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Ruptured intracranial aneurysms--learning from experience
R S Maurice-Williams1, N D Kitchen
1Royal Free Hospital and School of Medicine, London, UK.
Insights
Surgical outcomes for ruptured intracranial aneurysms significantly improved over 13 years. Increasing surgical experience reduced mortality and improved patient recovery, highlighting the impact of operative skill on patient management.
Area of Science:
- Neurosurgery
- Neurology
- Critical Care Medicine
Background:
- Ruptured intracranial aneurysms present a significant cause of mortality and morbidity.
- Optimal timing and surgical approach remain critical factors in patient management.
- Delayed surgical intervention is common, often exceeding 10 days post-hemorrhage.
Purpose of the Study:
- To assess the 1-year treatment outcomes for 400 consecutive patients with ruptured intracranial aneurysms.
- To evaluate the impact of surgical experience on patient mortality and functional recovery.
- To identify factors contributing to unsatisfactory outcomes and surgical complications.
Main Methods:
- Analysis of data from 400 consecutive patients treated over 13 years by a single surgeon.
- Categorization of patients into four 100-patient cohorts to track changes over time.
- Contemporary analysis of reasons for unsatisfactory outcomes recorded during treatment.
- Assessment of 1-year mortality and Glasgow Outcome Score (GOS) for all patients.
Main Results:
- Overall management mortality at 1 year decreased from 38% to 24% across the four cohorts.
- Surgical mortality at 1 year significantly reduced from 19% to 3%.
- The proportion of patients achieving a GOS of 5 at 1 year increased from 73% to 90% among operated patients.
- Postoperative deaths were primarily linked to surgical technical problems, which decreased from 15% to 1% over time.
- Preoperative deaths, largely due to rebleeding, accounted for the majority of fatalities.
Conclusions:
- Increasing surgical experience led to a steady improvement in the management of ruptured intracranial aneurysms.
- Operative efficiency significantly improved, with a marked reduction in technical complications.
- The study suggests that improvements in surgical skill, rather than changes in overall management strategy like early surgery, are key to better outcomes.
Abstract:
The outcome of treatment of 400 consecutive patients with ruptured intracranial aneurysms was assessed at 1 year. The patients were treated by a single surgeon over a period of 13 years. Data sheets completed as each patient was treated included a contemporary analysis of the reasons for any unsatisfactory outcome. Surgery was usually delayed for over 10 days from the last haemorrhage. Over the four successive 100-patient cohorts, in which the composition of the patient population remained unaltered, 1 year overall management mortality fell steadily from 38 to 24%. One year surgical mortality fell from 19 to 3%. The population of those operated on who were in Glasgow Outcome Score 5 at 1 year rose from 73 to 90% (from 51 to 71% for all patients). Of the 123 deaths, 89 occurred prior to operation, 24 after it. Thirty-five patients died from rebleeding prior to operation, but only eight of these occurred in patients judged fit for surgery at the time. All but one of the postoperative deaths resulted from technical problems related to the surgery. Over the successive cohorts, several factors indicated an improvement in operative efficiency, notably a fall in the proportion of cases with technical problems from 15 to 1%. We have demonstrated a steady improvement in management results, resulting largely from increasing operative experience. We do not believe that changes in overall management strategy, such as early surgery, would have any effect on overall outcome.