Anevrizmatik Subaraknoid Kanamada Ultra-Erken ve Erken Tedavinin Etkileri: Tek Merkezli Retroprospektif Çalışma

Yıl 2024, , 67 - 71, 28.04.2024

Mehmetselim Gel , Emrah Keskin , İskender Samet Daltaban

https://doi.org/10.29058/mjwbs.1452463

Öz

Amaç: Anevrizmal subaraknoid kanamaların (aSAK) cerrahi tedavisinin zamanlaması konusundaki
fikir ayrılıkları günümüzde hâlen devam etmektedir. Bu tartışmaya hastalığa bağlı sınırlamaların sebep
olduğu aşikâr olup; konuya yönelik çok sayıda araştırma mevcuttur. Bu çalışmalar özellikle erken ve
ultra erken cerrahiyi desteklemekle beraber; sonuçlar bu iki zamanlama içindeki tedavi seçeneklerinden
hangisinin (endovasküler tedavi (EVT) veya cerrahi tedavi (CT)) üstün olduğu konusunda da
henüz net değildir.
Gereç ve Yöntemler: Bu çalışma, Trabzon Kanuni Eğitim Araştırma Hastanesi Beyin ve Sinir Cerrahisi
Kliniğinde Haziran 2021 ile Haziran 2022 tarihleri arasında, aSAK tanısı ile tedavi edilen 50 hasta
üzerinde retroprospektif olarak yapılmıştır. Hastalar çalışmamızda tedavi yöntemine bakılmaksızın
(EVT veya CT) kanamanın ilk altı saat içinde tedavi edilenler ultra erken tedavi (Grup 1) ve altı saat-yirmi
dört saat arasında tedavi edilenler erken tedavi (Grup 2) olmak üzere iki ayrı gruba ayrıldı.
Bulgular: aSAK tanısıyla EVT veya CT ile tedavi edilen 50 hastanın 31’i erkek (%62) ve 19’u kadın
(%38) idi. Grup 1, 14’ü EVT ve 12’si CT ile olmak üzere toplam 26 hastadan; Grup 2 ise 13’ü EVT ve
11’i CT ile olmak üzere toplam 24 hastadan oluşmaktadır. Grup 1 ve Grup 2’deki hastalara gerek EVT
gerekse CT ile tedavi uygulanması durumunda istatistiksel olarak tedavinin tipi ve zamanlaması açısından
birbirine üstünlüğü olmadığı görülmüştür (Sırasıyla p=0,678, p=0,680).
Sonuç: Bu çalışma, aSAK tanılı hastaların klinik derecesine bakılmaksızın hem erken hem de ultra
erken dönemde yapılan her iki müdahalenin (EVT veya CT) sonuçları açısından farklılık olmadığını
göstermemiştir.

Anahtar Kelimeler

Subaraknoid kanama, erken cerrahi, ultra-erken cerrahi, endovasküler tedavi, serebral anevrizma cerrahisi

Effects of Ultra-Early and Early Treatment in Aneurysmatic Subarachnoid Hemorrhage: Single Center Retroprospective Study

Öz

Aim:There are on going disagreements about when to perform surgical treatment for aneurysmal
subarachnoid hemorrhage (aSAH), which is caused by limitations related to the disease. There is a lot
of research on this topic. However, it is stil lunclear which of the two treatment options (endovascular
therapy (EVT) or surgical therapy (CT)) is superior, despite studies that suggest early and ultra-earlysurgery as effective options.
Material and Methods: This retrospective study was carried out on 50 patients diagnosed with aSAH and treated at Trabzon Kanuni
Training and Research Hospital Brain and Nerve Surgery Clinic between June 2021 and June 2022. In this study, all patients, regardless
of their treatment method (EVT or CT), were divided into two groups based on the timing of their surgery: ultra-early treatment (Group 1),
where patients were treated with int he first six hours of bleeding, and early treatment (Group 2), where patients were treated between six
and twenty-four hours.
Results: Of the 50 patients diagnosed with aSAH and treated with EVT or CT, 31 were male (62%) and 19 were female (38%). Group 1
consists of a total of 26 patients, 14 with EVT and 12 with CT; Group 2 consists of a total of 24 patients, 13 with EVT and 11 with CT. If
patients in Group 1 and Group 2 were treated with either EVT or CT, it was observed that there was no statistical superiority to each other
in terms of the type and timing of treatment (p=0.678, p=0.680, respectively).
Conclusion: This study did not show that there was no difference in the outcomes of both interventions (EVT or CT) performed both in
the early and ultra-early period in patients diagnosed with aSAH, regardless of clinical grade.

