Comparison of microsurgery and endovascular treatment on clinical outcome following poor-grade subarachnoid hemorrhage

doi:10.1016/j.jocn.2012.11.012

Journal of Clinical Neuroscience

Volume 20, Issue 9, September 2013, Pages 1213-1218

https://doi.org/10.1016/j.jocn.2012.11.012 Get rights and content

Abstract

Poor-grade (World Federation of Neurological Surgeons [WFNS] clinical grading scale grades IV and V) subarachnoid hemorrhage (SAH) is associated with significant morbidity and mortality. However, the correlation between the timing, modality of intervention (clipping or coiling) and the clinical outcome is not clear. This study aims to examine this correlation. Patients presenting with WFNS grades IV and V aneurysmal SAH between 1997 and 2008 to a single centre were studied. An aggressive policy of early intervention was followed, and the selection of endovascular versus microsurgical intervention was made according to angiographic rather than clinical features. Clinical outcomes were graded using the modified Rankin scale (mRS) at 6 month follow-up. One hundred and forty-three poor-grade patients (23.9% of all 598 aneurysmal SAH patients) were studied. Treatment was microsurgical in 83 (58.0%) and endovascular in 60 (42%) patients. Twenty patients (14.0%) were lost to follow-up. Good outcome (mRS 0-2) at 6 months was found in 45 microsurgical patients (63.3%) and 24 endovascular patients (46.1%). This trend towards better clinical outcomes in the microsurgical group was not statistically significant. With an aggressive early treatment policy more than half of the poor-grade SAH patients demonstrated a good clinical outcome. Microsurgery and endovascular treatment, when selected primarily according to angiographic features, were equally likely to achieve good outcome.

Introduction

Recurrent bleeding of a ruptured aneurysm is associated with significant morbidity and mortality.1, 2 The goal of treatment is to minimise recurrent bleeding by the exclusion of the aneurysm from the circulation.3, 4, 5 The treatment options include neurosurgical clipping and endovascular coiling, however, there is ongoing debate regarding the efficacy of these two options. Following the publication of the International Subarachnoid Aneurysm Treatment Trial (ISAT),6, 7 a further increase in the proportion of aneurysms treated by coiling has been witnessed.8, 9, 10, 11, 12, 13 The results from the ISAT study are not directly applicable to all aneurysms as the study primarily examined anterior circulation aneurysms in good-grade patients amendable to treatment by either coiling or clipping. The best treatment for other types of aneurysms and especially for poor grade patients cannot be discerned from current trial results.6, 7, 14

Patients presenting as comatose or severely neurologically impaired (World Federation of Neurological Surgeons [WFNS] clinical grading scale grades IV and V)¹⁵ have worse outcomes than good-grade patients (grades I–III) and are more difficult to treat due to their poor clinical state.3, 7, 16 Even with the optimal treatment poor outcomes are common17, 18, 19, 20 with a high mortality rate.3, 16, 21 The tendency has been for these patients to undergo endovascular coiling due to perceived higher risks and technical difficulties with clipping, and potential shorter time to intervention.

Concerns about the long-term efficacy of endovascular coiling may be less relevant in high risk, poor-grade patients post-subarachnoid hemorrhage (SAH), and available studies indicate acceptable long term efficacy.7, 22 Widespread clinical opinion, with some supporting evidence, is that an early endovascular approach may lead to better outcomes for poor-grade patients possibly due to less delay to treatment and less procedural stress.3, 23, 24, 25 However, there are also strong advocates for a more hesitant approach to poor-grade patients, with supportive therapy only and selection of active intervention only in those who improve.26, 27, 28, 29 These perceptions often lead to potential referral and management biases for poor-grade patients, making it difficult to assess comparative outcomes for alternative treatment paradigms. Therefore, both the timing and nature of the treatment for poor-grade patients remain controversial.3, 13, 16, 30, 31, 32, 33

Section snippets

Study overview

This retrospective study aims to examine the relationship between the type of intervention, the timing of the intervention and the subsequent clinical outcome in patients who presented with poor-grade (WFNS grades IV and V) SAH treated at a single centre (the Royal Melbourne Hospital). Outcomes were graded 6 months later using the modified Rankin scale (mRS). Mortality was assessed at 30 days post-intervention. This study was approved by the Institutional Research Ethics Committee at the hospital.

