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aneurysmal_subarachnoid_hemorrhage_outcome

Aneurysmal subarachnoid hemorrhage outcome

The prognosis of patients with aneurysmal subarachnoid hemorrhage (aSAH) depends on their condition on arrival at the hospital. However, a small number of patients recover from an initially poor condition.

Generally aSAH has a very high mortality (>25%) and significant morbidity (>50%) among the survivors, and most survivors experience significant cognitive decline across multiple domains, including executive function 1).

aSAH has a high socioeconomic impact as it tends to affect younger patients. The NCEPOD study looking into management of aSAH has recommended that neurovascular units in the United Kingdom should aim to secure cerebral aneurysms within 48 h and that delays because of weekend admissions can increase the mortality and morbidity attributed to aSAH.

A study provides important data showing excess in-hospital mortality of patients with SAH on weekend admissions served by the United Kingdom's National Health Service.; However, there were no effects of weekend admission on long-term outcomes 2).

Scales

National Institute of Health Stroke Scale

Barthel Index

Extended Glasgow Outcome Scale.

Modified Rankin Scale


Systematic reviews for clinical prognostic factors and clinical prediction tools in aneurysmal subarachnoid hemorrhage (aSAH) face a number of methodological challenges. These include within and between study patient heterogeneity, regional variations in treatment protocols, patient referral biases, and differences in treatment, and prognosis viewpoints across different cultures 3).

It is critical to determine the neural basis for executive deficits in aSAH, in order to better understand and improve patient outcomes.


In a tertiary care center in India, despite recent advances in the treatment of patients with aSAH, the morbidity and mortality rates have failed to improve significantly in unselected patients and natural cohorts. This may be attributed to the natural history of aSAH, and calls for new strategies to diagnose and treat such patients before the catastrophe 4).

In the series of Nieuwkamp et al., despite an increase in the mean age of patients with SAH, case-fatality rates have decreased by 17% between 1973 and 2002 and show potentially important regional differences. This decrease coincides with the introduction of improved management strategies 5).

The case fatality after aneurysmal haemorrhage is 50%; one in eight patients with subarachnoid haemorrhage dies outside hospital.

Mortality is 10% within first few days

30-day mortality rate was 46% in one series, and in others over half the patients died within 2 weeks of their SAH.

overall mortality is 45% (range: 32—67%)

causes of mortality

neurogenic stunned myocardium

about 8% die from progressive deterioration from the initial hemorrhage

of those reaching neurosurgical care, vasospasm kills 7%, and causes severe deficit in another 7%.

about 30% of survivors have moderate to severe disability.

about 66 % of those who hove successful aneurysm clipping never return to the same quality of life as before the SAH.

With the limitation of an explorative cohort study the results indicate that routine transcranial doppler (TCD) studies do not improve the overall outcome of patients after aSAH 6).

Quality of life

Individuals who have aneurysmal subarachnoid hemorrhages (SAHs) experience decreased health-related qualities of life (HRQoLs) that persist after the primary insult.

Data collected from the CONSCIOUS-1 trial was used to extract 29 clinical variables including SAH presentation, hospital procedures, and demographic information in addition to 5 HRQoL outcome variables for 256 individuals. A partial least-squares analysis was performed by calculating a heterogeneous correlation matrix and applying singular value decomposition to determine components that best represent the correlations between the 2 sets of variables. Bootstrapping was used to estimate statistical significance.

The first 2 components accounting for 81.6% and 7.8% of the total variance revealed significant associations between clinical predictors and HRQoL outcomes. The first component identified associations between disability in self-care with longer durations of critical care stay, invasive intracranial monitoring, ventricular drain time, poorer clinical grade on presentation, greater amounts of cerebral spinal fluid drainage, and a history of hypertension. The second component identified associations between disability due to pain and discomfort as well as anxiety and depression with greater body mass index, abnormal heart rate, longer durations of deep sedation and critical care, and higher World Federation of Neurosurgical Societies and Hijdra scores.

