Objective-The aim of this study was to investigate prospectively in an unselected series of patients with an aneurysmal subarachnoid haemorrhage what at present the complications are, what the outcome is, how many of these patients have "modern treatment"-that is, early obliteration of the aneurysm and treatment with calcium antagonists-what factors cause a delay in surgical or endovascular treatment, and what the estimated eVect on outcome will be of improved treatment. Methods-A prospective, observational cohort study of all patients with aneurysmal subarachnoid haemorrhage in the hospitals of a specified region in The Netherlands. The condition on admission, diagnostic procedures, and treatments were recorded. If a patient had a clinical deterioration, the change in Glasgow coma score (GCS), the presence of focal neurological signs, the results of additional investigations, and the final diagnosed cause of the deterioration were recorded. Clinical outcome was assessed with the Glasgow outcome scale (GOS) at 3 month follow up. In patients with poor outcome at follow up, the cause was diagnosed. Results-Of the 110 patients, 47 (43%) had a poor outcome. Cerebral ischaemia, 31 patients (28%), was the most often occurring complication. Major causes of poor outcome were the eVects of the initial haemorrhage and rebleeding in 34% and 30% of the patients with poor outcome respectively. Of all patients 102 (93%) were treated with calcium antagonists and 45 (41%) patients had early treatment to obliterate the aneurysm. The major causes of delay of treatment were a poor condition on admission or deterioration shortly after admission, in 31% and 23% respectively. Conclusions-In two thirds of the patients with poor outcome the causes of poor outcome are the eVects of the initial bleeding and rebleeding. Improved treatment of delayed or postoperative ischaemia will have only minor eVects on the outcome of patients with subarachnoid haemorrhage.(J Neurol Neurosurg Psychiatry 2000;68:337-341)
Background and Purpose-The purpose of this study was to investigate the current direct costs of modern management of patients with aneurysmal subarachnoid hemorrhage in the first year after diagnosis. Methods-During a 1-year period, we studied all admitted patients with subarachnoid hemorrhage from a population of 2 million people. We calculated the direct costs of treatment, which included the costs of medical and nursing care and the related travel expenses of patients. We calculated true costs for all major healthcare resources. National census data, if available, and standard charges were used to determine healthcare resource expenses. Results-Hospital admissions and diagnostic and therapeutic interventions in 110 patients accounted for 85% of all costs; 64% of the total direct medical costs during admission were the medical, nursing, and overhead costs alone. Patients discharged directly to home generated 4% of the total budget, whereas admission to a nursing home accounted for the remaining 11% of the total costs. Of the diagnostic and therapeutic costs, 45% was caused by imaging and 42% by surgery or coiling. Angiography alone accounted for 52% of the total imaging costs and 24% of the total diagnostic and therapeutic costs. Prescribed medication accounted for only 3% of the total budget of diagnostic and therapeutic costs. Conclusions-Most direct costs during the first year after aneurysmal subarachnoid hemorrhage are caused by the hospital inpatient days, accounting for two thirds of the total costs generated during the first year after the initial bleeding. If new costly treatments succeed in reducing the average length of inpatient hospital stays, then progress in therapy may prove cost effective and might even be cost saving.
Background and Purpose-Patients with a history of subarachnoid hemorrhage (SAH) or familial intracranial aneurysms (FIA) are at increased risk for aneurysm formation and rupture. Small aneurysms detected at screening may be left untreated and followed over time. The yield of follow-up CT/MR angiography (CTA/MRA) 1 or 2 years after detection to evaluate growth of these aneurysms is unknown. Methods-We prospectively followed patients with small aneurysms detected at screening at a 1-year interval using CTA or MRA. We assessed size, site, and number of the aneurysms and risk factors such as smoking, alcohol use, and hypertension. We evaluated the short-term growth and rupture rate and possible risk factors for growth and rupture. Results-Ninety-three patients (67 with a history of SAH, 16 with FIA, and 10 with a history of both SAH and FIA) with 125 aneurysms underwent CTA/MRA follow-up. Sixty-five patients were followed up once, and 28 patients were followed up twice (median follow-up time, 1.3 years). In 3 of the 93 patients (3.2%), an aneurysm enlarged slightly (0.5 to 1.5 mm). Two patients (2.2%) had a SAH: 1 from an aneurysm at the clip-site from a previous operation that ruptured without enlargement and the other from a newly developed dissecting aneurysm. The only statistically significant risk factor for growth and rupture was a history of both SAH and FIA (relative risk, 10.1; 95% CI, 1.3 to 81.9). Conclusions-The yield of early follow-up of small aneurysms in patients with a history of SAH or FIA is small and does not eliminate the risk of rupture. Whether follow-up at intervals Ͼ1 year is useful requires further study.
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