Project

Swiss SOS - the Swiss Study on Aneurysmal Subarachnoid Hemorrhage

Goal: This is a prospective multicenter study that collects clinical and radiological data on consecutive patients admitted with aneurysmal subarachnoid hemorrhage to one of the eight participating centers: Aarau (Kantonsspital), Basel (Universitätsspital), Bern (Inselspital), Geneva (Hôpitaux Universitaires), Lausanne (CHUV), Lugano (EOC), St.Gallen (Kantonsspital), Zürich (UniversitätsSpital). The aims are to determine the incidence of aneurysmal subarachnoid hemorrhage in Switzerland, to monitor treatment and outcome, as well as to conduct cohort studies on a national level.

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Michel Roethlisberger
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Background: Favorable outcomes are seen in up to 50% of patients with World Federation of Neurosurgical Societies (WFNS) grade V aneurysmal subarachnoid hemorrhage. Therefore, the usefulness of the current WFNS grading system for identifying the worst scenarios for clinical studies and for making treatment decisions is limited. We previously modified the WFNS scale by requiring positive signs of brain stem dysfunction to assign grade V. This study aimed to validate the new herniation WFNS grading system in an independent prospective cohort. Methods: We conducted an international prospective multicentre study in poor-grade aneurysmal subarachnoid hemorrhage patients comparing the WFNS classification with a modified version-the herniation WFNS scale (hWFNS). Here, only patients who showed positive signs of brain stem dysfunction (posturing, anisocoric, or bilateral dilated pupils) were assigned hWFNS grade V. Outcome was assessed by modified Rankin Scale score 6 months after hemorrhage. The primary end point was the difference in specificity of the WFNS and hWFNS grading with respect to poor outcomes (modified Rankin Scale score 4-6). Results: Of the 250 patients included, 237 reached the primary end point. Comparing the WFNS and hWFNS scale after neurological resuscitation, the specificity to predict poor outcome increased from 0.19 (WFNS) to 0.93 (hWFNS) (McNemar, P<0.001) whereas the sensitivity decreased from 0.88 to 0.37 (P<0.001), and the positive predictive value from 61.9 to 88.3 (weighted generalized score statistic, P<0.001). For mortality, the specificity increased from 0.19 to 0.93 (McNemar, P<0.001), and the positive predictive value from 52.5 to 86.7 (weighted generalized score statistic, P<0.001). Conclusions: The identification of objective positive signs of brain stem dysfunction significantly improves the specificity and positive predictive value with respect to poor outcome in grade V patients. Therefore, a simple modification-presence of brain stem signs is required for grade V-should be added to the WFNS classification. Registration: URL: https://clinicaltrials.gov; Unique identifier: NCT02304328.
Martin N Stienen
added a research item
Background and Purpose The purpose of this study was to assess nationwide incidence and outcomes of aneurysmal subarachnoid hemorrhage (aSAH). The Swiss SOS (Swiss Study on Subarachnoid Hemorrhage) was established in 2008 and offers the unique opportunity to provide this data from the point of care on a nationwide level. Methods All patients with confirmed aneurysmal subarachnoid hemorrhage admitted between January 1, 2009 and December 31, 2014, within Switzerland were recorded in a prospective registry. Incidence rates were calculated based on time-matched population data. Admission parameters and outcomes at discharge and at 1 year were recorded. Results We recorded data of 1787 consecutive patients. The incidence of aneurysmal subarachnoid hemorrhage in Switzerland was 3.7 per 100 000 persons/y. The number of female patients was 1170 (65.5%). With a follow-up rate of 91.3% at 1 year, 1042 patients (58.8%) led an independent life according to the modified Rankin Scale (0–2). About 1 in 10 patients survived in a dependent state (modified Rankin Scale, 3–5; n=185; 10.4%). Case fatality was 20.1% (n=356) at discharge and 22.1% (n=391) after 1 year. Conclusions The current incidence of aneurysmal subarachnoid hemorrhage in Switzerland is lower than expected and an indication of a global trend toward decreasing admissions for ruptured intracranial aneurysms. REGISTRATION URL: https://www.clinicaltrials.gov . Unique identifier: NCT03245866.
Michel Roethlisberger
added a research item
Objective: Early permanent cerebrospinal fluid (CSF) diversion for hydrocephalus during the first 2 weeks after aneurysmal subarachnoid hemorrhage (aSAH) shortens the duration of external ventricular drainage (EVD) and reduces EVD-associated infections (EVDAI). The objective of this study was to detect any association with symptomatic delayed cerebral vasospasm (DCVS), or delayed cerebral ischemia (DCI) by the time of hospital discharge. Methods: We used a single-center dataset of aSAH patients who had received a permanent CSF diversion. We compared an 'early group' in which the procedure was performed up to 14 days after the ictus, to a 'late group' in which it was performed from the 15th day onward. Results: Among 274 consecutive aSAH patients, 39 (14%) had a permanent CSF diversion procedure following a silver-coated EVD. While the blood clot burden was similarly distributed, patients with early permanent CSF diversion (20 out of 39; 51%) had higher levels of consciousness on admission. Early permanent CSF diversion was associated with less colonized catheter, a shorter duration of extracorporeal CSF diversion (OR 0.73, 95%CI 0.58-0.92 per EVD day), and a lower rate of EVDAI (OR 0.08, 95%CI 0.01-0.80). The occurrence of CSF diversion device obstruction, the rate of symptomatic DCVS or detected DCI on computed tomography and the likelihood of a poor outcome at discharge did not differ between the two groups. Discussion: Early permanent CSF diversion lowers the occurrence of catheter colonization and infectious complication without affecting DCVS-related morbidity in good-grade aSAH patients. These findings need confirmation in larger prospective multicenter cohorts.
