[NORMAL] Key words

Bogdan Czapiga

_{, Marta Koźba-Gosztyła}

_,

Włodzimierz Jarmundowicz

_{, Tomasz Szczepański}

Surgical Management in Patients

with Aneurismal Subarachnoid Hemorrhage.

The Outcomes in the Paradigm Shift Period

Leczenie operacyjne pacjentów z krwotokiem podpajęczynówkowym

z pękniętego tętniaka. Wyniki w okresie zmiany trendów postępowania

Department of Neurosurgery, Wroclaw Medical University, Wrocław, Poland

A – research concept and design; B – collection and/or assembly of data; C – data analysis and interpretation;

D – writing the article; E – critical revision of the article; F – final approval of article; G – other

Abstract

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 interven-tional neuroradiology.

Material and Methods. The number of patients with subarachnoid hemorrhage treated by surgical means annu-ally 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 10 mm. In late 2006, after the new center for interventional neuroradiology was established in WMU, the number of aneurismal 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 result-ed in an almost halving of the number of patients treatresult-ed surgically. The outcomes of patients with cerebral aneu-rysms 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 aneurismal 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 recom-mend the treatment of unruptured aneurysms less than 10 millimeters as a prevention of SAH (Adv Clin Exp Med 2013, 22, 4, 539–547).

Key words: ruptured intracranial aneurysm, subarachnoid hemorrhage, outcomes.

Streszczenie

Wprowadzenie. W ciągu ostatnich dwóch dekad, po wprowadzeniu wewnątrznaczyniowych metod leczenia, stra-tegia postępowania z pacjentami z pękniętym tętniakiem naczyń mózgowych przeszła istotne zmiany. Po opubliko-waniu wyników badania ISAT (2002 r.) liczba chorych leczonych chirurgicznie znacznie zmalała z jednoczesnym zwiększeniem liczby pacjentów leczonych metodą embolizacji.

Adv Clin Exp Med 2013, 22, 4, 539–547 ISSN 1899–5276

OrIGINAl PAPErS

Aneurismal subarachnoid hemorrhage (SAH) is a common and frequently devastating condition affecting 6–10 people per 100,000 of the population per year [1]. For a long time, surgery was the sole therapy for intracranial aneurysm, however that has substantially changed since the introduction of endovascular treatment in 1990. Especially since the ISAT study publication in 2002, the applica-tion of endovascular coiling has increased consid-erably, shifting treatment paradigms [2]. Despite enormous progress in the diagnostic techniques and treatment, decrease in mortality and improve-ment of the outcomes in SAH patients, the optimal management has still not been established.

The aim of this study was to present the surgi-cal treatment outcomes in patients with ruptured cerebral aneurysms in the Department of Neuro-surgery, Wroclaw Medical University (WMU), which has never been conducted before in this center, as well as for the lower Silesia population. By choosing the years 2004–2010 the authors at-tempted to delineate the trends in surgical clipping in their department after a new center for inter-ventional neuroradiology in WMU was established in late 2006. In those “uncertain times” for surgical aneurysm clipping, the authors are presenting the results of their study, hoping that intracranial an-eurysms will still remain part of neurosurgery.

Material and Methods

Adult patients, admitted to the Department of Neurosurgery, WMU between January 2004 and December 2010 with a diagnosis of aneurismal

SAH, were identified from a clinical database. Pa-tients were included if diagnosed with a ruptured anterior circulation aneurysm and the aneurysm clipping procedure was performed within 24hrs after admission. Patients were excluded if they had a ruptured aneurysm of the vertebrobasilar sys-tem, underwent endovascular occlusion or were treated conservatively, or the aneurysm clipping procedure was performed more than 24 hrs after admission.

The authors collected and analyzed a num-ber of factors that were stratified into sever-al groups: factors related to the patient (age, sex, presence of comorbidities), factors related to the aneurysm (location, size, multiplicity), preoper-ative factors (the clinical status of the patient on admission assessed by the Hunt-Hess scale (H-Hs), Glasgow Coma Scale (GCS) and World Fed-eration of Neurological Surgeons Grading System for Subarachnoid Hemorrhage (WFNS), the ex-tension of subarachnoid hemorrhage assessed by the Fisher grade), intraoperative factors (intraop-erative aneurysm rupture, the length of temporary arterial occlusion-TAO) and factors of postopera-tive course (the presence of cerebral oedema, vaso-spasm, hydrocephalus). Additionally, the patients were divided into two groups: conscious on admis-sion (H-Hs I, II, III) and unconscious or poor neu-rological state on admission (H-Hs IV, V). The au-thors assessed mortality and morbidity separately for those two groups. They defined morbidity as the presence of neurological deficits and/or daily life dependency.

