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    The epidemia HSA

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    The epidemia HSA

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    © All Rights Reserved
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    26 views19 pages

    Kassell 1990

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    Roberto Andrade
    The epidemia HSA

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    J Neurosurg 73:18-36, 1990 The International Cooperative Study on the Timing of Aneurysm Surgery Part 1: Overall management results Neat. F. Kassett, MD., Janes C. Towner, Pu.D., E. Clarke Hatey, JR, M.D. Jonw A. Jane, MD, PH.D, HAROLD P. ADAMS, M.D. Gall. L. KONGABLE, BS.N., AND PARTICIPANTS Department of Newwological Surgery, University of Virginia Health Sciences Center, Charlottesville Virginia, and Department of Newology, University of lowa, lowa City. Towa © The International Cooperative Study on the Timing of Aneurysm Surgery evaluated the results of surgical ‘and medical management in 3521 patients between December, 1980, and July, 1983. At admission, 75% of patients were in good neurological condition and surgery was performed in 83%. At the 6-month evaluation, 26% of the patients had died and 58% exhibited a complete recovery. Vasospasm and rebleeding were the leading causes of morbidity and mortality in addition 10 the initial bled. Predictors for monalty included the patient's decreased level of consciousness and increased age, thickness of the subarachnoid heraorshage clot ‘on computerized tomography, clevated blood pressure, preexisting medical illnesses, and basilar aneurysms The results presented here document the status of management in the 1980's. Key Worps + aneurysm + subarachnoid hemorrhage + ‘an aneurysm arising from the circle of Willis kills or disables approximately 18,000 individuals in North America each year."** In order to effectively plan, develop, and evaluate therapeutic measures for improving the outcome in patients with ancurysmal SAH, a full understanding of the rates and causes of mortality and morbidity must be available. While there are numerous reports describing the results of surgery to correct ruptured aneurysms,"4!2120-25y838a846548 few series include death and disability occurring before as well as after surgery, or in unoperated patients” 8 Furthermore, it is difficult to compare these reports of management results because of differ- ences in patient populations with regard to prognostic factors for death and disability, in addition to varia- tions in the timing and methods for quantitating 0: come. Also, these reports usually describe the results Ste hemorrhage (SAH) from rupture of ‘The Advisory Committee and participating centers and individuals are listed in the Appendices at the end of this Report. 8 multicenter management study Cooperative Aneurysm Study achieved by individual surgeons and centers, there is currently no broad-based experience to serve as a stan- dard for comparison. The International Cooperative Study on the Timing of Aneurysm Surgery was initiated with two objectives, to define the relationship of the timing of surgery to ‘outcome in patients with ruptured aneurysms, and to document the results of contemporary medical and surgical management in a large number of centers Uhroughout the world. This paper addresses the second objective. Timing of surgery will be dealt with in the subsequent communication Clinical Material and Methods Overview ‘This study was a prospective, observational epide- miological survey. Outcome was evaluated 6 months following SAH by observers who were not involved in patient management, For analytical purposes, the study design required approximately 3000 patients who were admitted on Day 0 to 3 following their first major SAH; Day 0 was defined as the calendar day of the hemor- J. Neurosurg. / Volume 73 / July, 1990 Surgical and medic: TABLE 1 Loaion f participa centers No.of County Comers United Sates ™ Japan PR United Kingdom Australia Canad Scandinavia France West Germany aust Hotlans Hungary South Africa ‘Yopostavia ‘thage. In order to accomplish the data-collection phase ina reasonable time frame, a multicenter approach was required, Study Organization The three organizational components to this study included an Advisory Committee, a Central Registry. and the participants. Members of the Advisory Com- mittee and the Central Registry are listed in Appendix 1. The Central Registry consisted of that group of statisticians, epidemiologists, computer programmers, neurologists, neurosurgeons, and neurosurgical nurses who were responsible for the day-to-day operation of the study. They were involved in ongoing project ad- ministration, training of the participants, data manage- ‘ment, statistical analysis, and preparation of results