DELAYED SURGERY FOR RUPTURED INTRACRANIAL ANEURYSMS - A REAPPRAISAL

Delayed aneurysm surgery, once standard practice, is now followed by o nly a minority of neurosurgeons. We analysed the outcome of such a pol icy in 400 consecutive patients with ruptured aneurysms treated over a 14-year period. Despite an 'open door' admissions policy, admitting a ll patients immediately on referral, only 56% arrived within 24 h of t he ictus (69% within 72 h). Surgery was generally delayed for 8-10 day s in patients in Grades 1 and 2; for higher grade patients often for l onger until their condition was stable. Two-hundred-and-eighty-seven p atients (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 I n Glasgow Outcome Scale Grade 1, while 26% had died. Of the operated p atients 88% were in GOS grade 1, while 5% had died (30-day surgical mo rtality 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 we eks. Eighty-four patients experienced non-haemorrhagic deterioration ( NHD) all but 3 within 10 days. NHD peaked at days 4-9. Thirty-three pa tients died of rebleeding and 16 of NHD, bur only 12 of the patients w ho died from rebleeding were fit for operation at anytime and might ha ve been considered for early surgery. Two of these patients died so so on 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 conclud e that it is doubtful whether the timing of surgery has any significan t effect on management outcome in line with the conclusions of the Coo perative Study.