|
Introduction
Outcome of a subarachnoid hemorrhage (SAH) patient is influenced by many variables including aneurysm location, computed tomography (CT) grade of SAH amount, age clinical grade, and vasospasm.13)14)26)30)34) Clinical grade of a patient on admission is strongly associated with outcome and probably encompasses many other reported outcome predictors.2)13)14)26)30)34) It is widely accepted idea that Hunt-Hess grade16) is a good system to represent a patient's clinical grade and has powerful predictive value as itself. Hunt-Hess grade I-III are generally egarded as a good grade group and grade IV-V as a poor grade group. Most patients who fall into good clinical grade categories experience little surgical morbidity and have good outcome.4)9)13)35) The outcome of patients with poor-grade SAH is known to correlate inversely to admission grade.5)6)10)20) Most reported articles divided the Hunt-Hess grade in two, good and bad groups and showed surgical results, outcome predictors, treatment protocol of a group in two groups. There is no known report about the outcome and the outcome predictors of Hunt-Hess grade III patients group only within our knowledge. Hunt-Hess grade III patient group may differ from grade I or II group and grade IV or V group in outcome, because this grade patients are in better or worse clinical condition than other groups.
We designed this study to bring the outcome and the outcome predictors of Hunt-Hess grade III patients to light, and to be aid in determining treatment protocol of such a intermediate group.
Patients and method
The diagnosis of SAH was based on the patient 's symptoms and signs, and a CT scan. All CT scan were performed in the emergency room, unless the patient was referred from other clinical center. Because all Hunt-Hess grade III patient in our study showed definite SAH in their CT scans, no lumbar puncture was employed for diagnosis. All non traumatic SAH patients were evaluated with Hunt-Hess grade, and Fisher grade was used to evaluate the amount of SAH according to the CT scan result.
Between January 1998 and December 2004, 437 consecutive patients with non traumatic SAH visited our hospital. The presence and location of an intracranial aneurysm was confirmed with four-vessel cerebral angiography. We excluded 21 non aneurysmal SAH patient with negative or non aneurysmal cerebral angiography. Total 416 aneurysmal patients were reviewed, and 72 patients with Hunt-Hess grade III were selected for more detailed review with all available medical records.
The patients were either operated and the aneurysm treated by placing a clip on the aneurysmal neck, or it was coiled endovascularly. Postoperative vasospasm was initially detected clinically and additionally confirmed by angiography or transcranial Doppler. Nimodipine was used in all Hunt-Hess grade III patient to prevent vasospasm in our study. We also adopted triple H therapy (hypertension, hemodilution, hypervolemia) for the prevention of vasospasm in all the Fisher grade III patients who did not have any cardiovascular problem. We did not excluded from our study the two Hunt-Hess grade III patients with aneurysmal SAH who were treated only conservatively. The first degree relatives of those patients rejected the treatment for aneurysmal exclusion from circulation because of their advanced age (>75 years). We evaluated the outcome using Glasgow Outcome Scale (GOS) 6 months after the ictus of a aneurysmal rupture.
In statistical analysis, we dichotomized the outcome according to GOS. Those with a GOS of 1, 2 or 3 were categorized into the poor-outcome group (the group of dependent or dead patients), and those with a GOS of 4 or 5 were categorized into the good-outcome group (the group of independent patients). Univariate statistical analysis with the chi-squared test was used to evaluate the importance of each single factor for the outcome. We also used the forward stepwise method in multivariate logistic regression model to evaluate the overall importance of all factors. A p value lower than 0. 05 was considered statistically significant.
Result
Altogether 72 Hunt-Hess grade III aneurysmal SAH patients were admitted to neurosurgery department between january 1998 and december 2004. Of these, 26 (36%) were men and 46 (64%) were women. Their mean age was 54.7 years (SD 12 7 years). The youngest was 28 years old man and the oldest was 78 years old female. The number of ruptured aneurysms in different location is presented in Table 1. There were 37 anterior communicating artery and 15 posterior communicating artery ruptured aneurysms. In total 72 cases, 61 cases of aneurysms were excluded from circulation by placing a clip on the aneurysmal neck, and 10 cases of aneurysms were treated endovascularly. 1 patient died from aneurysmal rebleeding before the aneurysmal exclusion from circulation and 2 patients rejected the treatment for aneurysmal exclusion. Multiple aneurysms were showed in 4 patients. The unruptured aneurysms of the multiple aneurysms patients were treated endovascularly. The average time from aneurysmal rupture till its treatment was 1. 8 days (SD 2.2 days). Vasospasm occurred in 15 patients. In these 15 patients, 6 patients improved after intensive care, 9 patients had poor outcome.
The overall 6-month mortality from the moment of admission to the neurosurgical department was 5.6%. Perioerative mortality was 1.4%. and postoperative mortality due to complication related to SAH (vasospasm, brain infart, brain edema etc.) was 1.4%. The most common GOS grade after 6 month from the ictus was 5, and approximately 80 6%(n=58) of patients were independent (GOS 4 or 5).
