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Dissanayake AS, Burrows E, Ho KM, Phillips TJ, Honeybul S, Hankey GJ. Rebleeding following aneurysmal subarachnoid hemorrhage before 'endovascular first' treatment: a retrospective case-control study of published scoring systems. J Neurointerv Surg 2024; 16:498-505. [PMID: 37316197 DOI: 10.1136/jnis-2023-020390] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2023] [Accepted: 05/31/2023] [Indexed: 06/16/2023]
Abstract
BACKGROUND Pre-treatment re-bleeding following aneurysmal subarachnoid hemorrhage (aSAH) affects up to 7.2% of patients even with ultra-early treatment within 24 hours. We retrospectively compared the utility of three published re-bleed prediction models and individual predictors between cases who re-bled matched to controls using size and parent vessel location from a cohort of patients treated in an ultra-early, 'endovascular first' manner. METHODS On retrospective analysis of our 9-year cohort of 707 patients suffering 710 episodes of aSAH, there were 53 episodes of pre-treatment re-bleeding (7.5%). Forty-seven cases who had a single culprit aneurysm were matched to 141 controls. Demographic, clinical and radiological data were extracted and predictive scores calculated. Univariate, multivariate, area under the receiver operator characteristic curve (AUROCC) and Kaplan-Meier (KM) survival curve analyses were performed. RESULTS The majority of patients (84%) were treated using endovascular techniques at a median 14.5 hours post-diagnosis. On AUROCC analysis the score of Liu et al. had minimal utility (C-statistic 0.553, 95% confidence interval (CI) 0.463 to 0.643) while the risk score of Oppong et al. (C-statistic 0.645 95% CI 0.558 to 0.732) and the ARISE-extended score of van Lieshout et al. (C-statistic 0.53 95% CI 0.562 to 0.744) had moderate utility. On multivariate modeling, the World Federation of Neurosurgical Societies (WFNS) grade was the most parsimonious predictor of re-bleeding (C-statistic 0.740, 95% CI 0.664 to 0.816). CONCLUSIONS For aSAH patients treated in an ultra-early timeframe matched on size and parent vessel location, WFNS grade was superior to three published models for re-bleed prediction. Future re-bleed prediction models should incorporate the WFNS grade.
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Affiliation(s)
- Arosha S Dissanayake
- Department of Neurosurgery, Sir Charles Gairdner Hospital, Nedlands, Perth, Western Australia, Australia
| | - Emalee Burrows
- Department of Neurosurgery, Sir Charles Gairdner Hospital, Nedlands, Perth, Western Australia, Australia
| | - Kwok M Ho
- Department of Intensive Care Medicine, Royal Perth Hospital, Perth, Western Australia, Australia
| | - Timothy J Phillips
- Neurological Intervention and Imaging Service of Western Australia, Sir Charles Gairdner Hospital, Nedlands, Western Australia, Australia
| | - Stephen Honeybul
- Department of Neurosurgery, Sir Charles Gairdner Hospital, Nedlands, Perth, Western Australia, Australia
| | - Graeme J Hankey
- School of Medicine, The University of Western Australia, Perth, Western Australia, Australia
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Dissanayake AS, Ho KM, Phillips TJ, Honeybul S, Hankey GJ. Pre-treatment re-bleeding following aneurysmal subarachnoid hemorrhage: A systematic review of published prediction models with risk of bias and clinical applicability assessment. J Clin Neurosci 2024; 119:102-111. [PMID: 37995407 DOI: 10.1016/j.jocn.2023.10.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2023] [Revised: 10/18/2023] [Accepted: 10/29/2023] [Indexed: 11/25/2023]
Abstract
