title: Untreated subarachnoid hemorrhage: who, why, and when?
abstract: OBJECTIVE
  When subarachnoid hemorrhage (SAH) is caused by an aneurysm or other vascular anomaly, surgery or endovascular treatment is generally indicated. Nevertheless, some patients with SAH do not receive such therapy. The objective of this study was to characterize the patients who do not receive treatment.
  
  
  METHODS
  The records of all patients with SAH who were admitted to a tertiary care center during a 9-year period were retrospectively reviewed. Untreated patients were classified into one of three groups based on angiographic results. Demographic, clinical, and neuroimaging findings and outcomes were compared between these three groups and between treated and untreated patients. Definitive treatment of SAH was provided in 477 patients and 166 were untreated. Untreated patients were older, had a worse neurological status on presentation, and a higher mortality rate (43.4% compared with 11.7%). Among these, 76 had normal angiographic results and a low mortality rate (6.6%). Fifty-two patients in whom no cerebral angiogram was obtained (mostly because of their neurological condition) had the highest mortality rate (92.3%). Of 38 patients with abnormal angiographic results 50% died, mostly due to rebleeding. Among elderly patients or those with a severe neurological deficit, outcome was significantly better in the ones who were treated.
  
  
  CONCLUSIONS
  A significant proportion of patients who were admitted with SAH did not receive definitive therapy. Major reasons for this included normal results on angiographic studies and poor clinical grade. Untreated patients with normal angiographic results had a good outcome, whereas those in whom angiography was not performed and those with abnormal angiographic results had a high mortality rate from the consequences of the initial hemorrhage in the first instance or rebleeding in the second. Although among elderly patients and those with a poor clinical grade the mortality rate was lower among those who received treatment, a definitive conclusion favoring treatment in these high-risk groups can only be drawn from a prospective randomized study.
authors.affiliation: Neurology/Neurosurgery Intensive Care Unit, Department of Neurology, Washington University School of Medicine, St. Louis, Missouri 63110, USA.
authors.forename: Fang
authors.initials: F
authors.lastname: Qu
authors.forename: Venkatesh
authors.initials: V
authors.lastname: Aiyagari
authors.forename: DeWitte T
authors.initials: DT
authors.lastname: Cross
authors.forename: Ralph G
authors.initials: RG
authors.lastname: Dacey
authors.forename: Michael N
authors.initials: MN
authors.lastname: Diringer
mesh_terms: D000328:Adult; D000368:Aged; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D019635:Neurosurgical Procedures / Q000379:methods*; D017063:Outcome Assessment, Health Care; D016079:Refusal to Treat; D012189:Retrospective Studies; D012307:Risk Factors; D013345:Subarachnoid Hemorrhage / Q000628:therapy*; D016019:Survival Analysis; D028761:Withholding Treatment