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Aneurismal subarachnoid hemorrhage: who remains for surgical treatment in the post-ISAT era?

Koźba-Gosztyła M, Czapiga B, Jarmundowicz W - Arch Med Sci (2015)

Bottom Line: There were no linear trends regarding patients' mean age, clinical presentation and outcomes, but the number of patients in Fisher grade 4 increased and mortality slightly decreased.Unexpected trends in characteristics of aSAH patients treated surgically could be related to treatment decision modality.Trend patterns could be properly expressed in the constant availability of endovascular services.

View Article: PubMed Central - PubMed

Affiliation: Department of Neurosurgery, Wroclaw Medical University, Wroclaw, Poland.

ABSTRACT

Introduction: Although there have been a number of studies on changes and trends in the management of aneurismal subarachnoid hemorrhage (aSAH) since publication of the International Subarachnoid Aneurysm Trial (ISAT), no data exist on what category of patients still remains for surgical treatment. Our goal was to investigate the changes that occurred in the characteristics of a population of aSAH patients treated surgically in the post-ISAT period in a single neurosurgical center, with limited availability of endovascular service.

Material and methods: The study included 402 aSAH patients treated surgically in our unit between January 2004 and December 2011. Each year, data regarding number of admissions, age, aneurysm location and size, clinical and radiological presentation, outcome and mortality rates were collected and analyzed.

Results: The annual number of admissions more than halved in the study period (from 69 in 2004 to 32 in 2011). There were no linear trends regarding patients' mean age, clinical presentation and outcomes, but the number of patients in Fisher grade 4 increased and mortality slightly decreased. An unexpected, statistically significant increase occurred in the incidence of anterior communicating artery aneurysms (from 36.2% to 50%) and medium size aneurysms (from 34.7% to 56.2%) treated surgically, with a corresponding decrease in the incidence of middle cerebral artery aneurysms (from 40.5% to 34.3%) and large aneurysms (from 21.7% to 12.5%).

Conclusions: Unexpected trends in characteristics of aSAH patients treated surgically could be related to treatment decision modality. Trend patterns could be properly expressed in the constant availability of endovascular services.

No MeSH data available.


Related in: MedlinePlus

Percentage of anterior communicating artery (ACoA), middle cerebral artery (MCA) and internal carotid artery (ICA) aneurysms treated surgically, 2004–2011
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Figure 0005: Percentage of anterior communicating artery (ACoA), middle cerebral artery (MCA) and internal carotid artery (ICA) aneurysms treated surgically, 2004–2011

Mentions: The annual number of admissions decreased in successive years from 69 in 2004 to 32 in 2011 (Table II). There was a statistically significant (p < 0.001) trend toward a lower number of patients operated on annually. The highest number of patients was admitted in 2006 (82 patients), the lowest in 2008 (31 patients). The greatest decrease occurred in 2007, almost halving from 82 to 43 patients (Figure 1). The age range was 18–92 years. Pearson's correlation and Spearman's rank correlation revealed no linear trend in patient mean age in the study period. The biggest difference in the mean patients’ age appeared between 2007 and 2008, when it was 56.3 and 51.1 respectively (Figure 2). Sixty-seven percent of patients (271) were admitted in Hunt-Hess grade 1–3, which corresponds to 70.4% of patients (283) who achieved GCS 9-15 at presentation (Table I). There was no linear trend in the clinical presentation of the patients from 2004 to 2011 (Table II). However, the Cochran-Armitage test revealed that the number of patients with intracerebral or intraventricular hemorrhage (Fisher grade 4) tends to increase (Figure 3). In 2008 there was a lower number (9.6%) of patients in poor neurological grade (Hunt-Hess 4 and 5) as well as in Fisher grade 4 (35.4%). Overall, a favorable outcome (GOS 4 and 5) was achieved in 239 (59.4%) patients. The mortality rate was 20.1% (Table I). Although there was no linear trend in the overall outcomes, mortality slightly decreased over the study period (Figure 4). The highest percentage of favorable outcome occurred in 2008, with the lower mortality rate of 12.9% (Table II). Among the aneurysms that were more likely to bleed, 76.3% originated from the ACoA and MCA. Seventy-eight percent of aneurysms constituted those of small or medium size, i.e. equal to or less than 10 mm (Table I). There was a statistically significant increase in the percentage of patients with ACoA aneurysms (from 36.2% in 2004 to 50% in 2011), with a corresponding decrease in the percentage of patients with MCA aneurysms (from 40.5% to 34.3%) and ICA aneurysms (from 17.3% to 12.5%) (Table II, Figure 5). The percentage of patients with medium aneurysms (6–10 mm) also increased (from 34.7% in 2004 to 56.2% in 2011). In contrast, the percentage of patients with small (0–5 mm) aneurysms decreased from 34.7% in 2004 to 28.12% in 2011 and large (11–24 mm) aneurysms decreased from 21.7% to 12.5% (Table II, Figure 6). Due to the small study sample it was not statistically possible to establish the trend for PCoA, PA, ACA, AICA, BA and for giant aneurysms.


Aneurismal subarachnoid hemorrhage: who remains for surgical treatment in the post-ISAT era?

