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Gonçalves B, Rynkowski C, Turon R, Charris N, Miranda F, de Caro V, Prazeres M, Santos T, Greer DM, Sharshar T, Guillaume T, Bozza FA, Righy C, Kurtz P. Clinical Characteristics and Outcomes of Patients with Aneurysmal Subarachnoid Hemorrhage: A Prospective Multicenter Study in a Middle-Income Country. Neurocrit Care 2023; 38:378-387. [PMID: 36324005 DOI: 10.1007/s12028-022-01629-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2022] [Accepted: 10/03/2022] [Indexed: 04/13/2023]
Abstract
BACKGROUND Aneurysmal subarachnoid hemorrhage (SAH) is associated with high mortality and long-term functional impairment. Data on clinical management and functional outcomes from developing countries are scarce. We aimed to define patient profiles and clinical practices and evaluate long-term outcomes after SAH in a middle-income country. METHODS This was a prospective study including consecutive adult patients admitted with SAH to two reference centers in Brazil from January 2016 to February 2020. The primary outcome was functional status at 6 months using the modified Rankin Scale. Mixed multivariable analysis was performed to determine the relationship between clinical variables and functional outcomes. RESULTS From 471patients analyzed, the median time from symptom onset to arrival at a study center was 4 days (interquartile range 0-9). Median age was 55 years (interquartile range 46-62) and 353 (75%) patients were women. A total of 426 patients (90%) were transferred from nonspecialized general hospitals, initial computed tomography revealed thick hemorrhage in 73% of patients (modified Fisher score of 3 or 4), and 136 (29%) had poor clinical grade (World Federation of Neurological Surgeons score of 4 or 5). A total of 312 (66%) patients underwent surgical clipping, and 119 (25%) underwent endovascular coiling. Only 34 patients (7%) underwent withdrawal or withholding of life-sustaining therapy during their hospital stay, and in-hospital mortality was 24%. A total of 187 (40%) patients had an unfavorable long-term functional outcome (modified Rankin Scale score of 4 to 6). Factors associated with unfavorable outcome were age (adjusted odds ratio [OR] 1.05, 95% confidence interval [CI] 1.03-1.08), hypertension (adjusted OR 1.81, 95% CI 1.04-3.16), poor clinical grade (adjusted OR 4.92, 95% CI 2.85-8.48), external ventricular drain (adjusted OR 3.8, 95% CI 2.31-6.24), postoperative deterioration (adjusted OR 2.33, 95% CI 1.32-4.13), cerebral infarction (adjusted OR 3.16, 95% CI 1.81-5.52), rebleeding (adjusted OR 2.95, 95% CI 1.13-7.69), and sepsis (adjusted OR 2.68, 95% CI 1.42-5.05). CONCLUSIONS Our study demonstrated that SAH management in a middle-income country diverges significantly from published cohorts and current guidelines, despite comparable clinical profiles on presentation and admission to high-volume referral centers. Earlier aneurysm occlusion and increased use of endovascular therapy could potentially reduce modifiable in-hospital complications and improve functional outcomes in Brazil.
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Affiliation(s)
- Bruno Gonçalves
- Department of Neurointensive Care, Paulo Niemeyer State Brain Institute, Rio de Janeiro, Brazil
| | - Carla Rynkowski
- Department of Intensive Care Medicine, Hospital Cristo Redentor, Porto Alegre, Brazil
| | - Ricardo Turon
- Department of Neurointensive Care, Paulo Niemeyer State Brain Institute, Rio de Janeiro, Brazil
| | - Nestor Charris
- Department of Neurointensive Care, Paulo Niemeyer State Brain Institute, Rio de Janeiro, Brazil
| | - Fabio Miranda
- Department of Neurointensive Care, Paulo Niemeyer State Brain Institute, Rio de Janeiro, Brazil
- Department of Neurointensive Care, Hospital Copa Star, Rio de Janeiro, Brazil
| | - Vanessa de Caro
- Department of Neurointensive Care, Paulo Niemeyer State Brain Institute, Rio de Janeiro, Brazil
| | - Marco Prazeres
- Department of Neurointensive Care, Paulo Niemeyer State Brain Institute, Rio de Janeiro, Brazil
| | - Thayana Santos
- Department of Neurointensive Care, Paulo Niemeyer State Brain Institute, Rio de Janeiro, Brazil
- Department of Neurointensive Care, Hospital Copa Star, Rio de Janeiro, Brazil
| | - David M Greer
- Department of Neurology, Boston University School of Medicine, Boston Medical Center, Boston, MA, USA
| | - Tarek Sharshar
- Department of Neuro-Intensive Care Medicine, Sainte-Anne Hospital, Paris-Descartes University, Paris, France
| | - Turc Guillaume
- GHU Paris Psychiatrie et Neurosciences, Paris, France
- Université Paris Cité, Paris, France
- INSERM, Paris, France
- FHU NeuroVasc, Paris, France
| | - Fernando A Bozza
- D'Or Institute for Research and Education, Rua Diniz Cordeiro, 30 - 3º andar, Rio de Janeiro, RJ, CEP 22281-100, Brazil
- National Institute of Infectious Diseases, Fundação Osvaldo Cruz, Rio de Janeiro, Brazil
| | - Cassia Righy
- Department of Neurointensive Care, Paulo Niemeyer State Brain Institute, Rio de Janeiro, Brazil
- Department of Neurointensive Care, Hospital Copa Star, Rio de Janeiro, Brazil
- National Institute of Infectious Diseases, Fundação Osvaldo Cruz, Rio de Janeiro, Brazil
| | - Pedro Kurtz
- Department of Neurointensive Care, Paulo Niemeyer State Brain Institute, Rio de Janeiro, Brazil.
- Department of Neurointensive Care, Hospital Copa Star, Rio de Janeiro, Brazil.
- D'Or Institute for Research and Education, Rua Diniz Cordeiro, 30 - 3º andar, Rio de Janeiro, RJ, CEP 22281-100, Brazil.
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