Familial subarachnoid hemorrhage: Distinctive features and patterns of inheritance

To delineate the distinctive features of familial subarachnoid hemorrhage, we compared gender and age at the time of subarachnoid hemorrhage, as well as site and number of aneurysms, in patients with familial subarachnoid hemorrhage (at least 1 first-degree relative with subarachnoid hemorrhage) and patients with sporadic subarachnoid hemorrhage (no subarachnoid hemorrhage in first- or second-degree relatives), in a prospective, hospital-based series of patients. In addition we studied the pattern of inheritance in 17 families with familial subarachnoid hemorrhage. Mean age at the time of hemorrhage in patients with the familial form was 6.8 years lower than that in those with the sporadic form, and middle cerebral artery aneurysms occurred more often in patients with familial disease. Sex distribution and number of aneurysms were similar in the two groups. Inheritance was compatible with autosomal dominant transmission in some families, and with autosomal recessive or multifactorial transmission in others. In our 5 families as well as in all 18 previously reported families with two affected generations, the age at the time of subarachnoid hemorrhage was invariably lower in later generations, which is suggestive of anticipation. We conclude that familial subarachnoid hemorrhage is a separate entity with occurrence at a young age, predilection for aneurysms of the middle cerebral artery, and variable modes of inheritance, including autosomal dominant inheritance with possible anticipation.     

Comparison of prognosis and complications after warning leaks in subarachnoidal hemorrhage--experience with 214 patients following aneurysm clipping

OBJECTIVES: The 'warning leak', a smaller bleeding event from an aneurysm, which sometimes occurs before an acute massive subarachnoidal hemorrhage (SAH), was first described in 1967. The present study was performed to compare the complications and prognosis for 214 patients with and without a warning leak; aneurysm clipping had been performed in all.METHODS: The interval between the warning headache and the actual SAH was calculated. The following complications were examined: preoperative hemorrhage, intra-operative rupture of the aneurysm, postoperative re-bleeding, symptomatic vasospasm, shunt-requiring hydrocephalus, ventriculitis, postoperative wound infection, and outcome according to the Glasgow Outcome Scale (GOS).RESULTS: Sixty-seven (31%) out of the 214 patients had a warning leak with a median distance of 11 days before suffering from major SAH. Preoperative angiographic vasospasms occurred more frequently in the group with a warning bleeding (22.4 versus 6.1%; p<0.05), which means that the warning leaks induce vascular reactions similar to SAH. The outcome of both groups after a mean follow-up time of 22 months did not show any difference. But 30 out of the 67 patients with a warning leak were graded H&H III-V at admission to hospital after a major SAH. The overall outcome for patients graded H&H I and II was in 92% favorable, compared with only a 54% favorable outcome for H&H III-V patients. Long-term outcome in the warning leak group was not impaired by angiographically proven vasospasm.DISCUSSION: To give patients the chance to start their treatment in a better clinical condition it is important to recognize the early warning signs.     

Factors associated with hydrocephalus after subarachnoid hemorrhage. A report of the Cooperative Aneurysm Study

Hydrocephalus is an important complication of subarachnoid hemorrhage (SAH). We analyzed several factors possibly related to hydrocephalus following SAH in 3521 patients from the International Study on the Timing of Aneurysm Surgery. Hydrocephalus was diagnosed on admission computed tomographic (CT) scans in 15% of patients and was thought to be clinically symptomatic in 13.2% of patients. There was a 5.9% overlap between these groups. Using contingency table analysis, we found the following were significantly related to clinical hydrocephalus: increasing age; preexisting hypertension; admission blood pressure measurements; postoperative hypertension; admission CT findings of intraventricular hemorrhage, a diffuse collection of subarachnoid blood, and a thick focal collection of subarachnoid blood; posterior circulation site of aneurysm; focal ischemic deficits; use of antifibrinolytic drugs preoperatively; hyponatremia; admission level of consciousness; and a low score on the Glasgow outcome scale. Using discriminate factor analysis to predict clinical hydrocephalus, the most important variables in order were the following: CT hydrocephalus, intraventricular hemorrhage, admission level of consciousness, presubarachnoid hypertension, increasing age, subarachnoid blood noted on CT scan, posterior circulation aneurysm site, and hypertension postoperatively (canonical correlation = .399). We conclude that the development of hydrocephalus after SAH is multifactorial. Factors that compromise cerebrospinal fluid circulation acutely (eg, intraventricular hemorrhage, hemorrhage from a posterior circulation site of aneurysm, and diffuse spread of subarachnoid blood) contribute to the development of acute hydrocephalus. These same factors, plus the use of antifibrinolytic drugs preoperatively, are also important in the pathogenesis of clinical hydrocephalus, perhaps by promoting subarachnoid fibrosis.(ABSTRACT TRUNCATED AT 250 WORDS)     

