Acta Neurochirurgica

, Volume 159, Issue 3, pp 559–565 | Cite as

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

  • Vladimír Beneš3rd
  • Lubomír Jurák
  • Radim Brabec
  • Nina Nechanická
  • Miroslav Šercl
  • Ladislav Endrych
  • Pavel Buchvald
  • Petr Suchomel
Original Article - Vascular



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.


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.


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.


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.


Subarachnoid haemorrhage Aneurysm Outcome Surgical complication 


  1. 1.
    Akyuz M, Tuncer R (2006) The effects of fenestration of the interpeduncular cistern membrane arousted to the opening of lamina terminalis in patients with ruptured ACoA aneurysms: a prospective, comparative study. Acta Neurochir (Wien) 148:723–725, discussion 731–722CrossRefGoogle Scholar
  2. 2.
    Bardach NS, Zhao S, Gress DR, Lawton MT, Johnston SC (2002) Association between subarachnoid hemorrhage outcomes and number of cases treated at California hospitals. Stroke 33:1851–1856CrossRefPubMedGoogle Scholar
  3. 3.
    Barker FG II, Amin-Hanjani S, Butler WE, Ogilvy CS, Carter BS (2003) In-hospital mortality and morbidity after surgical treatment of unruptured intracranial aneurysms in the United States, 1996–2000: the effect of hospital and surgeon volume. Neurosurgery 52:995–1009CrossRefPubMedGoogle Scholar
  4. 4.
    Britz GW (2005) ISAT trial: coiling or clipping for intracranial aneurysms? Lancet 366:783–785CrossRefPubMedGoogle Scholar
  5. 5.
    Bulters DO, Santarius T, Chia HL, Parker RA, Trivedi R, Kirkpatrick PJ, Kirollos RW (2011) Causes of neurological deficits following clipping of 200 consecutive ruptured aneurysms in patients with good-grade aneurysmal subarachnoid haemorrhage. Acta Neurochir (Wien) 153:295–303CrossRefGoogle Scholar
  6. 6.
    Cowan JA, Ziewacz J, Dimick JB, Upchurch GR, Thompson BG (2007) Use of endovascular coil embolization and surgical clip occlusion for cerebral artery aneurysms. J Neurosurg 107:530–535CrossRefPubMedGoogle Scholar
  7. 7.
    Crobeddu E, Mittal MK, Dupont S, Wijdicks EF, Lanzino G, Rabinstein AA (2012) Predicting the lack of development of delayed cerebral ischemia after aneurysmal subarachnoid hemorrhage. Stroke 43:697–701CrossRefPubMedGoogle Scholar
  8. 8.
    Dupont SA, Wijdicks EF, Manno EM, Lanzino G, Rabinstein AA (2009) Prediction of angiographic vasospasm after aneurysmal subarachnoid hemorrhage: value of the Hijdra sum scoring system. Neurocrit Care 11:172–176CrossRefPubMedGoogle Scholar
  9. 9.
    Fisher CM, Kistler JP, Davis JM (1980) Relation of cerebral vasospasm to subarachnoid hemorrhage visualized by computerized tomographic scanning. Neurosurgery 6:1–9CrossRefPubMedGoogle Scholar
  10. 10.
    Frontera JA, Fernandez A, Schmidt JM, Claassen J, Wartenberg KE, Badjatia N, Connolly ES, Mayer SA (2009) Defining vasospasm after subarachnoid hemorrhage: what is the most clinically relevant definition? Stroke 40:1963–1968CrossRefPubMedGoogle Scholar
  11. 11.
    Graff-Radford NR, Torner J, Adams HP Jr, Kassell NF (1989) Factors associated with hydrocephalus after subarachnoid hemorrhage. A report of the Cooperative Aneurysm Study. Arch Neurol 46:744–752CrossRefPubMedGoogle Scholar
  12. 12.
    Harbaugh RE, Heros RC, Hadley MN (2003) More on ISAT. Lancet 361:783–784, author reply 784CrossRefPubMedGoogle Scholar
  13. 13.
    Hoh BL, Rabinov JD, Pryor JC, Carter BS, Barker FG 2nd (2003) In-hospital morbidity and mortality after endovascular treatment of unruptured intracranial aneurysms in the United States, 1996–2000: effect of hospital and physician volume. AJNR Am J Neuroradiol 24:1409–1420PubMedGoogle Scholar
  14. 14.
    Jurák L, Bradáč O, Kaiser M, Brabec R, Buchvald P, Endrych L, Suchomel P (2013) Hydrocefalus jako komplikace subarachnoidálního krvácení. Cesk Slov Neurol N 76:70–75Google Scholar
  15. 15.
