Sex Differences in Case Fatality of Aneurysmal Subarachnoid Hemorrhage: A Systematic Review.

INTRODUCTION: Aneurysmal subarachnoid hemorrhage (SAH) is more common in women than in men, contrary to most cardiovascular diseases. However, it is unclear whether the case fatality rate (CFR) of SAH also differs by sex. Thus, we performed a systematic review to address the relationship between sex and SAH CFRs. METHODS: We conducted a systematic literature search in PubMed, Scopus, and Cochrane library databases. We focused on population-based studies that included both nonhospitalized and hospitalized SAHs and had either reported 1-month (28-31 day) SAH CFRs separately for men and women or calculated risk estimates for SAH CFR by sex. For quality classification, we used the Cochrane Collaboration Handbook and Critical Appraisal Skills Program guidelines. We pooled the study cohorts and calculated relative risk ratios (RRs) with 95% confidence intervals (CIs) for SAH death between women and men using a random-effects meta-analysis model. RESULTS: The literature search yielded 5,592 initial publications, of which 33 study cohorts were included in the final review. Of the 33 study cohorts, only three reported significant sex differences, although the findings were contradictory. In the pooled analysis of all 53,141 SAH cases (60.3% women) from 26 countries, the 1-month CFR did not differ (RR = 0.99 [95% CI: 0.93-1.05]) between women (35.5%) and men (35.0%). According to our risk-of-bias evaluation, all 33 study cohorts were categorized as low quality. The most important sources of bias risks were related to the absence of proper confounding control (all 33 study cohorts), insufficient sample size (27 of 33 study cohorts), and poor/unclear diagnostic accuracy (27 of 33 study cohorts). CONCLUSION: Contrary to SAH incidence rates, the SAH CFRs do not seem to differ between men and women. However, since none of the studies were specifically designed to examine the sex differences in SAH CFRs, future studies on the topic are warranted.

Frailty indices predict mortality, complications and functional improvements in supratentorial meningioma patients over 80 years of age.

PURPOSE: To assess whether the Modified 5 (mFI-5) and 11 (mFI-11) Factor Frailty Indices associate with postoperative mortality, complications, and functional benefit in supratentorial meningioma patients aged over 80 years. METHODS: Baseline characteristics were collected from eight centers. Based on the patients' preoperative status and comorbidities, frailty was assessed by the mFI-5 and mFI-11. The collected scores were categorized as "robust (mFI=0)", "pre-frail (mFI=1)", "frail (mFI=2)", and "significantly frail (mFI≥3)". Outcome was assessed by the Karnofsky Performance Scale (KPS); functional benefit was defined as improved KPS score. Additionally, we evaluated the patients' functional independence (KPS≥70) after surgery. RESULTS: The study population consisted of 262 patients (median age 83 years) with a median preoperative KPS of 70 (range 20 to 100). The 90-day and 1-year mortality were 9.0% and 13.2%; we recorded surgery-associated complications in 111 (42.4%) patients. At last follow-up within the postoperative first year, 101 (38.5%) patients showed an improved KPS, and 183 (69.8%) either gained or maintained functional independence. "Severely frail" patients were at an increased risk of death at 90 days (OR 16.3 (CI95% 1.7-158.7)) and one year (OR 11.7 (CI95% 1.9-71.7)); nine (42.9%) of severely frail patients died within the first year after surgery. The "severely frail" cohort had increased odds of suffering from surgery-associated complications (OR 3.9 (CI 95%) 1.3-11.3)), but also had a high chance for postoperative functional improvements by KPS≥20 (OR 6.6 (CI95% 1.2-36.2)). CONCLUSION: The mFI-5 and mFI-11 associate with postoperative mortality, complications, and functional benefit. Even though "severely frail" patients had the highest risk morbidity and mortality, they had the highest chance for functional improvement.

Even short-term training improves the skills of novice exoscope users: a prospective laboratory experiment.