Michel Roethlisberger
added a research item
Background: Current prognostic tools in aneurysmal subarachnoid hemorrhage (aSAH) are constrained by being primarily based on patient and disease characteristics on admission. Objective: To develop and validate a complication- and treatment-aware outcome prediction tool in aSAH. Methods: This cohort study included data from an ongoing prospective nationwide multicenter registry on all aSAH patients in Switzerland (Swiss SOS [Swiss Study on aSAH]; 2009-2015). We trained supervised machine learning algorithms to predict a binary outcome at discharge (modified Rankin scale [mRS] ≤ 3: favorable; mRS 4-6: unfavorable). Clinical and radiological variables on admission ("Early" Model) as well as additional variables regarding secondary complications and disease management ("Late" Model) were used. Performance of both models was assessed by classification performance metrics on an out-of-sample test dataset. Results: Favorable functional outcome at discharge was observed in 1156 (62.0%) of 1866 patients. Both models scored a high accuracy of 75% to 76% on the test set. The "Late" outcome model outperformed the "Early" model with an area under the receiver operator characteristics curve (AUC) of 0.85 vs 0.79, corresponding to a specificity of 0.81 vs 0.70 and a sensitivity of 0.71 vs 0.79, respectively. Conclusion: Both machine learning models show good discrimination and calibration confirmed on application to an internal test dataset of patients with a wide range of disease severity treated in different institutions within a nationwide registry. Our study indicates that the inclusion of variables reflecting the clinical course of the patient may lead to outcome predictions with superior predictive power compared to a model based on admission data only.
Michel Roethlisberger
added a research item
Objective: The objective of this study was to determine patterns of care and outcomes in ruptured intracranial aneurysms (IAs) of the middle cerebral artery (MCA) in a contemporary national cohort. Methods: The authors conducted a retrospective analysis of prospective data from a nationwide multicenter registry of all aneurysmal subarachnoid hemorrhage (aSAH) cases admitted to a tertiary care neurosurgical department in Switzerland in the years 2009-2015 (Swiss Study on Aneurysmal Subarachnoid Hemorrhage [Swiss SOS]). Patterns of care and outcomes at discharge and the 1-year follow-up in MCA aneurysm (MCAA) patients were analyzed and compared with those in a control group of patients with IAs in locations other than the MCA (non-MCAA patients). Independent predictors of a favorable outcome (modified Rankin Scale score ≤ 3) were identified, and their effect size was determined. Results: Among 1866 consecutive aSAH patients, 413 (22.1%) harbored an MCAA. These MCAA patients presented with higher World Federation of Neurosurgical Societies grades (p = 0.007), showed a higher rate of concomitant intracerebral hemorrhage (ICH; 41.9% vs 16.7%, p < 0.001), and experienced delayed cerebral ischemia (DCI) more frequently (38.9% vs 29.4%, p = 0.001) than non-MCAA patients. After adjustment for confounders, patients with MCAA were as likely as non-MCAA patients to experience DCI (aOR 1.04, 95% CI 0.74-1.45, p = 0.830). Surgical treatment was the dominant treatment modality in MCAA patients and at a significantly higher rate than in non-MCAA patients (81.7% vs 36.7%, p < 0.001). An MCAA location was a strong independent predictor of surgical treatment (aOR 8.49, 95% CI 5.89-12.25, p < 0.001), despite statistical adjustment for variables traditionally associated with surgical treatment, such as (space-occupying) ICH (aOR 1.73, 95% CI 1.23-2.45, p = 0.002). Even though MCAA patients were less likely to die during the acute hospitalization (aOR 0.52, 0.30-0.91, p = 0.022), their rate of a favorable outcome was lower at discharge than that in non-MCAA patients (55.7% vs 63.7%, p = 0.003). At the 1-year follow-up, 68.5% and 69.6% of MCAA and non-MCAA patients, respectively, had a favorable outcome (p = 0.676). Conclusions: Microsurgical occlusion remains the predominant treatment choice for about 80% of ruptured MCAAs in a European industrialized country. Although patients with MCAAs presented with worse admission grades and greater rates of concomitant ICH, in-hospital mortality was lower and long-term disability was comparable to those in patients with non-MCAA.
Martin N Stienen
added a research item
Objective: The objective of this study was to determine patterns of care and outcomes in ruptured intracranial aneurysms (IAs) of the middle cerebral artery (MCA) in a contemporary national cohort. Methods: The authors conducted a retrospective analysis of prospective data from a nationwide multicenter registry of all aneurysmal subarachnoid hemorrhage (aSAH) cases admitted to a tertiary care neurosurgical department in Switzerland in the years 2009-2015 (Swiss Study on Aneurysmal Subarachnoid Hemorrhage [Swiss SOS]). Patterns of care and outcomes at discharge and the 1-year follow-up in MCA aneurysm (MCAA) patients were analyzed and compared with those in a control group of patients with IAs in locations other than the MCA (non-MCAA patients). Independent predictors of a favorable outcome (modified Rankin Scale score ≤ 3) were identified, and their effect size was determined. Results: Among 1866 consecutive aSAH patients, 413 (22.1%) harbored an MCAA. These MCAA patients presented with higher World Federation of Neurosurgical Societies grades (p = 0.007), showed a higher rate of concomitant intracerebral hemorrhage (ICH; 41.9% vs 16.7%, p < 0.001), and experienced delayed cerebral ischemia (DCI) more frequently (38.9% vs 29.4%, p = 0.001) than non-MCAA patients. After adjustment for confounders, patients with MCAA were as likely as non-MCAA patients to experience DCI (aOR 1.04, 95% CI 0.74-1.45, p = 0.830). Surgical treatment was the dominant treatment modality in MCAA patients and at a significantly higher rate than in non-MCAA patients (81.7% vs 36.7%, p < 0.001). An MCAA location was a strong independent predictor of surgical treatment (aOR 8.49, 95% CI 5.89-12.25, p < 0.001), despite statistical adjustment for variables traditionally associated with surgical treatment, such as (space-occupying) ICH (aOR 1.73, 95% CI 1.23-2.45, p = 0.002). Even though MCAA patients were less likely to die during the acute hospitalization (aOR 0.52, 0.30-0.91, p = 0.022), their rate of a favorable outcome was lower at discharge than that in non-MCAA patients (55.7% vs 63.7%, p = 0.003). At the 1-year follow-up, 68.5% and 69.6% of MCAA and non-MCAA patients, respectively, had a favorable outcome (p = 0.676). Conclusions: Microsurgical occlusion remains the predominant treatment choice for about 80% of ruptured MCAAs in a European industrialized country. Although patients with MCAAs presented with worse admission grades and greater rates of concomitant ICH, in-hospital mortality was lower and long-term disability was comparable to those in patients with non-MCAA.
