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• W2070971268 abstract "When a patient with a ruptured aneurysm has been fortunate enough to reach a hospital alive, the main fear is that the aneurysm may re-bleed. Although initial medical treatment guidelines include measures to reduce the risk of re-bleeding, the only sure way to avoid such a catastrophe is to exclude the aneurysm itself from circulation, whether by surgical or endovascular means. Since the inception of surgical treatment of aneurysms till the 1980s, exclusion of the aneurysm was postponed due to the limitations of surgical techniques, which were associated with unfavorable results while performed in an acute stage [1, 2]. At that time we were dealing with suboptimal surgical exposure leading to forceful brain retraction and manipulation on a very swollen and tense brain. Hence surgery was often postponed, and it was not uncommon to witness patients dying from re-bleeding while waiting for surgery. This uncomfortable waiting period allowed us to quantify that risk, which was associated with a high mortality rate, as well as to determine the timing of re-bleeding and when this risk is the greatest [3]. The introduction of microsurgical techniques together with better peri-operative medical management of the effects of the initial hemorrhage and vasospasm explain the results of the international cooperative study published in 1990, which revealed that there was no difference in outcome between early (1–3 days post SAH) and late surgery (>10 days) [4, 5]. That is to say, thanks to these improvements, that early surgery is now feasible, and in fact this is now a common practice. The experience gained over time has made it possible to secure the aneurysm earlier while limiting further damage to the brain. The advent of endovascular procedures has also helped to reach that goal. Yet despite earlier intervention, the risk of re-bleeding remains ominously significant, having been evaluated to be the most prevalent in the first 24 h [6–8]. Given all these improvements, presently, it would seem intuitive to occlude the aneurysm within 24 h (ultra-early aneurysm treatment). Indeed, some studies suggested that ultra-early aneurysm treatment might be associated with a better outcome [9–11]. Yet in this issue of Neurocritical Care, Oudshoorn et al., looked at two cohorts and concluded that aneurysm occlusion can be performed in daytime within 72 h after ictus, instead of on an emergency basis. In their observational study, the cohorts from the UMC Utrecht SAH database and from the randomized ISAT trial were categorized into aneurysm treatment 3 h after admission were recategorized into the group of 24–72 h [12]. This is not to say that we can postpone intervention to eliminate the aneurysm. These results in no way justify deliberate delay. This is a post-hoc analysis of two cohorts of patients admitted for aneurysmal SAH: the prospectively collected UMC Utrecht SAH database and the ISAT randomized trial. There are several aspects inherent in these two series that naturally bring about important bias to take into account. In both series, the patients were not randomized according to the timing of surgery, nor is it known how they were selected for their respective groups. Hence M. W. Bojanowski (&) Division of Neurosurgery, Centre Hospitalier de l’Universite de Montreal, University of Montreal, Montreal, QC, Canada e-mail: michel.bojanowski.chum@ssss.gouv.qc.ca" @default.
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• W2070971268 date "2014-06-25" @default.
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• W2070971268 title "Considerations About Ultra-early Treatment of Ruptured Aneurysms" @default.
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• W2070971268 doi "https://doi.org/10.1007/s12028-014-0002-z" @default.
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