BACKGROUND: The surgical 3D exoscopes have recently been introduced as an alternative to the surgical microscopes in microneurosurgery. Since the exoscope availability is still limited, it is relevant to know whether even a short-term exoscope training develops the skills needed for performing exoscope-assisted surgeries. METHODS: Ten participants (six consultants, four residents) performed two laboratory bypass test tasks with a 3D exoscope (Aesculap Aeos®). Six training sessions (6 h) were performed in between (interval of 2-5 weeks) on artificial models. The participants were divided into two groups: test group (n = 6) trained with the exoscope and control group (n = 4) with a surgical microscope. The test task was an artificial end-to-side microsurgical anastomosis model, using 12 interrupted 9-0 sutures and recorded on video. We compared the individual as well as group performance among the test subjects based on suturing time, anastomosis quality, and manual dexterity. RESULTS: Altogether, 20 bypass tasks were performed (baseline n = 10, follow-up n = 10). The median duration decreased by 28 min and 44% in the exoscope training group. The decrease was steeper (29 min, 45%) among the participants with less than 6 years of microneurosurgery experience compared to the more experienced participants (13 min, 24%). After training, the participants with at least 1-year experience of using the exoscope did not improve their task duration. The training with the exoscope led to a greater time reduction than the training with the microscope (44% vs 17%). CONCLUSIONS: Even short-term training with the exoscope led to marked improvements in exoscope-assisted bypass suturing among novice microneurosurgeons. For the more experienced participants, a plateau in the initial learning curve was reached quickly. A much longer-term effort might be needed to witness further improvement in this user group.

Surgeon experience in glioblastoma surgery of the elderly-a multicenter, retrospective cohort study.

PURPOSE: To assess the impact of individual surgeon experience on overall survival (OS), extent of resection (EOR) and surgery-related morbidity in elderly patients with glioblastoma (GBM), we performed a retrospective case-by-case analysis. METHODS: GBM patients aged ≥ 65 years who underwent tumor resection at two academic centers were analyzed. The experience of each neurosurgeon was quantified in three ways: (1) total number of previously performed glioma surgeries (lifetime experience); (2) number of surgeries performed in the previous five years (medium-term experience) and (3) in the last two years (short-term experience). Surgeon experience data was correlated with survival (OS) and surrogate parameters for surgical quality (EOR, morbidity). RESULTS: 198 GBM patients (median age 73.0 years, median preoperative KPS 80, IDH-wildtype status 96.5%) were included. Median OS was 10.0 months (95% CI 8.0-12.0); median EOR was 89.4%. Surgery-related morbidity affected 19.7% patients. No correlations of lifetime surgeon experience with OS (P = .693), EOR (P = .693), and surgery-related morbidity (P = .435) were identified. Adjuvant therapy was associated with improved OS (P < .001); patients with surgery-related morbidity were less likely to receive adjuvant treatment (P = .002). In multivariable testing, adjuvant therapy (P < .001; HR = 0.064, 95%CI 0.028-0.144) remained the only significant predictor for improved OS. CONCLUSION: Less experienced neurosurgeons achieve similar surgical results and outcome in elderly GBM patients within the setting of academic teaching hospitals. Adjuvant treatment and avoidance of surgery-related morbidity are crucial for generating a treatment benefit for this cohort.

Obesity Does Not Protect From Subarachnoid Hemorrhage: Pooled Analyses of 3 Large Prospective Nordic Cohorts.

BACKGROUND: Several population-based cohort studies have related higher body mass index (BMI) to a decreased risk of subarachnoid hemorrhage (SAH). The main objective of our study was to investigate whether the previously reported inverse association can be explained by modifying effects of the most important risk factors of SAH-smoking and hypertension. METHODS: We conducted a collaborative study of three prospective population-based Nordic cohorts by combining comprehensive baseline data from 211 972 adult participants collected between 1972 and 2012, with follow-up until the end of 2018. Primarily, we compared the risk of SAH between three BMI categories: (1) low (BMI<22.5), (2) moderate (BMI: 22.5-29.9), and (3) high (BMI≥30) BMI and evaluated the modifying effects of smoking and hypertension on the associations. RESULTS: We identified 831 SAH events (mean age 62 years, 55% women) during the total follow-up of 4.7 million person-years. Compared with the moderate BMI category, persons with low BMI had an elevated risk for SAH (adjusted hazard ratio [HR], 1.30 [1.09-1.55]), whereas no significant risk difference was found in high BMI category (HR, 0.91 [0.73-1.13]). However, we only found the increased risk of low BMI in smokers (HR, 1.49 [1.19-1.88]) and in hypertensive men (HR, 1.72 [1.18-2.50]), but not in nonsmokers (HR, 1.02 [0.76-1.37]) or in men with normal blood pressure values (HR, 0.98 [0.63-1.54]; interaction HRs, 1.68 [1.18-2.41], P=0.004 between low BMI and smoking and 1.76 [0.98-3.13], P=0.06 between low BMI and hypertension in men). CONCLUSIONS: Smoking and hypertension appear to explain, at least partly, the previously reported inverse association between BMI and the risk of SAH. Therefore, the independent role of BMI in the risk of SAH is likely modest.

