Patterns of care for ruptured aneurysms of the middle cerebral artery: analysis of a Swiss national database (Swiss SOS)

Restricted access

OBJECTIVE

The objective of this study was to determine patterns of care and outcomes in ruptured intracranial aneurysms (IAs) of the middle cerebral artery (MCA) in a contemporary national cohort.

METHODS

The authors conducted a retrospective analysis of prospective data from a nationwide multicenter registry of all aneurysmal subarachnoid hemorrhage (aSAH) cases admitted to a tertiary care neurosurgical department in Switzerland in the years 2009–2015 (Swiss Study on Aneurysmal Subarachnoid Hemorrhage [Swiss SOS]). Patterns of care and outcomes at discharge and the 1-year follow-up in MCA aneurysm (MCAA) patients were analyzed and compared with those in a control group of patients with IAs in locations other than the MCA (non-MCAA patients). Independent predictors of a favorable outcome (modified Rankin Scale score ≤ 3) were identified, and their effect size was determined.

RESULTS

Among 1866 consecutive aSAH patients, 413 (22.1%) harbored an MCAA. These MCAA patients presented with higher World Federation of Neurosurgical Societies grades (p = 0.007), showed a higher rate of concomitant intracerebral hemorrhage (ICH; 41.9% vs 16.7%, p < 0.001), and experienced delayed cerebral ischemia (DCI) more frequently (38.9% vs 29.4%, p = 0.001) than non-MCAA patients. After adjustment for confounders, patients with MCAA were as likely as non-MCAA patients to experience DCI (aOR 1.04, 95% CI 0.74–1.45, p = 0.830). Surgical treatment was the dominant treatment modality in MCAA patients and at a significantly higher rate than in non-MCAA patients (81.7% vs 36.7%, p < 0.001). An MCAA location was a strong independent predictor of surgical treatment (aOR 8.49, 95% CI 5.89–12.25, p < 0.001), despite statistical adjustment for variables traditionally associated with surgical treatment, such as (space-occupying) ICH (aOR 1.73, 95% CI 1.23–2.45, p = 0.002). Even though MCAA patients were less likely to die during the acute hospitalization (aOR 0.52, 0.30–0.91, p = 0.022), their rate of a favorable outcome was lower at discharge than that in non-MCAA patients (55.7% vs 63.7%, p = 0.003). At the 1-year follow-up, 68.5% and 69.6% of MCAA and non-MCAA patients, respectively, had a favorable outcome (p = 0.676).

CONCLUSIONS

Microsurgical occlusion remains the predominant treatment choice for about 80% of ruptured MCAAs in a European industrialized country. Although patients with MCAAs presented with worse admission grades and greater rates of concomitant ICH, in-hospital mortality was lower and long-term disability was comparable to those in patients with non-MCAA.

ABBREVIATIONS aOR = adjusted odds ratio; aSAH = aneurysmal subarachnoid hemorrhage; BRAT = Barrow Ruptured Aneurysm Trial; DCI = delayed cerebral ischemia; IA = intracranial aneurysm; ICH = intracerebral hemorrhage; ISAT = International Subarachnoid Aneurysm Trial; MCA = middle cerebral artery; MCAA = MCA aneurysm; mRS = modified Rankin Scale; RCT = randomized controlled trial; WFNS = World Federation of Neurosurgical Societies.

Supplementary Materials

  • Supplementary Tables and Figure (PDF 670 KB)
Article Information

Contributor Notes

Correspondence Martin N. Stienen: University Hospital Zurich, Clinical Neuroscience Center, University of Zurich, Switzerland. mnstienen@gmail.com.INCLUDE WHEN CITING Published online November 15, 2019; DOI: 10.3171/2019.9.JNS192055.Disclosures Dr. Regli is on the speakers bureau for B. Braun.
Headings
TrendMD
Metrics

Metrics

All Time Past Year Past 30 Days
Abstract Views 229 229 229
Full Text Views 33 33 33
PDF Downloads 26 26 26
EPUB Downloads 0 0 0
PubMed
Google Scholar