Rs. Mauricewilliams et Nd. Kitchen, RUPTURED INTRACRANIAL ANEURYSMS - LEARNING FROM EXPERIENCE, British journal of neurosurgery, 8(5), 1994, pp. 519-527
The outcome of treatment of 400 consecutive patients with ruptured int
racranial aneurysms was assessed at 1 year. The patients were treated
by a single surgeon over a period of 13 years. Data sheets completed a
s each patient was treated included a contemporary analysis of the rea
sons for any unsatisfactory outcome. Surgery was usually delayed for o
ver 10 days from the last haemorrhage. Over the four successive 100-pa
tient cohorts, in which the composition of the patient population rema
ined unaltered, 1 year overall management mortality fell steadily from
38 to 24%. One year surgical mortality fell from 19 to 3%. The popula
tion of those operated on who were in Glasgow Outcome Score 5 at 1 yea
r rose from 73 to 90% (from 51 to 71% for all patients). Of the 123 de
aths, 89 occurred prior to operation, 24 after it. Thirty-five patient
s died from rebleeding prior to operation, but only eight of these occ
urred in patients judged from for surgery at the time. All but one of
the postoperative deaths resulted from technical problems related to t
he surgery. Over the successive cohorts, several factors indicated an
improvement in operative efficiency, notably a fall in the proportion
of cases with technical problems from 15 to 1%. We have demonstrated a
steady improvement in management results, resulting largely from incr
easing operative experience. We do not believe that changes in overall
management strategy, such as early surgery, would have any effect on
overall outcome.