Case Fatality Rates of Subarachnoid Hemorrhage Are Decreasing with Substantial between-Country Variation: A Systematic Review of Population-Based Studies between 1980 and 2020.

BACKGROUND: The declining prevalence of smoking and hypertension has been associated with the decrease of subarachnoid hemorrhage (SAH) incidence in the 21st century. Since these same risk factors are linked to SAH mortality, the case fatality rate (CFR) of SAH has potentially also decreased during recent decades. Thus, we conducted a systematic review to address SAH CFR changes over the last 40 years. METHODS: We performed a systematic literature search in OVID Medline, Scopus, and Cochrane Library databases. We focused on population-based studies published between 1980 and 2020 that had included both hospitalized and nonhospitalized SAH cases, and reported 1-month CFRs for at least two individual study periods for the same population. Finally, we used a linear regression analysis to estimate the annual CFR changes in each identified population and pooled the regional changes for larger geographical and sex-specific analyses. RESULTS: Of the 4,562 initial publications, we included 22 studies (three of which reached a high-quality classification) consisting of 17,593 SAH patients from 16 different populations and 10 countries. Between 1980 and 2020, SAH CFR declined in all but two populations by an average of -1.5%/year. In the continent-based pooled geographical analyses, CFR decline was the most noticeable in North America (-2.4%/year) and Oceania (-2.2%/year). The decline was more moderate in Northern Europe (-0.8%/year) and Southern Europe (-0.7%/year). Overall, CFRs declined both in women (-1.9%/year) and in men (-1.2%/year). When comparing the first and second half of the study period, CFRs declined from 41% to 31%. CONCLUSION: Short-term SAH CFRs seem to have declined since 1980. Time trends of SAH CFRs can still be identified for only a few populations, and high-quality data are scarce. Whether the observed decline relates to changes in risk factors, treatment outcomes or diagnostics remains to be studied.

In-hospital postoperative opioid use and its trends in neurosurgery between 2007 and 2018.

BACKGROUND: Postoperative opioid use plays an important role in the global opioid crisis, but little is known about in-hospital opioid use trends of large surgical units. We investigated whether postoperative in-hospital opioid consumption changed in a large academic neurosurgical unit between 2007 and 2018. METHODS: We extracted the data of consumed opioids in the neurosurgical intensive care unit and two bed wards between 2007 and 2018. Besides overall consumption, we analyzed the trends for weak (tramadol and codeine), strong, and the most commonly used opioids. The use of various opioids was standardized using the defined daily doses (DDDs) of each opioid agent. A linear regression analysis was performed to estimate annual treatment day-adjusted changes with 95% confidence intervals. RESULTS: Overall, 121 361 opioid DDDs were consumed during the 196 199 treatment days. Oxycodone was the most commonly used postoperative opioid (49% of all used opioids) in neurosurgery. In the bed wards, the use of oral oxycodone increased 375% (on average 13% (9-17%) per year), and the use of transdermal buprenorphine 930% (on average 26% (9-45%) per year) over the 12-year period. Despite the increased use of strong opioids in the bed wards (on average 3% (1-4%) per year), overall opioid use decreased 39% (on average 6% (4-7%) per year) between 2007 and 2018. CONCLUSIONS: Due to the increase of strong opioid use in the surgical bed wards, we encourage other large teaching hospitals and surgical units to investigate whether their opioid use trends are similarly worrisome and whether the opioid consumption changes in the hospital setting are transferred to opioid use patterns or opioid-related harms after discharge.

Surgery on giant meningiomas in very old patients entails frequent postoperative intracranial hemorrhages and atypical histopathology.

PURPOSE: Surgical resection of intracranial meningiomas in patients that are 80 years old and older, i.e. very old patients, is increasingly considered. Meningiomas with a largest diameter of at least 5 cm-'giant meningiomas'-form a distinct entity, and their surgical resection is considered more difficult and prone to complications. Here, we evaluated functional outcome, morbidity and mortality, and the prognostic value of tumor size in very old patients who underwent resection of giant supratentorial meningiomas. METHODS: We retrospectively reviewed clinical and radiological data, functional performance (Karnofsky Performance Score), histopathological diagnosis and complications of very old patients who underwent surgery of a supratentorial meningioma at the Helsinki University Hospital between 2010 and 2018. RESULTS: We identified 76 very old patients, including 28 with a giant meningioma. Patients with a giant meningioma suffered from major complications more commonly than those with a non-giant meningioma (36% vs. 17%, p = 0.06), particularly from postoperative intracranial hemorrhages (ICH). At the 1-year follow-up, functional performance and mortality rate were comparable between patients with giant meningiomas and those with non-giant meningiomas. An exceptionally high rate of giant meningiomas were diagnosed as atypical meningiomas (WHO II) at an (11 out of 28 cases). CONCLUSIONS: Giant meningioma surgery entails a high complication rate in frail, very old patients. The prevention of postoperative ICH in this specific patient group is of utmost importance. An atypical histopathology was notably frequent among very old patients with a giant meningioma, which should be taken into account when planning the surgical strategy.

