Preoperative Prediction of Long-term Outcome in Poor-grade Aneurysmal Subarachnoid Hemorrhage

Mocco, J; Ransom, Evan R.; Komotar, Ricardo J.; Schmidt, J. Michael; Sciacca, Robert R.; Mayer, Stephan A.; Connolly, E. Sander

doi:10.1227/01.neu.0000228680.22550.a2

Cited by 157 publications

(117 citation statements)

References 39 publications

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“…In addition to supporting the well-accepted association between clinical grade at admission and outcome, 2,9,20,24,31,38,41 our results demonstrate the impact of cerebral ischemia on delayed recovery at all time points. Although the presence or absence of any stroke was not predictive of a patient's capacity to recover, the avoidance of a large (> 4 cm) stroke or ischemia in eloquent territory was highly predictive of delayed improvement.…”

Section: Figsupporting

confidence: 84%

“…This is consistent with prior studies demonstrating an association between younger age and more favorable outcomes following SAH. 10,11,14,20,24,31 Although patients 65 years of age or younger had more than 5 times the odds of improvement beyond 6 months, when improvement specific to the time intervals beyond 1 year was analyzed, age was no longer a significant predictor. This finding suggests that while younger age has its benefits in recovery, the most delayed improvement is driven primarily by other factors.…”

Section: Figmentioning

confidence: 98%

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Time course of recovery following poor-grade SAH: the incidence of delayed improvement and implications for SAH outcome study design

Wilson¹,

Nakaji²,

Albuquerque³

et al. 2013

JNS

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Object Data regarding the time course of recovery after poor-grade subarachnoid hemorrhage (SAH) is lacking. Most SAH studies assess outcome at a single time point, often as early as 3 or 6 months following SAH. The authors hypothesized that recovery following poor-grade SAH is a dynamic process and that early outcomes may not always approximate long-term outcomes. To test this hypothesis, they analyzed long-term outcome data from a cohort of patients with poor-grade aneurysmal SAH to determine the incidence and predictors of early and delayed neurological improvement. Methods The authors reviewed outcome data from 88 poor-grade SAH patients enrolled in a prospective SAH treatment trial (the Barrow Ruptured Aneurysm Trial). They assessed modified Rankin Scale (mRS) scores at discharge, 6 months, 12 months, and 36 months after treatment to determine the incidence and predictors of neurological improvement during each interval. Results The mean aggregate mRS scores at 6 months (3.31 ± 2.1), 12 months (3.28 ± 2.2), and 36 months (3.17 ± 2.3) improved significantly compared with the mean score at hospital discharge (4.33 ± 1.3, p < 0.001), but they did not differ significantly among themselves. Between discharge and 6 months, 61% of patients improved on the mRS. The incidence of improvement between 6–12 months and 12–36 months was 18% and 19%, respectively. Hunt and Hess Grade IV versus V (OR 6.20, 95% CI 2.11–18.25, p < 0.001) and the absence of large (> 4 cm) (OR 2.76, 95% CI 1.02–7.55, p = 0.05) or eloquent (OR 5.17, 95% CI 1.89–14.10, p < 0.01) stroke were associated with improvement up to 6 months. Age ≤ 65 years (OR 5.56, 95% CI 1.17–26.42, p = 0.02), Hunt and Hess Grade IV versus V (OR 4.17, 95% CI 1.10–15.85, p = 0.03), and absence of a large (OR 8.97, 95% CI 2.65–30.40, p < 0.001) or eloquent (OR 4.54, 95% CI 1.46–14.08, p = 0.01) stroke were associated with improvement beyond 6 months. Improvement beyond 1 year was most strongly predicted by the absence of a large stroke (OR 7.62, 95% CI 1.55–37.30, p < 0.01). Conclusions A substantial minority of poor-grade SAH patients will experience delayed recovery beyond the point at which most studies assess outcome. Younger patients, those presenting in better clinical condition, and those without CT evidence of large or eloquent stroke demonstrated the highest capacity for delayed recovery.