BACKGROUND Pre-treatment rebleeding following aneurysmal subarachnoid hemorrhage (aSAH) increases the risk of death and a poor neurological outcome. Current guidelines recommend aneurysm treatment "as early as feasible after presentation, preferably within 24 h of onset" to mitigate this risk, a practice termed ultra-early treatment. However, ongoing debate regarding whether ultra-early treatment is independently associated with reduced re-bleeding risk, together with the recognition that re-bleeding occurs even in centres practicing ultra-early treatment due to the presence of other risk-factors has resulted in a renewed need for patient-specific re-bleed risk prediction. Here, we systematically review models which seek to provide patient specific predictions of pre-treatment rebleeding risk. METHODS Following registration on the International prospective register of systematic reviews (PROSPERO) CRD 42023421235; Ovid Medline (Pubmed), Embase and Googlescholar were searched for English language studies between 1st May 2002 and 1st June 2023 describing pre-treatment rebleed prediction models following aSAH in adults ≥18 years. Of 763 unique records, 17 full texts were scrutinised with 5 publications describing 4 models reviewed. We used the semi-automated template of Fernandez-Felix et al. incorporating the Critical Appraisal and Data Extraction for Systematic Reviews of Prediction Modelling Studies (CHARMS) checklist and the Prediction model Risk Of Bias ASsessment Tool (PROBAST) for data extraction, risk of bias and clinical applicability assessment. To further standardize risk of bias and clinical applicability assessment, we also used the published explanatory notes for the PROBAST tool and compared the aneurysm treatment practices each prediction model's formulation cohort experienced to a prespecified benchmark representative of contemporary aneurysm treatment practices as outlined in recent evidence-based guidelines and published practice pattern reports from four developed countries. RESULTS Reported model discriminative performance varied between 0.77 and 0.939, however, no single model demonstrated a consistently low risk of bias and low concern for clinical applicability in all domains. Only the score of Darkwah Oppong et al. was formulated using a patient cohort in which the majority of patients were managed in accordance with contemporary, evidence-based aneurysm treatment practices defined by ultra-early and predominantly endovascular treatment. However, this model did not undergo calibration or clinical utility analysis and when applied to an external cohort, its discriminative performance was substantially lower that reported at formulation. CONCLUSIONS No existing prediction model can be recommended for clinical use in centers practicing contemporary, evidence-based aneurysm treatment. There is a pressing need for improved prediction models to estimate and minimize pre-treatment re-bleeding risk.
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Affiliation(s)
- Arosha S Dissanayake
- Department of Neurosurgery, Sir Charles Gairdner Hospital, Nedlands, Western Australia, Australia.
| | - Kwok M Ho
- Department of Intensive Care, Royal Perth Hospital, Perth, Western Australia, Australia; School of Population Health, The University of Western Australia, Crawley, Western Australia, Australia
| | - Timothy J Phillips
- Neurological Intervention and Imaging Service of Western Australia, Sir Charles Gairdner Hospital, Nedlands, Perth, Western Australia, Australia
| | - Stephen Honeybul
- Department of Neurosurgery, Sir Charles Gairdner Hospital, Nedlands, Western Australia, Australia
| | - Graeme J Hankey
- Medical School, Faculty of Health and Medical Sciences, The University of Western Australia, Crawley, Perth, Western Australia, Australia; Perron Institute for Neurological and Translational Science, Nedlands, Perth, Western Australia, Australia
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Jun SM, Kim SH, Leinonen H, Gan P, Bhat S. Impact of Off-Hour Admission with Subarachnoid Hemorrhage: A Meta-Analysis. World Neurosurg 2022; 166:e872-e891. [PMID: 35948214 DOI: 10.1016/j.wneu.2022.07.127] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2022] [Accepted: 07/26/2022] [Indexed: 12/15/2022]
Abstract