The patient outcomes were determined using three scales: the Glasgow Outcome Scale (GOS),

Cel pracy. Ocena wyników leczenia chirurgicznego pacjentów po krwotoku podpajęczynówkowym z tętniaka przedniej części koła tętniczego oraz określenie bieżących trendów w leczeniu w dobie powstawania ośrodków neuroradiologii.

Materiał i metody. Analizie poddano pacjentów leczonych operacyjne z powodu pękniętego tętniaka w latach 2004–2010. Scharakteryzowano roczną liczbę wykonanych operacji. Dane dotyczące pacjentów oraz zaklipsowa-nych tętniaków pochodziły z klinicznej bazy dazaklipsowa-nych. Wyniki leczenia oceniano w skali GOS. Czynniki prognostycz-ne dla wyników leczenia określono za pomocą analizy regresji wielorakiej.

Wyniki. Badanie objęło 361 pacjentów z SAH, w których zaklipsowano łącznie 409 tętniaków. Większość tętniaków (75,7%) była równa lub mniejsza niż 10 mm. Po utworzeniu nowego centrum neuroradiologii liczba pacjentów z SAH leczonych chirurgicznie znacząco zmniejszyła się i pozostała na tym poziomie w kolejnych latach. Korzystne wyniki leczenia uzyskano u 62,8% pacjentów, niekorzystne u 37,1%, wliczając 77 zgonów (21,3%). Analiza regresji wielorakiej wykazała, że czynniki wpływające na wyniki leczenia to: wiek pacjenta, stan neurologiczny przy przy-jęciu oceniany w skali GCS, niedowład połowiczy lub afazja przy przyprzy-jęciu, ciężkość krwotoku oceniana w skali Fishera, obecność krwiaka śródmózgowego, obecność współistniejących chorób przewlekłych, opóźniony skurcz naczyniowy.

Wnioski. Wprowadzenie endowaskularnych metod leczenia u pacjentów po krwotoku podpajęczynówkowym z tętniaka spowodowało zmniejszenie liczby pacjentów leczonych chirurgicznie niemal o połowę. Wyniki leczenia u pacjentów leczonych z powodu tętniaka naczyń mózgowych zależą przede wszystkim od czynników, na które nie można wpływać. Skala GCS ma lepsze właściwości prognostyczne dla wyników leczenia niż powszechnie używana skala WFNS oraz skala Hunta-Hessa. W związku z tym, że większość tętniaków jest rozmiaru małego lub średniego autorzy zalecają klipsowanie niepękniętych tętniaków mniejszych niż 10 mm jako prewencję SAH (Adv Clin Exp Med 2013, 22, 4, 539–547).

the Karnofsky scale (Ks) and the modified rankin scale (mrS). The outcomes were divided into fa-vorable (4 or 5 GOS points at discharge) and unfa-vorable (1–3 GOS points at discharge). The authors compared the groups of patients with favorable and unfavorable outcomes. The differences in fac-tors related to the patient, to the aneurysm, preop-erative factors, intraoppreop-erative factors and factors of postoperative course were examined using χ² and t tests. Multivariable linear regression was used to identify the association of the above-mentioned factors (dummy variables) with patients outcomes defined as favorable and unfavorable and assessed in GOS, mrS and KS. In total, 4 multivariable lin-ear regressions were calculated. A P-value of 0.05 was used as the level of statistical significance. De-scriptive data was presented as a median, medi-um and standard deviations. Statistical evaluations were made using STATISTICA 10.0 (Wrocław Economic University, Wrocław, Poland).

Results

During the study period, there were 361 pa-tients with ruptured anterior circulation aneurysms treated surgically. The number of patients with ruptured aneurysm treated annually in the Neuro-surgical Department of WMU between 2004–2010 is presented in Fig. 1. In late 2006, a new center for interventional neuroradiology was established in WMU and the number of patients with ruptured intracranial aneurysm treated by endovascular coiling increased significantly, which correspond-ed to a decrease in patients treatcorrespond-ed surgically dur-ing this period. This number decreased from 81 in 2006 to 42 in 2007 and has remained at that level for subsequent years.

