Surgical and endovascular treatment of poor-grade aneurysmal subarachnoid hemorrhage: A systematic review and meta-analysis

INTRODUCTION: Poor-grade aneurysmal subarachnoid hemorrhage (aSAH) is associated with high morbidity and mortality. We evaluated trends in outcomes and treatment of poor-grade aSAH and performed a meta-analysis evaluating outcomes by treatment modality. EVIDENCE ACQUISITION: We performed a literature search for studies on surgical and endovascular treatment of poor-grade aSAH. We performed a random effects meta-analysis evaluating long-term good neurological outcome, long-term poor neurological outcome and mortality, comparing rates between endovascular and surgical treatments. We performed a subgroup analysis of outcome by treatment timing relative to the aSAH separating treatment timing into three categories: 1) ultra-early (within 48 hours of aSAH); 2) early (between 48 hours-1 week postaSAH); and 3) delayed (>1 week post-aSAH). We also evaluated trends in treatment modalities and good neurological outcome. EVIDENCE SYNTHESIS: Eighty-five non-comparative studies with 4506 patients with poor-grade aSAH were included. The proportion of patients receiving endovascular treatment increased from 10.0% to 62.0% between 1990-2000 and 2010-2014. The rate of good neurological outcome increased from 37.0% to 44.0% over this time period. Long-term good neurological outcome was 38% (95% CI=33-43%) in the endovascular group and 39% (95% CI=34-44%) in the surgical group (P=0.74). Mortality rates were higher in the endovascular group compared to the surgical group (41% versus 31%, P=0.01). Overall, patients receiving ultra-early treatment had the highest rates of good neurological outcome (61% compared to 40% for early and 47% for delayed, P<0.01). CONCLUSIONS: Good neurological outcome rates are similar between surgery and endovascular treatment of poor grade aSAH. Ultra-early treatment is associated with improved clinical outcomes.