Statistical analysis

Three models were studied in which the WFNS grade (all patients, grade IV patients only and grade V patients only) was assessed in predicting morbidity and mortality against three independent variables; age, timing of intervention (<24 hours or later) and intervention type (endovascular or microsurgery). The models for all patients performed well. The model for grade IV patients only was not significant using the Omnibus test. However, the Hosmer and Lemeshow tests were not significant for all

Intervention

This study differs from most published studies in that a similar number of poor-grade patients were treated with endovascular rather than microsurgical clipping, and we consider this reflects our department policy of selecting the most appropriate intervention primarily according to the angiographic features rather than clinical grade, age or assumed prognosis. Nevertheless, the study does demonstrate that proportionally more patients who received an endovascular intervention were older, and of

Conclusions

This study suggests that with an aggressive early treatment policy more than half of poor-grade patients with SAH can achieve a good outcome. Importantly we found no significant difference between the microsurgical clipping and endovascular treatment when the selection was made according to angiographic rather than clinical criteria. The overall good outcomes seen in this study and findings in other studies give credence to treating these patients with an ultra-early intervention.

Conflicts of interest/disclosures

The authors declare that they have no financial or other conflicts of interest in relation to this research and its publication.

Acknowledgment

The authors wish to thank Marnie Collins and Dr. Chris Barras for helpful discussions about statistical analysis and Christie Decemara for aiding with data collection.

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Cited by (32)