动脉瘤性蛛网膜下腔出血患者认知功能影响因素研究

目的研究动脉瘤性蛛网膜下腔出血（SAH）患者认知功能的动态变化及其影响因素。方法以简易智能量表评估入院时、出院时和出院后2个月患者的认知功能;以Hunt-Hess、GCS、手术方式、GOS、年龄、性别和入院时并发症为变量,研究其与SAH患者认知功能间的关系。结果 100例动脉瘤性SAH患者认知功能损害率入院时为37%,出院时60%,出院后2个月38%;出院时认知功能损害率高于入院时（χ2=10.590,P=0.001）和出院后2个月（χ2=9.684,P=0.002）;对出院时认知功能有显著影响的因素是Hunt-Hess、GOS和手术方式,对出院后2个月认知功能有显著影响的因素是GOS。结论动脉瘤性蛛网膜下腔出血患者存在一定程度的认知功能损害,并与一定的影响因素相关;血管内治疗有助于减轻认知功能的损害。     

Predictors for cognitive impairment one year after surgery for aneurysmal subarachnoid hemorrhage

OBJECTIVE: To assess predictors for cognitive impairment one year after spontaneous subarachnoid hemorrhage (SAH). Evaluated predictors were the total amount of cisternal blood seen on computed tomography (CT) in the acute phase as measured by the Fisher grade, neurological grade at admission classified according to the Hunt and Hess scale, aneurysm site and patient's age, gender and education level. METHOD: 44 patients were operated by surgical clipping within 72 hours after CT verified aneurysmal SAH. After twelve months the remaining 42 patients were assessed by neuropsychological test, Beck Depression Inventory (BDI), the Glasgow Outcome Scale (GOS) and CT. Multiple regression analysis was conducted where predictor variables were independent factors and a global impairment index calculated for each patient was the dependent factor. RESULTS: The Fisher grade was the only independent predictor for neuropsychological impairment. Most patients had good neurological outcome as measured by the GOS and at the same time suffered from some degree of cognitive impairment at follow-up. Individual analysis of cognitive test scores showed mild to moderate dysfunction across multiple cognitive domains. Most frequent impairments were found in domains of memory, executive function and speed of information processing. Age below 50 years was associated with relatively better outcome. CONCLUSION: The severity of cognitive impairment one year post SAH is predicted by the volume of blood in the subarachnoid space as measured by the Fisher score.     

Prognostic Value of Serum S100 Protein by Elecsys S100 Immunoassay in Patients with Spontaneous Subarachnoid and Intracerebral Hemorrhages

Objective

The serum S100 protein has been known to reflect the severity of neuronal damage. The purpose of this study was to assess the prognostic value of the serum S100 protein by Elecsys S100 immunoassay in patients with subarachnoid hemorrhage (SAH) and intracerebral hemorrhage (ICH) and to establish reference value for this new method.

Methods

Serum S100 protein value was measured at admission, day 3 and 7 after bleeding in 42 consecutive patients (SAH : 20, ICH : 22) and 74 healthy controls, prospectively. Admission Glasgow coma scale (GCS) score, Hunt & Hess grade and Fisher grade for SAH, presence of intraventricular hemorrhage, ICH volume, and outcome at discharge were evaluated. Degrees of serum S100 elevation and their effect on outcomes were compared between two groups.