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Section: Figsupporting

confidence: 84%

Section: Figmentioning

confidence: 98%

Time course of recovery following poor-grade SAH: the incidence of delayed improvement and implications for SAH outcome study design

Wilson¹,

Nakaji²,

Albuquerque³

et al. 2013

JNS

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“…There are, however, theoretical advantages to early occlusion for aneurysms in poor-grade patients. Re-bleeding is more frequent with a poor grade and larger aneurysm size 9,11,13,15 . The incidence of vasospasm is greater in poor-grade patients: optimum therapy is best performed after aneurysm occlusion.…”

Section: Discussionmentioning

confidence: 99%

Follow-up of Large Aneurysms Treated with Coil Embolization at an Acute Stage in Patients with Poor-Grade Subarachnoid Hemorrhage

Hagiwara

Tanaka²,

Tani³

et al. 2009

Interv Neuroradiol

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This study evaluated the clinical and angiographic outcome of large aneurysms treated with coil embolization at an acute stage in patients with poor-grade subarachnoid hemorrhage (SAH). Between July 1, 2001 and June 30, 2004, eight consecutive WFNS grade 5 patients with large aneurysms (15!23mm) were treated with endovascular coil embolization within two days and followed for at least 30 months. There were three middle cerebral and five internal carotid artery aneurysms. No patients were treated by craniotomy and none survived without treatment. Two patients died of primary brain damage or cerebral vasospasm within one month. One patient died of pneumonia at 24 months. Four patients were alive with good recovery or moderate disability at the time of final follow-up (30!66 months). Angiography immediately after the procedure showed complete occlusion in three, neck remnant in four, and body filling in one patient. No complication was seen related to the procedure. Three aneurysms that were initially neck remnant developed body filling due to coil compaction. Two were re-treated with coils at six and 12 months and resulted in neck remnant. One patient refused re-treatment and died of re-bleeding. Endovascular coil embolization can be selected at an acute stage for the treatment of aneurysms in patients with poor-grade SAH without intraparenchymal hematoma even if the aneurysm is large. Serial follow up by MRA/angiography is necessary for at least 12 months.

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“…Previous studies have shown that age and initial Glasgow Coma Scale (GCS) can predict outcomes, but none have validated the exclusion criteria for aggressive treatment in patients with high-grade SAH. 9,11,12,14,[18][19][20]22,25,26) The present study describes the anatomical and clinical findings during surgical treatment of poorgrade ruptured MCA aneurysms, and tailored surgical strategies based on the distribution of hematoma. The three study objectives are to identify patients with the worst neurological status prior to treatment who were able to achieve useful daily life; to follow functional outcomes and living status in patients who underwent aggressive treatment; and to describe the surgical procedures and how these were employed in our clinical practice.…”

Section: Introductionmentioning

confidence: 99%

“…1,3,5,6,17,19,29,34) Patients do not always achieve outcomes consistent with their initial neurological status, and 50-60% of patients affected by rupture of an intracranial aneurysm can become functional survivors. 3,[9][10][11][12]14,18,20,22,25,26) However, insufficient surgical intervention may result in loss of potentially salvageable function or life. 1,3,9,12,15,26,27) Adequate treatment often requires hematoma evacuation and decompressive maneuvers in addition to clipping procedures.…”

Section: Introductionmentioning

confidence: 99%

Poor-Grade Ruptured Middle Cerebral Artery Aneurysm With Intracerebral Hematoma: Bleeding Characteristics and Management

Kazumata

Kamiyama

Yokoyama

et al. 2010

Neurol. Med. Chir.(Tokyo)

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Poor-grade ruptured middle cerebral artery aneurysm is frequently associated with intraparenchymal hemorrhage, which is associated with high morbidity rates. We analyzed the clinical presentations and surgical strategies of 23 cases of ruptured middle cerebral artery aneurysm. Hematomas were divided into three types: temporal hematoma (7 patients), sylvian hematoma (10 patients), and frontal hematoma (6 patients). In 13 of 23 patients, preoperative brainstem symptoms suggested impeding uncal herniation. Surgical procedures included external decompression in 11 patients, simple lateral temporal lobectomy in 5, and selective uncectomy in 9. Three patients died. Favorable outcome defined as upper half of severely disabled or better in the extended Glasgow Outcome Scale was achieved in 13 patients. Patients with frontal hematomas presented with both uncal herniation and brainstem signs preoperatively, but this subgroup showed unexpectedly good recovery. Patients with sylvian hematomas had relatively poor outcomes. The present series suggests that aggressive decompression and evacuation of hematoma in the acute stage may prevent significant postoperative brain swelling, and will not compromise the treatment of vasospasm.

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Preoperative Prediction of Long-term Outcome in Poor-grade Aneurysmal Subarachnoid Hemorrhage

Cited by 157 publications

References 39 publications

Time course of recovery following poor-grade SAH: the incidence of delayed improvement and implications for SAH outcome study design

Time course of recovery following poor-grade SAH: the incidence of delayed improvement and implications for SAH outcome study design

Follow-up of Large Aneurysms Treated with Coil Embolization at an Acute Stage in Patients with Poor-Grade Subarachnoid Hemorrhage

Poor-Grade Ruptured Middle Cerebral Artery Aneurysm With Intracerebral Hematoma: Bleeding Characteristics and Management

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