By applying a data-driven, multivariate approach, we identified robust associations between SAH clinical presentations and HRQoL outcomes 7).

Amount of Bleeding

Quantitative estimation of the hemorrhage volume associated with aneurysm rupture is a tool of assessing prognosis.

A prospective cohort of 206 patients consecutively admitted with the diagnosis of aneurysmal subarachnoid hemorrhage to Hospital 12 de Octubre were included in the study. Subarachnoid, intraventricular, intracerebral, and total bleeding volumes were calculated using analytic software. For assessing factors related to prognosis, univariate and multivariate analysis (logistic regression) were performed. The relative importance of factors in determining prognosis was established by calculating their proportion of explained variation. Maximum Youden index was calculated to determine the optimal cut point for subarachnoid and total bleeding volume.

Variables independently related to prognosis were clinical grade at admission, age, and the different bleeding volumes. The proportion of variance explained is higher for subarachnoid bleeding. The optimal cut point related to poor prognosis is a volume of 20 mL both for subarachnoid and total bleeding.

Volumetric measurement of subarachnoid or total bleeding volume are both independent prognostic factors in patients with aneurysmal subarachnoid hemorrhage. A volume of more than 20 mL of blood in the initial noncontrast computed tomography is related to a clear increase in poor outcome risk 8).

Age - Clinical Grade

While advanced age is already recognized as an independent risk factor for a poor functional outcome following an aneurysmal subarachnoid hemorrhage (SAH), it is also important to investigate the critical age for defining a higher risk population among elderly patients and the clinical grade at admission in order to provide a prognostic description and help guide the management of patients aged ≥ 70 years.

A retrospective study included 165 patients aged 70-90 years who underwent surgical or endovascular treatment for a ruptured aneurysm. In addition to medical and radiological data, telephone interviews were used to obtain the 1-year functional outcome.

A multivariate analysis revealed age (p = 0.001) and the World Federation of Neurological Surgeons (WFNS) grade (p = 0.001), regardless of the treatment modalities (surgical versus endovascular), as significant risk factors for a poor outcome, while a receiver operating characteristic analysis revealed 75 years as an appropriate cutoff value for the patient age to predict a poor 1-year functional outcome (area under the curve: 0.683). For the patients aged 70-75 years with good (1-3) and poor (4-5) WFNS grades, 81.9 % and 42.9 % achieved a favorable outcome (modified Rankin Scale 0-3), respectively, whereas for the patients over the critical age (> 75 years) with good and poor WFNS grades, 54.8 % and 5.9 % achieved a favorable outcome, respectively.

The long-term outcome for elderly patients with an aneurysmal SAH is affected primarily by the clinical condition at admission and the patient's age in relation to the critical age (> 75 years), regardless of the treatment modalities, including surgical clipping and endovascular coiling 9).

C reactive protein

Early recording of C reactive protein may prove useful in detecting those good grade patients who are at greater risk of clinical deterioration and poor outcome in aneurysmal subarachnoid hemorrhage 10).

IL-6

Higher early IL6 serum levels after aSAH are associated with poor outcome at discharge. In addition, involvement of leukemia inhibitory factor (LIF) in the early inflammatory reaction after aSAH has been demonstrated 11).

APOΕε4 polymorphism

The APOΕε4 polymorphism was analysed in 147 patients with aSAH. Allele and genotype frequencies were compared to those found in a gender- and area-matched control group of healthy individuals (n = 211). Early cerebral vasospasm (CVS) was identified and treated according to neurointensive care unit (NICU) guidelines. Neurological deficit(s) at admittance and at 1-year follow-up visit was recorded. Neurological outcome was assessed by the National Institute of Health Stroke Scale, Barthel Index and the Extended Glasgow Outcome Scale.