for presentation and publication, Participants included 68 neurosurgical centers in 14 countries (Table 1), Each center had a reporting inves- tigator who was responsible for the conduct of the study at that study site, one or more operating surgeons who performed the operative and perioperative patient care, ‘and an evaluator (usually @ neurologist) who conducted the follow-up examination and was independent of the ‘management of the patients and blind to the timing of surgery (Appendix 2). Criteria used by the Advisory Committee for selecting centers and surgeons included agreement to the terms of the study, capability to ad~ here to the protocol, utilization of contemporary man- agement practices, achievement of reasonable results, seographical accessibility to the Central Registry for training and auditing, an adequate caseload, and a se- rious interest in aneurysmal SAH, Data Collection Four principal data-collection instruments were util+ ized: en SAH log, a registration form, a treatment form, and a follow-up form. Each center kept a log of all patients admitted with a diagnosis of SAH or intracra- nil aneurysm. This log included patient identification, J. Neurosurg. / Volume 73 / July. 1990 ‘management results in aneurysm cases date of admission. eligibility status, and (when required) reasons for exclusion from the study. The registration form was completed following the initial evaluation, It contained demographic data initial neurological assessment, results of angiography and computerized tomography (CT), and a specification of planned time of surgery. The treatment form was com- pleted upon the patient's discharge. It included pre- and postoperative neurological assessments, medications and routines, and neurological and medical problems that arose during hospitalization. In addition, operative conditions and surgical techniques were recorded. The follow-up form was completed at 6 months + 2 weeks following the initial SAH or at the time of death (if prior to the 6-month evaluation). This form included the outcome neurological assessment, the disability status of the patient, andjor the estimated cause of death and disability, An adaptation of the Glasgow ‘Coma Scale" was used for the admission, and preop- erative, postoperative, and 6-month follow-up neuro- logical assessments (Table 2). The Glasgow Outeome Scale'" was used to document the disability level at the follow-up evaluation (Table 3). In addition, four supplemental data-request forms ‘were utilized to address research questions that devel- oped as the study evolved. These included forms to obtain detailed information about recurrent SAH. use of antifibrinolytic therapy, development of focal ische- mic deficits. and postoperative CT results The quality of data exceeded expectations. Comple- tion rates were 100% for the registration forms, 99.9% for the treatment forms, and 99.9% for the follow-up forms. Information was available on 99.7% of patients through hospitalization and only 0.6% of patients were lost to follow-up review. To verify the evaluation proc- ess. an audit in 57 centers of 760 patients who had been classified as good or moderately disabled was conducted, an average of 14 months after SAH. The misclassifica- tion rate was 3% for the good recovery and 9% for the moderately disabled categories. Outcome Measures Two main methods of measuring outcome were util- ized in this study: good results and death. These were quantitated using the Glasgow Outcome Scale (Table 3). A “good recovery” was considered the most impor- tant end-point. The functional status of the patients was graded according to the Glasgow Outcome Scale (scheduled at 6 months + 2 weeks following SAH). This evaluation and a neurological examination were performed by observers who were independent of the management of the patients and blind to the time of surgery. At the time of death or at the 6-month post-SAH evaluation, the cause of death or disability was estimated by the ‘operating surgeon based on clinical grounds. Pre-. in- tra-, and postoperative complications were recorded. by the operating surgeons during the patient’s hospital- ization, 19 TABLE 2 Newological assessor Caton) Level af Consciousness filly alert, drowsy Speech normal aysphasie vera rexponse Orientation immaired Response o Commands inappropriate or ‘one a al Motor Response noemal response mild foal dei severe focal defisit abnormal Rexor posturing abnormal extensor posturing no response Meningeal Signs none present headache si nsck Cranial Nerves no involvement third other (spect) 20 Desription yes open spontaneous): immediately re Sponsve to verbal sia ‘yer open when simalated verbally: con sciousness impaired slghly ‘ee open ony in response © inf ‘Simul: arousal incomplete and patient revens wo original state when not stimi- lated ves do not open to painful stimuli: pe