Early versus late intracranial aneurysm surgery in subarachnoid hemorrhage

The management results in 244 patients admitted to one institution within 3 days of aneurysmal subarachnoid hemorrhage (SAH) from January, 1979, to December, 1985, were analyzed with respect to the timing of surgical intervention. Twenty-six patients died prior to surgery. Patients surviving to surgery were divided into three groups according to the interval between preadmission SAH and surgery: 0 to 3 days (85 cases), 4 to 9 days (83 cases), and 10 or more days (50 cases). Of the patients who were categorized neurologically into Botterell Grades 1 and 2 (Hunt and Hess Grades I to III) on admission, 87% had an excellent or good result on follow-up evaluation. Patients undergoing surgery 0 to 3 days after SAH had a statistically significant increase in the incidence of postoperative ischemic symptoms (p less than 0.005), which was balanced by similar complications preoperatively in the 10-day post-SAH surgical group. Most rebleeds occurred before admission but delaying surgery did increase the risk of rebleeding in the hospital (p less than 0.0005). Management morbidity and mortality occurred primarily as a direct result of a severe initial hemorrhage; thus, the measured benefits of early surgery were less than might have been predicted.