Surgical Neurology International

Editor-in-Chief:
James I. Ausman, MD, PhD
University of California, Los
Angeles, CA, USA
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Orlglnal Artlcle
Age Iimit for surgicaI treatment of poor-grade patients with
subarachnoid hemorrhage: A project of the Chugoku-Shikoku
division of the Japan neurosurgicaI society
Satosli Slirao, Hirosli Yoncoa, Icliro Kunitsugu
1
, Iiicli Sucliro, Hiroyasu Koizumi,
Micliyasu Suzuki
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Recelveo: 10 August 12 Accepteo: 23 August 12 Publlsbeo: 27 November 12
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onIine
Website:
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DOI:
10.4103/2152-7806.103886
Quick Response Code:
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Objective: Management of elderly patients with poor-grade subarachnoid
hemorrhage (SAH) remains controversial. The objective of this study was to
investigate whether there is an age-dependent difference in the outcome of poor-
grade SAH after surgical obliteration of the aneurysm.
Methods: Data were reviewed retrospectively for 156 patients with poor-grade
aneurysmal SAH at multiple centers in Chugoku and Shikoku, Japan. Patients
were divided into age groups of 65-74 and 75 years old. Factors in!uencing
a favorable outcome at discharge (Glasgow Outcome Scale, good recovery or
moderately disabled) were determined using multivariate logistic regression
analyses.
ResuIts: A favorable outcome at discharge was achieved in 37 of the 156 patients
(23.7%). Advanced age (75 years old, ! < 0.01), improvement of World
Federation of Neurosurgical Societies (WFNS) Grade after admission (! = 0.02),
Fisher grade (! < 0.001), and a low density area (LDA) associated with vasospasm
on computed tomography (CT) (! < 0.01) were signi"cantly associated with
outcome. Multivariate analysis identi"ed advanced age (75 years old, ! = 0.01),
Fisher group 4 (! = 0.002), and a new LDA associated with vasospasm on CT
(! = 0.007) as predictors of a poor outcome in elderly patients with poor-grade SAH
after surgical obliteration of the aneurysm. WFNS Grade V at admission (! = 0.052)
was weakly associated with a poor outcome.
ConcIusions: Advanced age (75 years old), Fisher group 4, and LDA associated
with vasospasm on CT were independent predictors of clinical outcome in elderly
patients with poor-grade SAH. A favorable outcome in these patients occurred
more frequently after Guglielmi detachable coil embolization than after surgical
clipping, but without a signi"cant difference.
()* ,-%.#/ Aneurysm, elderly, poor grade, subarachnoid hemorrhage
012# &%$2'3) 4&* ") '2$). &#/
Sblrao S, Yoneoa H, Kunltsugu |, Sueblro L, Kolzuml H, Suzukl M. Age llmlt tor surglcal treatment ot poor-graoe patlents wltb subaracbnolo bemorrbage: A project ot tbe
Cbugoku-Sblkoku olvlslon ot tbe [apan neurosurglcal soclety. Surg Neurol |nt 2012,3:143.
Avallable FRLL ln open access trom: bttp://www.surglcalneurologylnt.com/tet.asp?2012/3/1/143/103886
Copyrlgbt: 2012 Sblrao S. Tbls ls an open-access artlcle olstrlbuteo unoer tbe terms ot tbe Creatlve Commons Attrlbutlon Llcense, wblcb permlts unrestrlcteo use, olstrlbutlon,
ano reproouctlon ln any meolum, provloeo tbe orlglnal autbor ano source are creolteo.
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!"#$%&'( *+"#,(,$- ./0+#/'0%,/'( 2012, 3:143 bttp://www.surglcalneurologylnt.com/content/3/1/143
560789:;0586
Iaticnts witl poor-graoc ancurysmal sularaclnoio
lcmorrlagc (SAH) ol Vorlo Icocration ol Ncurosurgical
Socictics (VINS) Craocs IV ano V lavc ligl
mortality ano morlioity, ano tlc majority arc trcatco
conscrvativcly.
|1,6,1S,26
Scvcral stuoics lavc slown tlat
angiograply ano ancurysm surgcry sloulo lc rcstrictco
to tlosc wlo slow clinical improvcmcnt.
|6,19
Ircviously,
wc lavc rcportco tlat aovancco agc, VINS Craoc V,
improvcmcnt ol VINS Craoc, ano a low ocnsity
arca (LDA) associatco witl vasospasm on computco
tomograply (CT) wcrc inocpcnocnt prcoictors ol
clinical outcomc, wlcrcas rcllccoing, carly ancurysm
surgcry, ano trcatmcnt mooality |surgical clipping or
Cugliclmi octaclallc coil (CDC) cmlolization wcrc not
inocpcnocntly associatco witl outcomc in paticnts witl
poor-graoc SAH.
|22
Tlc annual inciocncc ratc ol ancurysmal SAH incrcascs
witl agc
|1
ano incrcasing agc is associatco witl a
poor outcomc in paticnts witl SAH.
|2
Howcvcr,
clocrly paticnts arc unocr-rcprcscntco in most rcports
ol managcmcnt ol SAH ano, to our knowlcogc, tlc
inllucncc ol incrcasco agc on tlc outcomc ol paticnts
witl poor-graoc ancurysmal SAH las not lccn cxaminco.
