Surgical management in patients with aneurysmal subarachnoid hemorrhage. The outcomes in the paradigm shift period.

BACKGROUND: The treatment of cerebral aneurysms has undergone significant evolution since the 1990s when the endovascular methods were introduced. After the results of ISAT were published in 2002, a change in practice occurred which resulted in more ruptured aneurysms treated endovascularly rather than by surgical clipping. This change in practice was referred to as a paradigm shift. OBJECTIVES: The aim of this study was to review the treatment outcomes in patients with ruptured anterior cerebral aneurysms and to delineate the trends in surgical management in the age of the formation of centers for interventional neuroradiology. MATERIAL AND METHODS: The number of patients with subarachnoid hemorrhage treated by surgical means annually between 2004 and 2010 was identified. The patients' data and aneurysm characteristics were collected from the clinical database. The primary outcome measure was the GOS on discharge. Multivariable logistic regression was derived to define independent predictors of the outcomes. RESULTS: The study enrolled 361 SAH patients in which the total number of 409 aneurysm was clipped. Most of the aneurysms (75.7%) were equal to or less than 10mm. In late 2006, after the new center for interventional neuroradiology was established in WMU, the number of aneurysmal SAH patients treated surgically decreased significantly and has remained at that level for subsequent years. Favorable outcomes were achieved in 62.8% of the patients, unfavorable outcomes in 37.1%, including 77 deaths (21.3%). In multivariable analysis, unfavorable outcome was associated with increasing age, worsening neurological grade assessed by the Glasgow Coma Scale (GCS), hemiparesis or aphasia on admission, high Fisher grade, intracerebral hematoma, chronic comorbidities and delayed vasospasm. CONCLUSIONS: The introduction of endovascular methods in the treatment of patients with aneurismal SAH resulted in an almost halving of the number of patients treated surgically. The outcomes of patients with cerebral aneurysms depend mainly on non-modifiable factors (the neurological state of the patients on admission and age). GCS has a better predictive value for outcomes in patients with aneurysmal SAH than the commonly-used WFNS and Hunt-Hess scales. Due to the fact that the majority of aneurysms are small or medium sized, the authors recommend the treatment of unruptured aneurysms less than 10 millimeters as a prevention of SAH.