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Impact of medical treatment on the outcome of patients after aneurysmal subarachnoid hemorrhage
BACKGROUND AND PURPOSE: The rationale behind early aneurysm surgery in
patients with subarachnoid hemorrhage (SAH) is the prevention of
rebleeding as early as possible after SAH. In addition, by clipping the
aneurysm as early as possible, one can apply treatment for cerebral
ischemia more vigorously (induced hypertension) without the risk of
rebleeding. Hypervolemic hemodilution is now a well-accepted treatment for
delayed cerebral ischemia. We compared the prospectively collected
clinical data and outcome of patients admitted to the intensive care unit
in the period 1977 to 1982 with those of patients admitted in the period
1989 to 1992 to measure the effect of the change in medical management
procedures on patients admitted in our hospital with SAH. METHODS: We
studied 348 patients admitted within 72 hours after aneurysmal SAH.
Patients with negative angiography results and those in whom death
appeared imminent on admission were excluded. The first group (group A)
consisted of 176 consecutive patients admitted from 1977 through 1982.
Maximum daily fluid intake was 1.5 to 2 L. Hyponatremia was treated with
fluid restriction (<1 L/24 h). Antihypertensive treatment with diuretic
agents was given if diastolic blood pressure was >110 mm Hg. Patients in
the second group (172 consecutive patients; group B) were admitted from
1989 through 1992. Daily fluid intake was at least 3 L, unless cardiac
failure occurred. Diuretic agents and antihypertensive medications were
avoided. Cerebral ischemia was treated with vigorous plasma volume
expansion under intermittent monitoring of pulmonary wedge pressure,
cardiac output, and arterial blood pressure, aiming for a hematocrit of
0.29 to 0.33. Aneurysm surgery was planned for day 12. RESULTS: Patients
admitted in group B had less favorable characteristics for the development
of cerebral ischemia and for good outcome when compared with patients in
group A. Despite this, we found a significant decrease in the frequency of
delayed cerebral ischemia in patients of group B treated with tranexamic
acid (P=0.00005 by log rank test) and significantly improved outcomes
among patients with delayed cerebral ischemia (P=0.006 by chi2 test) and
among patients with deterioration from hydrocephalus (P=0.001 by chi2
test). This resulted in a significant improvement of the overall outcome
of patients in group B when compared with those in group A (P=0.006 by
chi2 test). The major cause of death in group B was rebleeding (P=0.011 by
chi2 test). CONCLUSIONS: We conclude that the outcome in our patients with
aneurysmal SAH was improved but that rebleeding remains a major cause o