Tlcrclorc, wc pcrlormco a rctrospcctivc rcvicw ol paticnts
witl poor-graoc ancurysmal SAH at multiplc ccntcrs in
Clugoku ano Slikoku, }apan, to invcstigatc wlctlcr
tlcrc was an agc-ocpcnocnt oillcrcncc in outcomc.
<!0=75!>? !69 <=0@89?
!"#$% '('#)*"+(,
Tlis stuoy was pcrlormco rctrospcctivcly in a colort
witl poor-graoc SAH (VINS Craocs IV ano V). Tlc
paticnts wcrc rccruitco lrom }anuary to Dcccmlcr
200 lrom 66 mcoical ccntcrs in Clugoku ano
Slikoku, }apan.
|22
Tlc rcgion in tlis stuoy consists ol
9 prclccturcs (Tottori, Slimanc, kayama, Hiroslima,
Yamagucli, Tokuslima, Kagawa, Ilimc ano Kocli)
ano lao a population ol 11,S0,000 in 2001. A total ol
110 paticnts witl spontancous SAH wcrc rcgistcrco in
tlc projcct, ol wlom 9 (S.0') wcrc ol poor clinical
graoc at aomission. Tlc cruoc annual inciocncc ol
SAH (VINS Craocs I-V) in tlis stuoy was 12.1 pcr
100,000 population, ano tlc cruoc annual inciocncc ol
poor-graoc SAH (VINS Craocs IV ano V) was 1.1 pcr
100,000. Tlc agc ano scx-aojustco annual inciocncc lor
paticnts witl poor- graoc SAH (VINS Craocs IV ano V)
lasco on ccnsus oata in }apan was 1.1S pcr 100,000, ano
tlis inciocncc aojustco to tlc Unitco Statcs population
was .1 pcr 100,000.
|22
Tlc inclusion critcria lor tlc stuoy wcrc paticnts witl
poor-graoc SAH (VINS Craocs IV ano V) wlo wcrc
unocrgoing surgical trcatmcnt ol surgical clipping or CDC
cmlolization. VINS graocs ol paticnts wcrc oltainco
at aomission ly tlc ncurosurgcon lclorc rcsuscitation,
trcatmcnt ol intracranial lypcrtcnsion, ano intracranial
prcssurc control. Iaticnts trcatco witl otlcr typcs ol coils
lor cnoovascular trcatmcnt wcrc cxcluoco lrom tlc stuoy.
SAH was conlirmco in all paticnts ly lcao CT scans ano
classilico lasco on tlc Iislcr graoc: Croup 1, no llooo
octcctco, Croup 2, a oillusc ocposition or tlin laycr
witl all vcrtical laycrs ol llooo (intcrlcmisplcric lissurc,
insular cistcrn, amlicnt cistcrn) <1 mm tlick, Croup ,
localizco clots ano/or vcrtical laycrs ol llooo 1 mm
in tlickncss, ano Croup 1, oillusc or no sularaclnoio
llooo, lut witl intraccrclral or intravcntricular clots.
|2

Tlc prcscncc ano location ol an ancurysm was oiagnosco
ly tlrcc-oimcnsional CT angiograply (D-CTA) or
ccrclral angiograply in all paticnts. Sclcctco oata lor
lasclinc claractcristics, trcatmcnt, raoiograplic oata,
ano postopcrativc lospital coursc wcrc oltainco lrom
a rctrospcctivc rcvicw ol paticnts witl poor-graoc
ancurysmal SAH at multiplc ccntcrs in Clugoku ano
Slikoku, }apan.
|22
-)+,+.*) *//0//10,"
Agc, scx, VINS graoc, improvcmcnt ol VINS graoc,
Iislcr graoc, ancurysm location, rcllccoing, trcatmcnt
mooality (surgical clipping ano CDC cmlolization),
ano timc to intcrvcntion (21 l, 21-2 l, >2 l)
wcrc rccoroco as lasclinc claractcristics. Tlc outcomc
mcasurcs wcrc symptomatic vasospasm, LDA associatco
witl vasospasm on CT, slunt-ocpcnocnt lyoroccplalus,
lcngtl ol lospital stay, clinical outcomc at oisclargc,
ano mortality. Symptomatic vasospasm was as prcviously
oclinco lasco on clinical critcria ol (1) onsct ol ncw
ncurological oclicits sucl as conlusion, oisoricntation,
orowsincss, or local motor oclicit on oays 1 to 11 altcr
onsct ol SAH, (2) ncgativc linoings on CT scans oltainco
to rulc out otlcr causcs ol ncurological octcrioration,
sucl as surgcry, lyoroccplalus, or intracranial rcllccoing,
ano () no otlcr iocntiliallc causc ol ncurological
octcrioration, sucl as scizurc, inlcction, clcctrolytc
imlalancc, or mctalolic oisturlanccs.
|22
Conlirmation
ol vasospasm ly angiograply or transcranial Dopplcr
ultrasonograply was rccommcnoco, lut not rcquirco.
