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Survival and outcome in patients with aneurysmal subarachnoid hemorrhage in Glasgow coma score 3–5

  • Original Article - Vascular Neurosurgery - Aneurysm
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Abstract

Background

Outcome of early, aggressive management of aneurysmal subarachnoid hemorrhage (aSAH) in patients with Hunt and Hess grade V is hitherto limited, and we therefore present our results.

Methods

Retrospective study analyzing the medical data of 228 aSAH patients in Glasgow Coma Score 3–5 admitted to our hospital during the years 2002–2012. Background and treatment variables were registered. Outcome was evaluated after 3 and 12 months.

Results

We intended to treat 176 (77.2%) patients, but only 146 went on to aneurysm repair. Of 52 patients managed conservatively, 27 had abolished cerebral circulation around arrival and 25 were deemed unsalvageable. One-year overall mortality was 65.8% and most (84.7%) of the fatalities occurred within 30 days. One-year mortality was higher in patients > 70 years. Without aneurysm repair, mortality was 100%. After 1 year, 21.9% of all patients lived independently and 4.8% lived permanently in an institution. Outcome in the 78 survivors (34.2%) was favorable in 64.1% in terms of modified Rankin Scale score 0–2, and 85.9% of survivors were able to live at home. Return to work was low for all 228 patients with 14.0% of those employed prior to the hemorrhage having returned to paid work, and respectively, 26.3% in the subgroup of survivors.

Conclusions

Even with aggressive, early treatment, 1-year mortality is high in comatose aSAH patients with 65.8%. A substantial portion of the survivors have a favorable outcome at 1 year (64.1%, corresponding to 21.9% of all patients admitted) and 85.9% of the survivors could live at home alone or aided.

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Abbreviations

aSAH:

Aneurysmal subarachnoid hemorrhage

CPP:

Cerebral perfusion pressure

CSF:

Cerebrospinal fluid

CT:

Computed tomography

CTA:

Computed tomography angiography

EVD:

External ventricular drain

GCS:

Glasgow Coma Scale

GOS:

Glasgow Outcome Scale

ICP:

Intracranial pressure

ICU:

Intensive care unit

IVH:

Intraventricular hemorrhage

MAP:

Mean arterial pressure

mRS:

Modified Rankin Scale

TCD:

Transcranial Doppler ultrasonography

WFNS:

World Federation of Neurological Surgeons

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Authors and Affiliations

  1. Department of Neurosurgery, Oslo University Hospital, Rikshospitalet, P.B. 0454, Nydalen, 0424, Oslo, Norway

    Aslan Lashkarivand, Wilhelm Sorteberg & Angelika Sorteberg

  2. Institute of Clinical Medicine, University of Oslo, P.B. 1072, Blindern, 0316, Oslo, Norway

    Aslan Lashkarivand, Leiv Arne Rosseland & Angelika Sorteberg

  3. Division of Emergencies and Critical Care, Oslo University Hospital, Rikshospitalet, P.B. 0454, Nydalen, 0424, Oslo, Norway

    Leiv Arne Rosseland

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Treatment of patients with poor-grade aneurysmal subarachnoid hemorrhage (aSAH) has changed in the last two decades. Where previously this group of patients has traditionally been offered conservative treatment, several studies have now been published in support of treatment of these patients. Not coincidentally, these new studies have been published since the rise of endovascular treatment of cerebral aneurysms. Lashkarivand et al. present here their institutional experience with treatment of patients with Hunt and Hess Grade V aSAH from 2002 to 2012. Among the 228 patients with Grade V aSAH, 146 underwent aneurysm repair, while 82 did not. Patients who were not treated included those with large, deep hematoma in the dominant hemisphere, signs of permanent brain dysfunction and those with evidence of severely deranged or abolished intracranial circulation. Unsurprisingly, those who did not receive aneurysmal treatment died. Of those who did undergo aneurysm repair, approximately half underwent surgical repair, while the other half underwent endovascular repair. Of all treated patients, approximately 53% were alive 1 year after ictus, with the majority (50/78) with good functional status (modified Rankin Scale 0–2). Neither survival outcomes nor functional outcomes stray from previously published data in this patient population. This is one of the largest series on outcomes of patients who present with Hunt and Hess grade V aSAH. The authors should be commended on their large series and patient outcomes. This addition to the literature only furthers the notion that many of the patients with a devastating high-grade aSAH, if selected properly for treatment, can recover to be functionally independent at 1 year after presenting with aSAH.

Joel Passer

Christopher M. Loftus,

Philadelphia, PA, USA

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Lashkarivand, A., Sorteberg, W., Rosseland, L.A. et al. Survival and outcome in patients with aneurysmal subarachnoid hemorrhage in Glasgow coma score 3–5. Acta Neurochir 162, 533–544 (2020). https://doi.org/10.1007/s00701-019-04190-y

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