Martin N Stienen
added 2 research items
Background and Purpose Commonly used tools to determine functional outcome after aneurysmal subarachnoid hemorrhage (aSAH) have limitations. Time spent at the patient’s home has previously been proposed as a robust outcome measure after ischemic stroke. Here, we set out to validate home-time as an outcome measure after aSAH. Methods We examined prospectively collected data from a nationwide multicenter registry of aSAH patients admitted to a tertiary neurosurgical department in Switzerland (Swiss SOS [Swiss Study on Aneurysmal Subarachnoid Hemorrhage]; 2009–2015). We calculated mean home-time (defined as days spent at home for the first 90 days after aSAH) and 95% CIs for each category of modified Rankin Scale at discharge and 1-year follow-up, using linear regression models to analyze home-time differences per modified Rankin Scale category. Results We had home-time data from 1076 of 1866 patients (57.7%), and multiple imputation was used to fill-in missing data from the remaining 790 patients. Increasing home-time was associated with improved modified Rankin Scale scores at time of hospital discharge (P<0.0001) and at 1-year follow-up (P<0.0001). Within each of the 8 participating hospitals, the relationship between home-time and modified Rankin Scale was maintained. Conclusions Home-time for the first 90 days after aSAH offers a robust and easily ascertainable outcome measure, discriminating particularly well across better recovery levels at time of hospital discharge and at 1-year follow-up. This measure complies with the modern trend of patient-centered healthcare and research, representing an outcome that is particularly relevant to the patient.
Martin N Stienen
added a research item
Aims: Several intrinsic and extrinsic risk factors for the rupture of intracranial aneurysms have been identified. Still, the cause precipitating aneurysm rupture remains unknown in many cases. In addition, it has been observed that aneurysm ruptures are clustered in time but the trigger mechanism remains obscure. As solar activity has been associated with cardiovascular mortality and morbidity we decided to study its association to aneurysm rupture in the Swiss population. Methods: Patient data was extracted from the Swiss SOS database, at time of analysis covering 918 patients with angiography-proven aSAH treated at seven Swiss neurovascular centers between 2009 and 2011. The number of aneurysm rupture per day (Rupture Frequency = RF) was correlated to the absolute amount and the change in various parameters of interest representing continuous measurements of solar activity (radioflux (F10.7 index), solar proton flux, solar flare occurrence, planetary K-index/planetary A-index) using Poisson regression analysis. Results: Precise determination of the date of aSAH was possible in 816 (88.9%). During the period of interest there were 517 days without recorded aSAH. There were 398, 139, 27 and 12 days with 1, 2, 3, and 4 ruptures per day. Five or 6 ruptures were only noted on a single day each. Poisson regression analysis demonstrated a significant correlation of F10.7 index and RF (incidence rate ratio (IRR) = 1.006303; standard error (SE) 0.0013201; 95% confidence interval (CI) 1.003719 - 1.008894; p < 0.001), according to which every 1-unit increase of the F10.7 index increased the count for an aneurysm to rupture by 0.63%. As the F10.7 index is known to correlate well with the Space Environment Services Center (SESC) sunspot number, we performed additional analyses on SESC sunspot number and sunspot area. Here, a likewise statistically significant relationship of both the SESC sunspot number (IRR 1.003413; SE 0.0007913; 95%CI 1.001864 - 1.004965; p < 0.001) and the sunspot area (IRR 1.000419; SE 0.0000866; 95%CI 1.000249 - 1.000589; p < 0.001) emerged. All other variables analyzed showed no correlation with RF. Conclusion: Using valid methods, we found higher radioflux, sunspot number and sunspot area to be associated with an increased count of aneurysm rupture.
Martin N Stienen
added a research item
Background The treatment of ruptured posterior circulation aneurysms remains challenging despite progresses in the endovascular and neurosurgical techniques. Objective To provide epidemiological characterization of subjects presenting with ruptured posterior circulation aneurysms in Switzerland and thereby assessing the treatment patterns and neurological outcomes. Methods This is a retrospective analysis of the Swiss SOS registry for patients with aneurysmal subarachnoid hemorrhage. Patients were divided in 3 groups (upper, lower, and middle third) according to aneurysm location. Clinical, radiological, and treatment-related variables were identified and their impact on the neurological outcome was determined. Results From 2009 to 2014, we included 264 patients with ruptured posterior circulation aneurysms. Endovascular occlusion was the most common treatment in all 3 groups (72% in the upper third, 68% in the middle third, and 58.8% in the lower third). Surgical treatment was performed in 11.3%. Favorable outcome (mRS ≤ 3) was found in 56% at discharge and 65.7% at 1 year. No significant difference in the neurological outcome were found among the three groups, in terms of mRS at discharge (p = 0.20) and at 1 year (p = 0.18). High WFNS grade, high Fisher grade at presentation, and rebleeding before aneurysm occlusion (p = 0.001) were all correlated with the risk of unfavorable neurological outcome (or death) at discharge and at 1 year. Conclusions In this study, endovascular occlusion was the principal treatment, with a favorable outcome for two-thirds of patients at discharge and at long term. These results are similar to high volume neurovascular centers worldwide, reflecting the importance of centralized care at specialized neurovascular centers.
