Progress in the management of patients with aneurysmal subarachnoid hemorrhage: a single hospital review for 20 years. Part I: Younger patients

Impaired intracellular signal transduction via cyclic AMP contributes to cerebral vasospasm in rats with subarachnoid hemorrhage

No drug can completely prevent vasospasm after subarachnoid hemorrhage. Impaired intracellular signal transduction by cyclic nucleotides might be involved. We investigated effects of intravenous isoproterenol and NKH477 on cerebral blood flow in rats with or without intracisternal injection of autologous blood one week previously. In controls without hemorrhage, isoproterenol at 0.01, 0.1, 1, and 10 mg kg(-1) min(-1) increased cerebral blood flow by 1.2%+/-9.5%, 19.7%+/-12.8%, 46.8%+/-23.5%, and 63.8%+/-32.9% respectively; 10mg kg(-1) min(-1) of isoproterenol increased systemic blood pressure by 66.6%+/-58.1%, while other doses decreased blood pressure. In the subarachnoid hemorrhage group, isoproterenol increased cerebral blood flow by -20.0%+/-6.5%, -7.6%+/-8.7%, 8.2%+/-8.8%, and 35.9%+/-83.1% respectively; 10 mg kg(-1) min(-1) of isoproterenol increased systemic blood pressure by 68.8%+/-79.5%, while other doses decreased blood pressure. In controls, NKH477 at 3, 10, and 30 mg kg(-1) increased cerebral blood flow by 2.3%+/-3.6%, 14.4%+/-7.0%, and 50.7%+/-14.6%, respectively; in the subarachnoid hemorrhage group, NKH477 changed cerebral blood flow by -1.3%+/-2.4%, 4.6%+/-2.8%, and -12.6%+/-10.8% (not significant difference from controls). NKH477 at 30 mg kg(-1) min(-1) decreased systemic blood pressure in both groups, but the effect in the hemorrhage group was greater. Either isoproterenol or NKH477 at appropriate doses can increase cerebral blood flow in vasospasm following subarachnoid hemorrhage without decreasing blood pressure.

Comparison of clinical results between GDC treatment and direct surgery for ruptured cerebral aneurysms

We present a comparison of clinical results between GDC treatment and direct surgery for ruptured cerebral aneurysms. From May 97 to April 98, 32 aneurysms were treated by direct surgery (DS) or GDC treatment. Treatments were selected depending on the clinical grade, degree of hematoma and anatomical aspect of the aneurysms. There were 13 GDC treated cases and 19 direct surgery cases. In GDC cases, there were acute stage embolization for ruptured basilar aneurysm, recurrence of case after clipping for BA-SCA aneurysm, advanced age cases, and systemic complication cases. Glasgow outcome scale (GOS) in GDC cases were 8 GR, 2 MD and 3 SD. GOS in direct surgery cases were 7 GR, 4 MD, 4 SD and 4 deaths. Cases of severe subarachnoid hemorrhage with hematoma influenced the high death rate in direct surgery group. There were three complications associated with the procedure in the GDC group, however, the rate improved after advancement of the procedure. In conclusion, GDC treatment for ruptured cerebral aneurysm was satisfactorily acceptable compared to the results of direct surgery, however, more cases will be needed for precise comparison.

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

OBJECT

Based on the concept that unfavorable clinical outcome after aneurysmal subarachnoid hemorrhage (SAH), to a large extent, is a consequence of all ischemic insults sustained by the brain during the acute phase of the disease, management of patients with SAH changed at the authors' institution in the mid-1980s. The new management principles affected referral guidelines, diagnostic and monitoring methods, and pharmacological and surgical treatment 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 been studied in detail. This was the present undertaking.

METHODS

The authors analyzed all patients with SAH admitted to the neurosurgery department between 1981 and 1992. This period was divided in two parts, Period A (1981-1986) and Period B (1987-1992), and different aspects of management and outcome were recorded for each period. In total, 1206 patients with SAH (mean age 52 years, 59% females) were admitted; an aneurysm presumably 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% (Period A 26%; Period B 16%; p<0.001). At follow-up review conducted 2 to 9 years (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 recovery 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 with aneurysmal SAH has improved during the last decades. The most striking results were a gradual reduction in mortality rates and improved clinical outcomes in patients with Hunt and Hess Grade I or II SAH and in those with intraventricular hemorrhage. The changes in mortality rates and the clinical outcomes of patients with Hunt and Hess Grades III to V SAH were less conspicuous, although reduced incidences of mortality were seen in some subgroups; however, few survivors subsequently appeared to attain a favorable outcome.

Progress in the management of patients with aneurysmal subarachnoid hemorrhage: a single hospital review for 20 years. Part II: Aged patients

BACKGROUND

We have reported improvement in the outcome of the younger patients with aneurysmal subarachnoid hemorrhage in the preceding article. The purpose of this article is to study if the same management protocol has simultaneously benefited the elderly patients.

METHODS

One hundred twenty-nine patients with aneurysmal subarachnoid hemorrhage, over 70 years old, who were consecutively admitted to Kagawa Prefectural Central Hospital from July 1972 to December 1992, were reviewed. Patient grouping and outcome evaluation were the same as those of younger patients.

RESULTS

Changes in treatment protocol in this period, which were similar to those of the younger counterparts, resulted in an increased number of patients who actually underwent aneurysm clipping. Although the outcome evaluated at 6 months after initial hemorrhage was significantly poorer than that of the younger counterparts, there have been some improvements during the study period. Patients in good clinical condition at 6 months' follow-up (Glasgow Outcome Scale: Good Recovery) increased from 37.5% to 42.9% in grades I-II and from 0% to 23.1% in grade III, respectively.

CONCLUSIONS

The improvement in the outcome of elderly patients was less remarkable than that observed in younger patients. Significantly higher incidence of preoperative rebleeding and postoperative symptomatic vasospasm has proven to be the major cause of mortality and major morbidity at present. More careful and sophisticated perioperative care is required in elderly patients with aneurysmal subarachnoid hemorrhage.