International Practice Variability in Treatment of Aneurysmal Subarachnoid Hemorrhage

Abstract

Prior research suggests substantial between-center differences in functional outcome following aneurysmal subarachnoid hemorrhage (aSAH). One hypothesis is that these differences are due to practice variability. To characterize practice variability, we sent a survey to 230 centers, of which 145 (63%) responded. Survey respondents indicated that an estimated 65% of ruptured aneurysms were treated endovascularly. Sixty-five percent of aneurysms were treated within 24 h of symptom onset, 18% within 24–48 h, and eight percent within 48–72 h. Centers in the United States (US) and Europe (EU) treat aneurysms more often endovascularly (72% and 70% vs. 51%, respectively, US vs. other p < 0.001, and EU vs. other p < 0.01) and more often within 24 h (77% and 64% vs. 46%, respectively, US vs. other p < 0.001, EU vs. other p < 0.01) compared to other centers. Most centers aim for euvolemia (96%) by administrating intravenous fluids to 0 (53%) or +500 mL/day (41%) net fluid balance. Induced hypertension is more often used in US centers (100%) than in EU (87%, p < 0.05) and other centers (81%, p < 0.05), and endovascular therapies for cerebral vasospasm are used more often in US centers than in other centers (91% and 60%, respectively, p < 0.05). We observed significant practice variability in aSAH treatment worldwide. Future comparative effectiveness research studies are needed to investigate how practice variation leads to differences in functional outcome.

Early predictors of functional outcome in poor-grade aneurysmal subarachnoid hemorrhage: a systematic review and meta-analysis

“…In agreement with current guidelines [ 4 , 5 ], the majority of aSAH patients are being treated within 24 h [ 6 ]. Aneurysm treatment in poor-grade patients is often delayed until signs of neurological recovery to avoid providing futile therapies to moribund patients or adding to a high proportion of patients ending up in vegetative or functionally dependent state.…”

Regional Variability in the Care and Outcomes of Subarachnoid Hemorrhage Patients in the United States

“…However, despite advances in intensive care unit (ICU) care and nearly a 50% reduction in SAH mortality over the last two decades ( 6 ), limited scientific data guide therapy in SAH and very few interventions have strong evidence for impacting survival and outcomes ( 3 ). As a consequence, significant variability in SAH care is expected and has been reported in prior studies ( 7 – 12 ).…”

“…Majority of the studies that assess clinical practice variability in SAH are national and international practice pattern surveys ( 7 – 12 ), that are often subject to recall biases and do not include individual patient data and thus have not been able to determine if variability in care practices are associated with patient outcomes. We, therefore, used the Vizient Clinical Data Base (CDB), that includes patient-level data for this study.…”

Vasospasm-Related Death after Aneurysmal Subarachnoid Hemorrhage: A Retrospective Case–Control Study

“…The morbidity and mortality of this condition are 40% and 35%, respectively [ 2 ]. Both the microsurgical and the endovascular treatment (EVT) of ruptured aneurysms have improved considerably during the last 30 years, despite variations in the techniques and timings [ 3 , 4 , 5 ].…”