The demographic characteristics of patients are shown in Table 1. Sixty-nine patients (19.1%) had a diagnosis of multiple aneurysms (54 patients had 2 aneurysms, 8 patients had 3 aneurysms, 7 pa-tients had more than 3 aneurysms), which were clipped during the same operating procedure if the exposure was appropriate, therefore, in the pe-riod of 2004–2010 a total of 409 intracranial aneu-rysms were clipped. The characteristics of the cere-bral aneurysms are given in Table 2. SAH severity

Table 1. Characteristics of the patients with ruptured anterior circulation aneurysm enrolled by the study (Neurosurg. Dep. WMU database, 2004–2010)

Tabela 1. Charakterystyka pacjentów z pękniętym tętniakiem przedniej części koła tętniczego objętych badaniem (baza danych Kliniki Neurochirurgii UMW, 2004–2010)

Factors (Czynniki) n Percent

Demographic Age, median (years) Female sex Comorbidities hypertension

53 ± 14 243 219 195 67.3 60.6 54.0 SAH Hunt-Hess grade I II III IV V 48 86 98 48 81 13.2 23.8 27.1 13.2 20.7 WFNS I II III IV V 48 110 34 47 122 13.2 30.4 9.4 13.0 33.7 GCS 15 14-13 12-7 6-3 48 144 47 122 13.2 39.8 13.0 33.7 Fisher grade I II III IV 25 99 63 174 6.9 27.4 17.4 48.1 Intraoperative

TAO – time, median (sec) Intraoperative aneurysm rupture

276 ± 306.2

88 24.3 Postoperative Cerebral oedema Delayed vasospasm Hydrocephalus 98 96 73 27.1 26.5 20.2

Fig. 1. Number of patients with ruptured anterior circulation aneurysms treated annually, 2004–2010 (Neurosurg. Dep. WMU database, 2004–2010)

was evaluated clinically (H-Hs, GCS, WFNS) and radiologically by the Fisher grade (Table 1). The time of maintaining temporary clips was defined as Temporary Arterial Occlusion time (TAO-time). The authors calculated the mean TAO-time and number of patients in which intraoperative aneurysm rupture occurred (Table 1). The charac-teristics of the postoperative course are presented in Table 1. The cerebral oedema was defined intra-operatively or postintra-operatively by radiographic im-ages. Intracranial Doppler was used to assess de-layed vasospasm.

There were 232 patients in good or fair neu-rological state on admission (H-Hs I, II, III) and all of them were conscious on admission. In this group, at discharge, 76 patients had focal neuro-logical deficits (FND), 12 patients died. From the subgroup of 129 patients in poor neurological state (unconscious) on admission (H-Hs IV, V), 65 died. Among 64 survivors, 17 were in a vegetative state, 41 were severely or moderately disabled and only 6 patients were in a good neurological state (inde-pendent in activities of daily life and demonstrated none of the neurological deficits).

A favorable outcome (GOS 4, 5) was achieved in 227 patients (62.8%), an unfavorable outcome (GOS 1–3) in 134 patients (37.1%). In the group of patients conscious on admission, 84.9% achieved

favorable outcomes, the mortality rate was 5.1% and the morbidity rate 34.5% among the survi-vors. In the group of patients in a poor neurologi-cal state, only 13.2% achieved favorable outcomes, mortality was 50.3% and morbidity was 90.7% (Fig. 2). In the study group, 77 patients died, which brought overall mortality to 21.3%.

Comparison of the Patients

with Favorable and Unfavorable

Outcomes

All the factors included in the comparative analysis are presented in Table 3. Among the fac-tors related to the patient (age, sex, comorbidi-ties), age was the only factor that differed signif-icantly in both groups (p = 0.001). The patients with favorable outcomes were younger (mean age 51 years) than the patients with unfavorable out-comes (mean age 57 years).

Among the factors related to the aneurysm (location, size), size was the only factor that dif-fered significantly in both groups. Mean aneurysm size in the group with unfavorable outcomes was 12 mm and was significantly greater than the mean aneurysm size in the group with the favorable out-comes, which was 9.1 mm (p = 0.003).

