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Management of subarachnoid hemorrhage patients: is early surgery better than delayed?

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There is no general consensus with regard to management of subarachnoid hemorrhage (SAH) patients. Early surgery has been advocated in order to minimize the rebleed risk, however it is more hazardous than delayed surgery, because the brain is tight and swollen, and the risk of vasospasm and infarction is increased.

The purpose of this retrospective study is to present our experiences in management of SAH patients. Between 1990–1995, 196 (59.4%) female and 134 (40.6%) male patients were admitted to our unit due to sudden onset of a headache. Subarachnoid hemorrhage was proven by CT scan and/or lumbar puncture and in 161 (48.8%) patients, three-vessels angiography showed one or more aneurysms. The conservatively treated group of SAH patients was statistically older than surgically treated group (P = 0.002). There was no statistically significant difference regarding age between male and female patients in both treated groups. Average timing of aneurysm surgery was 73.9 ± 75.5 h after the onset of bleeding (range: 4–550 h).

All but 20 patients (all conservatively treated) received nimodipine to prevent or treat vasospasm. In 14 (4.2%) patients vasospasm was seen on angiograms and 34 (21.1%) patients developed clinically significant vasospasm postoperatively between days 3–5. Mortality rate in conservatively treated group was 23.1%, and in surgically treated group 5%.

We conclude that early surgery (between days 1–3) is better, however it is more hazardous due to higher risk of vasospasm. Rebleed was the major problem in conservatively treated group of SAH patients, but over all outcome was better.

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Švigelj, V. Management of subarachnoid hemorrhage patients: is early surgery better than delayed?. Crit Care 2 (Suppl 1), P066 (1998).

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