Trends in incidence and treatments of spontaneous subarachnoid hemorrhage- a 10 year hospital based study

Abstract

Background: Improved endovascular methods make it possible to treat complex ruptured aneurysms, but surgery is still needed in certain cases. We evaluated the effects on the clinical results of the changes in aneurysm treatment.

Methods: The study cohort was 837 patients with spontaneous subarachnoid hemorrhage (SAH) and one or multiple aneurysms, admitted to Dept of Neurosurgery, Uppsala University Hospital from 2012 to 2021. Demography, location and treatment of aneurysms, neurologic condition at admission and discharge, mortality and last tier treatment of high intracranial pressure (ICP) was evaluated. Functional outcome was measured using the Extended Glasgow Outcome Scale (GOSE) Data concerning national incidences of stroke diseases was collected from open Swedish databases.

Results: Endovascular methods were used in 666 cases (79.6%). In 111 (13.3%) with stents. Surgery was performed in 115 cases (13.7%) and 56 patients (6.7%) had no aneurysm treatment. The indications for surgery were a hematoma (51 cases, 44.3%), endovascular treatment not considered safe (47 cases, 40.9%), or had been attempted without success (13 cases, 11.3%). Treatment with stent devices increased, and with surgery decreased over time. There was a trend in decrease in hemicraniectomias over time. Both the patient group admitted awake (n = 681) and unconscious (n = 156) improved significantly in consciousness between admission and discharge. Favorable outcome (GOSE 5-8) was seen in 69% for patients admitted in Hunt & Hess I-II and 25% for Hunt & Hess III-V. Mortality at one year was 10.9% and 42.7% for those admitted awake and unconscious, respectively.The number of cases decreased during the study period, which was in line with Swedish national data.

Conclusions: The incidence of patients with SAH gradually decreased in our material, in line with national data. The treatment policy in our unit has been shifting to more use of endovascular methods. During the study period the use of hemicraniectomies decreased.

Keywords: Aneurysm; ICP-treatment; Microsurgery; Neurointervention; Spontaneous SAH; Stent devices; Stroke incidence.

Fig. 1

The development during the study period of age at SAH, Fisher grade and Hunt & Hess. The figure shows that there is a shift in the middle years of the period, with lower age, lower Fisher grade and higher Hunt & Hess

Fig. 2

In this figure the distribution of treatments each year is displayed as percentage. There is a trend of decreasing surgical treatment, and at the same time of increased endovascular methods using stent devices

Fig. 3

This figure shows the numbers of the different treatments. There is a gradual decrease in the total number of cases during the study period

Fig. 4

This figure shows the relative incidence of SAH (I60), intracerebral hematoma (I61) and cerebral infarction (I63) on a Swedish national level and on a regional level in Uppsala geographical uptake area. The yearly incidences are related to the incidences at the start of the study period (2012)

Fig. 5

This figure shows the percentage of patients that were treated for aneurysm ruptures and that needed last-tier ICP treatment with either penthobarbiturates or hemicraniectomy (see methods). There is a gradual decrease over the years, except for 2012. Comparison between 2021 and 2013 showed a significant difference for hemicraniectomies