-Original-

Functional Outcome Following Ultra-Early Treatment for Ruptured Aneurysms in Patients with Poor-Grade Subarachnoid Hemorrhage

Junya Kaneko¹, Takashi Tagami^1-3, Kyoko Unemoto¹, Chie Tanaka¹, Kentaro Kuwamoto⁴, Shin Sato¹, Shosei Tani⁵, Ami Shibata⁶, Saori Kudo¹, Akiko Kitahashi¹ and Hiroyuki Yokota⁷

¹Department of Emergency and Critical Care Medicine, Nippon Medical School Tama Nagayama Hospital, Tokyo, Japan
²Health Services and Systems Research, Duke-NUS Medical School, Singapore, Singapore
³Department of Clinical Epidemiology and Health Economics, School of Public Health, The University of Tokyo, Tokyo, Japan
⁴Department of Neurosurgery, St. Luke's International Hospital, Tokyo, Japan
⁵Department of Neurosurgery, Tominaga Hospital, Osaka, Japan
⁶Department of Neurosurgery, Nippon Medical School Chiba Hokusoh Hospital, Chiba, Japan
⁷Department of Emergency and Critical Care Medicine, Nippon Medical School, Tokyo, Japan

Background: Little is known regarding functional outcome following poor-grade (World Federation of Neurosurgical Societies grades IV and V) aneurysmal subarachnoid hemorrhage (aSAH), especially in individuals treated aggressively in the early phase after ictus.
Methods: We provided patients with aSAH with ultra-early definitive treatment, coiling or clipping, within 6 hours from arrival as per protocol. We classified the patients into 3 groups according to their computed tomography findings: Group 1, intraventricular hemorrhage with obstructive hydrocephalus; Group 2, massive intracerebral hemorrhage with brain herniation; and Group 3, neither Group 1 nor Group 2. We retrospectively evaluated patients with poor-grade aSAH who were admitted to our department between January 2013 and December 2016. We evaluated functional outcome at 6 months, defining modified Rankin Scale (mRS) scores of 0-2 as good and those of 3-6 as poor outcomes.
Results: A good functional outcome was observed in 39.4% (28/71) of all cases. All-cause mortality at 6 months was 15.5% (11/71). A good outcome in Group 3 was significantly higher than that in the other two groups (Group 1 and 2 vs. Group 3, 20.8% vs. 48.9%, p = 0.02), even after adjustment with a multiple logistic regression analysis (odds ratio 6.1, 95% confidence interval 1.1 to 34.8).
Conclusions: Approximately 40% of patients with poor-grade aSAH became functionally independent, and approximately half of the patients with poor-grade aSAH who had neither intraventricular hemorrhage with obstructive hydrocephalus nor with brain herniation had good functional outcomes. Although further trials are required to confirm our results, ultra-early surgery may be considered for patients with poor-grade aSAH.

J Nippon Med Sch 2019; 86: 81-90

Keywords
aneurysm, intracerebral hemorrhage, subarachnoid hemorrhage, computed tomography

Correspondence to
Takashi Tagami, MD, MPH, PhD, Department of Emergency and Critical Care Medicine, Nippon Medical School Tama Nagayama Hospital, 1-7-1 Nagayama, Tama, Tokyo 206-8512, Japan
t-tagami@nms.ac.jp

Received, September 1, 2018
Accepted, November 8, 2018