Results

Median S100 levels in SAH and ICH groups were elevated at admission (0.092 versus 0.283 µg/L) and at day 3 (0.110 versus 0.099 µg/L) compared to healthy controls (0.05 µg/L; p<0001). At day 7, however, these levels were normalized in both groups. Time course of S100 level in SAH patient was relatively steady at least during the first 3 days, whereas in ICH patient it showed abrupt S100 surge on admission and then decreased rapidly during the next 7 days, suggesting severe brain damage at the time of bleeding. In ICH patient, S100 level on admission correlated well with GCS score (r=-0.859; p=0.0001) and ICH volume (r=0.663; p=0.001). A baseline S100 level more than 0.199 µg/L predicted poor outcome with 92% sensitivity and 90% specificity. Logistic regression analyses showed Ln (S100) on admission as the only independent predictor of poor outcome (odd ratio 36.1; 95% CI, 1.98 to 656.3).

Conclusion

Brain damage in ICH patient seems to develop immediately after bleeding, whereas in SAH patients it seems to be sustained for few days. Degree of brain damage is more severe in ICH compared to SAH group based on the S100 level. S100 level is considered an independent predictor of poor outcome in patient with spontaneous ICH, but not in SAH. Further study with large population is required to confirm this result.     

The prediction of long-term outcome after subarachnoid hemorrhage as measured by the Short Form-36 Health Survey

The Glasgow Outcome Scale (GOS) score is widely used to assess outcome after a subarachnoid hemorrhage (SAH). Patients who have recovered fully or with a mild disability (GOS scores 4 and 5) frequently complain about difficulties in conducting their daily activities. The Short Form-36 (SF-36) Health Survey is a questionnaire that assesses outcomes in multiple categories. This study was conducted to compare the quality of outcome assessment between the SF-36 Health Survey and GOS scores. A total of 128 patients with SAH (all data expressed as mean ± standard deviation) aged 53.1 ± 12.1 years, and a mean Hunt and Hess grade on admission of 2 ± 1, were retrospectively included in the study. Medical charts were reviewed to assess previous medical history, location of the aneurysm and the presence of vasospasm. The SF-36 and GOS scores were collected in structured interviews approximately 5 years (±2 years) after the SAH. The SF-36 data were compared to a historical healthy control cohort of 2,474 individuals. The results showed that 52% of patients experienced a favourable outcome after SAH (GOS scores 4 and 5). Vasospasm was recorded in 25% of patients. However, the average SF-36 results were lower in all tested categories for patients after SAH than the healthy normal controls. None of the SF-36 categories except physical function correlated significantly with the GOS score. Aneurysm location did not have an impact on SF-36 data. Patients after a SAH assessed as GOS score 5 are significantly impaired in social functioning and general health. We conclude that patients continue to suffer neuropsychological deficits years after a SAH. The GOS score is a rough outcome measure that primarily focuses on physical functioning. SF-36 is a useful tool to include in the neuropsychological outcome assessment of patients with SAH.     

Patients with Supratentorial Aneurysmal Subarachnoid Hemorrhage During the Intermediate Period: Waiting or Actively Treating

Perhaps the most difficult practical decision for neurosurgeons these days is whether to secure aneurysms during the intermediate period (4–10 days) after aneurysmal subarachnoid hemorrhage (SAH). We retrospectively reviewed a series of 115 patients with a Hunt-Hess grade I-III upon admission who were admitted 4–10 days after initial supratentorial aneurysmal SAH. Patients who underwent active treatment in the intermediate period were assigned to the intermediate group (n = 49) while those who accepted delayed obliteration of a ruptured aneurysm (11–30 days) were assigned to the late group (n = 66). The demographic characteristics, size and site of aneurysms, and clinical conditions were well balanced in the two groups. There was no difference in outcome between the two groups according to the Glasgow Outcome Scale (GOS) at discharge or a six-month follow-up. Rebleeding before aneurysms obliteration was the leading factor resulting in poor outcome. In conclusion, for patients with supratentorial aneurysmal SAH who were in good clinical condition upon admission, active treatment during the intermediate period offered a good chance of a favorable outcome. An even larger number of patients from randomized clinical trials might be necessary to draw more reliable conclusions.     

