Asikainen Aleksanteri, Rautalin Ilari, Raj Rahul, Korja Miikka, Niemelä Mika
Department of Neurosurgery, University of Helsinki and Helsinki University Hospital, P.O. Box 320, Helsinki, FI-00029, Finland.
The National Institute for Stroke and Applied Neurosciences, Auckland University of Technology, Private Bag 92006, Auckland, 1142, New Zealand.
Acta Neurochir (Wien). 2025 Feb 4;167(1):34. doi: 10.1007/s00701-025-06447-1.
Several studies have attributed decreasing case fatality rates (CFRs) of aneurysmal subarachnoid hemorrhage (aSAH) to the gradually increasing use of endovascular treatment without considering improvements in other outcome-affecting factors. To assess the independent effect of a treatment modality on CFRs, we investigated CFR changes in a high-volume center rapidly transitioning from surgical to endovascular operations as the first-line treatment for all aSAH patients except those with middle cerebral artery (MCA) aneurysms.
We identified all surgically/endovascularly treated aSAH patients in Helsinki University Hospital (HUH) during 2012-2017. As the treatment shift occurred in 2015, we defined two treatment eras: surgical (2012-2014) and endovascular (2015-2017). We compared time-dependent changes in 1-year CFRs between non-MCA and MCA patients using a Poisson regression model. To analyze consistency in operation rates, we also identified sudden-death and conservatively treated aSAHs in the HUH catchment area via two externally validated registers.
Of all 665 hospitalized aSAH cases in the HUH catchment area, 557 (84%) received operative treatment; 367 (66%) underwent surgical and 190 (34%) endovascular operations. Between the treatment eras, endovascular treatment for non-MCA cases increased from 21 to 79%, whereas 99% of the MCA cases were treated surgically during the whole study-period. Among the operatively treated patients, the 1-year CFRs decreased similarly in patients with non-MCA (42%; from 14 to 8%; adjusted risk ratio (aRR) = 0.66 (95% CI 0.37-1.19)) and MCA aneurysms (42%; from 15 to 9%; aRR = 0.66 (0.16-1.60)). The proportion of operatively treated patients, their clinical condition on admission, and amount of bleeding on the first CT-scan remained unchanged over time.
We found similar CFR decreases in aSAH groups with and without undergoing a fast transition from surgery to endovascular operations, providing real-world evidence on the small independent effect of endovascular treatment on the decreasing CFRs in high-volume centers.
多项研究将动脉瘤性蛛网膜下腔出血（aSAH）病死率（CFR）的下降归因于血管内治疗的使用逐渐增加，而未考虑其他影响预后因素的改善情况。为评估一种治疗方式对CFR的独立影响，我们调查了一家大型中心的CFR变化情况，该中心迅速从手术治疗过渡到血管内手术，将其作为除大脑中动脉（MCA）动脉瘤患者外所有aSAH患者的一线治疗方法。
我们确定了2012年至2017年期间在赫尔辛基大学医院（HUH）接受手术/血管内治疗的所有aSAH患者。由于治疗方式在2015年发生了转变，我们定义了两个治疗时期：手术治疗时期（2012 - 2014年）和血管内治疗时期（2015 - 2017年）。我们使用泊松回归模型比较了非MCA和MCA患者1年CFR的时间依赖性变化。为分析手术率的一致性，我们还通过两个外部验证登记册确定了HUH服务区域内的猝死和保守治疗的aSAH病例。
在HUH服务区域的所有665例住院aSAH病例中，557例（84%）接受了手术治疗；367例（66%）接受了手术，190例（34%）接受了血管内手术。在不同治疗时期之间，非MCA病例的血管内治疗从21%增加到79%，而在整个研究期间MCA病例的99%接受了手术治疗。在接受手术治疗的患者中，非MCA动脉瘤患者（42%；从14%降至8%；调整风险比（aRR）= 0.66（95%CI 0.37 - 1.19））和MCA动脉瘤患者（42%；从15%降至9%；aRR = 0.66（0.16 - 1.60））的1年CFR下降情况相似。接受手术治疗的患者比例、入院时的临床状况以及首次CT扫描时的出血量随时间保持不变。
我们发现，无论是否从手术快速过渡到血管内手术，aSAH组的CFR下降情况相似，这为血管内治疗对大型中心CFR下降的独立影响较小提供了真实世界的证据。
