The HSACat Project: A Prospective Multicenter Observational Study of Spontaneous Subarachnoid Hemorrhage in Catalonia, Spain.

BACKGROUND: Incidence, clinical course, and fatality of spontaneous subarachnoid hemorrhage (SAH) are evolving, with prevalence of risk factors diminishing, implementation of early detection programs and strategies for priority aneurysm exclusion, technical refinement with less invasive procedures, and improvements in neurocritical care. Modern epidemiological and prognostic data are lacking, especially in southern European and Mediterranean populations. METHODS: A prospective multicenter observational study on SAH was held in Catalonia, Northeast Spain, from 2020 to 2022 (HSACat project). All public tertiary hospitals participated in a common registry. Primary end points were functional outcomes (modified Rankin Scale) and mortality at 12 months. Secondary aims included epidemiological data, passage of patients between referral and tertiary hospitals, diagnostic and treatment delays, and in-hospital complications. RESULTS: Of 550 SAH cases reported in Catalonia (2020-2022), a complete registry for analysis was available for 474. Death rate was 20.6% during hospital admission and 26.9% at 1 year. Good functional outcome (modified Rankin Scale score 0-2) was observed in 63.4%, 70.1%, and 76.0% at 3, 6, and 12 months. Age at presentation was younger in men, patients who smoked, and patients with hypertension (P < 0.05). The female-to-male ratio was 3:2 except in the nonaneurysmal group. Time from onset to tertiary hospital admission was longer in rural than in metropolitan areas (7.0 hours vs. 4.7 hours, P < 0.01). Aneurysm occlusion in the first 72 hours was achieved in 83.3%; mainly endovascularly (77.5%) followed by microsurgically (19.3%). CONCLUSIONS: Even when most patients received timely aneurysm treatment, case fatality rates were considerably high. Data provided by the HSACat project may have public health effects and be used to guide prevention programs and screening strategies.

Prognosis of patients in coma after acute subdural hematoma due to ruptured intracranial aneurysm.

Acute subdural hematomas (aSDH) secondary to intracranial aneurysm rupture are rare. Most patients present with coma and their functional prognosis has been classically considered to be very poor. Previous studies mixed good-grade and poor-grade patients and reported variable outcomes. We reviewed our experience by focusing on patients in coma only and hypothesized that aSDH might worsen initial mortality but not long-term functional outcome. Between 2005 and 2013, 440 subarachnoid hemorrhage (SAH) patients were admitted to our center. Nineteen (4.3%) were found to have an associated aSDH and 13 (2.9%) of these presented with coma. Their prospectively collected clinical and outcome data were reviewed and compared with that of 104 SAH patients without aSDH who presented with coma during the same period. Median aSDH thickness was 10mm. Four patients presented with an associated aneurysmal cortical laceration and only one had good recovery. Overall, we observed good long-term outcomes in both SAH patients in coma with aSDH and those without aSDH (38.5% versus 26.4%). Associated aSDH does not appear to indicate a poorer long-term functional prognosis in SAH patients presenting with coma. Anisocoria and brain herniation are observed in patients with aSDH thicknesses that are smaller than those observed in trauma patients. Despite a high initial mortality, early surgery to remove the aSDH results in a good outcome in over 60% of survivors. Aneurysmal cortical laceration appears to be an independent entity which shows a poorer prognosis than other types of aneurysmal aSDH.

Posterior fossa arteriovenous malformations: Significance of higher incidence of bleeding and hydrocephalus.

OBJECTIVE: Hydrocephalus associated with different types of intracranial arteriovenous malformations (AVMs) has been scarcely studied. In the present report we investigate this association with posterior fossa AVMs (pfAVMs). We hypothesized that there is an increased risk of hydrocephalus and required permanent cerebrospinal fluid (CSF) shunt in patients with pfAVMs that may be linked to the increased risk of bleeding of these lesions. We also review the factors associated with this increased risk of hemorrhagic presentation and we assess how it affects management strategies and functional outcomes in these patients. METHODS: Out of a prospective registry of 374 patients with brain AVMs diagnosed in our center from 1993 to 2013, 60 (16%) had a pfAVM. We described these patients' demographics, their AVM characteristics, clinical presentation, and hydrocephalus incidence and compared the results with those of the supratentorial AVM (spAVM) patients recorded during the same period. RESULTS: Out of the 60 patients with pfAVMs, 10 (16.7%) presented AVMs located in the brainstem. Hemorrhagic presentation (49/60; 82%) was significantly higher in pfAVMs than in spAVMs (122/314; 38.8%; p<0.05). Hydrocephalus was a common complication in pfAVM patients who had a statistically significant higher need for both temporary external ventricular drain (EVD) (6.7 vs. 20%; p<0.05) and permanent CSF shunts (3.5 vs. 20%; p<0.05). The initial mortality was high (12/60; 20.3%) and half of these patients died before any treatment option could be offered. However, out of those who survived, 70% (42/60) had already shown good clinical outcome at the 6-month follow-up. CONCLUSIONS: Hemorrhagic presentation and hydrocephalus have a higher incidence in pfAVM patients, which initially results in more neurological deficits and an elevated mortality even before receiving any treatment. However, a large number of survivors present good functional outcomes at early follow-up, justifying an aggressive management strategy with microsurgery as the first treatment option in most cases, and radiosurgery as an alternative, especially in brainstem AVMs.