Delayed hospital admission of patients with aneurysmal subarachnoid hemorrhage: clinical presentation, treatment strategies, and outcome

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  • 1 University of Cologne, Medical Faculty and University Hospital, Center for Neurosurgery, and
  • 2 Institute for Diagnostic and Interventional Radiology, Medical Faculty and University Hospital, University of Cologne, Germany;
  • 3 Department of Neurosurgery, Harvey Cushing Neuro-Oncology Laboratories, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts; and
  • 4 Department of Radiology, University Hospitals Cleveland Medical Center, Cleveland, Ohio
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OBJECTIVE

Timely aneurysm occlusion and neurointensive care treatment are key principles in the management of aneurysmal subarachnoid hemorrhage (aSAH) to prevent secondary brain injury. Patients with early (EHA) and delayed hospital admission (DHA) were compared in terms of clinical presentation, treatment strategies, aSAH-related complications, and outcome.

METHODS

In this retrospective study, consecutive aSAH patients were treated at a single neurovascular center between 2009 and 2019. Propensity score matching was performed to account for divergent baseline characteristics.

RESULTS

Among 509 included patients, 55 were admitted more than 48 hours after ictus (DHA group). DHA patients were significantly younger (52 ± 11 vs 56 ± 14 years, p = 0.03) and had lower World Federation of Neurosurgical Societies scores (p < 0.01) than EHA patients. In 54.5% of the cases, DHA patients presented with neurological deterioration or aggravated symptoms. Propensity score matching revealed a higher vasospastic infarction rate in the DHA group (41.5%) than in the EHA group (22.6%) (p = 0.04). A similar portion of patients in both groups achieved favorable outcome at midterm follow-up (77.3% vs 73.6%, p = 0.87). DHA patients (62.3%) received conventional coiling more often than EHA patients (41.5%) (p = 0.03).

CONCLUSIONS

DHA patients are at an increased risk of cerebral infarction. Nevertheless, state-of-the-art neurointensive care treatment can result in a good clinical outcome.

ABBREVIATIONS aSAH = aneurysmal subarachnoid hemorrhage; CTA = CT angiography; DCI = delayed cerebral ischemia; DHA = delayed hospital admission; DSA = digital subtraction angiography; EHA = early hospital admission; EVD = external ventricular drain; mRS = modified Rankin Scale; WFNS = World Federation of Neurosurgical Societies.

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Contributor Notes

Correspondence Lukas Goertz: Center for Neurosurgery, University Hospital of Cologne, Germany. lukas.goertz@uk-koeln.de.

INCLUDE WHEN CITING Published online April 17, 2020; DOI: 10.3171/2020.2.JNS20148.

L.G. and M.P. contributed equally to this work.

Disclosures Dr. Kabbasch reports being a consultant for MicroVention and Acandis.

  • 1

    Molyneux A, Kerr R, Stratton I, International Subarachnoid Aneurysm Trial (ISAT) of neurosurgical clipping versus endovascular coiling in 2143 patients with ruptured intracranial aneurysms: a randomised trial. Lancet. 2002;360(9342):12671274.

    • Search Google Scholar
    • Export Citation
  • 2

    van Gijn J, Rinkel GJ. Subarachnoid haemorrhage: diagnosis, causes and management. Brain. 2001;124(Pt 2):249278.

  • 3

    Kowalski RG, Claassen J, Kreiter KT, Initial misdiagnosis and outcome after subarachnoid hemorrhage. JAMA. 2004;291(7):866869.

  • 4

    Schievink WI, van der Werf DJ, Hageman LM, Dreissen JJ. Referral pattern of patients with aneurysmal subarachnoid hemorrhage. Surg Neurol. 1988;29(5):367371.

    • Search Google Scholar
    • Export Citation
  • 5

    Chan BS, Dorsch NW. Delayed diagnosis in subarachnoid haemorrhage. Med J Aust. 1991;154(8):509511.

  • 6

    Inagawa T. Delayed diagnosis of aneurysmal subarachnoid hemorrhage in patients: a community-based study. J Neurosurg. 2011;115(4):707714.

    • Search Google Scholar
    • Export Citation
  • 7

    Kassell NF, Kongable GL, Torner JC, Delay in referral of patients with ruptured aneurysms to neurosurgical attention. Stroke. 1985;16(4):587590.

    • Search Google Scholar
    • Export Citation
  • 8

    Mayer PL, Awad IA, Todor R, Misdiagnosis of symptomatic cerebral aneurysm. Prevalence and correlation with outcome at four institutions. Stroke. 1996;27(9):15581563.

    • Search Google Scholar
    • Export Citation
  • 9

    Haley EC Jr, Kassell NF, Apperson-Hansen C, A randomized, double-blind, vehicle-controlled trial of tirilazad mesylate in patients with aneurysmal subarachnoid hemorrhage: a cooperative study in North America. J Neurosurg. 1997;86(3):467474.

    • Search Google Scholar
    • Export Citation
  • 10

    Hänggi D, Etminan N, Mayer SA, Clinical trial protocol: phase 3, multicenter, randomized, double-blind, placebo-controlled, parallel-group, efficacy, and safety study comparing EG-1962 to standard of care oral nimodipine in adults with aneurysmal subarachnoid hemorrhage [NEWTON-2 (Nimodipine Microparticles to Enhance Recovery While Reducing TOxicity After SubarachNoid Hemorrhage)]. Neurocrit Care. 2019;30(1):8897.