A ncw LDA associatco witl vasospasm on CT scans was
oclinco as a ncw inlarction il it lao not lccn olscrvco at
aomission ano tlcrc was no causc otlcr tlan vasospasm.
Clinical outcomc at oisclargc was asscssco using tlc
Clasgow utcomc Scalc (CS)
|
: a lavorallc outcomc
was oclinco as gooo rccovcry or moocratcly oisallco ano
a poor outcomc as scvcrcly oisallco, vcgctativc survival
or ocatl.
!"*"+/"+.*) *,*)%/+/
A
2
tcst ano Stuocnt ! tcst wcrc usco to comparc
variallcs lctwccn paticnts witl lavorallc ano poor
outcomcs. Iactors louno to lc signilicantly associatco
witl outcomc wcrc lurtlcr cxaminco ly multivariatc
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!"#$%&'( *+"#,(,$- ./0+#/'0%,/'( 2012, 3:143 bttp://www.surglcalneurologylnt.com/content/3/1/143
analysis (Statistical Analysis Systcm, SAS Institutc, Cary,
NC). Tlcsc lactors incluoco ocmograplic inlormation
(agc ano scx), SAH-rclatco variallcs (VINS Craoc
at aomission, improvcmcnt ol VINS Craoc witlin
2 l, Iislcr graoc, ancurysm location, rcllccoing,
timc to intcrvcntion, trcatmcnt mooality, symptomatic
vasospasm, LDA on CT, ano slunt-ocpcnocnt
lyoroccplalus), CS at oisclargc, ano mortality. Data
arc slown as mcan s stanoaro ocviation. A " valuc lcss
tlan 0.0 was consiocrco signilicant in all analyscs.
7=?:>0?
-(2(3" .2*3*."03+/"+./
Tlc mcan agc ol tlc 2S paticnts was 61.S ycars
olo, 6.' ol tlc paticnts wcrc lcmalc, 12 (11.9')
wcrc <6 ycars olo (mcan agc: .2 ycars olo), ano
16 (.1') wcrc 6 ycars olo (mcan agc: 1. ycars).
Tlc claractcristics ol tlc paticnts arc givcn lor all
paticnts ano lor tlc two agc groups in Tallc 1. Tlc goal
ol tlc stuoy was to cxaminc tlc outcomc ol surgical
trcatmcnt ol poor-graoc gcriatric paticnts witl SAH.
Tlcrclorc, wc usco 6 ycars olo as tlc cut-oll agc lor
lorming tlc two groups. Symptomatic vasospasm was
signilicantly morc common in paticnts agco 6 ycars olo
comparco to youngcr paticnts (" ~ 0.01). Tlc outcomc
was signilicantly worsc lor paticnts agco 6 ycars
olo comparco to youngcr paticnts (" < 0.001). VINS
Craoc IV/V at aomission ano improvcmcnt ol VINS
Craoc wcrc not signilicantly associatco witl an incrcasco
agc, lut paticnts wlo only improvco to prcopcrativc
Craoc IV lrom Craoc V at aomission wcrc signilicantly
morc likcly to lc 6 ycars olo (" < 0.0). Tlcrc wcrc
no otlcr signilicant oillcrcnccs lctwccn tlc agc groups.
Tlc mcan lospital stay ol paticnts agco 6 ycars olo
(9. oays) was longcr tlan tlat ol youngcr paticnts
(66.9 oays), lut tlc oillcrcncc was not signilicant.
4*."(3/ *//(.+*"0$ 5+"2 (#".(10
Iactors witl a potcntial association witl clinical outcomcs
at oisclargc (agc, scx, VINS Craoc at aomission,
improvcmcnt ol VINS Craoc witlin 2 l, Iislcr graoc,
ancurysm location, rcllccoing, trcatmcnt mooality,
symptomatic vasospasm, LDA on CT, slunt- ocpcnocnt
lyoroccplalus, ano timc to intcrvcntion) in tlc
16 paticnts agco 6 ycars olo wcrc cxaminco
ly univariatc analysis |Tallc 2. l tlcsc paticnts,
(2.') aclicvco a lavorallc outcomc at oisclargc,
incluoing 21 Craoc IV (6.0') ano 1 Craoc V (.0')
cascs. Tlc pcrccntagcs ol Craoc IV ano V paticnts witl
a lavorallc outcomc wcrc 2S.9' ano 1.S', rcspcctivcly.