Factors Affecting Outcomes of Poor-Grade Subarachnoid Hemorrhage
2024, World Neurosurgery
Poor-grade subarachnoid hemorrhage (SAH) accounts for 20% of all SAH and is associated with poor outcomes. The first step in improving outcomes is to analyze the factors that contribute to poor outcomes.
This was a multicenter, retrospective, observational, cohort study. Data fields included demographic, clinical, radiological, and outcome data for all spontaneous patients with SAH treated at 4 hospitals in Aomori Prefecture in Japan. Patients with modified Rankin Scale score 0–2 at discharge were defined as the good outcome group, and those with modified Rankin Scale score 3–6 were defined as the poor outcome group, and comparisons were made between the 2 groups.
There were 329 eligible patients with poor-grade SAH, 41 with good outcome group, and 288 with poor outcome group. On multivariate analysis of the outcome, conservative treatment (P < 0.001), Fisher group 4 (P < 0.007), age ≥65 years (P = 0.011), and Hunt and Kosnik grade V on admission (P = 0.021) were significant factors contributing to a poor outcome.
Nonelderly patients who are not in grade V and Fisher group 4 should undergo aneurysm treatment as soon as possible because they are more likely to have a good outcome, whereas elderly patients in grade V and Fisher group 4 are unlikely to benefit from aneurysm treatment at present. The development of a treatment for early brain injury may be important to improve the outcomes of patients with poor-grade SAH.
Hunt-Hess Score at 48 Hours Improves Prognostication in Grade 5 Aneurysmal Subarachnoid Hemorrhage
2023, World Neurosurgery
Patients with Hunt-Hess (HH)5 aneurysmal subarachnoid hemorrhage (SAH) have high mortality rates. Despite an initial moribund exam, a subset of patients progress to favorable outcomes.
To evaluate the utility of delayed HH grading to improve prognostication.
We retrospectively reviewed patients undergoing treatment of ruptured aneurysms at two level 1 stroke centers from January 2012 through December 2020. We collected relevant clinical information and developed a multivariate cox regression model to identify independent predictors of mortality. To evaluate the utility of delayed examinations in predicting outcomes, we re-assessed the HH grade at 48 hours post admission and constructed a logistic regression model with potential confounders to predict mortality.
From 2012 to 2020, 621 patients underwent treatment for aneurysmal SAH. We identified 63 HH5 patients (10%) with a mean age of 58 years. Among these patients, the median length of stay was 14 days, with 3 patients passing away within 48 hours. The overall mortality rate was 63% at 24 months. To predict mortality, our cox regression model found only age to be significant (P = 0.002). Delayed HH grading improved prognostication at 48 hours and remained significant on multivariate analysis as a predictor of mortality (P = 0.0001). We observed a significant difference in mortality between patients HH5 and patients HH4 or lower at 48 hours (P = 0.0003).
Delayed reassessment of HH grade 48 hours postadmission is a predictor of mortality, suggesting reassessment at 48 hours in high grade SAH leads to better prognostication.
Predictors for Functional Outcome in Patients with Aneurysmal Subarachnoid Hemorrhage Who Completed In-Hospital Rehabilitation in a Single Institution
2019, Journal of Stroke and Cerebrovascular Diseases
Background: Although many studies evaluated independent prognosis factors of functional outcome in patients with subarachnoid hemorrhage (SAH) at a suitable time point, some patients take a long time to get functional improvement. The purpose of this study is to evaluate predictors for functional outcome in SAH patients who underwent surgical clipping and in-hospital rehabilitation in our single institution using Modified Rankin Scale (MRS) and Barthel Index (BI). Methods: Two-hundred fifty-one SAH patients were admitted to our hospital from January 2008 to December 2017. Of them, 144 patients who diagnosed aneurysmal SAH, underwent surgical clipping within 72 hours, and completed subsequent in-hospital rehabilitation were included in this study. We explored their clinical variables and evaluated the relationships between those factors and functional outcome using MRS and BI. Results: In multivariate analysis, independent prognostic factors of both MRS and BI were age, World Federation of Neurologic Surgeons grade, and symptomatic vasospasm. Conclusions: We suggest that age, SAH severity, and symptomatic vasospasm are associated with functional outcome in patients with aneurysmal SAH who completed surgical clipping and in-hospital rehabilitation.
High-Grade Aneurysmal Subarachnoid Hemorrhage: Predictors of Functional Outcome
2019, World Neurosurgery
Citation Excerpt :
However, in recent years, considerable improvement in the outcome of patients with high-grade aSAH has been observed, with contemporary series reporting rates of functional independence and mortality of 30%–57% and 28%–36%, respectively.9,12,18,23-25 These improved results have been attributed to early aggressive resuscitation, the increasing use of endovascular techniques for aneurysm occlusion, and targeted postoperative neurologic intensive care.21,24,26-28 Consequently, the possibility of patient selection bias associated with the early prognostication of a poor outcome has been proposed.29
Because the prognosis of high-grade aneurysmal subarachnoid hemorrhage (aSAH), classified as World Federation of Neurosurgical Societies (WFNS) grade IV–V, is generally poor, the functional outcomes of survivors have not been thoroughly explored. The aim of this retrospective cohort study is to determine predictors of functional independence in patients who survive a high-grade aSAH.
We retrospectively evaluated consecutive patients with aSAH admitted to a single institution from January 2000 to April 2015. Adult (age ≥18 years) patients with WFNS grade IV–V aSAH were included for analysis. Patients without sufficient baseline data, those who died before discharge, and those without follow-up data were excluded. Univariable and multivariable logistic regression analyses were used to identify factors associated with functional independence, defined as a modified Rankin Scale score of 0–2, at last follow-up.
Of the 260 patients with a WFNS grade IV–V aSAH during the study period, 139 met the inclusion criteria. After a mean follow-up of 6.3 months, functional independence was achieved in 73% of high-grade aSAH survivors (101/139 patients) and in 39% of all high-grade aSAH cases (101/260 patients). Only a lack of cerebrospinal fluid shunt placement was found to be an independent predictor of functional independence in the multivariable analysis (odds ratio 0.28 [0.109–0.722]; P = 0.008).
Because functional independence can be achieved in the majority of high-grade aSAH survivors, aggressive initial management of high-grade aSAH is warranted. Strategies that reduce the need for permanent cerebrospinal fluid diversion may improve functional outcomes in survivors of high-grade aSAH.
Early management of poor-grade aneurysmal subarachnoid hemorrhage: A prognostic analysis of 104 patients
2019, Clinical Neurology and Neurosurgery
This study aimed to investigate the efficacy of early management for poor-grade aneurysmal subarachnoid hemorrhage (aSAH; WFNS grade IV and V), and analyze the prognostic factors.
A total of 104 consecutive patients with poor-grade aSAH from the Department of Neurosurgery, the Second Hospital of Shandong University were enrolled between January 2010 and December 2017. All these patients underwent early microsurgical clipping or endovascular coiling within three days after onset. Microsurgical clipping or endovascular coiling was selected according to aneurysm patterns, patient clinical status, interdisciplinary consultation, and the decision-making of the family. The individual prognosis was evaluated using the modified Rankin scale (mRS), while the prognostic factors were analyzed using multivariate logistic regression analysis.
There were 58 patients with grade IV aSAH and 46 patients with grade V aSAH. Microsurgical clipping was performed in 71 cases, while endovascular coiling was performed in 33 cases. According to the statistical results, microsurgical clipping was preferred by patients with CT Fisher grade III–IV, WFNS grade V, cerebral hernia, intracranial hematoma and preoperative rebleeding. At six months after onset, the overall rate of favorable outcome (mRS ≤ 2) was 36.5%. Furthermore, the favorable outcome rate was 56.9% in grade IV patients and 11.1% in grade V patients. Moreover, the univariate and multivariate logistic regression analyses revealed that CT Fisher grade I–II, WFNS grade IV and endovascular coiling were associated with a favorable prognosis, while the CT low-density area was slightly correlated to a poor prognosis.
The treatment of aSAH at the early stage by microsurgical clipping or endovascular coiling should be highlighted, especially for patients with WFNS grade IV. CT Fisher grade I–II, WFNS grade IV and endovascular coiling may predict a favorable prognosis, and the CT low-density area appeared to be a possible risk factor for poor prognosis.
Ultra-Early Treatment for Poor-Grade Aneurysmal Subarachnoid Hemorrhage: A Systematic Review and Meta-Analysis
2018, World Neurosurgery
Citation Excerpt :
When stratified by follow-up period, the rate of good functional outcome was higher in the studies with follow-up ≥6 months compared with a follow-up of 3 months or until discharge (50%; 95% CI, 40%–60% vs. 42%; 95% CI, 33%–51%) (Figure 3A). When stratified by treatment modality (Figure 3B), the incidence was 38% (95% CI, 33%–44%) in studies in which all patients were managed by aneurysm clipping,5,12,13,16,18,24 61% (95% CI, 49%–74%) in studies in which all patients were managed by aneurysm coiling,15,19,22 and 52% (95% CI, 38%–65%) in studies in which patients were managed by either aneurysm clipping or coiling.14,17,20,21 Sensitivity analysis showed that the results were not heavily influenced by specific studies.
It remains unknown if ultra-early (within 24 hours after onset) treatment can improve the prognosis in patients with poor-grade aneurysmal subarachnoid hemorrhage (aSAH). We aimed to evaluate the effect of ultra-early treatment on functional outcomes and mortality in patients with poor-grade aSAH via a systematic review and meta-analysis.
We performed a literature search in the PubMed, MEDLINE, and Web of Science databases. Primary outcomes were death and functional outcome assessed at any time period. Secondary outcomes were the rebleeding rate before an aneurysm occlusion procedure and the incidence of intraoperative technique difficulty (ITD). The results are reported as odds ratio (OR) with 95% confidence interval (CI).
A total of 14 articles containing 1111 patients met our inclusion criteria and were included in our analysis. The pooled incidence was 47% (95% CI, 40%–54%) for favorable outcome across 13 studies, 26% (95% CI, 19%–32%) for mortality in 11 studies, 10% (95% CI, 3%–16%) for rebleeding in 5 studies, and 20% (95% CI, 10%–31%) for ITD in 5 studies after ultra-early treatment of poor-grade aSAH. Compared with delayed treatment (>24 hours), the ultra-early treatment failed to improve outcomes (OR, 1.23; 95% CI, 0.75–2.01; P = 0.40) or reduce mortality (OR, 0.84; 95% CI, 0.58–1.22; P = 0.45), but tended to prevent preoperative rebleeding (OR, 0.59; 95% CI, 0.32 to 1.07; P = 0.08) in 6, 4, and 4 case-control studies, respectively.
Our findings show no significant change both in functional outcome and mortality between ultra-early and delayed treatment although ultra-early treatment may be associated with lower rebleeding rate.

