Management of Aneurysmal Subarachnoid Hemorrhage: Variation in Clinical Practice and Unmet Need for Follow-up among Survivors–A Single-Center Perspective

Abstract

The purpose of the present study is to investigate the existence and/or prevalence of clinical practice variation in management of aneurysmal subarachnoid hemorrhage (aSAH) and to determine the need for long-term follow-up. A single-center study was carried out of patients with aSAH over a 5-year period divided into 2 halves (2.5 years each) before and after addition of a dually trained cerebrovascular neurosurgeon. In-hospital clinical practice, clinical outcome (mortality and discharge destination) and long-term outcome (modified Rankin Scale score and Telephone Interview for Cognitive Status [TICS]) were compared using descriptive summaries and nonparametric tests. Among 251 patients admitted with aSAH, 115(45.8%) were before the index event, whereas 136 (54.2%) were during the later period. The aneurysm-securing procedure changed from coil embolization to clip ligation (12/115 [10.4%] vs. 84/136 [61.8%]; P < 0.0001) during the latter years. Interventional treatment for cerebral vasospasm has decreased (58/115 [50.4%] vs. 49/136 [36.0%]; P= 0.0002). Patients surviving hospitalization had more clinic follow-up after discharge during the latter period (42/85 [49.4%] vs. 76/105 [72.4%]; P= 0.0012) and ventriculoperitoneal shunt placement for delayed hydrocephalus (1/85 [1.2%] vs. 9/105 [8.6%]; P= 0.02). A subcohort of aSAH survivors (n= 46) had lower median TICS score during the earlier study period (31.5[interquartile range, 22-36] vs. 33 [interquartile range, 27-38]; P= 0.038). Similarly, preictal smoking status and hyperlipidemia were associated with adverse TICS score in a multivariate model (P= 0.007). Postdischarge clinical follow-up has improved facilitating recognition and treatment of delayed hydrocephalus. Existence of cognitive deficits among survivors calls for establishment of multidisciplinary clinics for long-term management of aSAH.