Predictors of poor outcome from aneurysmal subarachnoid hemorrhage and an exploratory analysis into the causes of delayed neurosurgical clipping at a major public hospital in the Philippines

Abstract

Objective: The provision of neurosurgical care for patients with aneurysmal subarachnoid hemorrhage (SAH) is beset with particular challenges in low- to middle-income countries (LMICs) like the Philippines. In this study located in a low-resource setting, we identify the factors that contribute to unfavorable outcomes of dependency and death. Methods: The authors retrospectively reviewed 106 patients who underwent surgery for aneurysmal subarachnoid hemorrhage in a single institution from January 2016 to September 2018. Data were obtained on exposure variables comprising patient demographics, clinical features, perioperative management, and complications and other interventions; while outcomes on discharge were investigated using the modified Rankin scale (mRS). Descriptive statistics and multivariate logistic regression analyses were done. Root cause analysis was done to identify the causes of delay. Results: The percentage of patients who had unfavorable outcome (mRS ≥ 3) was 29.2%. The timing of surgery—whether early (<3 days), intermediate (3-10 days), or late (>10 days)—was not found to be significantly associated with dependency or mortality. On multiple logistic regression, the factors associated with unfavorable outcome were: intraoperative rupture (OR 23.98, 95%CI 3.56–161.33, p=0.001), vasospasm (OR 12.47, 95%CI 3.01–51.57, p<0.001), and a high Hunt & Hess grade (OR 5.96, 95%CI 1.47–24.18, p=0.012). Intraoperative rupture and vasospasm were further found to be independent predictors of mortality. Many causes of delay were identified in terms of patient-, provider-, and health system-levels. These constitute as barriers to timely care and also contribute to the gap in quality and efficiency of neurosurgical treatment situated in low-resource settings in LMICs. Conclusion: The identified predictors of poor outcomes, as well as the causes delays in neurosurgical treatment, pose as significant challenges to the care of socioeconomically-disadvantaged SAH patients. When considering the solutions to these challenges, the broader environment of practice ought to be taken into account.