Subarachnoid hemorrhage (SAH)

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Subarachnoid hemorrhage (SAH)

A subarachnoid hemorrhage is a hemorrhage in the subarachnoid space. Subarachnoid hemorrhage (SAH) is a medical emergency that requires immediate intervention. The etiology varies between cases; however, rupture of an intracranial aneurysm accounts for 80% of medical emergencies. Early intervention and treatment are essential to prevent long-term complications. Over the years, treatment of SAH has drastically improved, which is responsible for the rapid rise in SAH survivors. Post-SAH, a significant number of patients exhibit impairments in memory and executive function and report high rates of depression and anxiety that ultimately affect daily living, return to work, and quality of life. Given the rise in SAH survivors, rehabilitation post-SAH to optimize patient outcomes becomes crucial 1)

Epidemiology

Spontaneous subarachnoid hemorrhage epidemiology.

Etiology

Subarachnoid Hemorrhage Etiology.

Classification

see Subarachnoid hemorrhage classification.

Scales

Subarachnoid hemorrhage scales

Clinical features

see Subarachnoid hemorrhage clinical features.

Diagnosis

see Subarachnoid hemorrhage diagnosis.

Outcome

see Subarachnoid hemorrhage outcome.

Complications

see Aneurysmal subarachnoid hemorrhage complications.

Treatment

see Subarachnoid hemorrhage treatment.

Models

The Rabbit Blood-shunt Model for the Study of Acute and Late Sequelae of Subarachnoid Hemorrhage 2).

3) 4) 5) 6) 7) 8) 9) 10)

Outcome

Subarachnoid hemorrhage (SAH) has a substantial impact on quality of life and future risk for mortality in patients who survive the initial injury and hospitalization. Poor neurological status and advanced age on admission have been recognized as poor clinical prognostic factors and is one of the life-threatening diseases with high morbidity and mortality rate 11).

A neurological disease that was disgraceful fifty years ago has lost any disquieting and embarrassing significance in the present time to the light of evolution of vascular neurosurgery 12)

Hospital case volume may be associated with improved outcomes after subarachnoid hemorrhage (SAH)

High SAH patient volume is robustly and strongly associated with lower inpatient mortality, fewer poor outcomes, and more discharges to home. The observed SAH patient volume association does not plateau until facilities are treating more than 100 SAH patients per year. This is a considerably higher patient volume threshold than the 20 SAH/year/facility set forth by the Joint Commission for CSC Certification.

Short-term SAH outcomes have improved. High-volume hospitals have more favorable outcomes than low-volume hospitals. This effect is substantial, even for hospitals conventionally classified as high volume. 13).

Using the Get With The Guidelines Stroke registry, Prabhakaran et al., analyzed patients with a discharge diagnosis of SAH between April 2003 and March 2012 and assessed the association of annual SAH case volume with in-hospital mortality by using multivariate logistic regression adjusting for relevant patient, hospital, and geographic characteristics.

Among 31,973 patients with SAH from 685 hospitals, the median annual case volume per hospital was 8.5 (25th-75th percentile, 6.7-12.9) patients. Mean in-hospital mortality was 25.7%, but was lower with increasing annual SAH volume: 29.5% in quartile 1 (range, 4-6.6), 27.0% in quartile 2 (range, 6.7-8.5), 24.1% in quartile 3 (range, 8.5-12.7), and 22.1% in quartile 4 (range, 12.9-94.5). Adjusting for the patient and hospital characteristics, hospital SAH volume was independently associated with in-hospital mortality (adjusted odds ratio 0.79 for quartile 4 vs 1, 95% confidence interval, 0.67-0.92). The quartile of SAH volume also was associated with length of stay but not with discharge home or independent ambulatory status.

