Maurice-Williams R S, Wadley J P
Department of Neurosurgery, Royal Free Hospital, London, UK.
Br J Neurosurg. 1997 Apr;11(2):104-9. doi: 10.1080/02688699746438.
Delayed aneurysm surgery, once standard practice, is now followed by only a minority of neurosurgeons. We analysed the outcome of such a policy in 400 consecutive patients with ruptured aneurysms treated over a 14-year period. Despite an 'open door' admissions policy, admitting all patients immediately on referral, only 56% arrived within 24 h of the ictus (69% within 72 h). Surgery was generally delayed for 8-10 days in patients in Grades 1 and 2; for higher grade patients often for longer until their condition was stable. Two-hundred-and-eighty-seven patients (72%) underwent surgery, 93% on day 8 or later (78% on day 11 or later). Outcome was assessed at 1 year. For all patients 68% were in Glasgow Outcome Scale Grade 1, while 26% had died. Of the operated patients 88% were in GOS grade 1, while 5% had died (30-day surgical mortality was 3.5%). Fifty-one patients (12.8%) rebled, 30 in the first 10 days. Rebleeding was distributed evenly in time over the first 2 weeks. Eighty-four patients experienced non-haemorrhagic deterioration (NHD) all but 3 within 10 days. NHD peaked at days 4-9. Thirty-three patients died of rebleeding and 16 of NHD, but only 12 of the patients who died from rebleeding were fit for operation at anytime and might have been considered for early surgery. Two of these patients died so soon after admission that surgery could not have been performed leaving 10 patients who might have been saved by early surgery. We review the theoretical advantages of delayed as against early surgery and conclude that it is doubtful whether the timing of surgery has any significant effect on management outcome in line with the conclusions of the Cooperative Study.
延迟性动脉瘤手术，曾是标准做法，如今只有少数神经外科医生采用。我们分析了在14年期间连续治疗的400例破裂动脉瘤患者采取这一策略的结果。尽管实行“开放入院”政策，即患者一经转诊就立即收治，但只有56%的患者在发病后24小时内入院（69%在72小时内）。1级和2级患者的手术通常延迟8至10天；病情较重的患者往往延迟更长时间，直到病情稳定。287例患者（72%）接受了手术，93%在第8天或之后（78%在第11天或之后）。在1年时评估结果。所有患者中，68%的格拉斯哥预后评分处于1级，26%死亡。接受手术的患者中，88%的格拉斯哥预后评分处于1级，5%死亡（30天手术死亡率为3.5%）。51例患者（12.8%）再次出血，30例在最初10天内。再次出血在最初2周内的时间分布均匀。84例患者出现非出血性病情恶化（NHD），除3例外在10天内发生。NHD在第4至9天达到高峰。33例患者死于再次出血，16例死于NHD，但因再次出血死亡的患者中只有12例在任何时候都适合手术，本可考虑早期手术。其中2例患者入院后很快死亡，无法进行手术，因此有10例患者本可通过早期手术获救。我们回顾了延迟手术与早期手术相比的理论优势，并得出结论，与合作研究的结论一致，手术时机是否对治疗结果有任何显著影响值得怀疑。
