Majority of UK neurosurgical units following published recommendations, but room for improvement remains

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It has been discovered via a national survey of current practice that six months post-publication of the National Confidential Enquiry into Patient Outcome and Death report, the majority of neurosurgical units across the United Kingdom and Ireland have been following most of the key recommendations for the management of aneurysmal subarachnoid haemorrhage.

Study authors Othman Al-Helli et al report in the Journal of Neurointerventional Surgery however, that in the remainder of neurosurgical units they found variability in clinical practice.

 


According to the authors, the management of aneurysmal subarachnoid haemorrhage has undergone extensive change in recent years with the publication of recommendations and guidelines by specialty bodies. The National Confidential Enquiry into Patient Outcome and Death report and recommendations were published in November 2013 as a follow-up to the 2012 recommendations for the management of aneurysmal subarachnoid haemorrhage published by the Royal College of Physicians and the American Heart Association/American Stroke Association. The aim of Al-Helli et al’s study was to assess how many of these recommendations were being followed six months after the latest publication, and to compare current practice with the National Confidential Enquiry into Patient Outcome and Death data collected in 2011.

 


To carry out their investigation, study authors formulated a survey composed of 19 questions regarding the management of aneurysmal subarachnoid haemorrhage, and conducted a telephone interview with the neurosurgical registrars on call. The 19 questions covered six areas: hospital policies and facilities for treatment of aneurysmal subarachnoid haemorrhage; medical measures to prevent rebleeding; surgical and endovascular methods of treatment; management of cerebral vasospasm and delayed cerebral ischaemia; management of hydrocephalus; and management of medical complications. Thirty neurosurgical units participated in the survey. The results were then compared against currently available published recommendations. 

 


According to the results, “22 out of the 30 centres aimed to treat ruptured aneurysms by coiling or clipping within 48 hours of ictus, yet only 15 units offered regular weekend interventional neuroradiological treatment. In nine units, all aneurysmal subarachnoid haemorrhages were routinely discussed in a multidisciplinary meeting.”

 


The authors note: “In the vast majority of neurosurgical centres, the main recommendations from the Royal College of Physicians, the American Heart Association/American Stroke Association, and the National Confidential Enquiry into Patient Outcome and Death report were being followed. Given data from previous studies over the past 15 years suggesting a longer interval to securing a ruptured intracranial aneurysm compared with other developed countries such as the USA, this survey suggests that there has been improvement in the service in the UK.”

 


They conclude noting that while there appears to be recent considerable improvement in the management of aneurysmal subarachnoid haemorrhage in the UK, more work is required before care delivery is optimised. They further state their intention to repeat the survey in the future to assess the progress made.

 


Al-Helli told NeuroNews: “The most concerning finding of the study is the fact that only half of the neuroscience centres provide weekend neurointerventional service despite the guidelines recommend very clearly that early treatment not later than 48 hours post-ictus is a key factor for better outcome. I believe that our findings imply that patients who their bleed on a Friday night will have worse outcome that those who have it on any other weekday.”

 


Commenting on what might be done to improve outcomes, he added, “Providing a six day service might help. I personally wish that neither myself or any friend or family or indeed anybody get their bleed on a Friday night. Otherwise they might have to wait more than 48 hours to secure aneurysm preventing the potentially disastrous complication of rebleeding!”

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