Results of treatment

Overall results of management in patients admitted to the 8 Italian centers participating in the International Cooperative Study on Timing of Aneurysm Surgery were rather unsatisfactory, with good recovery in only 42% of patients, and death in 45% of patients. As compared to the other centers included in the Study, Italian centers exhibited a significantly lower recovery rate and a significantly higher mortality rate. There were significant differences also between the individual Italian centers; independently of admission neurological status and timing of surgery, the outcome was better in centers 2 and 6 (a mortality rate under 20%) and worse in centers 1 and 8 (a mortality rate around 60%). Using prognostic factor models, higher than expected mortality rates were observed in 4 centers, and lower than expected good recovery rates in 3 centers. In Italian centers vasospasm accounted for the highest morbidity and mortality rate; the difference in mortality rate from vasospasm between Italian and other centers was very significant. Other important causes of death and disability were constituted by direct effect of the initial bleed and by recurrent hemorrhage. Patients operated on in Italian centers exhibited a good recovery in 57% of cases; the mortality was 27%. Differences from the other centers were less marked than for the overall management results. Mortality rates from vasospasm and from surgical complications were significantly higher in Italian than in the other study centers. Between the individual Italian centers, vasospasm accounted for the highest mortality rate in centers 7 and 8 (17% and 28% respectively). Postoperative pneumonia was significantly more frequent in Italian than in the other centers. In regard to timing of surgery, the differences in results between Italian and other centers were less marked when surgery was performed after 10 days from hemorrhage. In Italian centers as a whole, a delayed operation was linked with a better outcome than an early or subacute operation. The lowest recovery rate was observed in drowsy patients operated on between 4 and 10 days from the hemorrhage. Focal ischemic deficits and pneumonia were prevalent after an operation within 3 days of hemorrhage, while postoperative brain swelling was most frequent in patients operated on between 4 and 10 days from hemorrhage. The differences in results between Italian and other centers and among the individual Italian centers are widely discussed; possible explanations include inadequate modalities of treatment (especially inadequate management of vasospasm) and structural deficiencies of intensive care management in seriously ill patients.