Time of surgery for aneurysmal subarachnoid hemorrhage in patients >=70 years

ObjectiveTo establish a time-to-surgery threshold for elderly aneurysmal subarachnoid hemorrhage patients before the risk of mortality increases. MethodsA cohort study using data with consecutive patients 70 years and older(N=743). Risk-adjusted restricted cubic splines modeled the mortality according to wait-time. The inflection point (in hours) when mortality began to increase was used to define early-time, middle-time and late-time surgery. To evaluate the robustness of this definition, outcomes among propensity-score matched non-middle surgical and middle-time surgical patients were compared using percent absolute risk differences. ResultsThere were a total of 535 patients who met inclusion. Their mean age was 74.3 (4.38) years. Cox models with restricted cubic spline showed a statistically significant U shaped association for onset-to-surgery time with two year all cause mortality. 66 patients (12.3%) received middle-time surgery and 469 patients (87.7%) received early-time or late-time surgery. There were 60 (91%) patients in the middle-time surgery group matched to those in the non-middle-time group. Of the 60 matched patients who received surgery after less than 49 hours or more than 68 hours, 23 patients (38.3%) died within 24 months vs 14 patients (23.3%) of 60 who received surgery within 49 to 68 hours, for an absolute risk difference of 15% (95% CI, -2.68% to 31.50%). ConclusionsIn this study, onset-to-treatment time showed a U shaped association with 24 months all cause mortality. Early surgery was superior to delayed surgery in reducing death rate. Elderly patients with poor tolerance to ultra-early surgery in whom operation was probably postponed.