Tlc outcomc was signilicantly worsc lor paticnts agco
ycars olo comparco to youngcr paticnts (" < 0.01).
LDA associatco witl vasospasm on CT (" < 0.01)
was signilicantly associatco witl a poor outcomc, ano
improvcmcnt ol VINS Craoc (" ~ 0.02) was signilicantly
associatco witl a lavorallc outcomc. Iaticnts witl VINS
Craoc IV at aomission improvco to prcopcrativc Craocs
I, II ano III in 1, ano cascs, rcspcctivcly, ano .S'
ol paticnts witl prcopcrativc VINS Craoc I-III lao
a lavorallc outcomc. Iaticnts witl VINS Craoc V at
aomission improvco to prcopcrativc Craocs I, II ano III
ano IV in 0, 1, 2 ano 19 cascs, rcspcctivcly. Tlcrc was a
lavorallc outcomc in .' ol paticnts witl prcopcrativc
VINS Craocs II ano III, lut in only 21.0' ol tlosc
witl prcopcrativc VINS Craoc IV. A lavorallc outcomc
occurrco in a liglcr pcrccntagc ol paticnts witl VINS
Craoc IV at aomission (6.0') comparco to tlosc witl
VINS Craoc V at aomission (.0'), lut tlc oillcrcncc
was not signilicant. Iislcr graoc (" < 0.001) slowco a
signilicant association witl outcomc. Icllccoing was not
signilicantly associatco witl outcomc, ano a signilicant
numlcr ol cascs ol rcllccoing occurrco on oay 0 (SS.1')
or witlin 6 lr (0.') ol tlc onsct ol SAH. Vc also
cxaminco a sul- group ol 1S paticnts wlo unocrwcnt
surgical ollitcration ol tlc ancurysm ano in wlom tlc
timc to intcrvcntion was known accuratcly. Howcvcr, tlc
timc to intcrvcntion in tlis sul-group was not signilicantly
associatco witl outcomc. Among all paticnts rccruitco
into tlc original stuoy, 1S wcrc 6 ycars olo ano oio
not rcccivc surgical trcatmcnt. l tlcsc paticnts, 2 (1.1')
lao a lavorallc outcomc at oisclargc. Tlc mortality ratc
was 9.S' (16 / 1S), incluoing 2S Craoc IV (1.') ano
10 Craoc V (S1.') cascs (oata not slown).
4*."(3/ *//(.+*"0$ 5+"2 "30*"10," 1($*)+"%
Tlc trcatmcnt mooality (surgical clipping or CDC
cmlolization) in tlc 16 paticnts agco 6 ycars
olo was cxaminco ly univariatc analysis |Tallc .
Iostcrior circulation (lasilar artcry, vcrtclral artcry, ano
postcrior ccrclral artcry) ancurysms wcrc prcscnt in
only (.9') ol tlc 11S paticnts trcatco witl clipping,
lut in 11 (6.S') ol tlc S paticnts wlo rcccivco
CDC cmlolization (" < 0.001). A lavorallc outcomc
was oltainco in a liglcr pcrccntagc ol paticnts trcatco
witl CDC cmlolization (2S.9') comparco to tlosc
wlo unocrwcnt surgical clipping (22.0'), lut tlc
oillcrcncc not signilicant. Tlcrc wcrc no otlcr signilicant
oillcrcnccs lctwccn tlc trcatmcnt sul-groups.
6#)"+7*3+*"0 *,*)%/+/ *,$ (#".(10 '30$+."+(,
Tlc lour lactors witl a signilicant cllcct on outcomc
iocntilico in univariatc analysis in paticnts agco
6 ycars olo (agc, Iislcr graoc, improvcmcnt ol VINS
Craoc, LDA on CT) ano a lactor witl a signilicant cllcct
on outcomc iocntilico in univariatc analysis in paticnts
ol all agcs (VINS graoc at aomission)
|22
wcrc lurtlcr
cxaminco ly multivariatc analysis to octcrminc tlc ocgrcc
to wlicl cacl variallc was inocpcnocntly corrclatco witl
outcomc. In tlis analysis, agc (cspccially ycars olo,
" ~ 0.01), Iislcr group 1 (" ~ 0.002), ano LDA on CT
(" ~ 0.00) cmcrgco as prcoictors ol a poor outcomc in
paticnts agco 6 ycars olo |Tallc 1. Tlis analysis also
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!"#$%&'( *+"#,(,$- ./0+#/'0%,/'( 2012, 3:143 bttp://www.surglcalneurologylnt.com/content/3/1/143
slowco tlat VINS Craoc IV at aomission (" ~ 0.02)
was wcakly associatco witl a lavorallc outcomc in tlcsc
paticnts |Tallc 1.