Is surgery justified for 80-year-old or older intracranial meningioma patients? A systematic review.

Since the number of elderly people with intracranial meningiomas (IM) continues to rise, surgical treatment has increasingly become a considerable treatment option, even in very old (≥ 80 years old) meningioma patients. Since little is known about whether meningioma surgery in this age group is safe and justified, we conducted a systematic review to summarize the results of surgical outcomes in very old meningioma patients. We performed a systematic literature search in Pubmed, Cochrane Library, and Scopus databases. Primarily, we extracted 1-month and 1-year survival rates, and 1-year morbidity rates, as well as information about preoperative morbidity, operative complications, meningioma size, location, histology, and peritumoral edema. Quality of the included studies was evaluated by Cochrane Collaboration Handbook and Critical Appraisal Skills Program. From the 1039 reviewed articles, seven retrospective studies fulfilled our eligibility criteria. Motor deficits (27-65%) and mental changes (51-59%) were the most common indications for surgery. One-month and 1-year mortality rates varied between 0-23.5% and 9.4-27.3%, respectively. Most of the operated IM patients (41.2-86.5%) improved their performance during postoperative follow-up. Impaired preoperative performance and comorbidities were most commonly related to higher postoperative mortality. None of the studies fulfilled the criteria of high quality. Based on the evidence currently available, surgical treatment of very old IM patients seems to improve the performance of highly selected individuals. Given the rapid increase of the aging population, more detailed retrospective studies as well as prospective studies are needed to prove the outcome benefits of surgery in this patient group.

Smoking Causes Fatal Subarachnoid Hemorrhage: A Case-Control Study of Finnish Twins.

BACKGROUND AND PURPOSE: One of the largest twin studies to date suggested that subarachnoid hemorrhage (SAH) is mainly of nongenetic origin, but the causal effect of environmental factors on SAH is yet unknown. We hypothesized that if only one of the twins experience fatal SAH, they do not share the most important environmental risk factor for SAH, namely smoking. If true, such finding would suggest that smoking causes SAH. METHODS: Through the nationwide cause-of-death register, we followed 16 282 same-sex twin pairs of Finnish origin from the older Finnish Twin Cohort between 1976 and 2018 and identified all participants who died from SAH. For the baseline, we collected risk factor information about smoking, hypertension, physical activity, body mass index, alcohol consumption, and education. We classified the pairs as monozygotic, dizygotic, or of unknown zygosity. We examined the within-pair risk factor differences in the pairs discordant for SAH, that is, where one twin died from SAH and the other did not. We computed both individual (whole cohort) and pairwise (discordant pair) hazard ratios and 95% CIs. RESULTS: During the 869 469 person-years of follow-up, we identified 116 discordant and 2 concordant (both died from SAH) twin pairs for fatal SAH. Overall, 25 of the discordant twin pairs were monozygotic. For the whole cohort, smoking (occasional/current) was associated with increased risk of SAH death (hazard ratio, 3.33 [CI, 2.24-4.95]) as compared with nonsmokers (never/former). In the pairwise analyses for discordant twin pairs, we found that the twin who smoked had an increased risk of fatal SAH (hazard ratio, 6.33 [CI, 1.87-21.4]) as compared with the nonsmoking twin. The association remained consistent regardless of the twin pairs' zygosity or sex. CONCLUSIONS: Our results provide strong evidence for a causal, rather than associative, role of smoking in SAH.

Symptomatic peritumoral edema is associated with surgical outcome: a consecutive series of 72 supratentorial meningioma patients ≥ 80 years of age.