Both groups of patients differed significantly in terms of all the preoperative factors (clinical sta-tus of the patient on admission assessed by H-Hs and extension of subarachnoid hemorrhage as-sessed by the Fisher scale). In the group with unfa-vorable outcomes, 74% of the patients were in a se-vere neurological state on admission (H-Hs IV, V), 20% in H-Hs III and only 6% in a good neurologi-cal state (H-Hs I, II). In the group of patients with favorable outcomes, those values were significant-ly different (p = 0.001): 13%, 31% and 56% respec-tively. Seventy-seven percent of the patients with unfavorable outcomes had Fisher grade IV, com-pared to 31% of the patients with favorable out-comes (p = 0.001).

Fig. 2. The outcomes and mortality of patients in dif-ferent neurological states on admission

Ryc. 2. Wyniki leczenia i śmiertelność w zależności od stanu neurologicznego pacjenta przy przyjęciu

Table 2. Characteristics of aneurysms (ruptured and unruptured) clipped in SAH patients (Neurosurg. Dep. WMU database, 2004–2010; MCA – middle cerebral artery, ACoA – anterior communicating artery, ICA – internal carotid artery, PCoA – posterior communicat-ing artery, PcA – pericallosal artery)

Tabela 2. Charakterystyka tętniaków (pękniętych i niepękniętych) zaklipsowanych u pacjentów z krwoto-kiem podpajęczynówkowym (baza danych Kliniki Neurochirurgii UMW, 2004–2010);. MCA – tętnica środkowa mózgu, ACoA – tętnica łącząca przednia mózgu, ICA – tętnica szyjna wewnętrzna, PCoA – tętnica tylna łącząca mózgu, PCA – tętnica okołospoidłowa)

Factors (Czynniki) n percent

Status (Stan) ruptured

unruptured 36148 88.211.7 location (Umiejscowienie)

MCA

ACoA complex ICA

PCoA PcA

162 150 77 12 8

39.6 36.6 18.8 2.9 1.9 Size (rozmiar)

small (0–5 mm) medium (6–10 mm) large (11–25 mm) giant (> 25 mm)

143 167 72 27

Among the intraoperative factors, intraop-erative aneurysm rupture was the only factor that differed significantly in both groups (p = = 0.001); it was more frequent in the group of pa-tients with unfavorable outcomes. TAO-time was slightly prolonged in the group of patients with unfavorable outcomes (295 sec vs. 257 sec), but the difference was not statistically significant.

There were no statistically significant differenc-es in the rdifferenc-esults of the treatment in patients with TAO > 10 minutes.

Postoperative factors were also used in the comparative analysis. In patients with unfavor-able outcomes, cerebral oedema, vasospasm and hydrocephalus occurred significantly more fre-quently when compared to patients with favorable

Table 3. Comparison of patients with favorable and unfavorable outcomes

Tabela 3. Porównanie pacjentów z korzystnymi i niekorzystnymi wynikami leczenia

Factors

(Czynniki) Favorable outcomes group(Pacjenci z korzystnymi wynikami leczenia) (n = 227)

Unfavorable outcomes group (Pacjenci z niekorzystnymi wynikami leczenia) (n = 134)

P-value

Age, mean (years) 51.5 ± 11.9 57.3 ± 13.2 0.001

Sex female

male 156 (69%)71 (31%) 87 (65%)47 (35%)

0.46

Comorbidities absent

present 109 (48%)118 (52%) 33 (27%)101 (73%)

0.06

Aneurysm size, mean (mm) 9.1 ± 6.3 12 ± 10 0.003

Aneurysm location MCA

ACoA ICA PCoA PcA

99 (44%) 76 (33%) 37 (16%) 10 (4%) 5 (2%)

41 (31%) 64 (48%) 24 (18%) 2 (1%) 3 (2%)

0.28

Clinical grade (Hunt-Hess) good (I, II)

fair (III) poor (IV, V)

126 (56%) 71 (31%) 30 (13%)

8 (6%) 27 (20%) 99 (74%)

0.001

Fisher grade I

II III IV

25 (11%) 90 (40%) 42 (18%) 70 (31%)

0 (0%) 9 (7%) 21 (16%) 104 (77%)

0.001

TAO – time, median (sec) 257.32 ± 300.6 295.58 ± 307.6 0.31

TAO – time >10 min no

yes 192 (84%)35 (16%) 103 (77%)31 (23%)

0.11

Intraoperative aneurysm rupture no

yes 183 (81%)44 (19%) 94 (70%)40 (30%)

0.01

Cerebral oedema no

yes 214 (94%)13 (6%) 49 (36%)85 (64%)

0.001

Delayed vasospasm no

yes 186 (82%)41 (18%) 79 (59%)55 (41%)

0.001

Hydrocephalus no

yes 195 (86%)32 (14%) 93 (69%)41 (31%)

outcomes: 64% vs. 6% (p = 0.001), 41% vs. 18% (p = 0.001) and 31% vs. 14% (p = 0.001) respectively.