tien does nt obey commands ane doesnot speak intelligible words patient converses carly and with appro= priate inflections presents with elements of expressive and ‘oreomprehensive aphasia disorder of ‘sommuniation indicating fea in ‘olvement ofthe language center smay uter sounds or groans but doesnot develop incligtle speech accurate response fo questions regarding ‘renation to time place and person sberations in anyone oral of the three items mentioned above responds appropriately to such commands 35 “close our eyes” or “stick out your tongue” tis presupposes patient has cleared the aphasa test mentioned above responses carried out incompletely eb. ‘without precision oF nota all complet function of al pants: facial mus: ‘les, bulbar musculature, exerts slight weakress (e, pronator dif. slow. ra of rapid alternating movement ually of ene sie of body Chemins= ess) pronounced weakness: homonymous emianopsia exo osu in espns pun tens string. in espns in ‘complete Naciity, with no response 19 Painfal stimulation no neck sifines or complaint of head ‘ashe unique in its intensity and persistence; of ten asociated with vomiting and pho- tophobia limited motion and pin on antiexion al cranial ners intact ncang ocular partial or complete involvement of 3rd ner, including pupillary dilation as ur ofuneal herniation syndrome ‘occasionally gaze pals, involvement of ‘ocular roars other than 38 neve, of penpheral th and athr cranial nerves N. F. Kassell, ef al. TABLE 3 Glaxgone Ourome Seale Caezory Desrintion food weovery patient ean lead fll and independent bie ‘with or without minimal neurological Aeon roderatelydsabad—patint having neurological or intletuat implement but isindependent severely dusbled conscious patient ut toally dependent on ‘ters et through the atts ofthe ‘egetative survival ead Statistical Methods To adjust for the effects of differences in patient characteristics between centers on both overall manage- ‘ment results and surgical results, multivariate prognos- tic models for good results and mortality were derived using proportional hazards regression methods. Models were developed from the first half of the patient data base and verified utilizing the second half: The detaits of analysis will be reported subsequently elsewhere. Table 19 lists the factors examined and their level of significance for forecasting overall management and surgical good results and mortality. Study Population Eligibility and Exclusion Criteria. Eligibility eri- teria for this study included: admission to a participat- ing center on Day 0 to 3 following the first major SAH from a saccular aneurysm; confirmation of SAH by lumber puncture, CT scan, or surgery; and presence of an aneurysm confirmed by angiography. A CT scan \was required within $ days of the initial SAH. Between December, 1980, and July, 1983, 8879 pa- tients with the diagnosis of intracranial aneurysm or SAH were admitted to the 68 participating centers. OF these, 3521 were eligible and registered into the study. While the study design called for registration of 3000 patients in approximately 36 months, accrual was sub- stantially ahead of schedule and the total number of | patients was greater than planned. The principal reasons for exclusion from the study ‘were admission more than 3 days following SAH, fail- ure to demonstrate an aneurysm by angiography, and multiple bleeds prior to admission (Table 4). Demographic and Clinical Characteristics. The demographic characteristics of the study population ‘were very similar to those observed in other large series of patients with ruptured aneurysms."**"* Pa. tients ranged in age from 18 to 87 years (16 patients under the age of 18 years were excluded) and the average age was $0.4 years (Fig. 1). The female:male ratio was L.6:l. Prior io the age of 40 years there was equal distribution between men and women; subsequent 10 that, there was a strong increase in female preponder- J. Neurosurg. / Volume 73 / July, 1990 Surgical and medical management results in aneurysm cases TABLE 4 TABLE 5 eas for excision fam series Medical conditions presen prior to subarachnoid hemorthage — = (by histor) — Cases = No. Percent Medica Problems See “admitted more than 3 days post SAH 207457 pa cea SAI of unknown etiology 73149) hypertension 212 multiple Hees prio to admission 33113 sabetes meus 20 ‘noraneurysmal SAH Me TS asthma a Aneurysm tus not determined by angiography 3506.6 ‘hroni tung disease 3 ‘orautopsy antychmia 2 urgent evacuation of hematoma 2 82 tstrcintestinal bleeding ro Sneidemal aneurysm Ws 3 angina to ‘ongatcipating surgeon Rs 24 cardia failure to fusorm. mycouc. oF aumatic aeussm 84 ‘myocardial infarction os medical complications 8 OR anemia 06 late tests 2% 05 fenal flare 06 patient/family refusal Is 03 cereal ichemia 06 les than 18 years of age Ie 03 hone liver disease 04 riselasited—potentially