Anahtar Kelimeler

Subarachnoid hemorrhage, early surgery, ultra-early surgery, endovascular treatment, cerebral aneurysm surgery

Kaynakça

• 1. D'Andrea G, Picotti V, Familiari P, Barbaranelli C, Frati A, Raco A. Impact of early surgery of ruptured cerebral aneurysms on vasospasm and hydrocephalus after SAH: Our preliminary results. Clin Neurol Neurosurg 2020;192:105714.
• 2. Fujii Y, Takeuchi S, Sasaki O, Minakawa T, Koike T, Tanaka R. Ultra-early rebleeding in spontaneous subarachnoid hemorrhage. J Neurosurg 1996;84(1):35-42.
• 3. Siddiq F, Chaudhry SA, Tummala RP, Suri MF, Qureshi AI. Factors and outcomes associated with early and delayed aneurysm treatment in subarachnoid hemorrhage patients in the United States. Neurosurgery 2012;71(3):670-677; discussion 677-678.
• 4. Kassell NF, Torner JC, Haley EC Jr, Jane JA, Adams HP, Kongable GL. The International Cooperative Study on the Timing of Aneurysm Surgery. Part 1: Overall management results. J Neurosurg 1990;73(1):18-36.
• 5. Post R, Germans MR, Tjerkstra MA, Vergouwen MDI, Jellema K, Koot RW, Kruyt ND, Willems PWA, Wolfs JFC, de Beer FC, Kieft H, Nanda D, van der Pol B, Roks G, de Beer F, Halkes PHA, Reichman LJA, Brouwers PJAM, van den Berg-Vos RM, Kwa VIH, van der Ree TC, Bronner I, van de Vlekkert J, Bienfait HP, Boogaarts HD, Klijn CJM, van den Berg R, Coert BA, Horn J, Majoie CBLM, Rinkel GJE, Roos YBWEM, Vandertop WP, Verbaan D; ULTRA Investigators. Ultra-early tranexamic acid after subarachnoid haemorrhage (ULTRA): a randomised controlled trial. Lancet 2021;397(10269):112-118.
• 6. Tjerkstra MA, Post R, Germans MR, Vergouwen MDI, Jellema K, Koot RW, Kruyt ND, Willems PWA, Wolfs JFC, de Beer FC, Kieft H, Nanda D, van der Pol B, Roks G, de Beer F, Halkes PHA, Reichman LJA, Brouwers PJAM, Van den Berg-Vos RM, Kwa VIH, van der Ree TC, Bronner I, Bienfait HP, Boogaarts H, Klijn CJM, van den Berg R, Coert BA, Horn J, Majoie CBLM, Rinkel GJE, Roos YBWM, Vandertop WP, Verbaan D; ULTRA investigators. Tranexamic Acid After Aneurysmal Subarachnoid Hemorrhage: Post Hoc Analysis of the ULTRA Trial. Neurology 2022;99(23):e2605-e2614.
• 7. Vergouwen MD, Germans MR, Post R, Tjerkstra MA, Coert BA, Rinkel GJ, Peter Vandertop W, Verbaan D. Aneurysm treatment within 6 h versus 6-24 h after rupture in patients with subarachnoid hemorrhage. Eur Stroke J 2023;8(3):802-807.
• 8. Koester SW, Catapano JS, Rhodenhiser EG, Rudy RF, Winkler EA, Benner D, Cole TS, Baranoski JF, Srinivasan VM, Graffeo CS, Jha RM, Jadhav AP, Ducruet AF, Albuquerque FC, Lawton MT. Propensity-adjusted analysis of ultra-early aneurysmal subarachnoid hemorrhage treatment and patient outcomes. Acta Neurochir (Wien) 2023;165(4):993-1000.
• 9. Ohman J, Heiskanen O. Timing of operation for ruptured supratentorial aneurysms: a prospective randomized study. J Neurosurg 1989;70(1):55-60.
• 10. Oudshoorn SC, Rinkel GJ, Molyneux AJ, Kerr RS, Dorhout Mees SM, Backes D, Algra A, Vergouwen MD. Aneurysm treatment <24 versus 24-72 h after subarachnoid hemorrhage. Neurocrit Care 2014;21(1):4-13.
