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Choi YH, Ha EJ, Shim Y, Kim J, Choo YH, Kim HS, Lee SH, Kim KM, Cho WS, Kang HS, Kim JE. Clinical Outcome of Patients with Poor-Grade Aneurysmal Subarachnoid Hemorrhage with Bundled Treatments: A Propensity Score-Matched Analysis. Neurocrit Care 2024; 40:177-186. [PMID: 37610642 DOI: 10.1007/s12028-023-01818-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2023] [Accepted: 07/20/2023] [Indexed: 08/24/2023]
Abstract
BACKGROUND Poor-grade aneurysmal subarachnoid hemorrhage (aSAH), defined as Hunt and Hess (HH) grades IV and V, is a challenging disease because of its high mortality and poor functional outcomes. The effectiveness of bundled treatments has been demonstrated in critical diseases. Therefore, poor-grade aSAH bundled treatments have been established. This study aims to evaluate whether bundled treatments can improve long-term outcomes and mortality in patients with poor-grade aSAH. METHODS This is a comparative study using historical control from 2008 to 2022. Bundled treatments were introduced in 2017. We compared the rate of favorable outcomes (modified Rankin Scale score 0-2) at 6 months and mortality before and after the introduction of the bundled treatments. To eliminate confounding bias, the propensity score matching method was used. RESULTS A total of 90 consecutive patients were evaluated. Forty-three patients received bundled treatments, and 47 patients received conventional care. The proportion of patients with HH grade V was higher in the bundle treatment group (41.9% vs. 27.7%). Conversely, the proportion of patients with fixed pupils on the initial examination was higher in the conventional group (30.2% vs. 38.3%). After 1:1 propensity score matching, 31 pairs were allocated to each group. The proportion of patients with 6-month favorable functional outcomes was significantly higher in the bundled treatments group (46.4% vs. 20.7%, p = 0.04). The 6-month mortality rate was 14.3% in the bundled treatments group and 27.3% in the conventional group (p = 0.01). Bundled treatments (odd ratio 14.6 [95% confidence interval 2.1-100.0], p < 0.01) and the presence of an initial pupil reflex (odd ratio 12.0 [95% confidence interval 1.4-104.6], p = 0.02) were significantly associated with a 6-month favorable functional outcome. CONCLUSIONS The bundled treatments improve 6-month functional outcome and mortality in patients with poor-grade aSAH.
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Affiliation(s)
- Young Hoon Choi
- Department of Radiology, Seoul National University Hospital, Seoul, Republic of Korea
| | - Eun Jin Ha
- Department of Critical Care Medicine, Seoul National University Hospital, Seoul National University College of Medicine, 101, Daehak-ro Jongno-gu, Seoul, 03080, Republic of Korea.
- Department of Neurosurgery, College of Medicine, Seoul National University, Seoul, Republic of Korea.
| | - Youngbo Shim
- Department of Critical Care Medicine, Seoul National University Hospital, Seoul National University College of Medicine, 101, Daehak-ro Jongno-gu, Seoul, 03080, Republic of Korea
| | - Jungook Kim
- Department of Critical Care Medicine, Seoul National University Hospital, Seoul National University College of Medicine, 101, Daehak-ro Jongno-gu, Seoul, 03080, Republic of Korea
| | - Yoon-Hee Choo
- Department of Neurosurgery, Seoul St. Mary's Hospital and College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Hye Seon Kim
- Department of Neurosurgery, Incheon St. Mary's Hospital and College of Medicine, The Catholic University of Korea, Incheon, Republic of Korea
| | - Sung Ho Lee
- Department of Neurosurgery, College of Medicine, Seoul National University, Seoul, Republic of Korea
- Department of Neurosurgery, Seoul National University Hospital, Seoul, Republic of Korea
| | - Kang Min Kim
- Department of Neurosurgery, College of Medicine, Seoul National University, Seoul, Republic of Korea
- Department of Neurosurgery, Seoul National University Hospital, Seoul, Republic of Korea
| | - Won-Sang Cho
- Department of Neurosurgery, College of Medicine, Seoul National University, Seoul, Republic of Korea
- Department of Neurosurgery, Seoul National University Hospital, Seoul, Republic of Korea
| | - Hyun-Seung Kang
- Department of Neurosurgery, College of Medicine, Seoul National University, Seoul, Republic of Korea
- Department of Neurosurgery, Seoul National University Hospital, Seoul, Republic of Korea
| | - Jeoug Eun Kim
- Department of Neurosurgery, College of Medicine, Seoul National University, Seoul, Republic of Korea
- Department of Neurosurgery, Seoul National University Hospital, Seoul, Republic of Korea
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Size of Craniectomy Predicts Approach-Related Shear Bleeding in Poor-Grade Subarachnoid Hemorrhage. Brain Sci 2023; 13:brainsci13030371. [PMID: 36979181 PMCID: PMC10046376 DOI: 10.3390/brainsci13030371] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2022] [Revised: 02/16/2023] [Accepted: 02/17/2023] [Indexed: 02/23/2023] Open
Abstract
Decompressive craniectomy is an option to decrease elevated intracranial pressure in poor-grade aneurysmal subarachnoid hemorrhage (SAH) patients. The aim of the present study was to analyze the size of the bone flap according to approach-related complications in patients with poor-grade SAH. We retrospectively analyzed poor-grade SAH patients (WFNS 4 and 5) who underwent aneurysm clipping and craniectomy (DC or ommitance of bone flap reinsertion). Postoperative CT scans were analyzed for approach-related tissue injury at the margin of the craniectomy (shear bleeding). The size of the bone flap was calculated using the De Bonis equation. Between 01/2012 and 01/2020, 67 poor-grade SAH patients underwent clipping and craniectomy at our institution. We found 14 patients with new shear bleeding lesion in postoperative CT scan. In patients with shear bleeding, the size of the bone flap was significantly smaller compared to patients without shear bleeding (102.1 ± 45.2 cm2 vs. 150.8 ± 37.43 cm2, p > 0.0001). However, we found no difference in mortality rates (10/14 vs. 23/53, p = 0.07) or number of implanted VP shunts (2/14 vs. 18/53, p = 0.2). We found no difference regarding modified Rankin Scale (mRS) 6 months postoperatively. In poor-grade aneurysmal SAH, the initial planning of DC—if deemed necessary —and enlargement of the flap size seems to decrease the rate of postoperatively developed shear bleeding lesions.
