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Clinical Characteristics and Outcomes of Patients with Aneurysmal Subarachnoid Hemorrhage: A Prospective Multicenter Study in a Middle-Income Country

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Abstract

Background

Aneurysmal subarachnoid hemorrhage (SAH) is associated with high mortality and long-term functional impairment. Data on clinical management and functional outcomes from developing countries are scarce. We aimed to define patient profiles and clinical practices and evaluate long-term outcomes after SAH in a middle-income country.

Methods

This was a prospective study including consecutive adult patients admitted with SAH to two reference centers in Brazil from January 2016 to February 2020. The primary outcome was functional status at 6 months using the modified Rankin Scale. Mixed multivariable analysis was performed to determine the relationship between clinical variables and functional outcomes.

Results

From 471patients analyzed, the median time from symptom onset to arrival at a study center was 4 days (interquartile range 0–9). Median age was 55 years (interquartile range 46–62) and 353 (75%) patients were women. A total of 426 patients (90%) were transferred from nonspecialized general hospitals, initial computed tomography revealed thick hemorrhage in 73% of patients (modified Fisher score of 3 or 4), and 136 (29%) had poor clinical grade (World Federation of Neurological Surgeons score of 4 or 5). A total of 312 (66%) patients underwent surgical clipping, and 119 (25%) underwent endovascular coiling. Only 34 patients (7%) underwent withdrawal or withholding of life-sustaining therapy during their hospital stay, and in-hospital mortality was 24%. A total of 187 (40%) patients had an unfavorable long-term functional outcome (modified Rankin Scale score of 4 to 6). Factors associated with unfavorable outcome were age (adjusted odds ratio [OR] 1.05, 95% confidence interval [CI] 1.03–1.08), hypertension (adjusted OR 1.81, 95% CI 1.04–3.16), poor clinical grade (adjusted OR 4.92, 95% CI 2.85–8.48), external ventricular drain (adjusted OR 3.8, 95% CI 2.31–6.24), postoperative deterioration (adjusted OR 2.33, 95% CI 1.32–4.13), cerebral infarction (adjusted OR 3.16, 95% CI 1.81–5.52), rebleeding (adjusted OR 2.95, 95% CI 1.13–7.69), and sepsis (adjusted OR 2.68, 95% CI 1.42–5.05).

Conclusions

Our study demonstrated that SAH management in a middle-income country diverges significantly from published cohorts and current guidelines, despite comparable clinical profiles on presentation and admission to high-volume referral centers. Earlier aneurysm occlusion and increased use of endovascular therapy could potentially reduce modifiable in-hospital complications and improve functional outcomes in Brazil.

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Funding

This study was financed in part by the Coordenação de Aperfeiçoamento de Pessoal de Nível Superior, Brazil, Finance Code 001. No additional funding was available for this study.

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Authors and Affiliations

  1. Department of Neurointensive Care, Paulo Niemeyer State Brain Institute, Rio de Janeiro, Brazil

    Bruno Gonçalves, Ricardo Turon, Nestor Charris, Fabio Miranda, Vanessa de Caro, Marco Prazeres, Thayana Santos, Cassia Righy & Pedro Kurtz

  2. Department of Intensive Care Medicine, Hospital Cristo Redentor, Porto Alegre, Brazil

    Carla Rynkowski

  3. Department of Neurointensive Care, Hospital Copa Star, Rio de Janeiro, Brazil

    Fabio Miranda, Thayana Santos, Cassia Righy & Pedro Kurtz

  4. Department of Neurology, Boston University School of Medicine, Boston Medical Center, Boston, MA, USA

    David M. Greer

  5. Department of Neuro-Intensive Care Medicine, Sainte-Anne Hospital, Paris-Descartes University, Paris, France

    Tarek Sharshar

  6. GHU Paris Psychiatrie et Neurosciences, Paris, France

    Turc Guillaume

  7. Université Paris Cité, Paris, France

    Turc Guillaume

  8. INSERM, Paris, France

    Turc Guillaume

  9. FHU NeuroVasc, Paris, France

    Turc Guillaume

  10. D’Or Institute for Research and Education, Rua Diniz Cordeiro, 30 – 3º andar, Rio de Janeiro, RJ, CEP 22281-100, Brazil

    Fernando A. Bozza & Pedro Kurtz

  11. National Institute of Infectious Diseases, Fundação Osvaldo Cruz, Rio de Janeiro, Brazil

    Fernando A. Bozza & Cassia Righy

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  1. Bruno Gonçalves
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Contributions

FAB, PK, CR, RT, BG, FM, and CR contributed to the study conception and design, and data interpretation. VC, MP, TS, NC, and CR performed data collection and adjudication. PK and BG performed data processing and statistical analysis. PK, CR, and BG and TS, DG, and TG drafted the first version or critically reviewed the article. FAB, PK, FM, and CR supervised the study. All authors had full access to data, participated in data interpretation, revised the article, and approved the final version of the manuscript.

Corresponding author

Correspondence to Pedro Kurtz.

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Conflict of interest

The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the article. All authors declare that they have no conflict of interest.

Ethical Approval

This article adheres to ethical guidelines and was approved by the Ethics Review Board of the Evandro Chagas National Institute of Infectious Diseases—Oswaldo Cruz Foundation (Rio de Janeiro). The data were de-identified for analysis.

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Gonçalves, B., Rynkowski, C., Turon, R. et al. Clinical Characteristics and Outcomes of Patients with Aneurysmal Subarachnoid Hemorrhage: A Prospective Multicenter Study in a Middle-Income Country. Neurocrit Care 38, 378–387 (2023). https://doi.org/10.1007/s12028-022-01629-6

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  • DOI: https://doi.org/10.1007/s12028-022-01629-6

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