Patients with Supratentorial Aneurysmal Subarachnoid Hemorrhage During the Intermediate Period: Waiting or Actively Treating

Perhaps the most difficult practical decision for neurosurgeons these days is whether to secure aneurysms during the intermediate period (4–10 days) after aneurysmal subarachnoid hemorrhage (SAH). We reviewed retrospectively a series of 115 patients with a Hunt–Hess grade I–III upon admission who were admitted 4–10 days after initial supratentorial aneurysmal SAH. Patients who underwent active treatment in the intermediate period were assigned to the intermediate group (n = 49), while those who accepted delayed obliteration of a ruptured aneurysm (11–30 days) were assigned to the late group (n = 66). The demographic characteristics, size and site of aneurysms, and clinical conditions were well balanced in the two groups. There was no difference in outcome between the two groups according to the Glasgow Outcome Scale (GOS) at discharge or a 6-month follow-up. Rebleeding before aneurysms obliteration was the leading factor resulting in poor outcome. In conclusion, for patients with supratentorial aneurysmal SAH who were in good clinical condition upon admission, active treatment during the intermediate period offered a good chance for a favorable outcome. An even larger number of patients from randomized clinical trials might be necessary to draw more reliable conclusions.     

Atypical causes of nontraumatic intracranial subarachnoid hemorrhage

Background

To analyze the management and outcome of patients presenting with atypical causes of intracranial subarachnoid hemorrhage (SAH).

Methods

We performed a review of our last 820 nontraumatic-SAH patients and analyzed the management and outcome of patients where the SAH origin was not a ruptured aneurysm. The Glasgow Outcome Scale (GOS) was used to assess outcome 3 months after event.

Results

Thirty-two patients had atypical causes of SAH. In 15 patients with Hunt and Hess (H&H) scores from 1 to 3 without focal neurological deficit (FND), 8 perimesencephalic nonaneurysmatic SAH, 4 blood coagulation disorders, 1 sinus thrombosis, 1 vasculitis, and 1 unknown-origin-SAH (UOS) were diagnosed. Fourteen (93%) of these 15 patients were conservatively treated. In 17 patients with H&H scores from 3 to 5 and FND, 8 tumors, 1 cavernoma, 1 sinus thrombosis, 1 arteriovenous malformation, 1 blood coagulation disorders, 2 UOS, and 3 dural fistulas were diagnosed. Fifteen (88%) of these 17 patients were interventionally treated. The neurological condition 3 months later was good (GOS 4 and 5) in 12 of the 15 cases (80%) admitted with low-H&H scores, as well as in 13 of the 17 cases (76%) admitted with high-H&H scores. Three patients died and four developed a severe disability.

Conclusions

Patients presenting with atypical causes of SAH and high-H&H scores at admission are likely to harbor an intracranial organic process producing the bleeding. Despite this poor initial condition, their 3-month outcome can be similar to those of patients with low-H&H scores if the origin of the bleeding is properly treated.     

