Improved survival after aneurysmal subarachnoid hemorrhage: review of casemanagement during a 12-year period

Object. Based on the concept that unfavorable clinical outcome after aneury smal subarachnoid hemorrhage (SAH), to a large extent, is a consequence of all ischemic insults sustained by the brain during the acute phase of the d isease, management of patients with SAH changed at the authors' institution in the mid-1980s. The new management principles affected referral guidelin es, diagnostic and monitoring methods, and pharmacological and surgical tre atment in a neurointensive care setting. The impact of such changes on the outcome of aneurysmal SAH over a longer period of time has not previously b een studied in detail. This was the present undertaking. Methods. The authors analyzed all patients with SAH admitted to the neurosu rgery department between 1981 and 1992. This period was divided in two part s, Period A (1981-1986) and Period B (1987-1992), and different aspects of management and outcome were recorded for each period. In total, 1206 patien ts with SAH (mean age 52 years, 59% females) were admitted; an aneurysm pre sumably causing the SAH was found in 874 (72%). The 30-day mortality rate decreased from 29% during the first 2 years (1981 -1982) to 9% during the last 2 years (1991-1992) (Period A 22%; Period B 10 %; p < 0.0001) and the 6-month mortality rate decreased from 34 to 15% (Per iod A 26%; Period B 16%; p < 0.001). At follow-up review conducted 2 to 9 y ears (mean 5.2 years) after SAH occurred, patients were evaluated according to the Glasgow Outcome Scale. Subarachnoid hemorrhage-related poor outcome (vegetative or dead) was reduced (Period A 30%; Period B 18%; p < 0.001). There was an increase both in patients with favorable outcome (good recover y and moderate disability) (Period A 61%; Period B (66%) and in those with severe disability (Period A 9%; Period B 16%; p < 0.01). Conclusions. This study provides evidence that the prognosis for patients w ith aneurysmal SAH has improved during the last decades. The most striking results were a gradual reduction in mortality rates and improved clinical o utcomes in patients with Hunt and Hess Grade I or II SAH and in those with intraventricular hemorrhage. The changes in mortality rates and the clinica l outcomes of patients with Hunt and Ness Grades III to V SAH were less con spicuous, although reduced incidences of mortality were seen in some subgro ups; however, few survivors subsequently appeared to attain a favorable out come.