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Clinical StudyComparison of microsurgery and endovascular treatment on clinical outcome following poor-grade subarachnoid hemorrhage

Abstract

Introduction

Section snippets

Study overview

Statistical analysis

Intervention

Conclusions

Conflicts of interest/disclosures

Acknowledgment

Lancet

Lancet

Surg Neurol

Clin Neurol Neurosurg

Surg Neurol

Ultra-early rebleeding in spontaneous subarachnoid hemorrhage

J Neurosurg

Early rebleeding after coiling of ruptured cerebral aneurysms: incidence, morbidity, and risk factors

AJNR Am J Neuroradiol

Endovascular treatment of Hunt and Hess grade IV and V aneuryms

AJNR Am J Neuroradiol

Endovascular coiling for cerebral aneurysms

AACN Clin Issues

Outcome from poor grade aneurysmal subarachnoid haemorrhage – which poor grade subarachnoid haemorrhage patients benefit from aneurysm clipping?

Br J Neurosurg

Lessons to be learnt from the International Subarachnoid Haemorrhage Trial (ISAT)

Br J Neurosurg

The impact of the International Subarachnoid Aneurysm Treatment Trial (ISAT) on neurosurgical practice

Acta Neurochir

Aneurysm surgery after the International Subarachnoid Aneurysm Trial (ISAT)

J Neurol Neurosurg Psychiatry

Controversies in the management of aneurysmal subarachnoid hemorrhage

Crit Care Med

Endovascular coiling versus neurosurgical clipping for patients with aneurysmal subarachnoid haemorrhage

Cochrane Database Syst Rev

Report of World Federation of Neurological Surgeons Committee on a universal subarachnoid hemorrhage grading scale

J Neurosurg

Predicting outcome in poor-grade patients with subarachnoid hemorrhage: a retrospective review of 159 aggressively managed cases

J Neurosurg

Clinical Study
Comparison of microsurgery and endovascular treatment on clinical outcome following poor-grade subarachnoid hemorrhage