eligible sD hepatitis 04 multiple reasons 4 09 cerebral hemorrhage 03 tous 5358 1000 Dleding disorder on + SAH = subarachnoid hemorrhage, * Percent of 3521 patients ance. Thirty-two percent of the patients were from Japan, 22% from North America, 14% from Italy, 10% from Great Britain, 8% from Scandinavia, and 14% from other regions. The patients’ medical history is presented in Table 5. ‘The most common preexisting medical problem prior to SAH was hypertension, which was reported in 21% of these patients. The incidence of hypertension in- creased rapidly as patients approached the age of 40 years after which it continued to increase but at a more gradual rate (Fig. 2). ‘The interval from SAH until admission is shown in Table 6. Eighty percent of patients were admitted within 48 hours of onset. Eighty-one percent of the patients were alert or drowsy on admission, 76% had normal motor responses, and 75% had normal speech Accordingly it could be considered that approximately three-quarters of the patients were in good neurological status at admission, The longer the interval between | FEOALEDMLE TIO = 137 al mss | 12 Drewes i, Fic. 1. Graph showing distribution of patients by age and sex, J. Neurosurg, / Volume 73 /-uly, 1990 SAH and admission the better was the neurological status on admission (Table 6). Of the patients admit- ted on Day 0, 41% were alert while 68% of patients ‘who were admitted on Day 3 were alert, Normal motor responses were observed in 69% of the patients admitted on Day 0 versus 86% of those admitted on Day 2 or 3 Blood pressure on admission was determined by the average of three measurements | hour apart. Systolic pressure ranged from 60 to 300 mm Hg (mean + standard deviation (SD) 150 + 29 mm Hg) and diastolic pressure ranged from 26 to 230 mm Hg (mean :: SD 88 + 16 mm Hg). Mean blood pressure was higher in patients admitted on Day 0 (153/90 mm Hg) than on Day 2 (146/86 mm Hg), Day 3 (147/86 mm Hg), and Day 4 (147/85 mm Hg) (p < 0.001). Mean blood pressure was higher in patients with altered lev- els of consciousness (alert 145/86 mm Hg, drowsy 152/89 mm He; stuporous 157/92 mm Hg; and coma- tose 157/91 mm Hg) (p < 0.001). Older patients had ES ‘allll & Aeon re) Fi. 2. Graph showing distribution of preexisting hyperten- sion by age. a N. F. Kassell, er al. TABLE 6 Neurological worws on admission Day! Su Bowen’ Ne Penent —NoPenent Na Pont Day 3 Total Neurological Feature lel oP consciousness Faller S87 US 2H8 BL RS_Ta rows Bi Be 9 68 BA stuporous 719 S38 99 ME 9 ‘comatose ol tes 8S speech oral a3 T8 0 GOS éysphasic oF RA 410047 10 verbal response aa 6965S onenition ormal osha STOR Rs impaired nD 46026 HOD response to com mands spproprate Hat 66366 sd 8S MOH inappropriate se 378 405 3TH motor response ‘normal Ce mil focal defen BO BT 3S 9a 20 severe focal deft 1287.1 Se ST ee en rn styormal Rexor a8 14 1 02 3d oD ahnormalestensor == 9253 1a 1 02 1 oe 0 no response le Ss 0s 3 a? 108 sk ‘meningeal sins one wt 1% 68M Th eadache 664 HD 789 2ST BL 89 Peck Ma 9ST MSS SD MTR cranial nerve doit ‘none 87310089 HD MISS third oe S328 DT. ther 4 2 <5 SN totals 89 osha) higher admission blood pressure than younger patients (85%). Intracerebral hematoma and intraventricular (Fig. 3), hematoma were cach present in 17% of scans. Hydro- ‘The CT scan on admission was abnormal in 92% of cephalus was noted in 15%. As with the neurological patients (Table 7). The most frequent finding was SAH conditions, the CT findings were time-dependent. TABLE 7 Finding on fist compucrized vomography (CT) sean™ Dayo Day 1 Total CrFingings EO —— No. Percent Nov Peveent Nov Percent Nov Poweent No. Percent Nov Percent Ne. Percent oemal SU aa O12 BCS 39 273 OD decreaed density Hoon ow 134 95 2 25 1 300 mas effec oko oT SH ow 2 26 2 64 ou aneurysm 3 47 0 4k Ta 5 65 0 00 50 hydrocephalus MS i600 1682 SE a 6 79 3 OL SF 52 ieuaventicuar hema 3122078 W B22 61 sm eT inuocercral hematoma «294 «189TH ST BSR 8D NT subdural ematome moe 7 07 6 13 2 OF 1 1s 0 oo 4 43 Subarachnoid HAD ODE 906 REA OAS) TTBS B51 29M BSD hemorhaget ities 8% Sid 506 ARIST STAT MD RDB ‘ain pl 18S 2) 93 SHS SST thick 587 326 3 6 116 2608 eS 7g B20 OO totale W553 $5.2 109405 446130279 RT H_—22 33138511000 ™ Fiten patients underwent CT scanning afer Day 5:70 patens Gi not have a CT sean 1 Classification was determined according wo Fisher. a" 22 J. Neurosurg. / Volume 73 / July, 1990 Surgical and medi TABLE 8 Rupeared anecresm Ancurssm si ‘Sill Ica 7901752) 22) MCA 56000 an ACA 11584843) 30711511 “900) Ve 2031763) “S8218) S19) other —"370529) 6 (86) 114) foal 2788780) 703,200) __ 302.0) ICA = imernal carotid artery: MCA = middle cerebral artery: ACA = anterior cerebral arery: VB = vertebrobasilar circulation "Numbers in parentheses indicate pereentapes Angiographically, 78% of the aneurysms were small (< 12 mm in diameter), 20% were large (12 