Subarachnoid hemorrhage of unknown etiology

Abstract

During a 10-year-period, 80 of 510 (16%) patients with primary subarachnoid hemorrhage (SAH) had negative angiographic studies. On admission, 70 of 80 patients (88%) were in grades I-II according to Hunt and Hess, 9 (11%) in grade III, and 1 (1%) in grade IV. The most frequent CT feature was preponderance of subarachnoid blood in the peripontine cistern as observed in 35 of 51 cases (69%) in whom blood was visible on CT. During hospitalization, 3 patients (4%) rebledand 3 others (4%) had an infarction. However, in all of these complicated cases maximum hemorrhage was outside the peripontine cistern. Outcome after hospitalization as assessed by the Glasgow-Outcome-Scale (GOS) was favorable (GOS 1 and 2) in all patients who had maximum blood in the peripontine cistern, but only in 62% showing preponderance of blood outside the peripontine cistern, and 4 of them (25%) had died (GOS 5). These differences are statistically significant (p < 0.001). Long-term outcome of 56 patients as graded according to the Activities of Daily Living (ADL) system was favorable in 88% of cases with peripontine hemorrhage who returned to normal activities (ADL 1). At the same time> another patient with diffuse hemorrhage had died. Thus; overall mortality was 8.9% at a mean observation time of 5.5 years. In conclusion, SAH of unknown etiology generally has a good prognosis, although a nonneglegible percentage of patients have persistent minor side-effects. In our experience, maximum blood in the peripontine cistern particularly indicates a favorable outcome/ since all patients with this CT pattern survived in a good condition. [Neurol Res 1996; 18: 220–226]     

腰大池脑脊液持续引流治疗对蛛网膜下腔出血的预后分析

目的 观察腰大池脑脊液持续引流治疗对蛛网膜下腔出血(SAH)的预后影响.方法 将SAH患者92例随机分为对照组和脑脊液持续引流组,对照组使用常规治疗,治疗组在常规治疗的前提下加用腰大池脑脊液引流治疗结果治疗组病人发生脑梗死、死亡率较对照组低(P＜0.05),两组再出血发生率无明显差异(P＞0.05),出院时采用GOS评价.结果 显示两组间有明显差异(P＜0.05).结论 腰大池脑脊液持续引流治疗SAH的疗效肯定,能改善患者预后,减少并发症的发生.     

Angio-MR assessment of vasomotor reactivity impairment as a long-term outcome of SAH following intracerebral aneurysm rupture

Studies on long-term outcome of subarachnoid hemorrhage (SAH) have been carried out for many years using various neuroimaging techniques, such as e.g.: SPECT, PET, TCD and XeCT. In our study angio-MRI supplemented with the acetazolamide test was used to assess cerebrovascular reserve impairment in 30 patients within 6 months since clipping an intracranial aneurysm. Severity of the SAH course was evaluated using the WFNS (World Federation of Neurosurgical Societies) scale [3]. The patients' clinical status was assessed at follow-up by means of the Glasgow Outcome Scale (GOS) [8]. Cereberovascular reserve evaluated at the follow-up in hypercapneal conditions was found to be insufficient. The degree of vessel reactivity dysfunction as a long-term outcome of SAH turned out to depend on massiveness of hemorrhage from the ruptured aneurysm.     

The Utility and Benefits of External Lumbar CSF Drainage after Endovascular Coiling on Aneurysmal Subarachnoid Hemorrhage

Objective

Cerebral vasospasm still remains a major cause of the morbidity and mortality, despite the developments in treatment of aneurysmal subarachnoid hemorrhage. The authors measured the utility and benefits of external lumbar cerebrospinal fluid (CSF) drainage to prevent the clinical vasospasm and its sequelae after endovascular coiling on aneurysmal subarachnoid hemorrhage in this randomized study.

Methods

Between January 2004 and March 2006, 280 patients with aneurysmal subarachnoid hemorrhage were treated at our institution. Among them, 107 patients met our study criteria. The treatment group consisted of 47 patients who underwent lumbar CSF drainage during vasospasm risk period (about for 14 days after SAH), whereas the control group consisted of 60 patients who received the management according to conventional protocol without lumbar CSF drainage. We created our new modified Fisher grade on the basis of initial brain computed tomography (CT) scan at admission. The authors established five outcome criteria as follows : 1) clinical vasospasm; 2) GOS score at 1-month to 6-month follow-up; 3) shunt procedures for hydrocephalus; 4) the duration of stay in the ICU and total hospital stay; 5) mortality rate.