OBJECTIVE This meta-analysis assessed the impact of off-hour hospitalization (weekends, and evenings or nighttime on weekdays) on mortality and morbidity in patients with nontraumatic subarachnoid hemorrhage (SAH). METHODS Electronic databases were systematically searched for studies comparing outcomes between patients with nontraumatic SAH hospitalized during off-hour and on-hour periods (daytime on weekdays). The primary outcome was mortality (in-hospital and at different follow-up periods after hospitalization). Secondary outcomes included delays in treatment, and complications. Sensitivity analysis including only studies in which adjusted multivariate analyses were performed for any of the outcomes, and meta-regression controlling for clinically important patient factors, were also performed. RESULTS Sixteen studies were included. There was no significant difference in in-hospital mortality (adjusted odds ratio, 1.03; 95% confidence interval [CI], 0.97-1.09; P = 0.30) and at all follow-up periods (7/14 days and 1/3/6 months) after hospitalization between SAH patients who were admitted during off-hour compared with on-hour periods, despite adjusted multivariate meta-analysis being performed. However, patients who were admitted during off-hour periods experienced greater delays from their initial scan to treatment (mean difference, 42.7, 25.2-60.1 hours; P < 0.0001) and had higher rates of pneumonia (odds ratio, 1.65, 1.12-2.44; P = 0.011). CONCLUSIONS This meta-analysis has not shown an increased risk of mortality in the short-term and long-term among patients with nontraumatic SAH who were hospitalized during off-hour compared with on-hour periods, despite adjusting for potentially confounding patient factors. The delays to treatment and higher observed rates of pneumonia highlight areas in which hospital services and resources should be targeted during these off-hour periods in patients presenting with nontraumatic SAH.
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Affiliation(s)
- Sung-Min Jun
- Department of Surgery, Faculty of Medical and Health Sciences, The University of Auckland, Auckland, New Zealand
| | - Sang Ho Kim
- Department of Surgery, Faculty of Medical and Health Sciences, The University of Auckland, Auckland, New Zealand
| | - Heta Leinonen
- Department of Neurosurgery, Waikato Hospital, Hamilton, New Zealand
| | - Peter Gan
- Department of Neurosurgery, Waikato Hospital, Hamilton, New Zealand
| | - Sameer Bhat
- Department of Surgery, Faculty of Medical and Health Sciences, The University of Auckland, Auckland, New Zealand; Department of Surgery, Palmerston North Hospital, Palmerston North, New Zealand.
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Post R, Germans MR, Buis DR, Coert BA, Vandertop WP, Verbaan D. Interventions in Acute Intracranial Surgery: An Evidence-Based Perspective. World Neurosurg 2022; 161:432-440. [PMID: 35505564 DOI: 10.1016/j.wneu.2022.02.049] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2021] [Revised: 02/11/2022] [Accepted: 02/12/2022] [Indexed: 11/29/2022]
Abstract
From a pathophysiological point of view, early neurosurgical treatment seems essential to prevent secondary brain injury and has been stated as the "time-is-brain" concept. However, the question immediately rises: "Is there an optimal time window for acute intracranial neurosurgical interventions?" In neurosurgery, treatment modality has been studied far more extensively than timing to surgery ("time-to-surgery"). The majority of acute intracranial neurosurgical interventions are carried out for traumatic brain injury and hemorrhagic or ischemic stroke. Current guidelines for traumatic brain injury, spontaneous intracerebral hemorrhage, aneurysmal subarachnoid hemorrhage, and middle cerebral artery infarction are reviewed and lessons learned from the randomized controlled trials mentioned are discussed. In acute intracranial neurosurgical interventions, "delayed consent" procedures could play an important role for this field of research. Whether there is an optimal time window for acute intracranial neurosurgical interventions seems difficult to be answered with randomized controlled trials referred to in the current guidelines. Observational designs, such as comparative effectiveness research, and special statistical techniques, may provide a better understanding in the optimal "time-to-surgery."
