title: Specialized neurocritical care, severity grade, and outcome of patients with aneurysmal subarachnoid hemorrhage.
abstract: BACKGROUND
  To evaluate the impact of specialized neurocritical care on the population admitted to a neurovascular center and on the outcome of patients with severe aneurysmal subarachnoid hemorrhage (aSAH).
  
  
  METHODS
  After exclusion of patients treated with endovascular techniques, between 1999 and 2003, 198 patients with aSAH treated with early aneurysm clipping were analysed. In 1999, a new standardized protocol for intensive care treatment was established in the Department of Neurosurgery, University Hospital Zurich. The results were compared to the earlier time period (1993-1994) immediately after introduction of early aneurysm clipping.
  
  
  RESULTS
  Out of 198 patients with aSAH, 90 patients (45.5%) suffered from mild aSAH World Federation of Neurosurgical Societies (WFNS) grade 1 and 2, 41 (27.3%) from aSAH WFNS grade 3, 36 (18.2%) from grade 4, and 57 (28.8%) from grade 5. From 1999 to 2003, significantly more patients with severe aSAH WFNS grade 4 and 5 underwent (further) treatment (93 out of 198 patients; 47.0%) compared to the former time-period after introduction of early surgery (23 out of 150 patients; 15.3%) (p < 0.0001). In the early series, 10 out of 23 patients (43.5%) with WFNS 4 recovered with good outcome Glasgow Outcome Score 4 and 5, whereas in the later series 23 out of 36 (63.9%) with WFNS grade 4 survived in a good functional state. Before 1999, all patients with WFNS grade 5 died or survived in a vegetative state. From 1999 to 2003, 20 out of 57 patients (35.1%) with aSAH WFNS grade 5 survived with good outcome.
  
  
  CONCLUSIONS
  The availability of extended specialized neurocritical care seems to induce a change within the patient population towards a higher severity grade. Patients with highgrade aSAH might benefit most from highly specialized neurocritical care treatment.
authors.affiliation: Neurocritical Care Unit, Department of Neurosurgery, University Hospital, Zurich, Switzerland.
authors.forename: Corinne
authors.initials: C
authors.lastname: Lerch
authors.forename: Yasuhiro
authors.initials: Y
authors.lastname: Yonekawa
authors.forename: Carl
authors.initials: C
authors.lastname: Muroi
authors.forename: Miroslava
authors.initials: M
authors.lastname: Bjeljac
authors.forename: Emanuela
authors.initials: E
authors.lastname: Keller
mesh_terms: D000328:Adult; D017542:Aneurysm, Ruptured / Q000150:complications* / Q000473:pathology / Q000601:surgery; D002560:Cerebrovascular Circulation; D002985:Clinical Protocols; D003422:Critical Care; D005260:Female; D006801:Humans; D002532:Intracranial Aneurysm / Q000150:complications* / Q000473:pathology / Q000601:surgery; D008297:Male; D008875:Middle Aged; D019635:Neurosurgical Procedures; D012039:Regional Blood Flow; D012189:Retrospective Studies; D013345:Subarachnoid Hemorrhage / Q000209:etiology* / Q000473:pathology / Q000503:physiopathology / Q000601:surgery*; D013525:Surgical Instruments; D016896:Treatment Outcome; D020301:Vasospasm, Intracranial / Q000503:physiopathology / Q000628:therapy