Results

The incidence of clinical vasospasm in the lumbar drain group showed 23.4% compared with 63.3% of individuals in the control group. Moreover, the risk of death in the lumbar drain group showed 2.1% compared with 15% of individuals in the control group. Within individual modified Fisher grade, there were similar favorable results. Also, lumbar drain group had twice more patients than the control group in good GOS score of 5. However, there were no statistical significances in mean hospital stay and shunt procedures between the two groups. IVH was an important factor for delayed hydrocephalus regardless of lumbar drain.

Conclusion

Lumbar CSF drainage remains to play a prominent role to prevent clinical vasospasm and its sequelae after endovascular coiling on aneurysmal subarachnoid hemorrhage. Also, this technique shows favorable effects on numerous neurological outcomes and prognosis. The results of this study warrant clinical trials after endovascular treatment in patients with aneurysmal SAH.     

Outcome 1 year after aneurysmal subarachnoid hemorrhage: relation between cognitive performance and neuroimaging

OBJECTIVE: To assess the cognitive impairment and the association between neuropsychological measures and neuroimaging 1 year after aneurysmal subarachnoid hemorrhage (SAH). METHOD: Forty-two patients were examined clinically according to Glasgow Outcome Scale (GOS). Computed tomography (CT), single photon emission computed tomography (SPECT) and neuropsychological examination were performed. RESULTS: There were no association between GOS and cognitive impairment index based on the neuropsychological examination. CT showed no sign of cerebral ischemia in 17 (40%) and low attenuating areas indicating cerebral infarction(s) in 25 (60%) patients. A significant correlation (P = 0.01) was observed between the cognitive impairment index and the SPECT index (r = 0.6). SPECT measurement was the only independent predictor for cognitive impairment. CONCLUSION: GOS is a crude outcome measure and patients classified with good recoveries may have significant cognitive deficits. Neuropsychological examination is the preferred method for outcome evaluation as this method specifically addresses the disabilities affecting patients' everyday life.     

Cerebrospinal fluid nitrite/nitrate correlated with oxyhemoglobin and outcome in patients with subarachnoid hemorrhage

The findings of various studies reporting temporal changes in CSF total nitrite/nitrate (NOx) levels after subarachnoid hemorrhage (SAH) vary considerably. The study group comprised 10 patients with SAH and 10 control subjects. Total nitrite/nitrate concentration was measured by a vanadium-based assay with the colorimetric Griess reaction. CSF oxyhemoglobin level was assessed by spectrophotometry. After an initial peak (22.6+/-10.1 microM) within first 24 h after SAH, CSF NOx decreased gradually during the period of observation. There was a significant correlation between CSF concentrations of NOx and OxyHb in the entire observation period (R=0.87, p<0.001). When the impact of bleeding into CSF was considered, patients with very good outcome [Glasgow Outcome Scale (GOS)=5] had significantly lower CSF NOx (11.1+/-1.3 microM) than those with worse outcome (GOS<5) (21.8+/-11.2 microM, p<0.01). In conclusion, this study demonstrates that after aneurysm rupture CSF NOx levels correlate with OxyHb. We suggest this as a novel interpretation of other variable findings in relation to NO metabolites in the central nervous system (CNS) post SAH, and hence it could usefully be incorporated into the planning of future studies, correlating NOx with clinical outcome.     

The impact of cardiac complications on outcome in the SAH population

OBJECTIVES: To determine the impact of cardiac complications (CdCs) on outcomes in patients with acute subarachnoid hemorrhage (SAH). PATIENTS AND METHODS: Eighty-one adult aneurysmal SAH patients with a fisher grade >1 and/or a Hunt and Hess grade >2 were recruited for this study. CdCs were defined as electrocardiogram (ECG) changes, myocardial necrosis, arrythmias, or pulmonary edema. Outcomes were assessed at 3, 6 and 12 months by telephone interview using the Modified Rankin Scale (MRS), Glasgow Outcome Scale (GOS), Barthel Index and Medical Outcome study Short Form-36 (SF-36). RESULTS: The CdCs occurred in 33% of patients. The most common CdCs were arrythmias and pulmonary edema (30%). There was no significant difference in mortality between the two groups. At 3 months there was a significant difference in the Barthel (P = 0.007) and the SF-36 (P = 0.014) with trends in the GOS (P = 0.049) and the MRS (P = 0.063). At 6 months a significant difference remained in the SF-36 (P = 0.028) and a trend in the Barthel (P = 0.069). CONCLUSION: Results show that CdCs may negatively impact outcomes in SAH patients up to 6 months following hemorrhage.     

