Management of Aneurysmal Subarachnoid Hemorrhage: Variation in Clinical Practice and Unmet Need for Follow-up among Survivors-A Single-Center Perspective

World Neurosurg. 2020 Jul;139:e608-e617. doi: 10.1016/j.wneu.2020.04.067. Epub 2020 Apr 25.

Abstract

Objective: The purpose of the present study is to investigate the existence and/or prevalence of clinical practice variation in management of aneurysmal subarachnoid hemorrhage (aSAH) and to determine the need for long-term follow-up.

Methods: A single-center study was carried out of patients with aSAH over a 5-year period divided into 2 halves (2.5 years each) before and after addition of a dually trained cerebrovascular neurosurgeon. In-hospital clinical practice, clinical outcome (mortality and discharge destination) and long-term outcome (modified Rankin Scale score and Telephone Interview for Cognitive Status [TICS]) were compared using descriptive summaries and nonparametric tests.

Results: Among 251 patients admitted with aSAH, 115 (45.8%) were before the index event, whereas 136 (54.2%) were during the later period. The aneurysm-securing procedure changed from coil embolization to clip ligation (12/115 [10.4%] vs. 84/136 [61.8%]; P < 0.0001) during the latter years. Interventional treatment for cerebral vasospasm has decreased (58/115 [50.4%] vs. 49/136 [36.0%]; P = 0.0002). Patients surviving hospitalization had more clinic follow-up after discharge during the latter period (42/85 [49.4%] vs. 76/105 [72.4%]; P = 0.0012) and ventriculoperitoneal shunt placement for delayed hydrocephalus (1/85 [1.2%] vs. 9/105 [8.6%]; P = 0.02). A subcohort of aSAH survivors (n = 46) had lower median TICS score during the earlier study period (31.5 [interquartile range, 22-36] vs. 33 [interquartile range, 27-38]; P = 0.038). Similarly, preictal smoking status and hyperlipidemia were associated with adverse TICS score in a multivariate model (P = 0.007).

Conclusions: Postdischarge clinical follow-up has improved facilitating recognition and treatment of delayed hydrocephalus. Existence of cognitive deficits among survivors calls for establishment of multidisciplinary clinics for long-term management of aSAH.

Keywords: Cognitive outcome; Practice patterns; Subarachnoid hemorrhage; Systems of care.

MeSH terms

  • Adult
  • Aged
  • Disease Management*
  • Embolization, Therapeutic
  • Female
  • Follow-Up Studies
  • Humans
  • Hydrocephalus / etiology
  • Hydrocephalus / therapy
  • Hyperlipidemias / epidemiology
  • Male
  • Middle Aged
  • Needs Assessment
  • Postoperative Complications / therapy
  • Prevalence
  • Risk Factors
  • Smoking / epidemiology
  • Subarachnoid Hemorrhage / psychology
  • Subarachnoid Hemorrhage / therapy*
  • Survivors
  • Treatment Outcome
  • Vasospasm, Intracranial / etiology
  • Vasospasm, Intracranial / therapy
  • Ventriculoperitoneal Shunt