Outcome after Hunt and Hess Grade V subarachnoid hemorrhage: a comparison of pre-coiling era (1980–1995) versus post-ISAT era (2005–2014)

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OBJECTIVE

Outcome analysis of comatose patients (Hunt and Hess Grade V) after subarachnoid hemorrhage (SAH) is still lacking. The aims of this study were to analyze the outcome of Hunt and Hess Grade V SAH and to compare outcomes in the current period with those of the pre–International Subarachnoid Aneurysm Trial (ISAT) era as well as with published data from trials of decompressive craniectomy (DC) for middle cerebral artery (MCA) infarction.

METHODS

The authors analyzed cases of Hunt and Hess Grade V SAH from 1980–1995 (referred to in this study as the earlier period) and 2005–2014 (current period) and compared the results for the 2 periods. The outcomes of 257 cases were analyzed and stratified on the basis of modified Rankin Scale (mRS) scores obtained 6 months after SAH. Outcomes were dichotomized as favorable (mRS score of 0–2) or unfavorable (mRS score of 3–6). Data and number needed to treat (NNT) were also compared with the results of decompressive craniectomy (DC) trials for middle cerebral artery (MCA) infarctions.

RESULTS

Early aneurysm treatment within 72 hours occurred significantly more often in the current period (in 67% of cases vs 22% in earlier period). In the earlier period, patients had a significantly higher 30-day mortality rate (83% vs 39% in the current period) and 6-month mortality rate (94% vs 49%), and no patient (0%) had a favorable outcome, compared with 23% overall in the current period (p < 0.01, OR 32), or 29.5% of patients whose aneurysms were treated (p < 0.01, OR 219). Cerebral infarctions occurred in up to 65% of the treated patients in the current period.

Comparison with data from DC MCA trials showed that the NNTs were significantly lower in the current period with 2 for survival and 3 for mRS score of 0–3 (vs 3 and 7, respectively, for the DC MCA trials).

CONCLUSIONS

Early and aggressive treatment resulted in a significant improvement in survival rate (NNT = 2) and favorable outcome (NNT = 3 for mRS score of 0–3) for comatose patients with Hunt and Hess Grade V SAH compared with the earlier period. Independent predictors for favorable outcome were younger age and bilateral intact corneal reflexes. Despite a high rate of cerebral infarction (65%) in the current period, 29.5% of the patients who received treatment for their aneurysms during the current era (2005–2014) had a favorable outcome. However, careful individual decision making is essential in these cases.

ABBREVIATIONS ARR = absolute risk reduction; CVS = cerebral vasospasm; DC = decompressive craniectomy; DCI = delayed cerebral ischemia; EVD = external ventricular drain; GCS = Glasgow Coma Scale; ICH = intracerebral hematoma; ICU = intensive care unit; ISAT = International Subarachnoid Aneurysm Trial; MCA = middle cerebral artery; mRS = modified Rankin Scale; NNT = number needed to treat; PERRLA = pupils equal, round, and reactive to light and accommodation; SAH = subarachnoid hemorrhage; WFNS = World Federation of Neurosurgical Societies.
Article Information

Contributor Notes

Correspondence Juergen Konczalla, Department of Neurosurgery, Goethe-University Hospital Frankfurt/Main, Schleusenweg 2-16, 60528 Frankfurt am Main, Germany. email: j.konczalla@med.uni-frankfurt.de.INCLUDE WHEN CITING Published online February 24, 2017; DOI: 10.3171/2016.8.JNS161075.Disclosures The authors report no conflict of interest concerning the materials or methods used in this study or the findings specified in this paper.

© AANS, except where prohibited by US copyright law.