95?;:??586
In tlis rcport, wc ocscrilc a rctrospcctivc stuoy ol
2S paticnts witl poor-graoc SAH wlo unocrwcnt surgical
ollitcration ol tlc ancurysm at 66 mcoical ccntcrs in
Clugoku ano Slikoku, }apan. l tlcsc paticnts, 16
wcrc 6 ycars olo. Tlc cruoc annual inciocncc ol
SAH (VINS Craocs I-V) ano tlc agc ano scx-aojustco
inciocncc ol poor-graoc SAH (VINS Craocs IV ano V)
in tlis stuoy inoicatco tlat most paticnts witl SAH
in Clugoku ano Slikoku wcrc incluoco, ano tlus an
accuratc asscssmcnt ol outcomc lor poor-graoc SAH in
tlcsc rcgions is provioco in tlis onc-ycar stuoy.
|22
Scvcral stuoics lavc suggcstco tlat aovancco agc
is associatco witl a poor outcomc in paticnts witl
poor- graoc SAH,
|1,11,1
lut otlcrs lavc louno no
signilicant association lctwccn outcomc ano agc.
|9,1

In our oata, poor-graoc SAH paticnts ol all agcs lao a
lavorallc outcomc in 1.' ol cascs. Iurtlcr analysis
inoicatco lavorallc outcomcs in 1.2' ano 2.9' ol
paticnts agco <6 ano 6-1 ycars olo, rcspcctivcly,
lut in only 11.' ol paticnts agco ycars olo.
Multivariatc analysis iocntilico aovancco agc ( ycars
olo) as a prcoictor ol a poor outcomc. Tlcsc rcsults
inoicatc an association lctwccn aovancco agc (cspccially
ycars olo) ano a poor outcomc in paticnts witl poor-
graoc SAH.
LcIoux #! %&.
|11
suggcstco tlat clinical graoc (Hunt
ano Hcss Craoc V) at aomission was inocpcnocntly
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!**< *Q#S*D% ,HW( LH( W. 208 ,87+4. 84 ,7/+0. 226 ,48+1.
A*<#"R$#; "# J$'SP"<:%( &*+ ,-. 84 ,/1+4. /4 ,/2+1. 53 ,/7+8. GH
WFNS: Worlo Feoeratlon ot Neurosurglcal Socletles, GDC: Gugllelml oetacbable colls, NS: Not slgnl!cant, LDA: low oenslty area, CT: Computeo tomograpby, GOS: Glasgow
Outcome Scale, GR: Gooo recovery, MD: Mooerately olsableo, SD: Severely olsableo, vS: vegetatlve survlval, D: Deatb, |C: |nternal carotlo artery, ACA: Anterlor cerebral artery,
AcomA: Anterlor communlcatlng artery, MCA: Mloole cerebral artery, 8A: 8asllar artery, vA: vertebral artery, PCA: Posterlor cerebral artery. Aneurysm locatlon (Anterlor
clrculatlon) oe!neo as |C, ACA, AcomA, ano MCA. Aneurysm locatlon (Posterlor clrculatlon) oe!neo as 8A, vA, ano PCA. LDA on CT oe!neo as LDA assoclateo wltb
vasospasm on CT. Hyorocepbalus oe!neo as sbunt-oepenoent byorocepbalus. Favorable outcome oe!neo as GOS (GR, MD) at olscbarge ano poor outcome oe!neo as GOS
(SD, vS, ano D) at olscbarge
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corrclatco witl a poor outcomc, ano scvcral stuoics
lavc suggcstco tlat ncurological improvcmcnt is
associatco witl a lavorallc outcomc in paticnts witl
poor-graoc SAH.
|6,19,22,2
In our stuoy, VINS Craoc IV
at aomission in poor-graoc clocrly paticnts witl SAH was
a wcak inocpcnocnt prcoictor ol a lavorallc outcomc
in multivariatc analysis. Improvcmcnt ol VINS Craoc
was iocntilico as a prcoictor ol a lavorallc outcomc in
univariatc analysis, lut oio not slow an inocpcnocnt
association in multivariatc analysis. Altlougl tlc ratc
ol VINS Craoc IV/V at aomission ano improvcmcnt
ol VINS Craoc wcrc not signilicantly associatco witl
incrcasco agc, paticnts wlo only improvco to prcopcrativc
Craoc IV lrom Craoc V at aomission wcrc signilicantly
morc likcly to lc 6 ycars olo. Vc notc tlat wc
prcviously louno tlat most paticnts wlo only improvco
to prcopcrativc Craoc IV lrom Craoc V at aomission
oio not lavc a lavorallc outcomc.
|22
Tlc rcason lor
tlc wcak association ol improvcmcnt ol VINS Craoc
witl outcomc miglt lc tlc small numlcr ol cascs ol
improvcmcnt to prcopcrativc VINS graocs II ano III
among tlc clocrly paticnts.