In the statistical analysis, we dichotomized the outcome 6month after the ictus into a good group (GOS 4, 5) or a poor group (GOS 1-3). Univariate analysis of various single factors showed that age, presence of intracerabral hemorrhage (ICH) on the initial CT scan and vasospasm were significant for outcome (Table 2). In the multivariate analysis using logistic regression, we excluded 3 patients in whom 2 patients rejected the treatment for aneurysmal exclusion and 1 patient died before the treatment for aneurysmal exclusion. They could not have all factors and could distort the result in a multivariate logistic regression model. Using preoperative factors, age and presence of ICH on the initial CT scan had significance in the multivariate analysis. Using all possible factors, age, presence of ICH on the initial CT scan and vasospasm were statistically significant.
Discussion
This retrospective study describes our experience with the management of 72 unselected patient who were classified at admission as Hunt-Hess grade III after aneurysmal rupture between january 1998 and december 2004.
The overall mortality after 6 month from the ictus of our study was 5.6%. This result was comparable to the result of other studies.3)13)23) Because we could not find any other study that reported perioperative mortality or postoperative mortality of Hunt-Hess grade III patients only, we could not compare our result with any other studies. But perioperative and postoperative mortality of our study (both 1.4%) are very small and acceptable as a referable hospital.
Favorable outcome means the patient is independent in daily living (GOS 4 or 5). In our study, 80. 6% of Hunt-Hess grade III patients was independent after 6 months from the aneurysmal rupture. It was similar to other reports in the literature those showed the Hunt-Hess grade III patients ' outcome.13)20)23)
Only one patient died from rebleeding from ruptured aneurysm. It occurred shortly after the patient admitted neurosurgical department. Rebleeding rate of a ruptured aneurysm is highest within the first 24 hours.1)7)25) Fujii et al,.8) reported the ultra early ebleeding (between admission and early surgery, mostly within 24 hours) rate of ruptured aneurysms of Hunt-Hess grade III patient was 14. 6%. Miyaoka et al,.28) reported fatal rebleeding rate was 2.7% and 9.5% in the early and late management group, respectively and early surgery is more important in poor clinical grade patients.19)20) There is, however, a report from China in which the authors insisted there was no significant difference between early surgery and metaphase surgery (within 3 days or 3~10 days) in their seventy-five patients with ruptured cerebral anterior circulating aneurysm.11) The average time from aneurysmal rupture till its treatment of our study was 1.8 days. Our protocol management of Hunt Hess grade III patient is performing early surgery as soon as possible. Because most patients received early surgery, treatment interval from the ictus could not have significance as a outcome predictors.
Univariate statistical analysis revealed that age, presence of ICH on the initial CT scan, and vasospasm was related to the outcome significantly. This result was very consistent with the literature, supporting the validity of our study.3)15)18)22)23)24) A author reported that the initial loss of consciousness in spontaneous SAH patients had independent predictive power for poor neurologic condition on admission and related to the outcome.33) In our study, only same clinical grade patients were included so the initial loss of consciousness (LOS) could not have any predictive power even in univariate analysis. ICH on the initial CT scan was reported to be relate with high mortlaity and morbidity in univariate analysis but not in the multivariate analysis.22) In our study, it was significant in both univariate and mutivariate analysis. In other eport, ICH influenced the clinical grade thus in multivariate analysis, it lose its significance. In the same clinical patients group like our study, ICH might have significance in mutivariate analysis.
P.D. Le Roux, et al.,23) reported that because Hunt-Hess grade III patient most likely to develop symptomatic vasospasm, the successful management of vasospasm should have the greatest impact on outcome in these patient. There were 15 cases (21.1%) of clinical vasospasm in our series. And 6 patients improved after neurointensive care using triple H therapy and clacium channel blocker. Some authors reported incidence of clinical vasospasm was 32~32.4% in Hunt Hess grade III patients.28)29) Our incidence of clinical vasospasm was some what lower than literature. We adopted lumbar drainage for brain relaxation during surgery in most of our Hunt Hess grade III patients. There is a report the vasospasm rate was lower in lumbar drainage group than in control (17%, 51% respectively).17) Murayama et al,.29) reported that there was 90%improvement of vasospasm patinets after intensive therapy. In our study only 6 of 15 vasospasm could have improvement. Angioplasty was not available for us in early period of this series. More aggressive treatment of vasospasm including angioplasty can improve the outcome.
Interestingly, Fisher grade was not regarded as important factor. We thought that because the degree of SAH has strong relation to the consciousness and consciousness influence the Hunt-Hess grade, in the same Hunt-Hess grade patients, fisher grade can not have significance. Premature rupture of aneurysms occurred in 4 cases and well controlled.
