The likelihood of rupture of unruptured intracranial aneurysms that were less than 10 mm in diameter was exceedingly low among patients in group 1 and was substantially higher among those in group 2. The risk of morbidity and mortality related to surgery greatly exceeded the 7.5-year risk of rupture among patients in group 1 with unruptured intracranial aneurysms smaller than 10 mm in diameter.
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)
If good outcome is defined as the ability to perform outdoor activities mRs 0-1 should be chosen. If complex ADL are considered as good outcome mRs 0-2 is the outcome measure of choice. Independent of which outcome measure is chosen, the treatment effect in clinical trials must be large before good outcome is achieved. Therefore, it is likely that clinically important treatment effects can be missed in clinical trials with both these mRs endpoints.
Objective-To investigate prospectively the proportion of patients actually operated on early in units that aim at surgery in the acute phase of aneurysmal subarachnoid haemorrhage (SAH) and what is the main current determinant of poor outcome. Methods-A prospective analysis of all SAH patients admitted during a one year period at three neurosurgical units that aim at early surgery. The following clinical details were recorded: age, sex, date of SAH, date of admission to the neurosurgical centre, whether a patient was referred by a regional hospital or a general practitioner, Glasgow coma scale and grade of SAH (World Federation of Neurological Surgeons (WFNS) score) on admission at the neurosurgical unit, results of CT and CSF examination, the presence of an aneurysm on angiography, details of treatment with nimodipine or antifibrinolytic agents, and the date of surgery to clip the aneurysm. At follow up at three months, the patients' clinical outcome was determined with the Glasgow outcome scale and in cases of poor outcome the cause for this was recorded. Results-The proportion of patients that was operated on early-that is, within three days after SAH-was 55%. Thirty seven of all 102 admitted patients had a poor outcome. Rebleeding and the initial bleeding were the main causes of this in 35% and 32% respectively of all patients with poor outcome. Conclusions-In neurosurgical units with what has been termed "modern management" including early surgery, about half of the patients are operated on early. Rebleeding is still the major cause of poor outcome. (J Neurol Neurosurg Psychiatry 1997;63:490-493) Keywords: aneurysmal subarachnoid haemorrhage; timing of surgery; rebleeding Rebleeding in the first three weeks after aneurysmal subarachnoid haemorrhage (SAH) is a very frequent and severe complication. Without operative intervention and without antifibrinolytic treatment about 30% of the patients have a rebleed within one month of the initial SAH.1 In a series of patients with a rebleed established by CT about 50% progressively deteriorated and died from the rebleed and 30% died from other complications. Only 20% of the patients with a rebleed survived at three months and most had severe brain damage.
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