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References
  • 1

    Abla AAWilson DAWilliamson RWNakaji PMcDougall CGZabramski JM: The relationship between ruptured aneurysm location, subarachnoid hemorrhage clot thickness, and incidence of radiographic or symptomatic vasospasm in patients enrolled in a prospective randomized controlled trial. J Neurosurg 120:3913972014

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 2

    Awad IACarter LPSpetzler RFMedina MWilliams FC Jr: Clinical vasospasm after subarachnoid hemorrhage: response to hypervolemic hemodilution and arterial hypertension. Stroke 18:3653721987

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 3

    Bing ZRabinstein AAMurad MHLanzino GPanni PBrinjikji W: Surgical and endovascular treatment of poor-grade aneurysmal subarachnoid hemorrhage: A systematic review and meta-analysis. J Neurosurg Sci 2015

    • Search Google Scholar
    • Export Citation
  • 4

    Biondi ARicciardi GKPuybasset LAbdennour LLongo MChiras J: Intra-arterial nimodipine for the treatment of symptomatic cerebral vasospasm after aneurysmal subarachnoid hemorrhage: preliminary results. AJNR Am J Neuroradiol 25:106710762004

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 5

    Bruder MSchuss PKonczalla JEl-Fiki ALescher SVatter H: Ventriculostomy-related hemorrhage after treatment of acutely ruptured aneurysms: the influence of anticoagulation and antiplatelet treatment. World Neurosurg 84:165316592015

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 6

    Chua MHGriessenauer CJStapleton CJHe LThomas AJOgilvy CS: Documentation of improved outcomes for intracranial aneurysm management over a 15-year interval. Stroke 47:7087122016

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 7

    Connolly ES JrRabinstein AACarhuapoma JRDerdeyn CPDion JHigashida RT: Guidelines for the management of aneurysmal subarachnoid hemorrhage: a guideline for healthcare professionals from the American Heart Association/American Stroke Association. Stroke 43:171117372012

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 8

    De Marchis GMLantigua HSchmidt JMLord ASVelander AJFernandez A: Impact of premorbid hypertension on haemorrhage severity and aneurysm rebleeding risk after subarachnoid haemorrhage. J Neurol Neurosurg Psychiatry 85:56592014

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 9

    Findlay JM: Current management of aneurysmal subarachnoid hemorrhage guidelines from the Canadian Neurosurgical Society. Can J Neurol Sci 24:1611701997

  • 10

    Foreman PMChua MHHarrigan MRFisher WS IIITubbs RSShoja MM: External validation of the Practical Risk Chart for the prediction of delayed cerebral ischemia following aneurysmal subarachnoid hemorrhage. J Neurosurg [epub ahead of print May 13 2016. DOI: 10.3171/20161.JNS152554]

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 11

    Hofmeijer JKappelle LJAlgra AAmelink GJvan Gijn Jvan der Worp HB: Surgical decompression for space-occupying cerebral infarction (the Hemicraniectomy After Middle Cerebral Artery infarction with Life-threatening Edema Trial [HAMLET]): a multicentre, open, randomised trial. Lancet Neurol 8:3263332009

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 12

    Jauch ECSaver JLAdams HP JrBruno AConnors JJBDemaerschalk BM: Guidelines for the early management of patients with acute ischemic stroke: a guideline for healthcare professionals from the American Heart Association/American Stroke Association. Stroke 44:8709472013

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 13

    Jüttler ESchwab SSchmiedek PUnterberg AHennerici MWoitzik J: Decompressive Surgery for the Treatment of Malignant Infarction of the Middle Cerebral Artery (DESTINY): a randomized, controlled trial. Stroke 38:251825252007

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 14

    Kassell NFTorner JCHaley EC JrJane JAAdams HPKongable GL: The International Cooperative Study on the Timing of Aneurysm Surgery. Part 1: Overall management results. J Neurosurg 73:18361990

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 15

    Kassell NFTorner JCJane JAHaley EC JrAdams HP: The International Cooperative Study on the Timing of Aneurysm Surgery. Part 2: Surgical results. J Neurosurg 73:37471990

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 16

    Konczalla JKashefiolasl SBrawanski NLescher SSenft CPlatz J: Cerebral vasospasm and delayed cerebral infarctions in 225 patients with non-aneurysmal subarachnoid hemorrhage: the underestimated risk of Fisher 3 blood distribution. J Neurointerv Surg [epub ahead of print] 2016

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 17

    Konczalla JKashefiolasl SBrawanski NSenft CSeifert VPlatz J: Increasing numbers of nonaneurysmal subarachnoid hemorrhage in the last 15 years: antithrombotic medication as reason and prognostic factor?. J Neurosurg 124:173117372016