Martin N Stienen
added a research item
Background and Purpose—Commonly used tools to determine functional outcome after aneurysmal subarachnoid hemorrhage (aSAH) have limitations. Time spent at the patient’s home has previously been proposed as a robust outcome measure after ischemic stroke. Here, we set out to validate home-time as an outcome measure after aSAH. Methods—We examined prospectively collected data from a nationwide multicenter registry of aSAH patients admitted to a tertiary neurosurgical department in Switzerland (Swiss SOS [Swiss Study on Aneurysmal Subarachnoid Hemorrhage]; 2009–2015). We calculated mean home-time (defined as days spent at home for the first 90 days after aSAH) and 95% CIs for each category of modified Rankin Scale at discharge and 1-year follow-up, using linear regression models to analyze home-time differences per modified Rankin Scale category. Results—We had home-time data from 1076 of 1866 patients (57.7%), and multiple imputation was used to fill-in missing data from the remaining 790 patients. Increasing home-time was associated with improved modified Rankin Scale scores at time of hospital discharge (P<0.0001) and at 1-year follow-up (P<0.0001). Within each of the 8 participating hospitals, the relationship between home-time and modified Rankin Scale was maintained. Conclusions—Home-time for the first 90 days after aSAH offers a robust and easily ascertainable outcome measure, discriminating particularly well across better recovery levels at time of hospital discharge and at 1-year follow-up. This measure complies with the modern trend of patient-centered healthcare and research, representing an outcome that is particularly relevant to the patient.
Daniel Zumofen
added a research item
BACKGROUND: One-third of patients with aneurysmal subarachnoid hemorrhage (aSAH) have multiple intracranial aneurysms (MIA). OBJECTIVE: To determine the predictors of outcome in aSAH patients with MIA compared to aSAH patients with a single intracranial aneurysm (SIA). METHODS: The Swiss Study of Subarachnoid Hemorrhage dataset 2009-2014 was used to evaluate outcome in aSAH patients with MIA compared to patients with SIA with the aid of descriptive and multivariate regression analysis. The primary endpoints of this cohort study were presence of new stroke on computed tomography (CT) after aneurysm treatment, and presence of stroke on CT prior to discharge. The secondary endpoints were the clinical and the functional status, and the overall mortality at discharge and at 1 yr. RESULTS: Among 1689 consecutive patients, 467 had MIA (prevalence: 26.4%). The incidence of stroke was higher in the MIA than in the SIA group, both after aneurysm treatment (19.3% vs 15.1%) and at discharge (24% vs 21.4%). However, the 95% confidence interval (CI) for the corresponding odds ratio (OR) in our multivariate model included 1, indicating that the detected trends did not reach statistical significance. As for the secondary endpoints, aneurysm multiplicity was found to be an independent, statistically significant predictor for occurrence of a new focal neurological deficit between admission and discharge (OR 1.40, 95% CI 1.08-1.81). Yet, the MIA and SIA groups did not differ in terms of either functional outcome or overall survival. CONCLUSION: aSAH patients with MIA have a higher short-term morbidity than patients with SIA. This excess morbidity does not worsen the functional outcome or lower overall survival.
René Müri
added a research item
Objective: Common sequelae of subarachnoid hemorrhage (SAH) include somatic and/or cognitive impairment. This can cause emotional stress, social tensions, and difficulties in relationships. To test our hypothesis that more severe somatic and cognitive impairments increased the likelihood of disruption of a relationship after SAH, we assessed the integrity of marriage or partnership status in a well-evaluated subset of SAH patients. Methods: Our sample comprised 50 SAH patients who were discharged to a neurologic, in-house rehabilitation center between 2005 and 2010. Deficits on admission to the rehabilitation center were divided into 18 categories and grouped into minor and major somatic deficits, as well as cognitive deficits. Clinical outcome scores, marital/partnership status, and duration of partnership before ictus were recorded. A follow-up questionnaire after 4.3 (2012) and 8.8 (2017) years was used to assess changes in marital/partnership status. Possible predictor parameters were estimated and included in a stepdown regression analysis. Results: In 2012, after a mean follow-up of 4.3 years, 8 of the 50 SAH patients were divorced or separated, whereas after 8.8 years only 1 additional relationship had ended. In our regression model analysis, a "short duration of relationship" before SAH and the presence of a "few minor somatic deficits" were associated with a higher likelihood of divorce or separation in the near future and remained unchanged at long-term follow-up. Conclusion: Contrary to our hypothesis, neither the presence of severe somatic or cognitive deficits nor clinical evaluation scores reliably predicted divorce or separation after SAH.
Martin N Stienen
added a research item
Grading scales yield objective measure of the severity of aneurysmal subarachnoid hemorrhage and serve as to guide treatment decisions and for prognostication. The purpose of this cohort study was to determine what factors govern a patient's disease-specific admission scores in a representative Central European cohort. The Swiss Study of Subarachnoid Hemorrhage includes anonymized data from all tertiary referral centers serving subarachnoid hemorrhage patients in Switzerland. The 2009-2014 dataset was used to evaluate the impact of patient and aneurysm characteristics on the patients' status at admission using descriptive and multivariate regression analysis. The primary/co-primary endpoints were the GCS and the WFNS grade. The secondary endpoints were the Fisher grade, the presence of a thick cisternal or ventricular clot, the presence of a new focal neurological deficit or cranial nerve palsy, and the patient's intubation status. In our cohort of 1787 consecutive patients, increasing patient age by 10 years and low pre-ictal functional status (mRS 3-5) were inversely correlated with "high" GCS score (GCS ≥ 13) (OR 0.91, 95% CI 0.84-0.97 and OR 0.67, 95% CI 0.31-1.46), "low" WFNS grade (grade VI-V) (OR 1.21, 95% CI 1.04-1.20 and OR 1.47, 95% CI 0.66-3.27), and high Fisher grade (grade III-IV) (OR 1.08, 95% CI 1.00-1.17 and OR 1.54, 95% CI 0.55-4.32). Other independent predictors for the patients' clinical and radiological condition at admission were the ruptured aneurysms' location and its size. In sum, chronological age and pre-ictal functional status, as well as the ruptured aneurysm's location and size, determine the patients' clinical and radiological condition at admission to the tertiary referral hospital.
