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Causes of poor outcome in patients admitted with good-grade subarachnoid haemorrhage

  • Original Article - Vascular
  • Published:
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Abstract

Background

Surgical risk in patients with unruptured aneurysms is well known. The relative impact of surgery and natural history of subarachnoid haemorrhage (SAH) on patients in good clinical condition (World Federation of Neurological Surgeons [WFNS] grades 1 and 2) is less well quantified. The aim of this study was to determine causes of poor outcome in patients admitted in good grade SAH.

Methods

A retrospective study of prospectively collected data among WFNS-1 and -2 patients: demographics, SAH and aneurysm-related data, surgical complications and outcome as assesed by the Glasgow Outcome Scale (GOS). Causes of poor outcome (GOS 1–3) were determined.

Results

During a 7-year period (2009–15), 56 patients with SAH WFNS-1 (39 patients) or WFNS-2 (17 patients) were treated surgically (21 men, 35 women; mean age, 52.4 years). According to the Fisher scale, 19 patients were grade 1 or 2; 37 patients were grade 3 or 4. Most aneurysms were located at anterior communicating (26) or middle cerebral (15) artery.

Altogether, 11 patients (19.6%) achieved GOS 1–3. This was attributed to SAH-related complications in six patients (rebleeding, vasospasm), surgery in four patients (postoperative ischaemia in two, haematoma and ventriculitis in one patient each), grand-mal seizure with aspiration in one patient. Age over 60 years (p = 0.017) and presence of hydrocephalus (p < 0.001) were statistically significant predictors of poor GOS; other variables (e.g. sex, Fisher grade, aneurysm size or location, use of temporary clips, intraoperative rupture, vasospasm) were not significant.

Conclusions

Patients admitted in good-grade SAH achieve favourable outcome following surgical aneurysm repair in the majority of cases. Negative factors include age over 60 years and presence of hydrocephalus. Aneurysm surgery following good-grade SAH still carries a small but significant risk similar to that shown in large multi-institutional trials.

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Authors and Affiliations

  1. Department of Neurosurgery, Regional Hospital Liberec, Husova 10, Liberec, 46001, Czech Republic

    Vladimír Beneš 3rd, Lubomír Jurák, Radim Brabec, Nina Nechanická, Pavel Buchvald & Petr Suchomel

  2. Department of Radiology, Regional Hospital Liberec, Husova 10, Liberec, 46001, Czech Republic

    Miroslav Šercl & Ladislav Endrych

Authors
  1. Vladimír Beneš 3rd
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  2. Lubomír Jurák
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Correspondence to Vladimír Beneš 3rd.

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No funding was received for this research.

Conflict of interest

All authors certify that they have no affiliations with or involvement in any organization or entity with any financial interest (such as honoraria; educational grants; participation in speakers’ bureaus; membership, employment, consultancies, stock ownership, or other equity interest; and expert testimony or patent-licensing arrangements), or non-financial interest (such as personal or professional relationships, affiliations, knowledge or beliefs) in the subject matter or materials discussed in this manuscript.

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Comments

This is an important article particularly considering that the senior surgeon (and all the surgeons) are highly talented and the institution is an excellent one with great experience. So we can assume that the results are honest and valid.

To be concise, good-grade SAH patients in this series, WFNS 1 and 2, operated for primarily MCA or ACoA aneurysms, still experience a near 20% risk of poor outcome. This is not the 5% or so number that most of us would like to own or admit to for patients we consider good-grade, yet no doubt it reflects the state of the art and the realities that SAH patients face. The culprits are the usual ones, rebleeding, surgical complications, hydrocephalus, DIND, infection, epilepsy. We have lived this life and faced these adversaries routinely.

Let us be honest also. Many of us who completed training 25-30 years ago, prior to endovascular techniques, were experts in aneurysm surgery and approached with relish both unruptured and SAH patients, with the philosophy that what we offered was a surgical art as highly developed as we could make it, and with complete confidence that we were offering to the patient the best possible treatment. But the refinement of endovascular therapy changed the balance and reset the goalposts (or in the Rest of World we should say moved the goalkeeper’s net). The numbers of surgeons like us are declining, both in the number of cases that we do, and in the number of graduate neurosurgeons with the training and the case experience to perform these operations. As mentors and leaders we now encourage every surgeon interested in cerebrovascular disease to acquire endovascular skills. This was unthinkable when I graduated my own training. I do not believe we will ever go back to those days.

So this paper is an excellent one, from quality surgeons. What we do with the information is left to our own judgment. As for me, I need a comparator between these quality data and the results of endovascular treatment in the same patient group. Then I will know what is the best recommendation when I sit face to face with a patient or family.

I recommend this paper to all readers, and especially trainees, as a useful and learned dissertation on the philosophy and process of decision making in surgery for aneurysmal SAH.

Christopher Miranda Loftus

IL, USA

The submitted article has been in part presented at the 16th European Congress of Neurosurgery in Athens, Greece (4-8 September 2016) in the form of an e-poster

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Beneš, V., Jurák, L., Brabec, R. et al. Causes of poor outcome in patients admitted with good-grade subarachnoid haemorrhage. Acta Neurochir 159, 559–565 (2017). https://doi.org/10.1007/s00701-017-3081-8

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  • DOI: https://doi.org/10.1007/s00701-017-3081-8

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