- Overall mortality 35%
- 15% die before arriving to hospital
- 10 % die in first few days
- 46 % die in 30 days
- Causes of death
- 25% medical complication of SAH:
- Neurogenic pulmonary oedema,
- Neurogenic stun myocardium
- 8% progressive deterioration from initial haemorrhage
- If you survive the initial haemorrhage, the main thing that kills you is rebleed
- Risk of rebleed without tx (Winn et al 1977)
- 4% day 1
- 1.5%/day for 13days
- 20% in 1st 2 weeks
- 3%/yr Total risk
- Risk of rebleed after treatment
DSA+ SAH | Clipped | 1%/yr for first year |
DSA+ SAH | Coil | 2.6%/yr for first year |
- Spasm
- 7% dies
- 7% severe deficit
- > 50% of survivors make an incomplete recovery
- 30% of survivors have moderate to severe disability - Macdonald 2016
- Functional
- Subtle cognitive deficits (1/ 2)
- Emotional problems that impact on their day- to- day living (1/ 2 are dissatisfied with life)
- Only 30% to 60% return to their previous employment
- Clipping Vs coiling
- Some (non-randomized) studies suggest a poorer outcome with clipping at 1 year, with greater imaging evidence of focal encephalomalacia and infarction compared to coiled patients. Equally, some studies have shown poorer cognitive function in coiled patients compared to clipped patients at 4-6 months. Further studies/longer term follow up is needed, but each may have different effects on cognitive outcome at different time points since treatment.
- 1/3 who have clipping never return to the same quality of life
- >70 yrs
- Poorer outcome
- Higher proportion with severe neurological grade
- Predictors of poor outcomes
- Older age
- Female
- Ventilated breathing status
- Absence of pupillary reactivity or pupillary dilation
- Lower GCS (Poor WFNS)
- Higher modified Fisher grade
- Aneurysm location but not size
- Smoking diabetes
- Brunelli et al 2022:
- Brain plasticity makes it possible for patients to recover clinically from severe cerebral haemorrhage
- Outcome of 298 pts
- Good prognostic factors
- Factors associated with improvement in functional outcome in all patients (n = 298)ᵃ
Parameter | adjOR | 95% CI | p value |
mRS at ICU discharge | 0.74 | 0.56–0.97 | 0.031 |
Days on mechanical ventilation, per day | 0.96 | 0.93–0.99 | 0.041 |
Male sex | 0.45 | 0.22–0.95 | 0.036 |
Age, per year | 0.96 | 0.94–0.99 | 0.002 |
Hunt & Hess score | 0.79 | 0.64–0.98 | 0.033 |
- Hoffman 2023 retrospective study with logistic regression n =561
- Multivariant SHELTER-score to predict patient outcome
- Results
- SHELTER-score ≤ 4.5: Good outcome (favourable)
- 5 ≤ SHELTER-score ≤ 6.5: Poor outcome (disability)
- SHELTER-score ≥ 7: Dead
- EBI, early brain injury; mRS, modified Rankin Scale; SHELTER-score, Subarachnoid Hemorrhage Associated Early Brain Injury Outcome Prediction Score; WFNS, World Federation of Neurosurgical Societies
EBI-phase parameter | ㅤ | SHELTER-score points |
Age | <20 | 0 |
ㅤ | 20-39 | 1 |
ㅤ | 40-59 | 2 |
ㅤ | 60-79 | 3 |
ㅤ | ≥80 | 4 |
WFNS grade | 0 | 0 |
ㅤ | 1 | 0.5 |
ㅤ | 2 | 1 |
ㅤ | 3 | 1.5 |
ㅤ | 4 | 2 |
ㅤ | 5 | 2.5 |
Cardiopulmonary resuscitation | Ensued | 2 |
Mydriasis | Anisocoria | 1 |
ㅤ | Bilateral | 2 |
Midline shift | >10mm | 0.5 |
ㅤ | >20mm | 1 |
Early deterioration | Present | 1 |
Early ischemia | Present | 2 |
ㅤ | ㅤ | =sum score |
Made with Bullet