Martin N Stienen
added 2 research items
Objective To develop and validate a set of practical prediction tools that reliably estimate the outcome of subarachnoid haemorrhage from ruptured intracranial aneurysms (SAH). Design Cohort study with logistic regression analysis to combine predictors and treatment modality. Setting Subarachnoid Haemorrhage International Trialists’ (SAHIT) data repository, including randomised clinical trials, prospective observational studies, and hospital registries. Participants Researchers collaborated to pool datasets of prospective observational studies, hospital registries, and randomised clinical trials of SAH from multiple geographical regions to develop and validate clinical prediction models. Main outcome measure Predicted risk of mortality or functional outcome at three months according to score on the Glasgow outcome scale. Results Clinical prediction models were developed with individual patient data from 10 936 patients and validated with data from 3355 patients after development of the model. In the validation cohort, a core model including patient age, premorbid hypertension, and neurological grade on admission to predict risk of functional outcome had good discrimination, with an area under the receiver operator characteristics curve (AUC) of 0.80 (95% confidence interval 0.78 to 0.82). When the core model was extended to a “neuroimaging model,” with inclusion of clot volume, aneurysm size, and location, the AUC improved to 0.81 (0.79 to 0.84). A full model that extended the neuroimaging model by including treatment modality had AUC of 0.81 (0.79 to 0.83). Discrimination was lower for a similar set of models to predict risk of mortality (AUC for full model 0.76, 0.69 to 0.82). All models showed satisfactory calibration in the validation cohort. Conclusion The prediction models reliably estimate the outcome of patients who were managed in various settings for ruptured intracranial aneurysms that caused subarachnoid haemorrhage. The predictor items are readily derived at hospital admission. The web based SAHIT prognostic calculator (http://sahitscore.com) and the related app could be adjunctive tools to support management of patients.
Background: The Barrow Neurological Institute (BNI) scale is a novel quantitative scale measuring maximal subarachnoid hemorrhage (SAH) thickness to predict delayed cerebral ischemia (DCI). This scale could replace the Fisher score, which was traditionally used for DCI prediction. Objective: To validate the BNI scale. Methods: All patient data were obtained from the prospective aneurysmal SAH multicenter registry. In 1321 patients, demographic data, BNI scale, DCI, and modified Rankin Scale (mRS) score up to the 1-yr follow-up (1FU) were available for descriptive and univariate statistics. Outcome was dichotomized in favorable (mRS 0-2) and unfavorable (mRS 3-6). Odds ratios (OR) for DCI of Fisher 3 patients (n = 1115, 84%) compared to a control cohort of Fisher grade 1, 2, and 4 patients (n = 206, 16%) were calculated for each BNI grade separately. Results: Overall, 409 patients (31%) developed DCI with a high DCI rate in the Fisher 3 cohort (34%). With regard to the BNI scale, DCI rates went up progressively from 26% (BNI 2) to 38% (BNI 5) and corresponding OR for DCI increased from 1.9 (1.0-3.5, 95% confidence interval) to 3.4 (2.1-5.3), respectively. BNI grade 5 patients had high rates of unfavorable outcome with 75% at discharge and 58% at 1FU. Likelihood for unfavorable outcome was high in BNI grade 5 patients with OR 5.9 (3.9-8.9) at discharge and OR 6.6 (4.1-10.5) at 1FU. Conclusion: This multicenter external validation analysis confirms that patients with a higher BNI grade show a significantly higher risk for DCI; high BNI grade was a predictor for unfavorable outcome at discharge and 1FU.
Daniel Zumofen
added a research item
Background and purpose: To identify predictors of in-hospital mortality in patients with aneurysmal subarachnoid hemorrhage and to estimate their impact. Methods: Retrospective analysis of prospective data from a nationwide multicenter registry on all aneurysmal subarachnoid hemorrhage cases admitted to a tertiary neurosurgical department in Switzerland (Swiss SOS [Swiss Study on Aneurysmal Subarachnoid Hemorrhage]; 2009-2015). Both clinical and radiological independent predictors of in-hospital mortality were identified, and their effect size was determined by calculating adjusted odds ratios (aORs) using multivariate logistic regression. Survival was displayed using Kaplan-Meier curves. Results: Data of n=1866 aneurysmal subarachnoid hemorrhage patients in the Swiss SOS database were available. In-hospital mortality was 20% (n=373). In n=197 patients (10.6%), active treatment was discontinued after hospital admission (no aneurysm occlusion attempted), and this cohort was excluded from analysis of the main statistical model. In the remaining n=1669 patients, the rate of in-hospital mortality was 13.9% (n=232). Strong independent predictors of in-hospital mortality were rebleeding (aOR, 7.69; 95% confidence interval, 3.00-19.71; P<0.001), cerebral infarction attributable to delayed cerebral ischemia (aOR, 3.66; 95% confidence interval, 1.94-6.89; P<0.001), intraventricular hemorrhage (aOR, 2.65; 95% confidence interval, 1.38-5.09; P=0.003), and new infarction post-treatment (aOR, 2.57; 95% confidence interval, 1.43-4.62; P=0.002). Conclusions: Several-and among them modifiable-factors seem to be associated with in-hospital mortality after aneurysmal subarachnoid hemorrhage. Our data suggest that strategies aiming to reduce the risk of rebleeding are most promising in patients where active treatment is initially pursued. Clinical trial registration: URL: http://www.clinicaltrials.gov. Unique identifier: NCT03245866.