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Affiliation(s)
- René Post
- Department of Neurosurgery, Neurosurgical Centre Amsterdam, Amsterdam University Medical Centres, Amsterdam, the Netherlands.
| | - Menno R Germans
- Department of Neurosurgery, Clinical Neuroscience Centre, University Hospital Zurich, Zurich, Switzerland
| | - Dennis R Buis
- Department of Neurosurgery, Neurosurgical Centre Amsterdam, Amsterdam University Medical Centres, Amsterdam, the Netherlands
| | - Bert A Coert
- Department of Neurosurgery, Neurosurgical Centre Amsterdam, Amsterdam University Medical Centres, Amsterdam, the Netherlands
| | - W Peter Vandertop
- Department of Neurosurgery, Neurosurgical Centre Amsterdam, Amsterdam University Medical Centres, Amsterdam, the Netherlands
| | - Dagmar Verbaan
- Department of Neurosurgery, Neurosurgical Centre Amsterdam, Amsterdam University Medical Centres, Amsterdam, the Netherlands
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Phuong Nguyen T, Rehman S, Stirling C, Chandra R, Gall S. Time and predictors of time to treatment for aneurysmal subarachnoid haemorrhage (aSAH): a systematic review. Int J Qual Health Care 2021; 33:6127110. [PMID: 33533408 DOI: 10.1093/intqhc/mzab019] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2020] [Revised: 01/17/2021] [Accepted: 02/02/2021] [Indexed: 12/20/2022] Open
Abstract
BACKGROUND Aneurysmal subarachnoid haemorrhage (aSAH) is a serious form of stroke, for which rapid access to specialist neurocritical care is associated with better outcomes. Delays in the treatment of aSAH appear to be common and may contribute to poor outcomes. We have a limited understanding of the extent and causes of these delays, which hinders the development of interventions to reduce delays and improve outcomes. The aim of this systematic review was to quantify and identify factors associated with time to treatment in aSAH. METHODS This systematic review was performed according to the Preferred Reporting Items for Systematic Review and Meta-Analysis guidelines and was registered in PROSPERO (Reg. No. CRD42019132748). We searched four electronic databases (MEDLINE, EMBASE, Web of Science and Google Scholar) for manuscripts published from January 1998 using pre-designated search terms and search strategy. Main outcomes were duration of delays of time intervals from onset of aSAH to definitive treatment and/or factors related to time to treatment. RESULTS A total of 64 studies with 16 different time intervals in the pathway of aSAH patients were identified. Measures of time to treatment varied between studies (e.g. cut-off timepoints or absolute mean/median duration). Factors associated with time to treatment fell into two categories-individual (n = 9 factors, e.g. age, sex and clinical characteristics) and health system (n = 8 factors, e.g. pre-hospital delay or presentation out-of-hours). Demographic factors were not associated with time to treatment. More severe aSAH reduced treatment delay in most studies. Pre-hospital delays (patients delay, late referral, late arrival of ambulance, being transferred between hospitals or arriving at the hospital outside of office hours) were associated with treatment delay. In-hospital factors (patients with complications, procedure before definitive treatment, slow work-up and type of treatment) were less associated with treatment delay. CONCLUSIONS The pathway from onset to definitive treatment of patients with aSAH consists of multiple stages with multiple influencing factors. This review provides the first comprehensive understanding of extent and factors associated with time to treatment of aSAH. There is an opportunity to target modifiable factors to reduce time to treatment, but further research considering more factors are needed.
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Affiliation(s)
- Thuy Phuong Nguyen
- Menzies Institute for Medical Research, University of Tasmania, 17 Liverpool Street, Hobart, Tasmania 7000, Australia
| | - Sabah Rehman
- Menzies Institute for Medical Research, University of Tasmania, 17 Liverpool Street, Hobart, Tasmania 7000, Australia
| | - Christine Stirling
- School of Nursing, University of Tasmania, Tasmania 71 Brooker Avenue, Hobart, Tasmania 7001, Australia
| | - Ronil Chandra
- Neuro Interventional Radiology, Monash Health, 246 Clayton Road, Clayton, Victoria 3168, Australia.,Medicine Monash Health, Monash University, Wellington Rd, Clayton, Victoria 3800, Australia
| | - Seana Gall
- Menzies Institute for Medical Research, University of Tasmania, 17 Liverpool Street, Hobart, Tasmania 7000, Australia.,Medicine Monash Health, Monash University, Wellington Rd, Clayton, Victoria 3800, Australia
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