Article
Early and aggressive treatment improves outcome after high-grade (Hunt&Hess Grade 5) subarachnoid hemorrhage: a high-volume single-center cohort comparison of a pre-coiling-era (1980–1995) vs. post-ISAT-era (2005–2014)
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Authors
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Juergen Konczalla
- Universitätsklinikum Frankfurt, Goethe-Universität, Klinik und Poliklinik für Neurochirurgie, Frankfurt, Germany
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Volker Seifert
- Universitätsklinikum Frankfurt, Goethe-Universität, Klinik und Poliklinik für Neurochirurgie, Frankfurt, Germany
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Hartmut Vatter
- Rheinische Friedrich-Wilhelms-Universität, Klinik und Poliklinik für Neurochirurgie, Bonn, Germany
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Andreas Raabe
- Universitätsklinik Bern, Inselspital, Neurochirurgische Klinik, Bern, Switzerland
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Gerhard Marquardt
- Universitätsklinikum Frankfurt, Goethe-Universität, Klinik und Poliklinik für Neurochirurgie, Frankfurt, Germany
| Published: | June 8, 2016 |
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Outline
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Objective: Whereas outcome data for severe (Hunt & Hess (H&H) Grade 4+5) subarachnoid hemorrhage (SAH) exists, outcome analysis of comatose patients (H&H Grade 5) is still missing. During the last 35 years treatment strategies (early vs. late clipping vs. no treatment), treatment modalities (clipping alone vs. coiling or clipping with ICG-angiography), diagnosis and treatment of cerebral vasospasm and intensive-care-unit standards changed partially dramatically. The aim of the study was to compare the outcome of patients with SAH H&H Grade 5 between these two periods.
Method: We retrospectively analyzed patients with SAH H&H Grade 5 between 1980-1995 (earlier period) compared to 2005-2014 (actual period). Outcome of 257 patients was analyzed and stratified using the modified Rankin Scale (favorable (mRS 0-2) and unfavorable (3-6)) six months after SAH.
Results: In the earlier period 54 patients of the admitted patients had a SAH H&H Grade 5 compared to 203 patients in the actual period. In the earlier period 50% of the aneurysms were located in the anterior circulation, 7% in the posterior circulation and in 30% a diagnostic DSA was not performed, compared to 70% anterior, 20% posterior circulation and 6% w/o DSA in the actual period (P<0,01). In the earlier period 33% received an external ventricular drainage (EVD) compared to 79% in the actual period (P<0,01). In the earlier period 74% did not receive any treatment (vs. 32% actual period; P<0,01). Early aneurysm treatment within 48h occurred significantly more often in the actual period (P<0,01; OR 7.6). In the earlier period patients had a significant higher 30-day mortality rate (83% vs. 39%; OR 7.7) and 6-months-mortality rate (94% vs. 49%; OR 17.9). Whereas in the earlier period no patients had a favorable outcome, in the actual period 23% of patients (P<0,01; OR 32.0), respectively 29% of the aneurysm-treated patients (P<0,01; OR 219) had a favorable outcome. Of the treated patients the NNT (number needed to treat) is 2 for survival and 4 for favorable outcome in the actual period. In the actual period favorable outcome was similar often in both treatment modalities (29% clip vs. 31% coil).
Conclusions: Early and aggressive treatment (early insertion of vital EVD and early aneurysm treatment) resulted in a significant improvement in survival rate (NNT=2) and favorable outcome (NNT=4) of comatose patients with SAH (H&H Grade 5). Therefore, treatment of patients with H&H Grade 5 subarachnoid hemorrhage should be performed and not be delayed.