Daniel Zumofen
added a research item
BACKGROUND: Aneurysmal subarachnoid haemorrhage (aSAH) is a haemorrhagic form of stroke and occurs in a younger population compared with ischaemic stroke or intracerebral haemorrhage. It accounts for a large proportion of productive life-years lost to stroke. Its surgical and medical treatment represents a multidisciplinary effort. Due to the complexity of the disease, the management remains difficult to standardise and quality of care is accordingly difficult to assess. OBJECTIVE: To create a registry to assess management parameters of patients treated for aSAH in Switzerland. METHODS: A cohort study was initiated with the aim to record characteristics of patients admitted with aSAH, starting January 1st 2009. Ethical committee approval was obtained or is pending from the institutional review boards of all centres. In the study period, seven Swiss hospitals (five university [U], two non-university medical centres) harbouring a neurosurgery department, an intensive care unit and an interventional neuroradiology team so far agreed to participate in the registry (Aarau, Basel [U], Bern [U], Geneva [U], Lausanne [U], St. Gallen, Zürich [U]). Demographic and clinical parameters are entered into a common database. DISCUSSION: This database will soon provide (1) a nationwide assessment of the current standard of care and (2) the outcomes for patients suffering from aSAH in Switzerland. Based on data from this registry, we can conduct cohort comparisons or design diagnostic or therapeutic studies on a national level. Moreover, a standardised registration system will allow healthcare providers to assess the quality of care.
Michel Roethlisberger
added a research item
Background: Literature on multiple intracranial aneurysms (MIA) in patients with aneurysmal subarachnoid hemorrhage (aSAH) largely focuses on risk factor analysis and consists essentially of retrospective cohort studies of limited sample size, or else studies in populations outside Europe and North America. Objective: The purpose of this cohort study was to determine the predictors for aneurysm multiplicity and to investigate the anatomical distribution of MIA in a representative Western cohort of aSAH patients. Methods: The Swiss Study of Subarachnoid Hemorrhage (SOS) database includes anonymized data from all tertiary neurovascular facilities in Switzerland. The dataset 2009-2014 was used to compare characteristics of aSAH patients with MIA and aSAH patients with a single intracranial aneurysm (SIA) by means of descriptive and multivariate regression analysis. Results: Out of 1689 unselected aSAH patients, 467 had MIA (prevalence: 27.6%). The location of the ruptured index aneurysm was correlated with the probability of finding bystander aneurysm(s) and predicted their likely anatomical distribution. Patients with a ruptured basilar artery (OR 2.08, 95%CI 1.28-3.37) or a ruptured middle cerebral artery (OR 1.86, 95%CI 1.36-2.55) aneurysm had the highest likelihood for MIA. Larger size of the index aneurysm (OR per 1mm 1.03, 95%CI 1.01-1.06) was also positively correlated with aneurysm multiplicity. Males compared to females were less likely to have MIA (OR 0.78, 95%CI 0.61-1.01). Conclusion: In patients suffering from aSAH the location of the ruptured index aneurysm correlates with the probability of finding bystander aneurysm(s) and predicts the sites where bystander aneurysm(s) are the most likely found.
Philippe Bijlenga
added a research item
Background To determine the neurosurgeon’s agreement in aneurysmal subarachnoid haemorrhage (aSAH) management with special emphasis on the rater’s level of experience. A secondary aim was to analyse potential aneurysm variables associated with the therapeutic recommendation. Method Basic clinical information and admission computed tomography angiography (CTA) images of 30 consecutive aSAH patients were provided. Twelve neurosurgeons independently evaluated aneurysm characteristics and gave recommendations regarding the emergency management and aneurysm occlusion therapy. Inter-rater variability and predictors of treatment recommendation were evaluated. ResultsThere was an overall moderate agreement in treatment decision [κ = 0.43; 95% confidence interval ((CI), 0.387–0.474] with moderate agreement for surgical (κ = 0.43; 95% CI, 0.386–0.479) and endovascular treatment recommendation (κ = 0.45; 95% CI, 0.398–0.49). Agreement on detailed treatment recommendations including clip, coil, bypass, stent, flow diverter and ventriculostomy was low to moderate. Inter-rater agreement did not significantly differ between residents and consultants. Middle cerebral artery (MCA) aneurysm location was a positive predictor of surgical treatment [odds ratio (OR), 49.57; 95% CI, 10.416–235.865; p < 0.001], while patients aged >65 years (OR, 0.12; 95% CI, 0.03–0.0434; p = 0.001), fusiform aneurysm type (OR, 0.18; 95% CI, 0.044–0.747; p = 0.018) and intracerebral haematoma (ICA) aneurysm location (OR, 0.24; 95% CI, 0.088–0.643; p = 0.005) were associated with a recommendation for endovascular treatment. Conclusions Agreement on aSAH management varies considerably across neurosurgeons, while therapeutic decision-making is challenging on an individual patient level. However, patients aged >65 years, fusiform aneurysm shape and ICA location were associated with endovascular treatment recommendation, while MCA aneurysm location remains a surgical domain in the opinion of neurosurgeons without formal endovascular training.
Philippe Bijlenga
added 2 research items
Das Wichtigste für die Praxis • Neuropsychologische Defizite nach aneurysmatischer Subarachnoidalblutung (aSAB) haben eine hohe Prävalenz und werden bisher nur unzureichend und unsystematisch abgeklärt. • Selbst bei Patienten mit gutem klinisch-funktionellem Ergebnis nach aSAB ver- oder behindern diese Störungen häufig die Rückkehr zur prämorbiden Lebens- und Arbeitsfähigkeit. • Ein neuer schweizweiter Standard soll helfen, neuropsychologische Defizite nach aSAB systematisch zu diagnostizieren und zu behandeln. • Die Teilnahme von Patienten an der schweizweiten prospektiven Studie «Swiss SOS» (www.swiss-sos.ch) ermöglicht die Identifizierung von Risikofaktoren für neuropsychologische Defizite nach aSAB, was für deren zukünftige Prävention und Therapie essentiell ist.
