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

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  • 1 Department of Neurosurgery, Kantonsspital St. Gallen
  • 2 Department of Neurosurgery, University Hospital Bern
  • 3 Department of Neurosurgery, University Clinic Geneva
  • 4 Department of Neurosurgery, Basel University Hospital
  • 5 Section for Diagnostic and Interventional Neuroradiology, Department of Radiology, Basel University Hospital, Basel
  • 6 Department of Neurosurgery, Kantonsspital Aarau
  • 7 Department of Clinical Neurosciences, Service of Neurosurgery, Lausanne University Hospital (CHUV), Lausanne, Switzerland
  • 8 Department of Neurosurgery, Baylor College of Medicine, Houston, Texas
  • 9 Department of Neurosurgery, Ospedale Regionale di Lugano, Switzerland
  • 10 Department of Neurosurgery, University Hospital Göttingen, Germany
  • 11 Department of Neurosurgery, University Hospital Zurich
  • 12 Clinical Neuroscience Center, University of Zurich, Switzerland; and
  • 13 Department of Neurosurgery, University Hospital Freiburg, University of Freiburg, Germany
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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

    • pdf Supplementary Tables and Figure (PDF 670 KB)

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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.

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