to 24 mm in diameter), and 2% were giant (> 24 mm in diameter) (Table 8), Posterior circulation aneurysms were noted in 8% of the patients. OF the anterior circulation an- ‘eurysms, the order of frequency was: anterior com- municating/anterior cerebral artery aneurysms, then internal carotid artery aneurysms, then middle cere- bral artery ancurysms. The number of aneurysms per patient ranged from one to seven, Multiple aneurysms ‘were present in 19% of the cases. Thirty-one percent of the aneurysms were on the let, 34% were on the right, and 35% were midline. OF the 3521 eligible patients, 2877 had their initial angiogram on Days 0 to 7. Of these, 94% had no arterial narrowing or only minimal vessel changes (Table 9). ‘The appearance of angiographic vasospasm was related to the time at which the study was performed follow- ing SAH, Patient Management Medications and Management Routines. Medi cations utilized during hospitalization are listed in Ta- bble 10. The most frequently used medications were steroids and anticonvulsant agents, Hypervolemia was ‘management results in aneurysm cases setae Fiu. 3. Graph showing average (of three recordings) of systolic and diastolic blood pressure on day of admission stratified by ape TABLE 10 Preapeane and pooper medians admnstered Cases Medications —— No. Percent” ‘servis MoS anticonvulsants 2066 $87 Aaniibrinastics Ise a6 sedatives, iys 37 mannitol um 33 anthypenensives wa 303 Jow-molecularneight dextran RK 81 arctic analgesics ms Ro bypervcers mw 16 bureics an ‘asopressor agents 322 31 sminophll ne 112 22 isoproterenol o ry other 7400 Percent of 3521 patients, 2923 of whom underwent ancunsen surge. TABLE 9 Interval between subarachnotd hemorrhage and angiography (dass* Vasogpsm DVO Day 1 Day? Day 3 Days Days Day 6 Day? Gradet No % No % No % No % No % No % No % No 07 WS a6 #7 2 81 OE TE 0 aS) TS Re 1 SRO ' Moke 1 17 7) WT 647 2B 35D DAS 300 1 2% 43S GS SSS MOTO 2892 D6. 5 S06 8 O08 8 13 8 21 9 44 10 83 1 6H 8 160 4 2023 03 0 oo 3 08 3 15 @ 00 © of 0 oo Day 0= day ofhemorthage + Vasospasm categorized by the Fisher Grading Seale" as follows: Gade 0: no narrowing: Grae I minimal vest changes: Grade 2: proximal anterior cercbral artery or mile cerebral artery narrowed ut the lumen distinct ad at east | mm wide: Grade umen a the antenorcecbral artery or middle cerebral artery narrowed to about ©'S mam. the oul collateral anastomosis evident (ithe supraclinoidimermal cerebral artery involved, lumen about 1.3 ram) fof the shatow indisine, delayed forward flow, and often border 2one jade lumen ofthe proximal middle cerebral artery of anterior cerebral artery less than 0-S mim. forward low almost halted (dhe suprachoid internal carotid artery lumen less than 1S em), J. Neurosurg. /Volume 73 /ulv, 1990 23 TABLE 1 Preoperative and postoperative management rvines wed in this sries® N. F. Kassell, et al. Management Routines ‘enincular CSF drainage 621 permanent CSF shunt 2a lumbar CSF drainage m fuidrestrction ns 63 ICP monitoring 16 4 other 26 18 CSF = cerebrospinal id: IC 4 Percent of 3921 patients, supe: inaeeanial pressure ‘of whom underwent ancurysm TABLE 12 Causes of death and disability among 2521 patents® Death Disability Totals Cause No No “ict eet of bend 2 70 12s 36 vaorpaem 25432: 203 63 rebleding 236 6727 08 hydrocephalus 903 50 14 intracerebral hemonthage 341.036 1.0 compheatons of intracranial §) 7 BL 23 operation comphestionsofmediel 230.7 «1 G1 24 OF therapy other 4743 4 0 23 unknown 000 3 ol oS O1 tora 91S 260 575 163 1499 423 * Percentages ae of 3821 cases, Disability includes the moderate sats severe cisability, and vepeative survival Gsspow Outcome Seale categories used in 22% and vasopressor agents in 9%. Approxi- ‘mately two-thirds of the patients who had surgery planned subsequent to Day 7 received antifibrinolytic agents. Other interventions utilized in these patients are listed in Table 11. A permanent shunting procedure for hydrocephalus was employed in 8% of the total 3521 patients, Fluid restriction was utilized in 6% of cases. ‘Surgery. Of the 3521 patients admitted to the study, 2922 ultimately had aneurysm surgery. Figure 4 shows the distribution of the time of the operations after SAH. ‘Surgery was performed during Days 0 to 3 following ‘SAH in 51% of the operated cases, Days 4 to 6 in 12%, Days 7 10 10 in 13%, Days 11 to 14 in 9%, and Day 15 or later in 16%. ‘The procedures were conducted using the operating microscope in 97% of cases or loupes in 3%; in less than 1% no magnification was used. The aneurysm was ipped in 94% of cases, wrapped in 2%, and coated in 1%; a combination of methods for securing the aneu- rysm was utilized in 5%, 28 Fic, 4, Graph showing distribution of number of patients by cday of surgery Fic, 5. Graph showing rate of morality by time of treatment im the study period, Overall Management Results Although