LcIoux #! %&.
|11
ano Slimooa #! %&.
|21
lavc suggcstco
tlat intravcntricular lcmorrlagc (Iislcr group 1) in
paticnts witl poor-graoc SAH is also associatco witl
a poor outcomc. In our stuoy, tlc Iislcr graoc in
clocrly paticnts witl poor-graoc SAH was iocntilico
as an inocpcnocnt prcoictor ol a lavorallc outcomc
in multivariatc analysis. Tlus, clocrly paticnts miglt
lc rcsistant to rccovcry lrom initial oamagc sucl as
intravcntricular ano/or intraccrclral lcmorrlagc, as wcll
as to improvcmcnt ol VINS Craoc. Lc Ioux #! %&.
|11

also louno tlat a LDA on CT was signilicantly corrclatco
witl a poor outcomc in paticnts witl poor-graoc SAH,
wlicl is consistcnt witl our linoings lor clocrly paticnts
witl poor-graoc SAH. Howcvcr, tlis is not rclcvant to
octcrmining wlctlcr surgical trcatmcnt sloulo lc ollcrco
to paticnts witl ncw SAH. Lanzio #! %&.
|10
louno tlat
!"#$% @( A?41+*% 6+- ."40%245 ",%3 89 :%"-5 +$3 #"5%3 +2 3%*+,-"./01 "23 1$0201"$ 1/"-"14%-054015
;/"-"14%-05401B C">+-"#$% +?41+*% =++- +?41+*% = >"$?%
!"#$%&#'( &*+ ,-. 14 ,/1+4. 226 ,48+1.
A%"& ":% ,;<. 4/+/ 47+1 @3+32
9:% ,;<.( &*+ ,-.
87>45 ;< /8 ,43+1. 71 ,55+7. @3+32
47 ;< 22 ,/6+4. 88 ,77+7.
A%&BC*D%&( &*+ ,- C*D%&. 21B/5 ,85+6. /0B62 ,48+7. GH
EFGH I<"J%( &*+ ,-.
I<"J% KL "# "JD$''$*& /5 ,87+3. 76 ,56+8. GH
I<"J% L "# "JD$''$*& 21 ,17+3. 83 ,73+5.
KDM<*?%D%&# *N EFGH I<"J%( &*+ ,-. 21 ,17+2. /2 ,24+8. 3+3/
!<%*M%<"#$?% EFGH I<"J% ,I<"J% KL "# "JD$''$*&. KOKKOKKK 1/4/2 0/1/1
!<%*M%<"#$?% EFGH I<"J% ,I<"J% L "# "JD$''$*&. KOKKOKKKOKL 3O/O3O5 3O/O/O27
F$'P%< :<"J%( &*+ ,-.
I<*QM' 2 "&J / 3 ,3. / ,2+4. @3+332
I<*QM 1 1/ ,08+7. 83 ,73+5.
I<*QM 5 7 ,21+7. 74 ,54+6.
9&%Q<;'D R*S"#$*&( &*+ ,-.
9&#%<$*< S$<SQR"#$*& /6 ,40+5. 238 ,06+2. GH
!*'#%<$*< S$<SQR"#$*& 0 ,/2+8. 21 ,23+6.
=%TR%%J$&:( &*+ ,-. 4 ,20+6. 23 ,0+5. GH
U<%"#D%&# D*J"R$#;( &*+ ,-.
VR$MM$&: /8 ,43+1. 6/ ,44+1. GH
IWV %DT*R$X"#$*& 22 ,/6+4. /4 ,//+4.
H;DM#*D"#$S ?"'*'M"'D( &*+ ,-. 20 ,50+8. 55 ,14+3. GH
YW9 *& VU( &*+ ,-. 4 ,20+6. 72 ,5/+6. @ 3+32
Z;J<*S%MP"RQ'( &*+ ,-. 20 ,50+8. 82 ,72+1. GH
U$D% #* $&#%<?%&#$*&( &*+ ,-.
\
/5 P< /6 ,07+1. 63 ,08+7. GH
/5>4/ P< 5 ,22+0. 5 ,1+0.
]4/ P< 2 ,/+6. 23 ,6+8.
*All cbaracterlstlcs reter to tbe patlents oescrlbeo ln Table 1 unless otberwlse lnolcateo,
|
n = 138 patlents wbo unoerwent surglcal obllteratlon ot tbe aneurysm ano ln wbom tbe
tlme to lnterventlon was known accurately
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symptomatic vasospasm was morc lrcqucnt in clocrly
paticnts, wlcrcas Iyttlclors #! %&.
|16
suggcstco tlat agc
was not a signilicant prcoictor lor ccrclral vasospasm
altcr SAH. In our stuoy, symptomatic vasospasm was
wcakly associatco witl paticnts agco 6 ycars olo
comparco to youngcr paticnts witl poor-graoc SAH.
