例为 26.8%、44.7%、73.0%和 96.1%。在修复时间和再出血方面存在昼夜节律变化。在动脉瘤修复之前发生的再出血发生率为 9.7%，且随着 aSAH 严重程度的增加而增加，并且常常与患者转移或干预有关。手术修复在非工作时间发生再出血的频率更高，而修复后的再出血（1.8%）与血管内修复有关。
即使进行超早期动脉瘤修复，再出血的风险也会在整个 aSAH 管理的时间线上持续存在。一些可改变的因素与再出血的发生有关，应在神经外科部门内确定和优化这些因素。
