Prognosis

Advances in operative and endovascular techniques and postoperative critical care have led to a decrease in case-fatality rate over the past 3 decades. This might be related to improved diagnosis and improved surgical and medical management. The emergence of neurocritical care units may have contributed to better subarachnoid haemorrhage (SAH) outcomes.[184][185] However, overall outcome in SAH is still poor.[186][187] SAH is responsible for about one third of premature deaths related to stroke.[188] Mortality is slightly greater in black patients and women. Causes of early mortality are initial haemorrhage (19%), rebleeding (22%), vasospasm (23%), and medical complications (23%).[84][189] Old age, level of responsiveness on admission (measured by the World Federation of Neurological Surgeons [WFNS] Scale), and volume of subarachnoid blood are powerful predictors of 30-day mortality.[1][190] In patients undergoing clipping, perioperative and immediate postoperative neurological injury could account for a percentage of poor outcomes in those with good admission WFNS grades.[191]

Medical complications account for one-quarter of deaths in SAH.[56] About 40% of patients will have at least one medical complication during the first 3 months after SAH.[10][11][84][192] Cardiac and respiratory complications are most frequent. The presence of cardiac wall motion abnormality seem to portend a worse overall outcome after SAH.[193] Some degree of hepatic dysfunction is seen in 24% (4% with severe hepatic dysfunction).[84] Renal failure (1.4%), anaemia (5%), thrombophlebitis (1.4%), and pulmonary embolism (0.8%) are also complications encountered during hospitalisation.[10][11]

At 6 months after SAH, more than 25% of patients are dead and up to half of the survivors are moderately to severely disabled.[10][11] Over 50% of survivors report problems with memory, mood, and other cognitive impairment, resulting in negative impact on functional status, emotional health, and quality of life.[194][195] At 6 months, 75% of patients who were alert on admission had a good recovery, whereas only 11% of those comatose on admission survived.[10][11] Late epilepsy (measured at 12 months after SAH) is seen in around 5%.[196] More than 40% of patients who die after SAH have extracerebral organ system dysfunction, which is an independent predictor of outcome.[197][198] This identifies organ system dysfunction, other than the brain, as a potential therapeutic target that might have a positive effect on outcome. The frequency of aneurysm repairs in a hospital (more than 30 craniotomies for aneurysm repair per year) and the presence and use of endovascular therapy are independently associated with better outcome after SAH.[199][200][201] This led some to justify regionalisation of SAH treatment.[202]

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