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Ota N, Noda K, Chida D, Kiko K, Miyoshi N, Kondo T, Haraguchi K, Kamiyama H, Tokuda S, Tanikawa R. Emergent Subarachnoid Clot Removal with Aneurysm Repair for Subarachnoid Hemorrhage Might Improves Clinical Outcome. World Neurosurg 2022; 167:e100-e109. [PMID: 35953044 DOI: 10.1016/j.wneu.2022.07.151] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2022] [Accepted: 07/22/2022] [Indexed: 12/01/2022]
Abstract
BACKGROUND The goal in treating patients with subarachnoid hemorrhage (SAH) is shifting to preventing early brain injury. Intracranial pressure must be controlled to manage such an injury. We retrospectively analyzed the impact of aggressive removal of cisternal subarachnoid clots with simultaneous aneurysm repair for all grades of SAH. METHODS Our study included 260 consecutive patients with SAH treated through aggressive subarachnoid clot removal with simultaneous aneurysm repair. Baseline patient characteristics, history, radiographic findings, and time of SAH onset to arrival in the operating room were retrospectively collected. Factors related to poor outcome (modified Rankin Scale score >2) were analyzed. RESULTS Multivariate analysis revealed several characteristics were significantly associated with poor outcome: advanced age (adjusted odds ratio [aOR] 1.07, 95% confidence interval [CI] 1.04-01.10); time of SAH onset to operating room per 1-hour increments (aOR 1.03, 95% CI 1.01-01.05; postoperative hematoma volume (aOR 1.04, 95% CI 1.01-01.06); and poorer World Federation of Neurosurgical Societies grade (aOR 2.18, 95% CI 1.63-02.92). According to a receiver operating characteristic analysis, the cut-off time of SAH onset to operating room was 6.0 hours (area under the curve 0.61, P = 0.01, 95% CI 0.52-0.69, sensitivity = 0.79, specificity = 0.43) as the threshold between modified Rankin Scale scores of 0-2 and 3-6. CONCLUSIONS Prognostic factors of SAH in patients undergoing emergent aneurysm repair with simultaneous removal of a cisternal subarachnoid clot are advanced age, poorer World Federation of Neurosurgical Societies grade, postoperative hematoma volume, and a longer time from SAH onset to operating room. The clinical outcome may improve with emergent reduction of intracranial pressure through removal of the subarachnoid clot as soon as possible.
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Affiliation(s)
- Nakao Ota
- Stroke Center, Department of Neurosurgery, Sapporo Teishinkai Hospital, Sapporo, Hokkaido, Japan.
| | - Kosumo Noda
- Stroke Center, Department of Neurosurgery, Sapporo Teishinkai Hospital, Sapporo, Hokkaido, Japan
| | - Daiki Chida
- Stroke Center, Department of Neurosurgery, Sapporo Teishinkai Hospital, Sapporo, Hokkaido, Japan
| | - Katsunari Kiko
- Stroke Center, Department of Neurosurgery, Sapporo Teishinkai Hospital, Sapporo, Hokkaido, Japan
| | - Norio Miyoshi
- Stroke Center, Department of Neurosurgery, Sapporo Teishinkai Hospital, Sapporo, Hokkaido, Japan
| | - Tomomasa Kondo
- Stroke Center, Department of Neurosurgery, Sapporo Teishinkai Hospital, Sapporo, Hokkaido, Japan
| | - Kenichi Haraguchi
- Stroke Center, Department of Neurosurgery, Sapporo Teishinkai Hospital, Sapporo, Hokkaido, Japan
| | - Hiroyasu Kamiyama
- Stroke Center, Department of Neurosurgery, Sapporo Teishinkai Hospital, Sapporo, Hokkaido, Japan
| | - Sadahisa Tokuda
- Stroke Center, Department of Neurosurgery, Sapporo Teishinkai Hospital, Sapporo, Hokkaido, Japan
| | - Rokuya Tanikawa
- Stroke Center, Department of Neurosurgery, Sapporo Teishinkai Hospital, Sapporo, Hokkaido, Japan
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