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Background: Receiving early treatment for aneurysmal subarachnoid hemorrhage (aSAH) is associated with better outcomes for the patient. However, delays in treatment of aSAH are common but the causes are not well understood. We explored predictors of early treatment within 12.5 hours or 24 hours after aSAH. Methods: Consecutive cases of confirmed first-ever aSAH were identified from two Australian tertiary referral centers between 2010 and 2016. We used medical and ambulance records to extract details of participants, including time from onset to definitive treatment of either endovascular coiling or neurosurgical clipping, demographics, severity of aSAH (modified Fisher grade; World Federation of Neurosurgeons Scale [WFNS]), risk factors, pre-hospital care, and presenting symptoms. Factors associated with treatment to secure the aneurysm within 12.5 hours or 24 hours on univariable logistic regression were entered into a multivariable model to identify factors independently associated with (odds ratio [OR], 95% CI) earlier treatment. Results: Among 482 patients (mean [SD] age 54.1 [14.5]; 69.9% female) with aSAH, median (IQR) time to treatment was 19.4 (10.6, 31.0) hours, 30% were treated Conclusions: A substantial proportion of people after aSAH were not treated within timeframes associated with better outcomes. Recognition of the urgency and severity aSAH cases were associated with more timely treatment of aSAH.

Delays in treatment of aSAH appear to be common but the causes are not well understood. We explored facilitators and barriers to timely treatment of aSAH.We used a multiple case study with cases of aSAH surviving 1 day identified prospectively. We conducted semi-structured interviews with the patient, their next-of-kin and health professionals involved in the case. Within-case analysis identified barriers and facilitators in 4 phases (pre-hospital, presentation, transfer, in-hospital) followed by thematic analysis across cases using a case-study matrix.Twenty-seven cases with 90 interviewees yielded five themes related to facilitators or barriers of timely treatment. "Early recognition" led to urgent response. "Accessibility to health care" depended on patient's location, transport, and environmental conditions. Good "Coordination" between and within health services was a key facilitator. "Complexity" of patient's condition affected time to treatment in multiple time periods. "Availability of resources" was identified most frequently during the diagnostic and treatment phases as both barrier and facilitator.The identified themes may be modifiable at the patient/health professional level and health system level and may improve timely treatment of aSAH through targeted interventions, subsequently contributing to improve morbidity and mortality of patients with aSAH.

Background and aims: Rapid access to specialised care improves outcomes after aneurysmal subarachnoid haemorrhage (aSAH) but there is limited evidence on the optimal time-to-treatment. We investigated onset-to-treatment time and hospital discharge destination in aSAH. Methods: Consecutive first-ever aSAH patients were retrospectively identified from multiple overlapping sources in two comprehensive cerebrovascular referral centres between 2010-2016. Onset-to-treatment time (hours from onset of symptoms to treatment to secure aneurysm), clinical characteristics, and neurological complications (NINDS classifications) were extracted by clinical data collectors from medical records. Among survivors, we estimated the effect of continuous onset-to-treatment on hospital discharge destination (i.e. home vs. rehabilitation/other hospital as proxy for functional recovery) using logistic regression with adjustment for gender, treatment type (clipping or coiling), hospital presentation (direct admission or transfer), and severity (World Federation of Neurosurgical Societies scale, modified Fisher scale). Non-linear effects were investigated using natural cubic splines. Results: Among 402 survivors at discharge, there was a strong non-linear effect of onset-to-treatment time on odds of being discharged home compared to discharge to rehabilitation independent of severity, gender, treatment type and transfer (see Figure). The greatest benefit to discharge home was evident with treatment at up to 12.5 hours but the benefit remained at up to 20 hours post-onset. Conclusions: aSAH Treatment occurring within 12.5 hours led to greater discharge to home. Our use of continuous modelling provides clarity around optimal treatment times for aSAH to guide clinical practice.

Women are over-represented in aSAH cohorts, but whether their outcomes differ to men remains unclear. We examined if sex differences in neurological complications and aneurysm characteristics contributed to aSAH outcomes.In a retrospective cohort (2010-2016) of all aSAH cases across two hospital networks in Australia, information on severity, aneurysm characteristics and neurological complications (rebleed before/after treatment, postoperative stroke 48 h, neurological infections, hydrocephalus, seizures, delayed cerebral ischemia [DCI], cerebral infarction) were extracted. We estimated sex differences in (1) complications and aneurysm characteristics using chi square/t-tests and (2) outcome at discharge (home, rehabilitation or death) using multinomial regression with and without propensity score matching on prestroke confounders.Among 577 cases (69% women, 84% treated) aneurysm size was greater in men than women and DCI more common in women than men. In unadjusted log multinomial regression, women had marginally greater discharge to rehabilitation (RRR 1.15 95% CI 0.90-1.48) and similar likelihood of in-hospital death (RRR 1.02 95% CI 0.76-1.36) versus discharge home. Prestroke confounders (age, hypertension, smoking status) explained greater risk of death in women (rehabilitation RRR 1.13 95% CI 0.87-1.48; death RRR 0.75 95% CI 0.51-1.10). Neurological complications (DCI and hydrocephalus) were covariates explaining some of the greater risk for poor outcomes in women (rehabilitation RRR 0.87 95% CI 0.69-1.11; death RRR 0.80 95% CI 0.52-1.23). Results were consistent in propensity score matched models.The marginally poorer outcome in women at discharge was partially attributable to prestroke confounders and complications. Improvements in managing complications could improve outcomes.

Performance of 11 commercially available 4- and 5-F aortic flush catheters was evaluated with respect to the extent of upstream injection, catheter motion, and downstream homogeneity of a 10-, 15-, and 20-mL/sec bolus of 76% meglumine sodium diatrizoate at room temperature. Tests were made in a pulsatile aortic flow model containing circulating fluid isoviscous to blood. The injection process was recorded on videotape. Homogeneity of the contrast material bolus was determined spectrophotometrically from samples collected from the center and each of the four quadrants of the vessel lumen. Upstream contrast material injection between 1.5 and 7 cm in length emerged from all catheters; it was lowest with one of the "tennis racket" designs from one and a new spiral end-loop design (Halo) from another manufacturer. All catheters, except the most rigid and largest-caliber catheter (5.8 F) showed considerable shaft motion at the higher injection rates. Downstream contrast material mixing homogeneity was always best at the highest injection rate but altogether was better for the Halo catheter than for any other catheter tested. It is concluded that all tested 4- and 5-F aortic flush catheters show some undesirable features, but certain design modifications improve performance and comparative testing is helpful to distinguish such features.