What Factors Determine Treatment Outcome in Aneurysmal Subarachnoid Hemorrhage in the Modern Era? A Post Hoc STASH Analysis

World Neurosurg. 2017 Sep:105:270-281. doi: 10.1016/j.wneu.2017.05.005. Epub 2017 May 11.

Abstract

Background: The management of aneurysmal subarachnoid hemorrhage (aSAH) has changed dramatically in the last few decades with the publication of a few major studies, including ISAT (International Subarachnoid Aneurysm Trial, the International Cooperative Study on the Timing of Aneurysm Surgery Study). The aim of this study is to analyze the outcome of patients with aSAH based on a contemporary series, identify the risk factors for poor outcome, and focus on patients with good-grade aSAH (to match the ISAT cohort).

Methods: Baseline demographic and outcome data (modified Rankin Scale) were available for the 803 patients recruited from the STASH (Simvastatin in Aneurysmal Subarachnoid Haemorrhage) trial for post hoc analysis, using a χ2 test or 2-sample t test. Logistic regression analysis was performed to assess the risk factors for poor outcome at 6 months. Propensity matched analysis comparing coiling and clipping, and subgroup analysis of good-grade patients (World Federation of Neurosurgical Societies grade I-II) were also performed.

Results: Logistic regression analysis showed that the treatment modality (i.e., coiling or clipping) was not associated with poor outcome at 6 months (P = 0.839). The risk factors associated with poor outcome at 6 months were poor admission World Federation of Neurosurgical Societies grade (P < 0.0001), Fisher grade on initial computed tomography scan (P = 0.013), and the development of delayed cerebral ischemia (P < 0.0001). Subgroup analysis for good-grade patients only showed that 82% of patients after coiling and 78% of patients after clipping were classed as good outcome at 6 months (P = 0.181).

Conclusions: In the current era of aSAH management, apart from patients' admission status, SAH blood load and the development of delayed cerebral ischemia, treatment modality with either coiling or clipping was not associated with poor outcome difference at 6 months.

Keywords: Endovascular coiling; Neurosurgical clipping; Post hoc analysis; Propensity matched analysis; aSAH.

MeSH terms

  • Adolescent
  • Adult
  • Age Factors
  • Aged
  • Angiography, Digital Subtraction
  • Anticholesteremic Agents / therapeutic use*
  • Endovascular Procedures / adverse effects
  • Endovascular Procedures / instrumentation
  • Female
  • Humans
  • International Cooperation
  • Intracranial Aneurysm / complications
  • Intracranial Aneurysm / diagnostic imaging
  • Intracranial Aneurysm / etiology
  • Intracranial Aneurysm / surgery*
  • Male
  • Middle Aged
  • Outcome Assessment, Health Care*
  • Regression Analysis
  • Risk Factors
  • Simvastatin / therapeutic use*
  • Subarachnoid Hemorrhage / complications
  • Subarachnoid Hemorrhage / diagnostic imaging
  • Subarachnoid Hemorrhage / surgery*
  • Tomography Scanners, X-Ray Computed
  • Treatment Outcome
  • Young Adult

Substances

  • Anticholesteremic Agents
  • Simvastatin