APOEε4 and non-APOEε4 allele frequencies were similar in aSAH patients and healthy individuals. The presence of APOEε4 was not associated with the development of early CVS. We could not find an influence of the APOE polymorphism on 1-year neurological outcome between groups. Subgroup analyses of patients treated with surgical clipping vs endovascular coiling did not reveal any associations.

For Csajbok et al. APOEε4 polymorphism has no major influence on risk of aSAH, the occurrence of CVS or long-term neurological outcome after aSAH 12).


For Cheng et al., Apolipoprotein E (APOEε4) may induce cerebral perfusion impairment in the early phase, contributing to early brain injury (EBI) following aneurysmal subarachnoid hemorrhage (aSAH), and assessment of APOE genotypes could serve as a useful tool in the prognostic evaluation and therapeutic management of aSAH 13).

Case series

Sasahara et al., performed plain computed tomography (CT) perfusion (CTP), and CT angiography (CTA) in all patients with aSAH on arrival. Aneurysms were surgically obliterated in patients with stable vital signs and the presence of a brain stem response. They measured the average mean transit time (aMTT) and compared it with the modified Rankin Scale (mRS) score at 1 month. Regions of interest were identified as 24 areas in the bilateral anterior, middle, and posterior cerebral artery territories and 2 areas in the basal ganglia.

A total of 57 patients were treated between 2007 and 2014. None of the 21 patients with aMTT >6.385 seconds achieved a favorable outcome, whereas 8 of the 36 patients with aMTT <6.385 seconds did achieve a favorable outcome (P = 0.015). Furthermore, comparing the number of areas showing a mean transit time (MTT) >7.0 seconds among the aforementioned 8 areas and mRS, favorable outcomes were not seen in 24 patients with more than 2 such areas (P = 0.009).

We cannot expect a favorable outcome for patients with WFNS grade V aSAH with aMTT >6.385 seconds or more than 2 of 8 areas with MTT >7.0 seconds 14).