The Outcomes Predictors

Four multivariable linear regressions were performed, separately for GOS, mrS, Ks and out-comes determined as favorable/unfavorable. The results of the analysis and predictor variables are presented in Table 4. There was a strict correlation between the initial clinical condition of the patient and the final outcome. Unfavorable outcome was associated with a worsening neurological grade as-sessed by GCS (the strongest factor in all analyses; the Hunt-Hess grade was present in only one analy-sis, WFNS in none), hemiparesis or aphasia on ad-mission. The age of the patient was also a strong predictive factor. More extensive SAH on admis-sion, computed tomography (evaluated by Fisher grade) and the presence of intracerebral hematoma (ICH) were both negative predictive factors. The oc-currence of delayed vasospasm and the presence of chronic comorbidities had a weak predictive value.

Discussion

Treatment of cerebral aneurysms has under-gone a significant evolution since the 1990s, when endovascular methods were introduced. Clini-cal studies comparing the mortality and cliniClini-cal

outcomes of patients with aneurismal SAH treat-ed with either surgical or endovascular techniques were conducted and supported coiling as an equal or better alternative [2–5]. In 2002, the results of the International Subarachnoid Aneurysm Trial (ISAT) were first published and revealed that pa-tients who underwent coiling had lower mortali-ty and a better outcome at 1 year than those who had an open surgery [2]. As a result of this trial, a change in practice pattern followed, with more ruptured aneurysms treated endovascularly, which is referred as the paradigm shift [6–8]. In their de-partment, the paradigm shift occurred in late 2006, when a new center for interventional neuroradiol-ogy in WMU was established. Since then, the num-ber of aneurismal SAH patients treated by surgi-cal means has almost halved. However, it seems to not be the end of the surgical clipping age. recent ISAT results from 2009 showed no significant dif-ferences in long-term neurological outcomes be-tween the two techniques [5]. Andaluz et al. re-ported that, although the number of endovascular procedures had doubled, the number of aneu-rysm clipping procedures remains stable [7]. Sev-eral authors raised the problem of the costs asso-ciated with the embolization procedure, which is significantly higher than the cost of surgical clip-ping even though patients required a shorter time of hospitalization [9–11].

This study covered SAH patients with anteri-or circulation aneurysms treated surgically within

Table 4. Outcomes predictor variables (multivariable linear regression); r2 _{– coefficient of determination; β – regression} coefficient

Tabela 4. Wpływ poszczególnych czynników na wyniki leczenia; r2 _{– współczynnik determinacji; β – współczynnik regresji}

Outcomes (Wyniki) Variable (Zmienna) r2 _{β p-value}

GOS GCS

hemiparesis age ICH

0,44 0.46

–0.23 –0.16 –0.15

< 0.001 < 0.001 0.009 0.023

Karnofsky Scale GCS

age hemiparesis Fisher grade

0.49 0.45

–0.20 –0.21 –0.19

< 0.001 0.001 0.001 0.006

mrS GCS

age hemiparesis Fisher grade

chronic comorbidities

0.49 –0.43

0.16 0.24 0.19 0.14

< 0.001 0.012 < 0.001 0.006 0.030 Outcomes favorable/unfavorable GCS

Hunt-Hess grade ICH

aphasia

delayed vasospasm

0.35 –0.67

–0.31 0.18 0.16 0.13

the first 24 hrs after admission, which yields bet-ter results than labet-ter treatment [12, 13, 14]. The favorable outcomes (GOS 4, 5) were achieved in 62.8% of patients, the unfavorable outcomes (GOS 1, 2, 3) were achieved in 37.1% of patients, includ-ing 77 deaths (21.3%). Multivariable linear regres-sion revealed two groups of factors directly affect-ing the outcome: the factors related to the patient (age, chronic comorbidities) and preoperative fac-tors (the patient’s neurological condition on ad-mission, the presence of neurological deficits on admission and the SAH severity determined by a Fisher grade). In the postoperative course, the presence of vasospasm had less influence on the outcome. Intraoperative factors (aneurysm rup-ture, the length of TAO) do not affect the out-comes. Therefore, the outcomes depend mainly on non-modifiable factors.