between 75% and 80% of patients were in good condition at the time of admission, at 6 months following the initial SAH only 58% had recovered to their premorbid state without neurological deficit. Nine percent of the patients were moderately disabled, 5% were severely disabled, 25 were vegetative, and 26% hhad died, During the 30-month time span of this study, there was essentially no change in outcome. The data base was divided into quarters based on time of regis- tration and there was no difference in good results or deaths bevween these four time periods (Fig. 5). The leading causes of death and disability, as esti- mated by the follow-up evaluator, were (in descending order): vasospasm, the direct effects of the initial insult (massive subarachnoid, subdural, or intracerebral he- matoma with parenchymal disruption or permanent ischemic effets of increased intracranial pressure), re- bleeding, and surgical complications (Table 12). The from rebleeding and vasospasm was equi lent, but the morbidity fom vasospasm accounted for 39% ofthe total 575 cases of disability. The direct effect of the initial hemorshage was implicated in 22% and surgical complications in 14% of patients with mor- bidity J. Neurosurg. / Volume 73 / July, 1990 Surgical and medical management results in aneurysm cases TABLE 13 Results of neurological assesonent et flop evaluation TABLE 14 actors tui ir prgnostic relaionship on overall tein Neutoogical Feature No. level oF consciousness Tully ale Dass 956 drowsy 20 stuporous 45 17 comatose % a9 unknown 0 40 speech normal ass dysphasic 202 7 no vert response M4 unknown 00 ‘mental status normal 208 impaired 26 td ‘unknown a) response to commands rar 36 17 6a rT) motoe response ‘normal rosy Tar ‘ld focal dei ws 13 severe focal det m 78 Abnormal flexor pesturing 2 OR abnormal extensor postunng 10D ro response 0g unknown 000 meningeal signs ore oro headache 26 sii neck oa unknown 00 cranial nerve ‘no invlvement 0887 third mas other m3 ‘akon ) * Percent of the 2604 patients alive and available for follow ap evaluation. Abnormal consciousness level was still noted in 4.6% ‘of the 2604 surviving patients at follow-up examination (Table 13). Nearly 8% of patients were aphasic, 11% ‘were not oriented, and 9.6% had major motor deficits. Fact Category “ested demographics Dre SAH conaitons angina cythmia asthma, care fl ture, cbetes. hepatitis. hypertension Interval to admission consciousness level. speech, orientation, response 10 commands, motor r- sponse, meningeal sigs, eran nerve abnormalities, syste blood pressure iste blood pressure aneurysm characteristics admission time mission sats CT findings normal decreased easy, masse, hydrocephalus, intraventicularhera- toma, intracerebral hemorrhage, SAH, Fisher sale for subarachnod blood study comer center center volume SAH = sotarachnoid hemorrhage: CT = computerized tomog- raphy Prognostic Factors Univariate Analysis. Patient characteristics, includ- ing age, sex, preexisting medical conditions, aneurysm location and size, time to admission, admission neuro- logical and blood pressure status, CT findings, and center were analyzed to determine relationships to out- ‘come (Table 14), There was a strong relationship be- tween the level of consciousness on admission and ‘outcome (p < 0.001) (Table 15). Approximately 75% of patients who were alert on admission had a good recovery and! 13% died, while 11% of patients who were adimitted in a comatose state made a good recovery and 72% perished. The patient's age was inversely related to favorable outcome (Table 16). Approximately 86% of patients between the ages of 18 and 29 years had a good result while only 26% of patients between the ages of 70 and 87 years had 2 similar outcome. The mortality rate of these two groups was 7% and 49%, respectively. The distribution of the Glasgow Outcome Scale categories in men and women was equivalent, No increased disa- bility existed for women, Patients with smaller aneurysms (< 12 mm) had Cranial nerves were abnormal in 11.8%. ‘more favorable results than those with large aneurysms TABLE 15 Overall outcome by consciousness level on admission* Moderately ‘Severely onions Good Recovery "sah Disabled No. Percent No. Percent al 1279743 4d srowsy og 335 nm 63 stuporous wos 302 RD comatose 3d 319 totals 077576 1485, * Percentages ae ofr totals: Relat J. Newosurg./ Volume 73 / July. 1990 25 TABLE 16 Overal nteurne by age om adbiosion® : Moderato ‘ee Cote Recovery en Ded “ovals os - - Percent Ro Pe Ne. No Pevent No. Pereent ms M2 is 89261-1000 Bs me 82k iss 47600 S637 ms 31000 S80 S560 NYSP ms 273101000 2 BT 24506) t000 S86 GS No S27 190. m7 576 md 9175035211000 * Percentages are of row totals, Relationship between age at admission and outcome: chisguate = 312.4 p< 0001 TABLE 17 vere otcome by aneurysms Moderatey Severe aecinan GoatReoves “eS ey Dead Tova