L’essentiel pour la pratique • Les déficits neuropsychologiques à la suite d’une hémorragie sousarachnoïdienne (HSA) anévrismale ont une prévalence élevée et ne sont pas encore caractérisés de manière adéquate et systématique. • Même pour les patients bénéficiant d’une bonne évolution clinique, il persiste des déficits qui entravent le retour à un niveau de fonctionnement prémorbide et une pleine capacité de travail. • L’établissement d’une nouvelle norme nationale aiderait au diagnostique systématique des troubles neuropsychologiques après une HSA anévrismale, permettrait de quantifier leur impact et d’améliorer le traitement des patients. • La participation des patients à l’étude prospective multicentrique «Swiss SOS» (www.swiss-sos.ch) permet l’identification des facteurs de risque conduisant à des déficits neuropsychologiques après une HSA anévrismale, ce qui est essentiel pour leur prévention et le traitement futur.
Michel Roethlisberger
added a research item
Aims: To compare patient, aneurysm, and outcome characteristics of individuals with multiple intracranial aneurysms (MIA) compared with patients with single intracranial aneurysms (SIA) in a large-scale unselected population of patients with acute aneurysmal subarachnoid hemorrhage (aSAH). Methods: The SwissSOS dataset was used to study the relationship between patient variables, aneurysm characteristics, and clinical outcome at discharge and at 1 year with descriptive and multivariate regression analysis. Results: 1787 consecutive patients with aSAH including 474 with MIA (26.5%) were analyzed. The mean age was 55.9yrs (SD/−12yrs) for patients with MIA, and 55.9years (SD/−13.8yrs) for those with SIA. Males were less likely to have MIA than females (OR 0.76 [95% CI 0.56 – 0.96] p = .024). Patients with a ruptured [r] MCA or BA aneurysm were more prone to having MIA than patients with a ruptured AcommA aneurysm (MCA OR 1.96 [1.45–2.65] p = <.0001; BA OR 2.34 [1.47–3.70] p = .0003). The mean diameter was significantly larger for rMIA than for rSIA (mean 7.7mm, SD/−4.8mm versus mean 7.1mm, SD/−4.5mm; p = .005). Similarly, aneurysms were more likely larger in males and in patients with MIA than in females or patients with SIA (Male OR 1.07 [1.01–1.13] p = .03 per mm; rMIA OR 1.07 [1.01–1.14] p = .026 per mm). Also, the rMIA was likely larger than any bystanding nrMIA (OR 0.72 [0.66–0.79] p < .0001 per mm). The modality of aneurysm treatment, treatment- or vasospasm-related infarction, and the overall survival at both discharge and at one year did not differ between patients with MIA except for MCA-location, were surgery was performed with a higher proportion in MIA- than in SIA patients (69% versus 76%). Patients with MIA were more prone for having a thick clot on admission CT (OR 1.47 [1.01–2.14] p = 0.042), had a higher chance for developing a new FND during hospitalization (OR 1.49 [1.15 – 1.93] p = .003), and hence more likely suffered from a FND at discharge (OR 1.74 [1.25 – 2.42] p = .001). Interpretation: About one quarter of patients with acute aSAH has MIA, with females and patients with a ruptured MCA or BA aneurysm being particularly prone to having MIA. While the modality of aneurysm treatment and the overall survival at both discharge and at one year do not differ in patients with MIA compared with patients with SIA, MIA patients are associated with a higher morbidity including more new FND, potentially due to a higher amount of surgically treated ruptured MCA-aneurysms.
Martin N Stienen
added a research item
Objective: The objective of this study was to determine interrater agreement in the initial radiological characterization of ruptured intracranial aneurysms based on CTA with special emphasis on the rater's level of experience. Methods: One junior and one senior rater of five high volume neurovascular tertiary centers evaluated anonymized CTA images of 30 consecutive aneurysmal SAH patients. Each rater described location, side, size and morphology in a standardized manner. Interrater variability was analyzed using intraclass correlation and Fleiss´kappa analysis. Results: There was a high level of agreement for location (κ = 0,76, 95% confidence interval (CI) 0.74 - 0.79), side (κ = 0.95, CI 0.91 - 0.99), maximum diameter (Intraclass Correlation Coefficient (ICC) = 0.81, CI 0.70 - 0.90) and dome (ICC = 0.78, CI 0.66 - 0.88) of IA. In contrast a lower level of agreement was observed for aneurysms neck diameter (ICC = 0.39, CI 0.28 - 0.58), presence of multiple aneurysms (κ = 0.35, CI 0.30 - 0.40) and aneurysm morphology (blister κ=0.11, CI -0.05 - 0.07; fusiform κ=0.54, CI 0.48 - 0.60; multilobular, κ=0.39 CI 0.33 - 0.45). The interrater agreement in the senior rater group was higher than in the junior rater group. Conclusions: Interrater agreement confirms the benefit of CTA as initial diagnostic imaging in ruptured intracranial aneurysms but not for aneurysm morphology and presence of multiple aneurysms. A trend towards higher interrater agreement between more experienced raters was noticed.
