Causes of Mortality in Spontaneous Subarachnoid Hemorrhage

To investigate the causes of death in patients with spontaneous subarachnoid hemorrhage, 460 consecutive patients with a subarachnoid hemorrhage were reviewed. Angiography was not performed in 78 patients due to poor clinical conditions or discharge against admission. Of all these patients, 54(69.2%) died, 28 from serious clinical condition, 21 from rebleeding, 3 from pulmonary complications. 1 from vasospasm, and 1 with unknown causes. Thirty-eight patients were angiographically negative, of which 6(15.8%) died, 3 due to rebleeding, 2 due to poor clinical condition, and 1 due to cerebral infarction caused by vasospasm. Of the 344 patients who had an aneurysmal subarachnoid hemorrhage. 74 were discharged against admission or died before the surgery. The remaining 270 patients underwent aneurysm clipping. Early surgery(within 72 hours after subarachnoid hemorrhage) was performed in 151 patients, intermediate surgery (between Day 4 and 7 post SAH) in 74, and late surgery(Day 8 or later after SAH) in 45. Fifty-one patients (18.9%) died after aneurysm clipping. The remaining 270 patients underwent aneurysm clipping. Early surgery(within 72 hours after subarachnoid hemorrhage) was performed in 151 patients, intermediate surgery(between Day 4 and 7 post-SAH) in 74, and late surgery(Day 8 or later after SAH) in 45, Fifty-one patients(18.9%) died after aneurysm clipping. The causes were vasospasm in 17, complications related to surgery in 13, poor clinical condition in 12, preoperative rebleeding in 7, and other systemic condition in 2. A total of 59 patients suffered at least one rebleeding after the initial hemorrhage ; these patients had a mortality rate of 76.3% and the highest rate of rebleeding occurred within the first 24 hours after initial hemorrhage. Vasospasm and rebleeding were the leading causes of mortality in addition to the initial bleeding. Predictors for mortality included poor clinical grade, early surgery in patients aged 60 years or more, and association with intracerebral hematoam, intraventricular hemorrhage, or subdural hematoma.

Traumatic Intracerebral Hematoma

During a 36-month period, clinical outcome in 170 patients with traumatic intracerebral hematoma(TICH) was analysed. These patients represented 5.1% of 3328 consecutive patients with head injuries admitted to the Soonchunhyang University Chunan Hospital. The overall mortality was 33.5%. A significant number of patients(52.6%), who were not comators at the time of admission(GCS0.005) ; 2) the presence of associated lesions(p>0.01) ; 3) time delay of two hours or more from admission to operation(p>0.05) ; 4) actual midline shift of 4.5mm or above on initial CT scan(p>0.005) ; 5) obliteration of suprasellar cistern(p>0.005) ; 6) the presence of delayed traumatic intracerebral hematoma(DTICH) in non-surgical patients with GCS score of 8 or above(p>0.01). Age and location of hematoma did not affect outcome, but the patients with multiple located hematoma showed higher mortality than the others. Time delay in the treatment of TICH and DTICH contribute significantly to poor outocme. Rapidly progressive DTICH within 48 hours after trauma is high in mortality. Follow-up CT scan might as well be performed till 48 hours after injury and 8 hours after initial operation, even though neurological status did not alter for the worse.

Repeated Operations in Head Injury

Repeated operation in head injury is not uncommon. We experienced 46 repeated operations in 36 patients during 22-month-period. Rate of repeated operation is 14.6%. Occurrence of delayed or recurrent lesions was more common in the aged(mean=44years of age). Acute subdural hematoma was the most common initial lesion requiring repeated operation. The rate of repeated operation was relatively high in intracerebral hematoma(21.4%), acute subdural hematoma(16.0%), and chronic subdural hematoma(15.6%). The most common lesion requiring repeated operation was delayed intracerebral hematoma. Repeated operations were performed within 24 hours in 50% of the cases. Outcome at discharge was good recovery in 6, moderate disability in 12, severe disability in 8 and death in 10. It seemed to be related to the initial lesions rather the lesions requiring repeated operation. Even in the patients requiring repeated operations, early detection and appropriate management could improve the outcome. Early, repeated CT scans has almost importance especially in patients with certain risk of delayed or recurrent lesions.

Coma Without Mass Lesions on CT Scan after Head Injury

We present a retrospective study on the patients with coma without mass lesion on CT scan after non-missile head injury. We reviewed various clinical and radiological features of these 53 cases and compared the outcome at one month with several variables which may affect the prognosis. The patients were selected by the following criteria;the patients had lost consciousness at least for 6 hours, the Glasgow coma scores were below B, and the CT scan did not demonstrate a mass lesion but might have small contusion, subarachnoid hemorrhage and pneumocephalus that caused no mass effect. Characteristic CT findings for the diffuse axonal injury-small intracerebral hemorrhage on corpus callosum, white mater, basal ganglia or around the third ventricle-were observed in only 21 of 53 cases(39.6%). Thus diffuse axonal injury can be diagnosed by clinical features not by the CT findings at present and the CT scan was required for ruling out any mass lesions. The mortality rate was 32.1%. However, 37.7% was remained in the vegetative state or severe disability. Only 30.2% could obtain functional recovery. The changes of pupil, duration of coma, Glasgow coma score, skull fracture and collapsed lateral ventricle on CT scan were identified as important features in determining the outcome(p<0.05). Age, systolic BP, PaO2 and obliteration of basal cistern and third ventricle on CT scan had no statistical significance.

Coma Without Mass Lesions on CT Scan after Head Injury

We present a retrospective study on the patients with coma without mass lesion on CT scan after non-missile head injury. We reviewed various clinical and radiological features of these 53 cases and compared the outcome at one month with several variables which may affect the prognosis. The patients were selected by the following criteria;the patients had lost consciousness at least for 6 hours, the Glasgow coma scores were below B, and the CT scan did not demonstrate a mass lesion but might have small contusion, subarachnoid hemorrhage and pneumocephalus that caused no mass effect. Characteristic CT findings for the diffuse axonal injury-small intracerebral hemorrhage on corpus callosum, white mater, basal ganglia or around the third ventricle-were observed in only 21 of 53 cases(39.6%). Thus diffuse axonal injury can be diagnosed by clinical features not by the CT findings at present and the CT scan was required for ruling out any mass lesions. The mortality rate was 32.1%. However, 37.7% was remained in the vegetative state or severe disability. Only 30.2% could obtain functional recovery. The changes of pupil, duration of coma, Glasgow coma score, skull fracture and collapsed lateral ventricle on CT scan were identified as important features in determining the outcome(p<0.05). Age, systolic BP, PaO2 and obliteration of basal cistern and third ventricle on CT scan had no statistical significance.