In a large nationwide registry, they observed that patients treated at hospitals with higher volumes of SAH patients have lower in-hospital mortality, independent of patient and hospital characteristics suggesting that experienced centers may provide more optimized care for SAH patients. 14)

Studies

ICONS study

1)

Nwafor DC, Kirby BD, Ralston JD, Colantonio MA, Ibekwe E, Lucke-Wold B. Neurocognitive Sequelae and Rehabilitation after Subarachnoid Hemorrhage: Optimizing Outcomes. J Vasc Dis. 2023 Jun;2(2):197-211. doi: 10.3390/jvd2020014. Epub 2023 Apr 1. PMID: 37082756; PMCID: PMC10111247.
2)

Andereggen L, Neuschmelting V, von Gunten M, Widmer HR, Takala J, Jakob SM, Fandino J, Marbacher S. The Rabbit Blood-shunt Model for the Study of Acute and Late Sequelae of Subarachnoid Hemorrhage: Technical Aspects. J Vis Exp. 2014 Oct 2;(92). doi: 10.3791/52132. PubMed PMID: 25350004.
3)

Mori K, Fujii K, Tomura S, Ueno H, Wada K, Otani N, Osada H, Tomiyama A. Canine double hemorrhage model of experimental subarachnoid hemorrhage. Acta Neurochir Suppl. 2015;120:347-51. doi: 10.1007/978-3-319-04981-6_60. PubMed PMID: 25366650.
4)

Fathi AR, Bakhtian KD, Marbacher S, Fandino J, Pluta RM. Blood Clot Placement Model of Subarachnoid Hemorrhage in Non-human Primates. Acta Neurochir Suppl. 2015;120:343-6. doi: 10.1007/978-3-319-04981-6_59. PubMed PMID: 25366649.
5)

Marbacher S, Fathi AR, Muroi C, Coluccia D, Andereggen L, Neuschmelting V, Widmer HR, Jakob SM, Fandino J. The rabbit blood shunt subarachnoid haemorrhage model. Acta Neurochir Suppl. 2015;120:337-42. doi: 10.1007/978-3-319-04981-6_58. PubMed PMID: 25366648.
6)

Kikkawa Y. A rabbit cisterna magna double-injection subarachnoid hemorrhage model. Acta Neurochir Suppl. 2015;120:331-5. doi: 10.1007/978-3-319-04981-6_57. PubMed PMID: 25366647.
7)

Güresir E, Schuss P, Borger V, Vatter H. Rat cisterna magna double-injection model of subarachnoid hemorrhage – background, advantages/limitations, technical considerations, modifications, and outcome measures. Acta Neurochir Suppl. 2015;120:325-9. doi: 10.1007/978-3-319-04981-6_56. PubMed PMID: 25366646.
8)

Sehba FA. The rat endovascular perforation model of subarachnoid hemorrhage. Acta Neurochir Suppl. 2015;120:321-4. doi: 10.1007/978-3-319-04981-6_55. PubMed PMID: 25366645.
9)

Attia MS, Macdonald RL. Anterior circulation model of subarachnoid hemorrhage in mice. Acta Neurochir Suppl. 2015;120:311-4. doi: 10.1007/978-3-319-04981-6_53. PubMed PMID: 25366643.
10)

Marbacher S. Foreword Chapter Animal Models of SAH. Acta Neurochir Suppl. 2015;120:309. doi: 10.1007/978-3-319-04981-6_52. PubMed PMID: 25366642.
11)

Kooijman E, Nijboer CH, van Velthoven CT, Kavelaars A, Kesecioglu J, Heijnen CJ. The rodent endovascular puncture model of subarachnoid hemorrhage: mechanisms of brain damage and therapeutic strategies. J Neuroinflammation. 2014;11:2.
12)

Longatti P, Giombelli E, Pavesi G, Carteri A, Feletti A. Management of subarachnoid hemorrhage in two important Italian political leaders: a paradigm of ethical and technological evolution of neurosurgery during the past half-century. World Neurosurg. 2016 Jan 13. pii: S1878-8750(16)00007-3. doi: 10.1016/j.wneu.2015.12.089. [Epub ahead of print] Review. PubMed PMID: 26775232.
13)

Pandey AS, Gemmete JJ, Wilson TJ, Chaudhary N, Thompson BG, Morgenstern LB, Burke JF. High Subarachnoid Hemorrhage Patient Volume Associated With Lower Mortality and Better Outcomes. Neurosurgery. 2015 Sep;77(3):462-70. doi: 10.1227/NEU.0000000000000850. PubMed PMID: 26110818.
14)

Prabhakaran S, Fonarow GC, Smith EE, Liang L, Xian Y, Neely M, Peterson ED, Schwamm LH. Hospital case volume is associated with mortality in patients hospitalized with subarachnoid hemorrhage. Neurosurgery. 2014 Nov;75(5):500-8. doi: 10.1227/NEU.0000000000000475. PubMed PMID: 24979097.

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