    Kassell NF, Torner JC, Haley EC Jr, Jane JA, Adams HP, Kongable GL (1990) The International Cooperative Study on the Timing of Aneurysm Surgery. Part 1: Overall management results. J Neurosurg 73:18–36CrossRefPubMedGoogle Scholar
  16. 16.
    Kassell NF, Torner JC, Jane JA, Haley EC Jr, Adams HP (1990) The International Cooperative Study on the Timing of Aneurysm Surgery. Part 2: Surgical results. J Neurosurg 73:37–47CrossRefPubMedGoogle Scholar
  17. 17.
    Krisht AF, Gomez J, Partington S (2006) Outcome of surgical clipping of unruptured aneurysms as it compares with a 10-year nonclipping survival period. Neurosurgery 58:207–216, discussion 207–216CrossRefPubMedGoogle Scholar
  18. 18.
    McDougall CG, Spetzler RF, Zabramski JM, Partovi S, Hills NK, Nakaji P, Albuquerque FC (2011) The Barrow Ruptured Aneurysm Trial. J Neurosurg 116:135–144CrossRefPubMedGoogle Scholar
  19. 19.
    McLaughlin N, Bojanowski MW (2004) Early surgery-related complications after aneurysm clip placement: an analysis of causes and patient outcomes. J Neurosurg 101:600–606CrossRefPubMedGoogle Scholar
  20. 20.
    Molyneux A, Kerr R, Stratton I, Sandercock P, Clarke M, Shrimpton J, Holman R (2002) International Subarachnoid Aneurysm Trial (ISAT) of neurosurgical clipping versus endovascular coiling in 2143 patients with ruptured intracranial aneurysms: a randomised trial. Lancet 360:1267–1274CrossRefPubMedGoogle Scholar
  21. 21.
    Raaymakers TW, Rinkel GJ, Limburg M, Algra A (1998) Mortality and morbidity of surgery for unruptured intracranial aneurysms: a meta-analysis. Stroke 29:1531–1538CrossRefPubMedGoogle Scholar
  22. 22.
    Rabinstein AA, Pichelmann MA, Friedman JA, Piepgras DG, Nichols DA, McIver JI, Toussaint LG 3rd, McClelland RL, Fulgham JR, Meyer FB, Atkinson JL, Wijdicks EF (2003) Symptomatic vasospasm and outcomes following aneurysmal subarachnoid hemorrhage: a comparison between surgical repair and endovascular coil occlusion. J Neurosurg 98:319–325CrossRefPubMedGoogle Scholar
  23. 23.
    Saveland H, Hillman J, Brandt L, Edner G, Jakobsson KE, Algers G (1992) Overall outcome in aneurysmal subarachnoid hemorrhage. A prospective study from neurosurgical units in Sweden during a 1-year period. J Neurosurg 76:729–734CrossRefPubMedGoogle Scholar
  24. 24.
    Spetzler RF, McDougall CG, Albuquerque FC, Zabramski JM, Hills NK, Partovi S, Nakaji P, Wallace RC (2013) The Barrow Ruptured Aneurysm Trial: 3-year results. J Neurosurg 119:146–157CrossRefPubMedGoogle Scholar
  25. 25.
    Teasdale GM, Drake CG, Hunt W, Kassell N, Sano K, Pertuiset B, De Villiers JC (1988) A universal subarachnoid hemorrhage scale: report of a committee of the World Federation of Neurosurgical Societies. J Neurol Neurosurg Psychiatry 51:1457CrossRefPubMedPubMedCentralGoogle Scholar
  26. 26.
    Todd MM, Hindman BJ, Clarke WR, Torner JC (2005) Mild intraoperative hypothermia during surgery for intracranial aneurysm. N Engl J Med 352:135–145CrossRefPubMedGoogle Scholar
  27. 27.
    Wester K (2009) Lessons learned by personal failures in aneurysm surgery: what went wrong, and why? Acta Neurochir (Wien) 151:1013–1024CrossRefGoogle Scholar
  28. 28.
    Wiebers DO, Whisnant JP, Huston J 3rd, Meissner I, Brown RD Jr, Piepgras DG, Forbes GS, Thielen K, Nichols D, O’Fallon WM, Peacock J, Jaeger L, Kassell NF, Kongable-Beckman GL, Torner JC (2003) Unruptured intracranial aneurysms: natural history, clinical outcome, and risks of surgical and endovascular treatment. Lancet 362:103–110CrossRefPubMedGoogle Scholar

Copyright information

© Springer-Verlag Wien 2017

Authors and Affiliations

  • Vladimír Beneš3rd
    • 1
  • Lubomír Jurák
    • 1
  • Radim Brabec
    • 1
  • Nina Nechanická
    • 1
  • Miroslav Šercl
    • 2
  • Ladislav Endrych
    • 2
  • Pavel Buchvald
    • 1
  • Petr Suchomel
    • 1
  1. 1.Department of NeurosurgeryRegional Hospital LiberecLiberecCzech Republic
  2. 2.Department of RadiologyRegional Hospital LiberecLiberecCzech Republic

Personalised recommendations