Time trends in causes of death after aneurysmal subarachnoid hemorrhage: A hospital-based study

Abstract

Objective: To compare causes of in-hospital death after aneurysmal subarachnoid hemorrhage (aSAH) in 2 time periods within the same institution.

Methods: From a prospectively collected institutional database, we retrieved data on 844 consecutive patients with aSAH admitted ≤3 days after ictus in 1999-2002 and 2009-2012. We assessed case-fatality <90 days and causes of in-hospital death and used Poisson regression analyses to calculate adjusted risk ratios (aRR) with corresponding 95% confidence intervals (CI) for change in individual causes of death, with the first time period as the reference group.

Results: Ninety-day case-fatality declined from 150/381 patients (39%) in 1999-2002 to 140/463 (30%) in 2009-2012 (aRR 0.74 [95% CI 0.62-0.88]). Compared with 1999-2002, the aRR for specific cause of in-hospital death in 2009-2012 was 1.06 (95% CI 0.72-1.56) for death from the initial bleeding, 0.47 (95% CI 0.31-0.71) for death from rebleeding, and 0.91 (95% CI 0.50-1.65) for death from delayed cerebral ischemia. Over time, the proportion of patients with in-hospital rebleeding declined from 90/381 (24%) to 78/463 (17%) (aRR 0.68 [95% CI 0.52-0.90]), median day of rebleeding from day 5 (IQR 1-10) to day 0 (IQR 0-1), and median day of aneurysm treatment from day 4 (IQR 2-13) to day 1 (IQR 1-2).

Conclusions: An important contributor to the reduction in in-hospital death is the reduction in death from rebleeding, which probably results from earlier aneurysm treatment. Our results stress the need for early occlusion of the aneurysm and the need for other strategies that improve outcome by reducing the risk of rebleeding.