ze (mm) —— = No. Percent No Percent No. Pereent_ No. Percent No Percent No, Pernt <2 3383S KS28DTHS 10D 26 MRT DR BR DLT 22K 7031000 >a 27 867 DKS 100 tous 2007763392805 * Percentages are of row totals Relationship between aneurysm se and outcome: chi-square = 961; p= 0.01 TABLE 18) vera xacome by aneurysn sitet Moderately Severely Vegetative ea Disabled Disabled Survival a a No. Peroni No. Percent No, Pevoeni No, Percent No, Percent No, _ Peroni internal carota arery 2 392 6 661328038 10St ‘idl cereral artery 460 61k % S91 1k el 208786 Anterior cetera artery 9-52 18 4729 ah 413301 erebrabaslarposterior circulation 140-26 nao 8 30 2 Oh other % 91S 2045 1 23) m7 a tows 7576 320836817 2603501 * Percentages are ofr totals, Relationship tetwcen aneurysm site and outcome: hisquare = 430: p < 0.001 (120 24 mm) (Table 17). Only 39% of cases with giant aneurysms (> 24 mm) had a good outcome. Outcome \was worse when aneurysms were located in the anterior cerebral or vertebrobasilar circulations than on the i ternal carotid or middie cerebral arteries (Table 18). Multivariate Factor Results. Multivariate analysis was performed utilizing proportional hazards regression methods. The details of the results will be presented in another report. The most important factors related to 4 favorable outcome were: the highest consciousness score on admission, a lower age, a lower admission blood pressure, the subarachnoid clot distribution on CT, the absence of preexisting medical conditions, the aneurysm site, the absence of vasospasm on admission 26 angiography, the admission motor response, and the patient's orientation on admission, On the other hand, factors prognostic for death were: the level of conscious- ness on admission, age, the CT findings, the admission blood pressure, preexisting medical conditions, and the aneurysm site (Table 19). Medical and Neurological Complications Medical problems that altered the patient’s clinical ‘course during hospitalization are listed in Table 20. The most frequently noted problems were hypertension and pneumonia. ‘Neurological problems encountered during hospital- ization included: focal ischemic neurological deficits in J. Neurosurg. / Volume 73 / uly, 1990 Surgical and medical management results in aneurysm cases suRceRr oveRaLe OVERALL Fic, 6, Graphs showing overall and surgical good recovery rates (ef) and overall and surgical morality rates (right) ranked by center. TABLE 19 Maltvariate prognostic factors for overall otevme® Prognostic Factor Dead Dissbed? consciousness level = = ee + + ‘dial condition + + SAH tin yer = 7 (CT: intraereval hemorshage + + idle cerebral site ‘sili blood pressure + + motor response e 2 tsi ste + + SAH cle deposition + + SAN tick yer + + spasm at admission + + (CT inwraventricularhemorttage + + Relationship ~ = favorable, + = unlavorabe. All significant at <.Q05. CT = computerized tomography: SAH = appearance of subarachnoid hemortage on CT scans, *Desths excluded 28% of the 3521 patients, hydrocephalus in 13%, re- current SAH in 11, brain swelling in 11%, intraceze- bral hematoma in 8%, and seizures in 4.5%. Regional and Center Differences There were appreciable differences in outcome be- tween different geographic regions and individual cen- ters. These differences will be elaborated upon in a future report. The results in the two regions which contributed the largest number of cases (Japan and North America) were essentially identical. In Japan, there were 59% good results and a 22% mortality rate, while in North America there were 58% good results and a 22% mortality rate There was wide variability in the overall outcome obtained in different centers: the percentage of good results ranged from 100% to 20% and the mortality rates from 0% to 66% (Fig. 6) In an attempt to deter- mine the relationship between center activity and out- come, the results from each center were compared to the annualized number of cases (Table 21). There was J. Neurosurg, / Volume 73 / July, 1990 TABLE 20 Medical probiems among 3521 patients during hospialization Cases Medical Problem No. Percent ‘hypertension ou RS peumnia, 270 anemia m 49 eatrointestinal Meeding BL 3? senythmia be ke B36 hypotension Ws 30 atelectasis sh 3 diabetes melitas % 2 dul respiratory distesssyrdrome 7D 20 ‘andiae failure do hepatic lure og pulmonary edema 7 17 thrombophlebs ois renal failure sot asthma 2 hepa 38 bleeding disorder 6 pulmonary embotisa 8 myocardial infarction 2s sngna 20 1no statistically significant relationship between the amount of center activity and the mortality rate dem- onstrated (chi-square statistical test p 2 0.05), Five centers exhibited what appears to be an unusu- ally poor outcome (Fig. 7). Each of these hala low rate of good results and a high mortality rate, and each had a significant number of cases (21, $9, 67, 95, and 96 cases, respectively). It