From the Departments of Neurology (F.H.V., D.H.) and Neurosurgery
(H.W.C.B., C.J.J.A.), Academisch Ziekenhuis Rotterdam Dijkzigt, the
Netherlands.
Correspondence to Djo Hasan, MD, PhD, Intensive Care Neurology and Neurosurgery, 40 Dr Molewaterplein, 3015 GD Rotterdam, Netherlands. E-mail hasan{at}mediaport.org
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
Conclusions—We conclude that the outcome in our patients with
aneurysmal SAH was improved but that rebleeding remains a major
cause of death. Patient outcome can be further improved if we can
increase the efficacy of preventive measures against rebleeding by
performing early aneurysm surgery.
© 1998 American Heart Association, Inc.
Original Contributions
Impact of Medical Treatment on the Outcome of Patients After Aneurysmal Subarachnoid Hemorrhage
2 test) and among patients
with deterioration from hydrocephalus (P=0.001 by
2 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 2 test). The major
cause of death in group B was rebleeding (P=0.011 by
2 test).
Key Words: hemodilution • intracranial aneurysm • outcome • subarachnoid hemorrhage
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