title: Functional Outcome After Poor-Grade Subarachnoid Hemorrhage: A Single-Center Study and Systematic Literature Review.
abstract: Poor-grade subarachnoid hemorrhage (SAH) (World Federation of Neurosurgical Societies grade 4 and 5) is associated with high mortality rates and unfavorable functional outcomes. We report a single-center cohort of poor-grade SAH patients, combined with a systematic review of studies reporting functional outcome in the poor-grade SAH population.
  
  
  
  Data on a cohort of poor-grade SAH patients treated between 2009 and 2013 were retrospectively collected and combined with a systematic review (from inception to November 2015; PubMed, Embase). Two reviewers assessed the studies independently based on predefined inclusion criteria: consecutive poor-grade SAH, functional outcome measured at least 3 months after hemorrhage, and the report of patients who died before aneurysm treatment.
  
  
  
  The search yielded 329 publications, and 23 met our inclusion criteria with 2713 subjects enrolled from 1977 to 2014 in 10 countries (including 179 poor-grade patients from our cohort). Mortality rate was 60 % (1683 patients), of which 806 (29 %) died before and 877 (31 %) died after aneurysm treatment, respectively. Treatment was undertaken in 1775 patients (1775/2826-63 %): 1347 by surgical clipping (1347/1775-76 %) and 428 (428/1775-24 %) by endovascular methods. Outcome was favorable in 794 patients (28 %) and unfavorable in 1867 (66 %). When the studies were grouped into decades, favorable outcome increased from 13 % in the late 1970s to early 1980s to 35 % in the late 1980s to early 1990s, and remained unchanged thereafter.
  
  
  
  Although mortality remains high in poor-grade SAH patients, a favorable functional outcome can be achieved in approximately one-third of patients. The development of new diagnostic methods and implementation of therapeutic approaches were probably responsible for the decrease in mortality and improvement in the functional outcome from 1970 to the 1990s. The plateau in functional outcome seen thereafter might be explained by the treatment of sicker and older patients and by the lack of new therapeutic interventions specific for SAH.
authors.affiliation: Department of Medical Imaging, Interventional Neuroradiology, St. Michael's Hospital, University of Toronto, 3-141 CC, St. Michael's Hospital, 30 Bond Street, Toronto, ON, M5B 1W8, Canada. airtonleo.manoel@gmail.com.|Department of Critical Care Medicine, Trauma and Neurosurgical Intensive Care Unit, St. Michael's Hospital, University of Toronto, Toronto, ON, Canada. airtonleo.manoel@gmail.com.|Neuroscience Research Program, Keenan Research Centre for Biomedical Science of St. Michael's Hospital, Toronto, Canada. airtonleo.manoel@gmail.com.|Neurology and Neurosurgery Department, Universidade Federal de São Paulo, São Paulo, Brazil. airtonleo.manoel@gmail.com.
authors.forename: Airton Leonardo
authors.identifier: 0000-0002-9593-1013
authors.initials: AL
authors.lastname: de Oliveira Manoel
authors.affiliation: Neuroscience Research Program, Keenan Research Centre for Biomedical Science of St. Michael's Hospital, Toronto, Canada.|Faculty of Medicine, University of Toronto, Toronto, Canada.
authors.forename: Ann
authors.initials: A
authors.lastname: Mansur
authors.affiliation: Neurology and Neurosurgery Department, Universidade Federal de São Paulo, São Paulo, Brazil.|Instituto Israelita de Pesquisa Albert Einstein, Neurology Program, São Paulo, Brazil.
authors.forename: Gisele Sampaio
authors.initials: GS
authors.lastname: Silva
authors.affiliation: Department of Neurosurgery, Radboud University Medical Center, Nijmegen, The Netherlands.
authors.forename: Menno R
authors.initials: MR
authors.lastname: Germans
authors.affiliation: Neuroscience Research Program, Keenan Research Centre for Biomedical Science of St. Michael's Hospital, Toronto, Canada.
authors.forename: Blessing N R
authors.initials: BN
authors.lastname: Jaja
authors.affiliation: Department of Medical Imaging, Interventional Neuroradiology, St. Michael's Hospital, University of Toronto, 3-141 CC, St. Michael's Hospital, 30 Bond Street, Toronto, ON, M5B 1W8, Canada.
authors.forename: Ekaterina
authors.initials: E
authors.lastname: Kouzmina
authors.affiliation: Department of Medical Imaging, Interventional Neuroradiology, St. Michael's Hospital, University of Toronto, 3-141 CC, St. Michael's Hospital, 30 Bond Street, Toronto, ON, M5B 1W8, Canada.|Neuroscience Research Program, Keenan Research Centre for Biomedical Science of St. Michael's Hospital, Toronto, Canada.
authors.forename: Thomas R
authors.initials: TR
authors.lastname: Marotta
authors.affiliation: Department of Critical Care Medicine, Trauma and Neurosurgical Intensive Care Unit, St. Michael's Hospital, University of Toronto, Toronto, ON, Canada.|Department of Anesthesiology, St. Michael's Hospital, University of Toronto, Toronto, ON, Canada.
authors.forename: Simon
authors.initials: S
authors.lastname: Abrahamson
authors.affiliation: Neuroscience Research Program, Keenan Research Centre for Biomedical Science of St. Michael's Hospital, Toronto, Canada.
authors.forename: Tom A
authors.initials: TA
authors.lastname: Schweizer
authors.affiliation: Neuroscience Research Program, Keenan Research Centre for Biomedical Science of St. Michael's Hospital, Toronto, Canada.|Division of Neurosurgery, Department of Surgery, St. Michael's Hospital, University of Toronto, Toronto, ON, Canada.
authors.forename: Julian
authors.initials: J
authors.lastname: Spears
authors.affiliation: Neuroscience Research Program, Keenan Research Centre for Biomedical Science of St. Michael's Hospital, Toronto, Canada.|Division of Neurosurgery, Department of Surgery, St. Michael's Hospital, University of Toronto, Toronto, ON, Canada.
authors.forename: R Loch
authors.initials: RL
authors.lastname: Macdonald
mesh_terms: D000328:Adult; D000368:Aged; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D017063:Outcome Assessment, Health Care; D011379:Prognosis; D012189:Retrospective Studies; D012720:Severity of Illness Index; D013345:Subarachnoid Hemorrhage / Q000401:mortality* / Q000628:therapy*
keywords: Mortality; Prognosis; Subarachnoid hemorrhage; Systematic review