破裂脳動脈瘤の治療成績 地方都市におけるくも膜下出血の治療成績の変化―単独施設における２０年間５８７例の解析結果から―

Abstract

This study seeks to determine how changes in outcomes and causal events are associated with outcome in patients with subarachnoid hemorrhage over time in an aging population. This retrospective study included 587 patients between 1989 and 2008. In that period, the mean age of the patients became older, from 55 to 65 years. Outcomes were assessed using the Glasgow Outcome Scale (GOS). Initial events that preceded unfavorable outcomes (GOS SD and V) and dead were identified. The overall outcome was GR in 36%, MD in 11%, SD in 13%, V in 3% and D in 37%. We compared data during the previous 10-year period from 1989 to 1998 with those during 1999 to 2008. The proportion of the patients over 70 years old increased from 25% to 46%, Hunt & Kosnik Grade V increased from 9% to 24%, and outcomes of SD increased from 9% to 17%. However, no change in the case-fatality rate was observed. As causative events, primary damage accounted for 56% of all cases with unfavorable outcomes and dead, while the rate of vasospasm and systemic complications were significantly decreased. Among 349 cases (66.3%) that underwent aneurysm obliteration, unfavorable outcomes of SD and V rose twofold to 23.5%, and the fatality rate fell by one-half to 11%. Overall outcome of subarachnoid hemorrhage has not improved. Advances in treatment have saved many patients; however, the increasing number of severe patients without surgical indication offsets the improvement in outcome. Although early surgery and intensive management reduced the rate of fatalities, vasospasm and systemic complications, this may have resulted in increasing unfavorable outcomes. These findings reflect the conditions associated with an aging population with a long life expectancy and offer a possible model for other rural cities in Japan.