Kerkeni Hassen
added 2 research items
Aims: Aneurysmal subarachnoid hemorrhage (aSAH) accounts for a large proportion of productive life years lost to stroke. Its management requires a multidisciplinary effort. Much of the presently available data on incidence, treatment, and outcomes come from studies with a strong selection bias, studies confounding all kinds of SAH, that is, aneurysmal and nonaneurysmal, and cohorts of single centers or retrospective series. The aim of this study is to assess incidence, treatment modalities, and outcomes after SAH from a national registry. Methods: Patients admitted with aSAH across Switzerland are included starting January 1, 2009. All eight Swiss hospitals providing neurovascular care for aSAH patients participated in the registry. Admission parameters, treatment, and outcomes at discharge and one year were recorded. Incidence was calculated after WHO standardization and age stratification, and was based on population data from the Swiss Federal Bureau of Statistics. Results: From 2009 to 2013, 1,580 patients were recorded in the Swiss SOS database. The annual incidence of aSAH in the observation period ranged at ∼2.61/100,000/year. Its peak of 7.6/100,000/year was reached in the age group 55 to 59 years. Eighty-six percent of patients arrived at a tertiary neurovascular care center on the same or within one day of symptom occurrence. The ratio of female to male patients was 2:1. Median age at aSAH was 55 years. Good grade aSAH (World Federation of Neurosurgical Societies [WFNS] grades 1 and 2) accounted for more than 38 and 18% of cases, respectively. WFNS grades 3, 4, and 5 made up 7, 10, and 26%, respectively. Fisher grades 1 and 2 accounted for 14% of cases, while 86% were Fisher grades 3 and 4. Surgical aneurysm occlusion was performed in 36% and endovascular occlusion in 48% of cases. After a mean length of stay of 20 days, 51% of patients were discharged with good outcome (mRS <3) and 30% with poor outcome (mRS 3–5). In-hospital mortality was 19%. At one year, good outcome ranged at 68%. Conclusions: The Swiss SOS laid the foundation for a multidisciplinary self-assessment and scientific research by highly specialized health care providers in this complex and costly disease. As previously found for ischemic cerebrovascular disease, the incidence of aSAH in Switzerland ranges at the lower end of the international spectrum with ∼3.5 to 4.0/100,000/year. The results of this first national outcomes database on aSAH reflect a high level of care. Admission rates at a special request.
Background: Comparison of artery diameters between CT angiography (CTA) and subtraction arteriography (DSA) has the limitation that measurements on DSA are provided as relative units, making a quantitative comparison difficult. On CTA, artery diameters may depend on windowing settings and may lead to false measurements. This study assesses the correlation between CTA and DSA based on measurements in a basic imaging viewer using normalized DSA values, and assesses whether the validity is time dependent. Methods: Patients with aneurysmal subarachnoid hemorrhage (aSAH) were included if they underwent both CTA and DSA within 24 h. The analysis was performed using the basic imaging application Centricity Enterprise PACS viewer (GE Healthcare). A total of 15 arterial locations were assessed on CTA and DSA and a specific measurement protocol with normalization of all artery diameters to the cavernous segment of the internal carotid artery was used. Pearson correlation analysis was calculated to access the correlation of normalized arterial diameters measured with both methods at admission and at clinical onset of CVS. Results: A total of 627 arteries in 38 patients were analyzed in both CTA and DSA. There was a significant correlation coefficient (R = 0.706) of artery diameters between CTA and DSA measures (p < 0.0001). This correlation remained high when comparing CTA and DSA at admission (correlation coefficient: 0.641; p < 0.0001) vs. in the vasospasm period (0.835; p < 0.0001). The correlation was good in all proximal artery segments and lost significance only when distal vessel segments were considered. Conclusion: Using basic imaging viewers, mostly accessible for clinicians, CTA is a noninvasive and reliable method to assess proximal arterial diameters of the brain in the management of cerebral vasospasm in the acute phase after aSAH. Significance is reached, independent of whether CTA is obtained in the acute phase or during the period of vasospasm, by normalization of basal cerebral artery diameters to a non-variable anatomic landmark, i.e., the petrous or cavernous internal carotid artery diameter.
Martin N Stienen
added a research item
IntroductionTo analyze whether the computed tomography angiography (CTA) spot sign predicts the intraprocedural rupture rate and outcome in patients with aneurysmal subarachnoid hemorrhage (aSAH). Methods From a prospective nationwide multicenter registry database, 1023 patients with aneurysmal subarachnoid hemorrhage (aSAH) were analyzed retrospectively. Descriptive statistics and logistic regression analysis were used to compare spot sign-positive and -negative patients with aneurysmal intracerebral hemorrhage (aICH) for baseline characteristics, aneurysmal and ICH imaging characteristics, treatment and admission status as well as outcome at discharge and 1-year follow-up (1YFU) using the modified Rankin Scale (mRS). ResultsA total of 218 out of 1023 aSAH patients (21%) presented with aICH including 23/218 (11%) patients with spot sign. Baseline characteristics were comparable between spot sign-positive and -negative patients. There was a higher clip-to-coil ratio in patients with than without aICH (both spot sign positive and negative). Median aICH volume was significantly higher in the spot sign-positive group (50 ml, 13-223 ml) than in the spot sign-negative group (18 ml, 1–416; p < 0.0001). Patients with a spot sign-positive aICH thus were three times as likely as those with spot sign-negative aICH to show an intraoperative aneurysm rupture [odds ratio (OR) 3.04, 95% confidence interval (CI) 1.04–8.92, p = 0.046]. Spot sign-positive aICH patients showed a significantly worse mRS at discharge (p = 0.039) than patients with spot sign-negative aICH (median mRS 5 vs. 4). Logistic regression analysis showed that the spot sign was an aICH volume-dependent predictor for outcome. Both spot sign-positive and -negative aICH patients showed comparable rates of hospital death, death at 1YFU and mRS at 1YFU. Conclusion In this multicenter data analysis, patients with spot sign-positive aICH showed higher aICH volumes and a higher rate of intraprocedural aneurysm rupture, but comparable long-term outcome to spot sign-negative aICH patients.
Martin N Stienen
added a project goal
This is a prospective multicenter study that collects clinical and radiological data on consecutive patients admitted with aneurysmal subarachnoid hemorrhage to one of the eight participating centers: Aarau (Kantonsspital), Basel (Universitätsspital), Bern (Inselspital), Geneva (Hôpitaux Universitaires), Lausanne (CHUV), Lugano (EOC), St.Gallen (Kantonsspital), Zürich (UniversitätsSpital). The aims are to determine the incidence of aneurysmal subarachnoid hemorrhage in Switzerland, to monitor treatment and outcome, as well as to conduct cohort studies on a national level.