Assessment of the haemostatic system in patients surgically treated for ruptured cerebral aneurysm

BACKGROUND AND PURPOSE: The aim of the study was to evaluate selected markers of thrombin generation and subsequent fibrinolysis in patients with aneurysmal subarachnoid haemorrhage (SAH) and to assess the relationship between thrombin generation/fibrinolysis and clinical course and outcome. MATERIAL AND METHODS: This prospective study included 72 patients after aneurysmal SAH who underwent surgery within 72 hours after onset of symptoms. The results were compared with 84 control patients without SAH. Selected markers of thrombin generation (thrombin-antithrombin complexes, TAT), fibrinolysis (D-dimer) and fibrinogen level were examined in blood just after admission and on day 7 after surgery. The relationship between levels of those markers and selected clinical and radiological data, and outcome at 3-6 months after surgery, were assessed. RESULTS: On admission, patients with SAH had higher levels of TAT (p<0.001), D-dimer (p=0.048), and fibrinogen than the control group (p<0.001). Also, patients with severe bleeding demonstrated higher TAT (p<0.001) and D-dimer (p=0.04) levels. The admission level of TAT (higher than 24 g/l; odds ratio = 10.8) and the elevated blood fibrinogen level (odds ratio = 1.2) showed a strong correlation with mortality. Furthermore, a level of TAT higher than 24 g/l (odds ratio = 9.98) and the level of fibrinogen (odds ratio = 1.3) strongly correlated with poor outcome. There was no significant correlation between markers of coagulation on the 7th day after surgery for SAH and the outcome. CONCLUSIONS: Activation of blood coagulation as well as the fibrinolytic system occurred early in the course of SAH. Such activation was associated with poor clinical status of patients on admission, greater amount of subarachnoid blood, and poor clinical outcome. Thus, blood levels of TAT and fibrinogen are independent factors associated with mortality and morbidity after aneurysmal SAH.     

Results of surgery for aneurysmal subarachnoid haemorrhage in northern Norway: a retrospective study with special focus on timing of surgery in a rural area

OBJECTIVES: This study reports data on time consumption before aneurysm surgery and the results of treatment in northern Norway. MATERIAL AND METHODS: A total of 279 cases were identified and included in our analysis of time span from bleeding to arrival at our department. Fifty-one patients were treated conservatively, either because of bad clinical condition or because angiography revealed no aneurysm. The remaining 228 patients were operated and included in our analysis of outcome after early aneurysm surgery. RESULTS: Among all 279 patients with aneurysmal subarachnoid haemorrhage (SAH), median time from ictus to arrival at the university hospital was 1 (0-30) day. Forty-one per cent arrived at the day of bleeding and 86% within the first 3 days after bleeding. Among the 228 patients who underwent surgical aneurysm repair, median time from bleeding to operation was 2 (0-33) days. Early aneurysm surgery (< 72 h) was performed in 146 patients (64%). Fifty patients (22%) underwent intermediate surgery (days 4-10) and 32 patients (14%) were operated later (day 11 or later). A significant association was found between Hunt and Hess (HH) grade and Glasgow Outcome Scale (GOS) score (P < 0.001). CONCLUSIONS: Most patients suffering aneurysmal SAH in northern Norway undergo early aneurysm surgery and the outcome is comparable with that obtained in other Scandinavian centres. Initial Hunt and Hess grade is a major determinant for outcome in aneurysmal subarachnoid haemorrhage.