Author: Konczalla J, Seifert V, Beck J, et al. Outcome after Hunt and Hess grade V subarachnoid hemorrhage: a comparison of pre-coiling era versus post-ISAT era (2005-2014). J Neurosurg 2018; 128:100-110.
Reviewed by: Kyle Hobbs, MD, Assistant Professor, Wake Forest School of Medicine
Treatment of poor grade subarachnoid hemorrhage (SAH) is controversial, both in terms of aggressiveness of care as well as modality of treatment (coiling vs clipping). This retrospective outcome analysis compared patients from two time periods admitted to Goethe-University Hospital with Hunt and Hess (HH) Grade V SAH. The earlier period (1980-1995) was pre-International Subarachnoid Aneurysm Trial (ISAT), and represented conservative treatment. The current period (2005-2014) represented more aggressive care. 257 patients were included during the time periods mentioned above (54 from the early period and 203 from the current period). Only patients who were comatose on admission (HH Grade V SAH) were included in the analysis, and patients who had an improvement in HH grade within 24 hours were excluded. If the aneurysm was treated within 24 hours after EVD placement, improvement to a better HH grade on the day after treatment led to patient exclusion. For patients treated in the early period, standard treatment involved medical stabilization with the aneurysm only if the patient’s condition improved. In the current period, only a minority of patients with inoperable status received no further aneurysm treatment. Outcome assessed was the modified Rankin Scale (mRS) at 6 months (favorable outcome 0-2, unfavorable 3-6). Results with a p value < 0.05 were statistically significant. Multivariate analysis was performed on current-period cases in which aneurysms were treated to identify independent predictors of favorable outcome. Outcome and NNT were also compared with findings of a meta-analysis of the prospective trials for decompressive hemicraniectomy for malignant MCA infarction (randomized within 48 hours: HAMLET, DECIMAL, DESTINY), in which favorable outcome was defined as mRS of 0-3.
In the earlier period, 54/654 (8%) of SAH patients had Grade V SAH (60% anterior circulation, 7% posterior, and 30% angiography was not performed). Only 33% of Grade V patients received an EVD, and 74% did not receive aneurysm treatment. 30-day and 6-month mortality rates were 83% and 94% respectively, and no patients had a favorable outcome (mRS 0-2). 37% of patients died within the first 2 days, 65% died within the first week, and 81% died within 2 weeks. Only three patients survived until 6-month follow-up, one with mRS of 3 and two with mRS of 5. In the current period, 203/1174 (17%) had Grade V SAH. EVD was placed in 79%, and aneurysm was treated in 68% of patients (96% within 48 hours, and 99% within 72 hours). 32% had no aneurysm treatment. 49% of patients died before 6-month follow-up. Favorable outcome occurred in 23% of patients (29% of patients in which aneurysm was treated). Favorable outcome was similar for clipping and coiling (28% vs 31%, respectively). During the current period, 17% of patients died within 2 days, 29% within the first week, and 37% within 2 weeks. Overall survival rate at follow up was 51% for all patients, and 68% for those who received aneurysm treatment. Patients in the earlier period were younger than the current period (52 vs 57 years old, p < 0.05). Identification of aneurysm location and EVD placement occurred less often in the earlier period. 74% (earlier period) vs. 32% (current) of patients did not receive aneurysm treatment (p < 0.0001). The 30-day and 6-month mortality rates were significant higher in the earlier period than in the current period (30-day: 83% vs 39%, OR 7.7, p < 0.001; 6-month: 94% vs 49%, OR 17.9, p < 0.001). 23% of current period patients had favorable outcomes vs 0% of earlier period patients, P < 0.0001). In the current period, the ARR for survival was 46% overall (NNT=3), and 52% for patients who received aneurysm treatment (NNT=2). For favorable outcome, NNT was 5 for all patients and 4 for patients who received aneurysm treatment. By comparison with the meta-analysis for DC after MCA infarction, treatment of Grade V SAH had better rate of favorable outcome but slightly reduced rate of survival. The NNT was better in both groups in the Grade V SAH patients when compared to DC MCA meta-analysis. (2 for survival and 3 for favorable outcome, instead of 3 and 7). Likelihood of mRS 0-2 was also significantly better in the Grade V SAH group. Treatment of the aneurysm was an independent predictor of outcome, but timing of aneurysm treatment (12, 24, or 48 hours after ictus) was not. Positive prognostic factors for favorable outcome included younger age, early hydrocephalus, pupils equal, round, and reactive; and bilateral positive corneal reflex. Multivariate analysis identified younger age and bilateral corneal reflexes as independent predictors.
This study showed that early and aggressive treatment of Grade V SAH resulted in a significant decrease in mortality and increase in favorable outcome. Aggressive treatment consisted of early EVD placement, early aneurysm treatment (within 72 hours), and advanced ICU therapeutics including monitoring for cerebral vasospasm. The NNT of 2 for survival and 3 for favorable outcome suggest that aggressive treatment of Grade V SAH is appropriate in most cases, and compares favorably with the trials for DHC in malignant MCA infarction. Revision of current SAH guidelines is suggested by the authors. This trial suffered from many limitations, including that it was a single-center comparison of retrospective data (earlier period) with prospectively collected data (post-ISAT era). Selection bias existed in the current period due to physicians’ decision of whether or not to treat the patient. The comparison with the DHC for MCA infarction trials, while interesting, suffered from the strict inclusion/exclusion criteria of those trials; attempts were made to match these in the current study, but readers should take care not to over-generalize this comparison. Overall, this study suggests that outcome in Grade V SAH can be favorable with aggressive early treatment, particularly if positive prognostic factors (younger age, positive corneal reflex) are present. #LiteratureWatch
Read the article