should be noted that while these five centers contributed 9.6% of the total patients to the study, they accounted for 20.3% percent of the total deaths. This makes it unlikely that the adverse results were due to sampling error. Furthermore, adjustment by prognostic factors for death and disability in the patients admitted to these five centers did not change their results. These centers were all located in approxi- mately the same geographic region. The above data ar N.F. Kassell, ev al. TABLE 21 TABLE 22 tomeunt of center activi coreleted with outcome Operative ails n 2022 patents onder acre surgery Moray - ~ - Necof No.of Avene: alts Gawd Ss Cees Comers Activity no) Reger it Sannnanet No Peet a wt thE compli anesthesia as aa oo as 7 sa sen mk 28 ia st ‘mapifation sso 327 12 312 pone i oy Shana x07 oa loupes 5 a sah as «7 isotope we 7 cxposre * Trea ebsquare = 078 ° 2 ‘Tren: haga = 331: p 006, bag vn ea aor resection %8 3 Sisson suggest that the differences in outcome observed in con Be a8 these five centers were related to differences in specific Teak tot 33 aspects of management of the patients rather than rupture mI 23 differences in characteristis of this subpopulation. blterton nos ‘At the other end of the spectrum, it appeared that oun a OS there were several centers that had unusually favorable ‘rappine/ packing 3 13 results. However, the numbers of cases admitted from ther 131 4s these centers were very small and there was no relation- ship between low mortality rates and good results. These centers were within geographically disparate regions; accordingly, itis likely that the apparent good results in these centers were related to the statistical variation resulting from the small number of cases In an attempt to develop a more accurate sense of the contemporary overall management results in tert ary care centers, the results were recalculated without the five centers with unusually poor results. The mor- tality rate in the remaining 63 centers was 23%, and the percentage of good results was 60% versus a 26% ‘mortality rate and 57% good results when all 68 centers ‘were considered. Data Affecting Surgical Results Of the 3521 patients in this study, 2922 (83%) were operated on for treatment of the ruptured aneurysm. At the time of intraoperative exposure, the brain was assessed by the operating surgeon as being tight in 34% ‘of cases. Major brain resection was required in 3% of the patients. Dissection of the aneurysm was judged to bbe difficult in 46%; there was a premature blood leak in 6% and frank rupture in 13% (Table 22), Intraoperatively. occlusion of a feeding or perforating. artery occurred in 3% and brain contusion, laceration, or intracerebral hematoma in 4%. Rupture of the an- eurysm causing sufficient blood loss to produce shock occurred in 1% (Table 23). Of the 2922 patients who underwent aneurysm sur gery. 69% had a good result and 14% were dead at the 6-month post-SAH evaluation (Table 24). The surgical results were closely related to the preoperative neuro- logical status of the patients. Of the 1882 patients who were alert preoperatively, 79%% had a good result and 8% died, whereas of the L11 patients who were coma- tose, 14% had a good result and 45% died (Table 24). Younger patients had more favorable operative results Fi. 7, Gran sowing overall ood recovery rates ef) and overall mortality rates (righ) by center ranked from low to high. J. Neurosurg, / Volume 73 / uly, 1990 Surgical and medical management results in ancurysm cases TABLE 23 Invaoperative compicavions anne 2 Cases Complication mae No. Percent occlusion af eeding or pevtorting = WA brain comsion Be 4s itracerebral hemorrhage 2.4 hemorshagic hypotension shock) 3H LT byain laceration Moo ‘occlusion of major vein 702 than older patients. Patients aged 18 to 29 years had 90% good resultsand a 3% mortality rate, while patients aged 60 to 69 years had 56% good results and a 20% mortality rate (Table 25). There were no major differ- cences in resulls of surgery for aneurysms in different location (Table 26). However, surgical results were re- lated to aneurysm size: patients with small aneurysms had 70% good results and a 14% mortality rate, while those with giant aneurysms had 52% good results and 21% mortality rate (Table 27). Factors prognostic for good recovery in surgical pa- tients included: preoperative level of consciousness, absence of other medical conditions, lower age, normal Surgical cess by preoperative level of consetosess 2922 patents® Preep CoM Good Moderately Severely eget seus Recoery Disb Dred te ist RIED) WD BH) TO) 156 (6) Gromy DL79) 10240) $9 9) 34E—) 181 9A Sruporous 67332) 264128) 26128) 269) 71880 Somacoe 154135) 14026) 210089) 11199) 501450) fet 19840679) 304104) 167 (87) AULT SIR I43) * Relationship between preoperative level of corsccusness and surgical sults: cisquare = 483%