1)
Connolly ES, Jr, Rabinstein AA, Carhuapoma JR, Derdeyn CP, Dion J, Higashida RT, et al. Guidelines for the management of aneurysmal subarachnoid hemorrhage: A guideline for healthcare professionals from the American Heart Association/american Stroke Association. Stroke. 2012;43:1711–37.
2)
Deshmukh H, Hinkley M, Dulhanty L, Patel HC, Galea JP. Effect of weekend admission on in-hospital mortality and functional outcomes for patients with acute subarachnoid haemorrhage (SAH). Acta Neurochir (Wien). 2016 May;158(5):829-35. doi: 10.1007/s00701-016-2746-z. Epub 2016 Mar 1. PubMed PMID: 26928730; PubMed Central PMCID: PMC4826657.
3)
Lo BW, Fukuda H, Nishimura Y, Farrokhyar F, Thabane L, Levine MA. Systematic review of clinical prediction tools and prognostic factors in aneurysmal subarachnoid hemorrhage. Surg Neurol Int. 2015 Aug 11;6:135. doi: 10.4103/2152-7806.162676. eCollection 2015. PubMed PMID: 26322245.
4)
Sodhi HB, Savardekar AR, Mohindra S, Chhabra R, Gupta V, Gupta SK. The clinical profile, management, and overall outcome of aneurysmal subarachnoid hemorrhage at the neurosurgical unit of a tertiary care center in India. J Neurosci Rural Pract. 2014 Apr;5(2):118-26. doi: 10.4103/0976-3147.131650. PubMed PMID: 24966547.
5)
Nieuwkamp DJ, Setz LE, Algra A, Linn FH, de Rooij NK, Rinkel GJ. Changes in case fatality of aneurysmal subarachnoid haemorrhage over time, according to age, sex, and region: a meta-analysis. Lancet Neurol. 2009 Jul;8(7):635-42. doi: 10.1016/S1474-4422(09)70126-7. Epub 2009 Jun 6. PubMed PMID: 19501022.
6)
Ehrlich G, Kirschning T, Wenz H, Hegewald AA, Groden C, Schmiedek P, Scharf J, Seiz-Rosenhagen M. Is there an influence of routine daily transcranial doppler examination on clinical outcome in patients after aneurysmal subarachnoid hemorrhage? World Neurosurg. 2016 Jan 5. pii: S1878-8750(15)01714-3. doi: 10.1016/j.wneu.2015.11.091. [Epub ahead of print] PubMed PMID: 26768855.
7)
Young JM, Morgan BR, Mišić B, Schweizer TA, Ibrahim GM, Macdonald RL. A Partial Least-Squares Analysis of Health-Related Quality-of-Life Outcomes After Aneurysmal Subarachnoid Hemorrhage. Neurosurgery. 2015 Dec;77(6):908-15. doi: 10.1227/NEU.0000000000000928. PubMed PMID: 26248048.
8)
Lagares A, Jiménez-Roldán L, Gomez PA, Munarriz PM, Castaño-León AM, Cepeda S, Alén JF. Prognostic Value of the Amount of Bleeding After Aneurysmal Subarachnoid Hemorrhage: A Quantitative Volumetric Study. Neurosurgery. 2015 Dec;77(6):898-907. doi: 10.1227/NEU.0000000000000927. PubMed PMID: 26308629.
9)
Park J, Woo H, Kang DH, Kim Y. Critical age affecting 1-year functional outcome in elderly patients aged ≥ 70 years with aneurysmal subarachnoid hemorrhage. Acta Neurochir (Wien). 2014 Jun 21. [Epub ahead of print] PubMed PMID: 24950994.
10)
Turner CL, Budohoski K, Smith C, Hutchinson PJ, Kirkpatrick PJ; STASH collaborators. Elevated Baseline C-Reactive Protein as a Predictor of Outcome After Aneurysmal Subarachnoid Hemorrhage: Data From the Simvastatin in Aneurysmal Subarachnoid Hemorrhage (STASH) Trial. Neurosurgery. 2015 Nov;77(5):786-93. doi: 10.1227/NEU.0000000000000963. PubMed PMID: 26280117; PubMed Central PMCID: PMC4605277.
11)
Höllig A, Remmel D, Stoffel-Wagner B, Schubert GA, Coburn M, Clusmann H. Association of early inflammatory parameters after subarachnoid hemorrhage with functional outcome: A prospective cohort study. Clin Neurol Neurosurg. 2015 Aug 28;138:177-183. doi: 10.1016/j.clineuro.2015.08.030. [Epub ahead of print] PubMed PMID: 26355810.
12)
Csajbok LZ, Nylén K, Öst M, Blennow K, Zetterberg H, Nellgård P, Nellgård B. Apolipoprotein E polymorphism in aneurysmal subarachnoid haemorrhage in West Sweden. Acta Neurol Scand. 2015 Sep 16. doi: 10.1111/ane.12487. [Epub ahead of print] PubMed PMID: 26374096.
13)
Cheng C, Jiang L, Yang Y, Wu H, Huang Z, Sun X. Effect of APOE Gene Polymorphism on Early Cerebral Perfusion After Aneurysmal Subarachnoid Hemorrhage. Transl Stroke Res. 2015 Sep 14. [Epub ahead of print] PubMed PMID: 26370543.
14)
Sasahara A, Suzuki K, Takahashi Y, Koseki H, Hirota K, Ohbuchi H, Kasuya H. Prognostic Assessment of Aneurysmal Subarachnoid Patients with WFNS Grade V by CT Perfusion on Arrival. World Neurosurg. 2016 Aug;92:1-6. doi: 10.1016/j.wneu.2016.04.097. Epub 2016 May 4. PubMed PMID: 27155385.
aneurysmal_subarachnoid_hemorrhage_outcome.txt · Last modified: 2016/09/02 15:39 (external edit)