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 18

    Konczalla JPlatz JBrawanski NGüresir ELescher SSenft C: Endovascular and surgical treatment of internal carotid bifurcation aneurysms: comparison of results, outcome, and mid-term follow-up. Neurosurgery 76:5405512015

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 19

    Livingston KGuterman LRHopkins LN: Intraarterial papaverine as an adjunct to transluminal angioplasty for vasospasm induced by subarachnoid hemorrhage. AJNR Am J Neuroradiol 14:3463471993

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 20

    Lovelock CERinkel GJERothwell PM: Time trends in outcome of subarachnoid hemorrhage: Population-based study and systematic review. Neurology 74:149415012010

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 21

    Mayberg MRBatjer HHDacey RDiringer MHaley ECHeros RC: Guidelines for the management of aneurysmal subarachnoid hemorrhage. A statement for healthcare professionals from a special writing group of the Stroke Council, American Heart Association. Stroke 25:231523281994

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 22

    Molyneux AKerr RStratton ISandercock PClarke MShrimpton J: International Subarachnoid Aneurysm Trial (ISAT) of neurosurgical clipping versus endovascular coiling in 2143 patients with ruptured intracranial aneurysms: a randomised trial. Lancet 360:126712742002

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 23

    Platz JGüresir ESchuss PKonczalla JSeifert VVatter H: The impact of the body mass index on outcome after subarachnoid hemorrhage: is there an obesity paradox in SAH?. A retrospective analysis Neurosurgery 73:2012082013

    • Search Google Scholar
    • Export Citation
  • 24

    Platz JGüresir EWagner MSeifert VKonczalla J: Increased risk of delayed cerebral ischemia in subarachnoid hemorrhage patients with additional intracerebral hematoma. J Neurosurg [epub ahead of print March 11 2016. DOI: 10.3171/201512.JNS151563]

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 25

    Raabe ABeck JKeller MVatter HZimmermann MSeifert V: Relative importance of hypertension compared with hypervolemia for increasing cerebral oxygenation in patients with cerebral vasospasm after subarachnoid hemorrhage. J Neurosurg 103:9749812005

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 26

    Rosenwasser RHArmonda RAThomas JEBenitez RPGannon PMHarrop J: Therapeutic modalities for the management of cerebral vasospasm: timing of endovascular options. Neurosurgery 44:9759801999

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 27

    Schuss PHadjiathanasiou ABorger VWispel CVatter HGüresir E: Poor-grade aneurysmal subarachnoid hemorrhage: factors influencing functional outcome—a single-center series. World Neurosurg 85:1251292016

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 28

    Schuss PKonczalla JPlatz JVatter HSeifert VGüresir E: Aneurysm-related subarachnoid hemorrhage and acute subdural hematoma: single-center series and systematic review. J Neurosurg 118:9849902013

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 29

    Spetzler RFMcDougall CGAlbuquerque FCZabramski JMHills NKPartovi S: The Barrow Ruptured Aneurysm Trial: 3-year results. J Neurosurg 119:1461572013

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 30

    Vahedi KVicaut EMateo JKurtz AOrabi MGuichard JP: Sequential-design, multicenter, randomized, controlled trial of early decompressive craniectomy in malignant middle cerebral artery infarction (DECIMAL Trial). Stroke 38:250625172007

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 31

    van Donkelaar CEBakker NAVeeger NJGMUytten-boogaart MMetzemaekers JDMLuijckx GJ: Predictive factors for rebleeding after aneurysmal subarachnoid hemorrhage: Rebleeding Aneurysmal Subarachnoid Hemorrhage Study. Stroke 46:210021062015

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 32

    Wan AJaja BNRSchweizer TAMacdonald RL: Clinical characteristics and outcome of aneurysmal subarachnoid hemorrhage with intracerebral hematoma. J Neurosurg [epub ahead of print February 26 2016. DOI: 10.3171/201510.JNS151036]

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 33

    Zheng BQiu YJin HWang LChen XShi C: A predictive value of hyponatremia for poor outcome and cerebral infarction in high-grade aneurysmal subarachnoid haemorrhage patients. J Neurol Neurosurg Psychiatry 82:2132172011

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
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