According to The International Cooperative Study on the Timing of Aneurysm Surgery, the most important factors related to a favorable out-come were: the highest consciousness score on admission, a lower age, a lower admission blood pressure, the subarachnoid clot distribution on computed tomography and the absence of vasos-pasm on admission angiography [12]. Säveland et al. noted that there was a strict correlation be-tween the initial clinical condition and also the amount of extravasated blood and the final out-come. The mortality rate was worse for posterior circulation aneurysms [15]. In a study of Deruty el al., the outcome was strongly related to the lev-el of consciousness and also the age of the patient with aneurismal SAH, but the relationship be-tween the outcome and age was less marked [16]. The analysis of Sandalcioglu et al. revealed that in-traoperative aneurysm rupture has no impact on the outcome, neither in the patients in good nor poor initial condition. Poor initial clinical condi-tion (H-Hs IV and V) as well as the initial Fish-er grades III and IV wFish-ere strongly associated with a poor clinical outcome [17]. rosen et al. have identified GOS, age, pre-existing hypertension, the amount of blood present on admission comput-ed tomography, time of admission after SAH, an-eurysm location and size, the presence of intrace-rebral or intraventricular hemorrhage, and blood pressure at admission as factors commonly known to influence prognosis [18]. According to rosen-gart et al., most of the prognostic factors for out-come after SAH are present on admission and are not modifiable. The patient outcome is associated with increasing age, worsening neurological con-dition, ruptured posterior circulation aneurysm, larger aneurysm size, more SAH on admission computed tomography, intracerebral hematoma or intraventricular hemorrhage, elevated systolic

blood pressure on admission, and a previous di-agnosis of hypertension, myocardial infarction or liver disease [19]. In the EHSA project, the authors determined the non-modifiable independent risk variables for mortality as: age, male gender, history of arterial hypertension, coma upon arrival at the hospital and hydrocephalus [20].

In this study, the strongest predictive factor for outcomes is the neurological condition of the patient on admission (the largest absolute value of the beta coefficient in multivariable linear regres-sion) determined by GCS. The neurological condi-tion of the patient determined by H-Hs or WFNS had a lower predictive value.

Although the Hunt-Hess scale and WFNS are the most widely used subarachnoid hemorrhage grading systems, neither system has achieved uni-versal acceptance and their predictive value re-garding the patient outcome is questionable. Teas-dale at al. states that the GCS should be used to assess the level of consciousness [21]. According to Gotoh el al., the GCS proved useful in the preoper-ative evaluation of the patients with SAH, in terms of outcome prediction [22]. Oshiro et al. conclud-ed that the GCS has equal or greater prconclud-edictive value regarding outcome after SAH than the cur-rently-used grading systems and that it has great-er reproducibility across obsgreat-ervgreat-ers [23]. In anoth-er study, rosen et al. detanoth-ermined the prognostic factors for outcome as: age, WFNS grade, history of hypertension, systolic blood pressure at admis-sion, ruptured aneurysm location and size, blood clot thickness on computed tomography scans, and angiographic vasospasm on admission. They concluded that adding supplementary clinical and radiological factors to the WFNS may improve its predictive value, although it would be more com-plex to use [24].

of Juvela et al., 70% of ruptured aneurysms had dimensions less than 6 mm [29]. Dr. Bryce Weir estimated that the average size of a ruptured an-eurysm is less than 10 mm. He explained the quan-titative difference between the group of small-me-dium sized aneurysms and large-giant by the fact that small and medium-sized aneurysms rupture before reaching large or giant size [30].

The authors concluded that the introduction of endovascular methods in the treatment of patients with aneurismal SAH resulted in an almost halving

of patients treated surgically. The outcomes of pa-tients with cerebral aneurysms depend mainly on non-modifiable factors (the neurological state of the patients on admission and age). GCS has a bet-ter predictive value for outcomes in patients with aneurismal SAH than the commonly-used WFNS and Hunt-Hess scales. Due to the fact that the ma-jority of aneurysms are small or medium-sized, the authors recommend the treatment of unruptured aneurysms less than 10 millimeters as a prevention of SAH.

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Address for correspondence:

Bogdan Czapiga

Department of Neurosurgery Wroclaw Medical University Borowska 213

50-556 Wrocław Poland

Tel.: + 48 509 079 343, 501 487 717 E-mail: [email protected]

Conflict of interest: None declared