    • Search Google Scholar
    • Export Citation
  • 11

    Kassell NF, Haley EC Jr, Apperson-Hansen C, Alves WM. Randomized, double-blind, vehicle-controlled trial of tirilazad mesylate in patients with aneurysmal subarachnoid hemorrhage: a cooperative study in Europe, Australia, and New Zealand. J Neurosurg. 1996;84(2):221228.

    • Search Google Scholar
    • Export Citation
  • 12

    Goertz L, Dorn F, Kraus B, Improved occlusion rate of intracranial aneurysms treated with the Derivo embolization device: one-year clinical and angiographic follow-up in a multicenter study. World Neurosurg. 2019;126:e1503e1509.

    • Search Google Scholar
    • Export Citation
  • 13

    Goertz L, Dorn F, Kraus B, Safety and efficacy of the Derivo Embolization Device for the treatment of ruptured intracranial aneurysms. J Neurointerv Surg. 2019;11(3):290295.

    • Search Google Scholar
    • Export Citation
  • 14

    Goertz L, Dorn F, Siebert E, Safety and efficacy of the Neuroform Atlas for stent-assisted coiling of intracranial aneurysms: a multicenter experience. J Clin Neurosci. 2019;68:8691.

    • Search Google Scholar
    • Export Citation
  • 15

    Goertz L, Smyk MA, Mpotsaris A, Long-term angiographic results of the low-profile Acandis Acclino stent for treatment of intracranial aneurysms: a multicenter study [published online November 15, 2019]. Clin Neuroradiol. doi:10.1007/s00062-019-00847-4

    • Search Google Scholar
    • Export Citation
  • 16

    Goertz L, Hamisch C, Kabbasch C, Impact of aneurysm shape and neck configuration on cerebral infarction during microsurgical clipping of intracranial aneurysms [published online April 12, 2019]. J Neurosurg. doi:10.3171/2019.1.JNS183193

    • Search Google Scholar
    • Export Citation
  • 17

    Miyazaki T, Ohta F, Moritake K, The key to improving prognosis for aneurysmal subarachnoid hemorrhage remains in the pre-hospitalization period. Surg Neurol. 2006;65(4):360366.

    • Search Google Scholar
    • Export Citation
  • 18

    Vermeulen MJ, Schull MJ. Missed diagnosis of subarachnoid hemorrhage in the emergency department. Stroke. 2007;38(4):12161221.

  • 19

    Dankbaar JW, Rijsdijk M, van der Schaaf IC, Relationship between vasospasm, cerebral perfusion, and delayed cerebral ischemia after aneurysmal subarachnoid hemorrhage. Neuroradiology. 2009;51(12):813819.

    • Search Google Scholar
    • Export Citation
  • 20

    Etminan N, Vergouwen MD, Ilodigwe D, Macdonald RL. Effect of pharmaceutical treatment on vasospasm, delayed cerebral ischemia, and clinical outcome in patients with aneurysmal subarachnoid hemorrhage: a systematic review and meta-analysis. J Cereb Blood Flow Metab. 2011;31(6):14431451.

    • Search Google Scholar
    • Export Citation
  • 21

    Vergouwen MD, Vermeulen M, van Gijn J, Definition of delayed cerebral ischemia after aneurysmal subarachnoid hemorrhage as an outcome event in clinical trials and observational studies: proposal of a multidisciplinary research group. Stroke. 2010;41(10):23912395.

    • Search Google Scholar
    • Export Citation
  • 22

    Inagawa T. Ultra-early rebleeding within six hours after aneurysmal rupture. Surg Neurol. 1994;42(2):130134.

  • 23

    Phan K, Moore JM, Griessenauer CJ, Ultra-early angiographic vasospasm after aneurysmal subarachnoid hemorrhage: a systematic review and meta-analysis. World Neurosurg. 2017;102:632638.e1.

    • Search Google Scholar
    • Export Citation
  • 24

    Naidech AM, Janjua N, Kreiter KT, Predictors and impact of aneurysm rebleeding after subarachnoid hemorrhage. Arch Neurol. 2005;62(3):410416.

    • Search Google Scholar
    • Export Citation
  • 25

    Dankbaar JW, Slooter AJ, Rinkel GJ, Schaaf IC. Effect of different components of triple-H therapy on cerebral perfusion in patients with aneurysmal subarachnoid haemorrhage: a systematic review. Crit Care. 2010;14(1):R23.

    • Search Google Scholar
    • Export Citation
  • 26

    Hoh BL, Ogilvy CS. Endovascular treatment of cerebral vasospasm: transluminal balloon angioplasty, intra-arterial papaverine, and intra-arterial nicardipine. Neurosurg Clin N Am. 2005;16(3):501516, vi.

    • Search Google Scholar
    • Export Citation
  • 27

    Al-Khindi T, Macdonald RL, Schweizer TA. Cognitive and functional outcome after aneurysmal subarachnoid hemorrhage. Stroke. 2010;41(8):e519e536.

    • Search Google Scholar
    • Export Citation
  • 28

    Huenges Wajer IM, Cremers CH, van Zandvoort MJ, CT perfusion on admission and cognitive functioning 3 months after aneurysmal subarachnoid haemorrhage. J Neurol. 2015;262(3):623628.

    • Search Google Scholar
    • Export Citation

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