In our study, age, presence of ICH on intial CT scan and vasospasm had significance in multivariate analysis. Especially It is in agreement with other reports from the literature that Age and vasospasm have statistical significance to the outcome.12)21)22)27)31)32) Univariate analysis has some limitation for several reason.23) Relative small sample size of a factor can make it difficult to estimate the precise magnitude of the association between predictors and outcome, and when the two events occurred in turn, the early event can influence both the late event and outcome. Using multivariate analysis, one can prevent this bias in part. But in our study, We thought because the Hunt-Hess grade, the powerful predictive value was same, the results for univariate and mutivariate analysis could be same.
The search for more accurate outcome predictors and the continued development of more precise outcome-based measure remains important.36)
Conclusion
In the Hunt-Hess grade III aneurysmal SAH patient, age, presence of ICH on intial CT scan vasospasm have independent statistical significance to the outcome. More aggressive treatment of vasospasm can improve the outcome.
REFERENCES
-
Bogdahn U, Lau W, Hassel W. Continuous-pressure controlled, external ventricular drainage for treatment of acute hydrocephalus -evaluation of risk factors. Neurosurgery 31:898-904, 1992
-
Broderick JP, Brott TG, Duldner JE. Initial and recurrent bleeding are the major causes of death following subarachnoid hemorrhage. Stroke 25:1342-7, 1994
-
Cesarini KG, Hardemark HG, Persson L. Improved survival after aneurysmal subarachnoid hemorrhage :review of case management during a 12-year period. J Neurosurg 90:664-72, 1999
-
Deruty R, Mottolese C, Pelissou-Guyotat I. Management of the ruptured intracranial aneurysm-early surgery, late surgery, or modulated surgery?. Acta Neurochir 113:1-10, 1991
-
L, Weir B, Grace M. Factors influencing the outcome of aneurysm rupture in poor grade patients :a prospective series. Neurosurgery 23:1-9, 1988
-
Drake CG. Report of World Federation of Neurological Surgeons Committee on a Universal Subarachnoid Hemorrhage Grading Scale. J Neurosurg 68:985-6, 1988
-
Fischer EG, Ames A III. Studies on mechanisms of impairment of cerebral circulation following ischemia :effect of hemodilution and perfusion pressure. Stroke 3:538-42, 1972
-
Fujii Y, Takeuchi S, Sasaki O. Ultra-early rebleeding in spontaneous subarachnoid hemorrhage. J Neurosurg 84:35-42, 1996
-
Gerber CJ, Lang DA, Neil-Dwyer G. A simple scoring system for accurate prediction of outcome within four days of a subarachnoid haemorrhage. Acta Neurochir 122:11-22, 1993
-
Groden C, Kremer C, Regelsberger J, Hansen HC, Zeumer H. Comparison of operative and endovascular treatment of anterior circulation aneurysms in patients if poor grades. Neuroradiology 43:778-83, 2001
-
Gu YX, Mao Y, Song DL, Zhou LF, Zhu W. Early-mid-phase microsurgery for ruptured cerebral anterior circulating aneurysm. Zhongghua Wai Ke Za Zhi 15;44(6):412-5, 2006
-
Hamada J, Morioka M, Fujioka S, Marubayashi T, Ushio Y. Management outcome for ruptured anterior circulation aneurysms with a Hunt and Hess clinical grade of III in patients in the 9th decade of life. Surg Neurol 56:294-300, 2001
-
Hernesniemi J, Vapalahti M, Niskanen M. One-year outcome in early aneurysm surgery :a 14 year experience. Acta Neurochir 122:1-10, 1993
-
Hijdra A, Braakman R, van Gijn J. Aneurysmal subarachnoid hemorrhage. Complication and outcome in a hospital population. Stroke 18:1061-7, 1987
-
Hoh Bl, Topcuoglu Ma, Singhal AB, Pryor JC, Rabinov JD, Rordorf GA, et al. Effect of clipping, Craniotomy or Intravascular Coiling on cerebral vasospasm and patient outcome after aneurysmal subarachnoid hemorrhage. Neurosurgery 55:779-89, 2004
-
Hunt WE, Hess RM. Surgical risk as related to time of intervention in the repair of intracranial aneurysms. J Neurosurg 28:14-20, 1968
-
Klimo JP, Kestle JRW, Mcdonald JD, Schmidt RH. Marked reduction of cerebral vasospasm with lumbar drainage of cerebrospinal fluid after subarachnoid hemorrhage. J Neurosurg 100:215-24, 2004
-
Kongable GL, Lanzino G, Germanson TP, Truskowski LL, Alves WM, Torner JC, et al. Gender-related differences in aneurysmal subarachnoid hemorrhage. J Neurosurg 84:43-8, 1996
-
Laidlaw JD, Siu KH. Poor-grade aneurysmal subarachnoid hemorrhage:outcome after treatment with urgent surgery. Neurosurgery 53:1275-82, 2003
-
|
PDF Links
Full text via DOI
Download Citation