CDC cmlolization las lccn applico to poor-graoc SAH
paticnts in prcvious stuoics
|,11,21
ano is a major aovancc in
tcrms ol surgical ollitcration ol an ancurysm. Tlc currcnt
cviocncc ol a potcntial lcnclit ol CDC cmlolization
ovcr surgical clipping is lasco mainly on tlc Intcrnational
Sularaclnoio Ancurysm Trial.
|11
Howcvcr, tlc numlcr
ol paticnts witl a poor graoc SAH in tlis trial was
small ano tlc trcatmcnt cllcct ol CDC cmlolization
was lctcrogcncous ano oillicult to intcrprct lasco on
tlc VINS graoc at lasclinc. ur stuoy inoicatco tlat
tlc pcrccntagc ol lavorallc outcomcs in paticnts witl
poor-graoc SAH agco 6 ycars olo trcatco witl CDC
cmlolization was liglcr tlan tlat lor surgical clipping,
lut tlc oillcrcncc was not signilicant. Icccntly, Horiucli
#! %&.
|
suggcstco tlat aovancco agc was not a risk lactor
lor a poor outcomc ol clipping surgcry in clocrly paticnts,
ano Karamanakos #! %&.
|S
suggcstco tlat intcgration ol coil
trcatmcnt in clinical practicc las not improvco tlc ovcrall
outcomc ol SAH in tlc clocrly. Altlougl cnoovascular
coiling las lccomc a major lorm ol trcatmcnt lor SAH
in clocrly paticnts, not all rupturco ancurysms can lc
managco witl an cnoovascular approacl. ur stuoy may
provioc critcria lor sclcction ol tlc surgical trcatmcnt
mooality in clocrly paticnts witl poor-graoc SAH. Vc
proposc tlat tlis occision sloulo lc maoc lasco on tlc
ancurysm lcaturcs ano gcncral conoition, ano tlat clinical
graoc ano agc sloulo lc incluoco as rclcrcncc inlormation.
Scvcral stuoics lavc louno tlat carly surgcry lor
poor- graoc SAH is associatco witl a lavorallc
outcomc,
|1,9,12,20
lut tlcrc is littlc availallc inlormation
on tlc optimum timc at wlicl sucl paticnts sloulo
unocrgo surgcry. Iurtlcrmorc, to our knowlcogc, tlc
association ol tlc timc to intcrvcntion witl a poor
outcomc las not lccn cxaminco prcviously in clocrly
paticnts witl poor-graoc SAH. ur oata oio not inoicatc
a signilicant association lctwccn tlc timc to intcrvcntion
ano a poor outcomc in tlcsc paticnts. nc aim ol carly
surgcry is prcvcntion ol rcllccoing, lut tlc ultra-carly
rcllccoing ratc ano risk ol rcllccoing arc liglcr in poor-
graoc paticnts.
|21
In our stuoy, most cascs ol rcllccoing
occurrco on Day 0 (21 l) or witlin 6 l ol onsct ol SAH,
ano ultra-carly surgcry (21 l) miglt not lcsscn tlc risk
ol rcllccoing in clocrly paticnts witl poor-graoc SAH.
;86;>:?586?
ur analysis ocmonstratcs tlat aovancco agc ( ycars
olo), Iislcr group 1, ano a ncw LDA associatco witl
vasospasm on CT arc inocpcnocnt prcoictors ol outcomc
!"#$% D( )%*+,-"./01 "23 1$0201"$ 1/"-"14%-054015 02
."40%245 ",%3 89 :%"-5 +$3 "11+-302, 4+ 4-%"4*%24
*+3"$04:
;/"-"14%-05401 ;$0..02, E); %*#+$0F"40+2 =G>"$?%
!"#$%&#'( &*+ ,-. 220 ,47+8. 10 ,/5+5.
A%"& ":% ,;<. 45+8 45+1 GH
A%&BC*D%&( &*+ ,-
C*D%&.
/6B06 ,47+5. 2/B/8 ,80+5. GH
EFGH I<"J%( &*+ ,-.
I<"J% KL "# "JD$''$*& 84 ,78+0. 28 ,5/+2. GH
I<"J% L "# "JD$''$*& 72 ,51+/. // ,74+6.
KDM<*?%D%&# *N EFGH
I<"J%( &*+ ,-.
/5 ,/3+1. 6 ,/1+4.
F$'P%< :<"J%( &*+ ,-.
I<*QM' 2 "&J / 2 ,3+0. 2 ,/+8. GH
I<*QM 1 84 ,78+0. /7 ,87+0.
I<*QM 5 73 ,5/+5. 2/ ,12+8.