• 11. Phillips TJ, Dowling RJ, Yan B, Laidlaw JD, Mitchell PJ. Does treatment of ruptured intracranial aneurysms within 24 hours improve clinical outcome? Stroke 2011;42(7):1936-1945.
• 12. Qian Z, Peng T, Liu A, Li Y, Jiang C, Yang H, Wu J, Kang H, Wu Z. Early timing of endovascular treatment for aneurysmal subarachnoid hemorrhage achieves improved outcomes. Curr Neurovasc Res 2014;11(1):16-22.
• 13. Debette S, Mazighi M, Bijlenga P, Pezzini A, Koga M, Bersano A, Kõrv J, Haemmerli J, Canavero I, Tekiela P, Miwa K, J Seiffge D, Schilling S, Lal A, Arnold M, Markus HS, Engelter ST, Majersik JJ. ESO guideline for the management of extracranial and intracranial artery dissection. Eur Stroke J 2021;6(3):XXXIX-LXXXVIII.
• 14. Hoh BL, Ko NU, Amin-Hanjani S, Chou SH-Y, Cruz-Flores S, Dangayach NS, Derdeyn CP, Du R, Hänggi D, Hetts SW, Ifejika NL, Johnson R, Keigher KM, Leslie-Mazwi TM, Lucke-Wold B, Rabinstein AA, Robicsek SA, Stapleton CJ, Suarez JI, Tjoumakaris SI, Welch BG. 2023 Guideline for the Management of Patients With Aneurysmal Subarachnoid Hemorrhage: A Guideline From the American Heart Association/American Stroke Association. Stroke 2023;54(7):e314-e370.
• 15. Wong GK, Boet R, Ng SC, Chan M, Gin T, Zee B, Poon WS. Ultra-early (within 24 hours) aneurysm treatment after subarachnoid hemorrhage. World Neurosurg 2012;77(2):311-315.
• 16. Şimsek O, Akinci AT. The effects of ultra-early clipping on survival and neurological outcome in poor-grade aneurysmal subarachnoid haemorrhage. Ideggyogy Sz 2022;75(9-10):325-332.
• 17. Connolly ES Jr, Rabinstein AA, Carhuapoma JR, Derdeyn CP, Dion J, Higashida RT, Hoh BL, Kirkness CJ, Naidech AM, Ogilvy CS, Patel AB, Thompson BG, Vespa P; American Heart Association Stroke Council; Council on Cardiovascular Radiology and Intervention; Council on Cardiovascular Nursing; Council on Cardiovascular Surgery and Anesthesia; Council on Clinical Cardiology. Guidelines for the management of aneurysmal subarachnoid hemorrhage: a guideline for healthcare professionals from the American Heart Association/american Stroke Association. Stroke 2012;43(6):1711-1737.
• 18. Steiner T, Juvela S, Unterberg A, Jung C, Forsting M, Rinkel G; European Stroke Organization. European Stroke Organization guidelines for the management of intracranial aneurysms and subarachnoid haemorrhage. Cerebrovasc Dis 2013;35(2):93- 112.
• 19. Wan A, Jaja BN, Schweizer TA, Macdonald RL; , on behalf of the SAHIT collaboration. Clinical characteristics and outcome of aneurysmal subarachnoid hemorrhage with intracerebral hematoma. J Neurosurg 2016;125(6):1344-1351.
• 20. Gu DQ, Zhang X, Luo B, Long XA, Duan CZ. Impact of ultra-early coiling on clinical outcome after aneurysmal subarachnoid hemorrhage in elderly patients. Acad Radiol 2012;19(1):3-7.
• 21. Luo YC, Shen CS, Mao JL, Liang CY, Zhang Q, He ZJ. Ultra- early versus delayed coil treatment for ruptured poor-grade aneurysm. Neuroradiology 2015;57(2):205-210.
• 22. Zhao B, Rabinstein A, Murad MH, Lanzino G, Panni P, Brinjikji W. Surgical and endovascular treatment of poor-grade aneurysmal subarachnoid hemorrhage: a systematic review and meta-analysis. J Neurosurg Sci 2017;61(4):403-415.