title: Outcome after Hunt and Hess Grade V subarachnoid hemorrhage: a comparison of pre-coiling era (1980-1995) versus post-ISAT era (2005-2014).
abstract: OBJECTIVE Outcome analysis of comatose patients (Hunt and Hess Grade V) after subarachnoid hemorrhage (SAH) is still lacking. The aims of this study were to analyze the outcome of Hunt and Hess Grade V SAH and to compare outcomes in the current period with those of the pre-International Subarachnoid Aneurysm Trial (ISAT) era as well as with published data from trials of decompressive craniectomy (DC) for middle cerebral artery (MCA) infarction. METHODS The authors analyzed cases of Hunt and Hess Grade V SAH from 1980-1995 (referred to in this study as the earlier period) and 2005-2014 (current period) and compared the results for the 2 periods. The outcomes of 257 cases were analyzed and stratified on the basis of modified Rankin Scale (mRS) scores obtained 6 months after SAH. Outcomes were dichotomized as favorable (mRS score of 0-2) or unfavorable (mRS score of 3-6). Data and number needed to treat (NNT) were also compared with the results of decompressive craniectomy (DC) trials for middle cerebral artery (MCA) infarctions. RESULTS Early aneurysm treatment within 72 hours occurred significantly more often in the current period (in 67% of cases vs 22% in earlier period). In the earlier period, patients had a significantly higher 30-day mortality rate (83% vs 39% in the current period) and 6-month mortality rate (94% vs 49%), and no patient (0%) had a favorable outcome, compared with 23% overall in the current period (p < 0.01, OR 32), or 29.5% of patients whose aneurysms were treated (p < 0.01, OR 219). Cerebral infarctions occurred in up to 65% of the treated patients in the current period. Comparison with data from DC MCA trials showed that the NNTs were significantly lower in the current period with 2 for survival and 3 for mRS score of 0-3 (vs 3 and 7, respectively, for the DC MCA trials). CONCLUSIONS Early and aggressive treatment resulted in a significant improvement in survival rate (NNT = 2) and favorable outcome (NNT = 3 for mRS score of 0-3) for comatose patients with Hunt and Hess Grade V SAH compared with the earlier period. Independent predictors for favorable outcome were younger age and bilateral intact corneal reflexes. Despite a high rate of cerebral infarction (65%) in the current period, 29.5% of the patients who received treatment for their aneurysms during the current era (2005-2014) had a favorable outcome. However, careful individual decision making is essential in these cases.
authors.forename: Juergen
authors.initials: J
authors.lastname: Konczalla
authors.forename: Volker
authors.initials: V
authors.lastname: Seifert
authors.forename: Juergen
authors.initials: J
authors.lastname: Beck
authors.forename: Erdem
authors.initials: E
authors.lastname: Güresir
authors.forename: Hartmut
authors.initials: H
authors.lastname: Vatter
authors.forename: Andreas
authors.initials: A
authors.lastname: Raabe
authors.forename: Gerhard
authors.initials: G
authors.lastname: Marquardt
mesh_terms: D003128:Coma / Q000175:diagnosis* / Q000401:mortality / Q000628:therapy*; D005260:Female; D006801:Humans; D020244:Infarction, Middle Cerebral Artery / Q000175:diagnosis / Q000401:mortality / Q000628:therapy; D008297:Male; D008875:Middle Aged; D019635:Neurosurgical Procedures; D011446:Prospective Studies; D012189:Retrospective Studies; D012720:Severity of Illness Index; D013345:Subarachnoid Hemorrhage / Q000175:diagnosis* / Q000401:mortality / Q000628:therapy*; D013997:Time Factors; D016896:Treatment Outcome
keywords: ARR = absolute risk reduction; CVS = cerebral vasospasm; DC = decompressive craniectomy; DCI = delayed cerebral ischemia; EVD = external ventricular drain; GCS = Glasgow Coma Scale; Hunt and Hess Grade V; ICH = intracerebral hematoma; ICU = intensive care unit; ISAT = International Subarachnoid Aneurysm Trial; MCA = middle cerebral artery; NNT = number needed to treat; PERRLA = pupils equal, round, and reactive to light and accommodation; SAH = subarachnoid hemorrhage; WFNS = World Federation of Neurosurgical Societies; clinical outcome; coma; mRS = modified Rankin Scale; prognostic factors; severe SAH; stroke trials; subarachnoid hemorrhage; vascular disorders