E-ISSN: 1019-5157
ISSN: 2651-5024
Review
The Effect of Surgical Timing on Outcomes in Aneurysmal Subarachnoid Hemorrhage: A Systematic Review, Meta-Analysis, and Meta-Regression
Hasan Matar✉ ,
Bassel Alrabadi ,
Mohammad Alananbeh ,
Mustafa Alkhateeb ,
Abdullah Itayem
DOI: 10.5137/1019-5149.JTN.50758-25.2
Article in Press
Corresponding Author:
Hasan Matar (hasanmatar9f@gmail.com)
Abstract
Background: The timing of surgery for aneurysmal subarachnoid hemorrhage (aSAH) remains controversial.
Objective: To evaluate the effect of earlier versus later surgery on the functional outcomes and mortality in patients with aSAH.
Methods: Following PRISMA 2020 guidelines, we searched PubMed, Scopus, and the Cochrane Library through August 2025. Data were pooled using random-effects models. Heterogeneity was assessed with I² statistics and meta-regression analyses were performed.
Results: Early surgery was not associated with a significant reduction in poor functional outcomes compared with delayed surgery (RR = 0.90, P = 0.46; I² = 90%). Excluding studies that classified patients by pre-surgical status significantly reduced heterogeneity and showed a protective effect of early intervention (RR = 0.70, P < 0.001). In patients with poor-grade aSAH, early surgery significantly reduced poor outcomes (RR = 0.72, P < 0.0001) and mortality (RR = 0.65, P = 0.04), while in patients with good-grade aSAH, early surgery significantly reduced mortality (RR = 0.65, P = 0.004). No mortality benefit was observed in the overall population (RR = 0.95, P = 0.83).
Conclusions: Early surgical intervention did not significantly improve overall functional outcomes or mortality in unselected aSAH populations, and substantial heterogeneity was observed across studies. However, sensitivity analyses demonstrated that study methodology, particularly the timing of clinical status assessment affected outcomes and that early surgery became significantly beneficial when pre-surgical status studies were excluded. Importantly, early surgery consistently reduced both poor functional outcomes and mortality among patients presenting with poor-grade aSAH and mortality only among patients presenting with good-grade aSAH, supporting its use especially in patients with poor-grade aSAH. These findings highlight the importance of stratifying results by admission grade and carefully defining surgical timing in future studies.
Objective: To evaluate the effect of earlier versus later surgery on the functional outcomes and mortality in patients with aSAH.
Methods: Following PRISMA 2020 guidelines, we searched PubMed, Scopus, and the Cochrane Library through August 2025. Data were pooled using random-effects models. Heterogeneity was assessed with I² statistics and meta-regression analyses were performed.
Results: Early surgery was not associated with a significant reduction in poor functional outcomes compared with delayed surgery (RR = 0.90, P = 0.46; I² = 90%). Excluding studies that classified patients by pre-surgical status significantly reduced heterogeneity and showed a protective effect of early intervention (RR = 0.70, P < 0.001). In patients with poor-grade aSAH, early surgery significantly reduced poor outcomes (RR = 0.72, P < 0.0001) and mortality (RR = 0.65, P = 0.04), while in patients with good-grade aSAH, early surgery significantly reduced mortality (RR = 0.65, P = 0.004). No mortality benefit was observed in the overall population (RR = 0.95, P = 0.83).
Conclusions: Early surgical intervention did not significantly improve overall functional outcomes or mortality in unselected aSAH populations, and substantial heterogeneity was observed across studies. However, sensitivity analyses demonstrated that study methodology, particularly the timing of clinical status assessment affected outcomes and that early surgery became significantly beneficial when pre-surgical status studies were excluded. Importantly, early surgery consistently reduced both poor functional outcomes and mortality among patients presenting with poor-grade aSAH and mortality only among patients presenting with good-grade aSAH, supporting its use especially in patients with poor-grade aSAH. These findings highlight the importance of stratifying results by admission grade and carefully defining surgical timing in future studies.
Keywords
Subarachnoid Hemorrhage
Surgical Timing
Early Surgery
Mortality
Functional Outcomes.