9&%Q<;'D R*S"#$*&( &*+ ,-.
9&#%<$*< S$<SQR"#$*& 222 ,65+2. /5 ,81+/. @ 3+332
!*'#%<$*< S$<SQR"#$*& 4 ,7+6. 25 ,18+0.
=%TR%%J$&:( &*+ ,-. 2/ ,23+/. 7 ,21+/. GH
H;DM#*D"#$S ?"'*'M"'D(
&*+ ,-.
54 ,16+0. 27 ,16+7. GH
YW9 *& VU( &*+ ,-. 57 ,10+2. 21 ,15+/. GH
Z*'M$#"R '#"; ,J";'. 02+7 41+/ GH
I[H "# J$'SP"<:%( &*+ ,-.
F"?*<"TR% *Q#S*D%
,I=( AW.
/8 ,//+3. 22 ,/0+6. GH
!**< *Q#S*D% ,HW( LH( W. 6/ ,40+3. /4 ,42+2.
!"#$% H( I23%.%23%24 .-+,2+5401 6"14+-5 +6 " .++- +?41+*%
"4 3051/"-,% 6+- ."40%245 ",%3 89 :%"-5 +$3 #"5%3
+2 *?$40>"-0"4% "2"$:505 +6 ",%J C05/%- ,-"3%J K+-$3
C%3%-"40+2 +6 L%?-+5?-,01"$ M+10%40%5 ,-"3%J 0*.-+>%*%24
+6 K+-$3 C%3%-"40+2 +6 L%?-+5?-,01"$ M+10%40%5 ,-"3%J "23
$+N 3%2504: "-%" +2 1+*.?4%3 4+*+,-"./:
;/"-"14%-05401 A335 -"40+ O9P ;I = >"$?%
9:% ,;<.
87>45 ;< 2
47 ;< 1+/36 2+128>4+0/3 3+32
F$'P%< :<"J%
I<*QM' 2(/ "&J 1 2
I<*QM 5 7+5/1 2+018>28+320 3+33/
EFGH I<"J%
I<"J% KL "# "JD$''$*& 2
I<"J% L "# "JD$''$*& /+821 3+66/>8+00/ 3+37/
KDM<*?%D%&# *N EFGH I<"J%
KDM<*?%D%&# ,>. 2
KDM<*?%D%&# , ^ . 3+737 3+245>2+58/ 3+/30
YW9 *& VU
YW9 ,>. 2
YW9 ,^. 1+662 2+57/>23+688 3+334
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in clocrly paticnts witl poor- graoc SAH. VINS Craoc V
at aomission may also lc an inocpcnocnt prcoictor ol
outcomc in tlis paticnt population. Improvcmcnt ol VINS
Craoc was iocntilico as a prcoictor ol a lavorallc outcomc
in univariatc analysis, lut oio not slow an inocpcnocnt
corrclation witl outcomc in multivariatc analysis. Tlc
ratc ol a lavorallc outcomc in clocrly paticnts witl poor-
graoc SAH trcatco witl CDC cmlolization was liglcr
tlan tlat witl surgical clipping, lut witl no signilicant
oillcrcncc. Iarly ancurysm surgcry was not louno to lc an
inocpcnocnt prcoictor ol outcomc in clocrly paticnts witl
poor-graoc ancurysm. Tlc rcsults ol tlis stuoy sloulo not
lc takcn as prool ol prcopcrativc prcoiction ol outcomc in
clocrly paticnts witl poor-graoc SAH, sincc wc only lookco
at paticnts wlo rcccivco surgical trcatmcnt ano cxcluoco
tlosc wlo wcrc not trcatco. Irool ol prcopcrativc prcoiction
ol outcomc in clocrly paticnts witl poor-graoc SAH can
only lc accomplislco in a ranoomizco controllco trial in a
largc numlcr ol paticnts at multiplc ccntcrs. Howcvcr, our
rcsults oo conlirm prcviously iocntilico trcnos lor outcomc
in clocrly paticnts witl poor-graoc SAH.
!;(68,>=9A<=60?
Vc tlank tlc mcmlcrs ol tlc Clugoku-Slikoku Division ol tlc
}apan Ncurosurgical Socicty wlo maoc tlc projcct possillc: Isao
Datc, M.D., Kaoru Kurisu, M.D., Kciji Slimizu, M.D., Masaaki
Uno, M.D., Slinji Nagaliro, M.D., Takanori lnisli, M.D.,
Takasli Tamiya, M.D., Takasli Vatanalc, M.D., ano Yasuliko
Akiyama, M.D. Vc also tlank tlc mcmlcrs ol tlc projcct ol
tlc Clugoku-Slikoku Division ol tlc }apan Ncurosurgical
Socicty lor provioing oata.
7=B=7=6;=?
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DiscIaimer: The authors report no con!ict of interest concerning
the methods and "ndings in this study.
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