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.[149]​ This may be related to improved diagnosis and improved surgical and medical management. The emergence of neurocritical care units may have contributed to better SAH outcomes.[150][151] However, overall outcome in SAH is still poor.[152][153] SAH is responsible for about one third of premature deaths related to stroke.[154] Mortality is slightly greater in black patients and women. Causes of early mortality are initial hemorrhage (19%), rebleeding (22%), vasospasm (23%), and medical complications (23%).[49][155] Older 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][121] In patients undergoing clipping, perioperative and immediate postoperative neurologic injury could account for a percentage of poor outcomes in those with good admission WFNS grades.[156]

Medical complications account for one-quarter of deaths in SAH.[44] Forty percent of patients will have at least 1 medical complication during the first 3 months after SAH.[11][12][49][157] Cardiac and respiratory complications are most frequent. The presence of cardiac wall motion abnormality seem to portend a worse overall outcome after SAH.[158] Some degree of hepatic dysfunction is seen in 24% (4% with severe hepatic dysfunction).[49] Renal failure (1.4%), anemia (5%), thrombophlebitis (1.4%), and pulmonary embolism (0.8%) are also complications encountered during hospitalization.[11][12]

In-hospital mortality from SAH is around 20%, with all-cause mortality increasing to 25% at 6 months. In one study, 35% of patients were “dead or disabled” (defined as modified Rankin Scale ≥4) at 6 months.[159]​ 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.[160][161]​ At 6 months, 75% of patients who were alert on admission had a good recovery, whereas only 11% of those comatose on admission survived.[11][12]​ Late epilepsy (measured at 12 months after SAH) is seen in 4% to 5%.[162][163]​ More than 40% of patients who die after SAH have extracerebral organ system dysfunction, which is an independent predictor of outcome.[164][165]​ 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.[166][167][168]​ This led some to justify regionalization of SAH treatment.[169]

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