Koźba-Gosztyła M, Czapiga B, Jarmundowicz W - Arch Med Sci (2015)

Percentage of anterior communicating artery (ACoA), middle cerebral artery (MCA) and internal carotid artery (ICA) aneurysms treated surgically, 2004–2011
© Copyright Policy - open-access
Related In: Results  -  Collection

License
Show All Figures
getmorefigures.php?uid=PMC4495139&req=5

Figure 0005: Percentage of anterior communicating artery (ACoA), middle cerebral artery (MCA) and internal carotid artery (ICA) aneurysms treated surgically, 2004–2011
Mentions: The annual number of admissions decreased in successive years from 69 in 2004 to 32 in 2011 (Table II). There was a statistically significant (p < 0.001) trend toward a lower number of patients operated on annually. The highest number of patients was admitted in 2006 (82 patients), the lowest in 2008 (31 patients). The greatest decrease occurred in 2007, almost halving from 82 to 43 patients (Figure 1). The age range was 18–92 years. Pearson's correlation and Spearman's rank correlation revealed no linear trend in patient mean age in the study period. The biggest difference in the mean patients’ age appeared between 2007 and 2008, when it was 56.3 and 51.1 respectively (Figure 2). Sixty-seven percent of patients (271) were admitted in Hunt-Hess grade 1–3, which corresponds to 70.4% of patients (283) who achieved GCS 9-15 at presentation (Table I). There was no linear trend in the clinical presentation of the patients from 2004 to 2011 (Table II). However, the Cochran-Armitage test revealed that the number of patients with intracerebral or intraventricular hemorrhage (Fisher grade 4) tends to increase (Figure 3). In 2008 there was a lower number (9.6%) of patients in poor neurological grade (Hunt-Hess 4 and 5) as well as in Fisher grade 4 (35.4%). Overall, a favorable outcome (GOS 4 and 5) was achieved in 239 (59.4%) patients. The mortality rate was 20.1% (Table I). Although there was no linear trend in the overall outcomes, mortality slightly decreased over the study period (Figure 4). The highest percentage of favorable outcome occurred in 2008, with the lower mortality rate of 12.9% (Table II). Among the aneurysms that were more likely to bleed, 76.3% originated from the ACoA and MCA. Seventy-eight percent of aneurysms constituted those of small or medium size, i.e. equal to or less than 10 mm (Table I). There was a statistically significant increase in the percentage of patients with ACoA aneurysms (from 36.2% in 2004 to 50% in 2011), with a corresponding decrease in the percentage of patients with MCA aneurysms (from 40.5% to 34.3%) and ICA aneurysms (from 17.3% to 12.5%) (Table II, Figure 5). The percentage of patients with medium aneurysms (6–10 mm) also increased (from 34.7% in 2004 to 56.2% in 2011). In contrast, the percentage of patients with small (0–5 mm) aneurysms decreased from 34.7% in 2004 to 28.12% in 2011 and large (11–24 mm) aneurysms decreased from 21.7% to 12.5% (Table II, Figure 6). Due to the small study sample it was not statistically possible to establish the trend for PCoA, PA, ACA, AICA, BA and for giant aneurysms.

Bottom Line: There were no linear trends regarding patients' mean age, clinical presentation and outcomes, but the number of patients in Fisher grade 4 increased and mortality slightly decreased.Unexpected trends in characteristics of aSAH patients treated surgically could be related to treatment decision modality.Trend patterns could be properly expressed in the constant availability of endovascular services.

View Article: PubMed Central - PubMed

Affiliation: Department of Neurosurgery, Wroclaw Medical University, Wroclaw, Poland.

ABSTRACT

Introduction: Although there have been a number of studies on changes and trends in the management of aneurismal subarachnoid hemorrhage (aSAH) since publication of the International Subarachnoid Aneurysm Trial (ISAT), no data exist on what category of patients still remains for surgical treatment. Our goal was to investigate the changes that occurred in the characteristics of a population of aSAH patients treated surgically in the post-ISAT period in a single neurosurgical center, with limited availability of endovascular service.

Material and methods: The study included 402 aSAH patients treated surgically in our unit between January 2004 and December 2011. Each year, data regarding number of admissions, age, aneurysm location and size, clinical and radiological presentation, outcome and mortality rates were collected and analyzed.

Results: The annual number of admissions more than halved in the study period (from 69 in 2004 to 32 in 2011). There were no linear trends regarding patients' mean age, clinical presentation and outcomes, but the number of patients in Fisher grade 4 increased and mortality slightly decreased. An unexpected, statistically significant increase occurred in the incidence of anterior communicating artery aneurysms (from 36.2% to 50%) and medium size aneurysms (from 34.7% to 56.2%) treated surgically, with a corresponding decrease in the incidence of middle cerebral artery aneurysms (from 40.5% to 34.3%) and large aneurysms (from 21.7% to 12.5%).

Conclusions: Unexpected trends in characteristics of aSAH patients treated surgically could be related to treatment decision modality. Trend patterns could be properly expressed in the constant availability of endovascular services.

No MeSH data available.


Related in: MedlinePlus