PURPOSE: To assess the association of peritumoral brain edema (PTBE) with postoperative outcome in old (≥ 80 years) meningioma patients. METHODS: All supratentorial meningioma patients (≥ 80 years old) who underwent surgery between 2010 and 2018 were retrospectively identified. Patients were classified into poor (≤ 40), intermediate (50-70), or good (≥ 80) preoperative Karnofsky Performance Status (KPS) subgroups. Outcome was evaluated at 3 months and at last follow-up within the first year after surgery, and categorized as improved, stable, or deteriorated. Three-dimensional volumetric assessment of tumor and PTBE volume was conducted. Volumes were categorized as small (< 10 cm3), medium (10-50 cm3), large (> 50 cm3). RESULTS: Seventy-two patients (mean age 83 ± 3 years, median 83; median follow-up 3 years) were included. The mean tumor volume was 39 ± 31 cm3 (median 27), and mean PTBE volume was 57 ± 79 cm3 (median 27). The mean preoperative KPS and at last follow-up was 58 ± 16 (median 60) and 59 ± 30 (median 70). Thirty-three patients were classified as improved, 16 as stable, and 23 deteriorated; eleven patients died within the first year. Large PTBE volume was more common for patients with poor preoperative status (p = 0.001). However, patients with large PTBE and poor preoperative status improved most frequently following surgery (p = 0.037 at 3 months, p = 0.074 at last follow-up). Large PTBE volume was not associated with treatment-associated complications (p = 0.538) or mortality (p = 0.721). A decision support tool to predict outcome was developed (p = 0.038). CONCLUSION: Elderly patients with large PTBE volumes usually had a poor preoperative performance status, but appeared to benefit most often from surgery.

Screening tools for early neuropsychological impairment after aneurysmal subarachnoid hemorrhage.

BACKGROUND: Although most aneurysmal subarachnoid hemorrhage (aSAH) patients suffer from neuropsychological disabilities, outcome estimation is commonly based only on functional disability scales such as the modified Rankin Scale (mRS). Moreover, early neuropsychological screening tools are not used routinely. OBJECTIVE: To study whether two simple neuropsychological screening tools identify neuropsychological deficits (NPDs), among aSAH patients categorized with favorable outcome (mRS 0-2) at discharge. METHODS: We reviewed 170 consecutive aSAH patients that were registered in a prospective institutional database. We included all patients graded by the mRS at discharge, and who had additionally been evaluated by a neuropsychologist and/or occupational therapist using the Montreal Cognitive Assessment (MoCA) and/or Rapid Evaluation of Cognitive Function (ERFC). The proportion of patients with scores indicative of NPDs in each test were reported, and spearman correlation tests calculated the coefficients between the both neuropsychological test results and the mRS. RESULTS: Of the 42 patients (24.7%) that were evaluated by at least one neuropsychological test, 34 (81.0%) were rated mRS 0-2 at discharge. Among these 34 patients, NPDs were identified in 14 (53.9%) according to the MoCA and 8 (66.7%) according to the ERFC. The mRS score was not correlated with the performance in the MoCA or ERFC. CONCLUSION: The two screening tools implemented here frequently identified NPDs among aSAH patients that were categorized with favorable outcome according to the mRS. Our results suggest that MoCA or ERFC could be used to screen early NPDs in favorable outcome patients, who in turn might benefit from early neuropsychological rehabilitation.

Obesity paradox in subarachnoid hemorrhage: a systematic review.

As the number of obese people is globally increasing, reports about the putative protective effect of obesity in life-threatening diseases, such as subarachnoid hemorrhage (SAH), are gaining more interest. This theory-the obesity paradox-is challenging to study, and the impact of obesity has remained unclear in survival of several critical illnesses, including SAH. Thus, we performed a systematic review to clarify the relation of obesity and SAH mortality. Our study protocol included systematic literature search in PubMed, Scopus, and Cochrane library databases, whereas risk-of-bias estimation and quality of each selected study were evaluated by the Critical Appraisal Skills Program and Cochrane Collaboration guidelines. A directional power analysis was performed to estimate sufficient sample size for significant results. From 176 reviewed studies, six fulfilled our eligibility criteria for qualitative analysis. One study found paradoxical effect (odds ratio, OR = 0.83 (0.74-0.92)) between morbid obesity (body mass index (BMI) > 40) and in-hospital SAH mortality, and another study found the effect between continuously increasing BMI and both short-term (OR = 0.90 (0.82-0.99)) and long-term SAH mortalities (OR = 0.92 (0.85-0.98)). However, according to our quality assessment, methodological shortcomings expose all reviewed studies to a high-risk-of-bias. Even though two studies suggest that obesity may protect SAH patients from death in the acute phase, all reviewed studies suffered from methodological shortcomings that have been typical in the research field of obesity paradox. Therefore, no definite conclusions could be drawn.

Surgical Outcome of Patients With Supratentorial Meningiomas Aged 80 Years or Older-Retrospective International Multicenter Study.

BACKGROUND AND OBJECTIVES: Demographic changes will lead to an increase in old patients, a population with significant risk of postoperative morbidity and mortality, requiring neurosurgery for meningiomas. This multicenter study aims to report neurofunctional status after resection of patients with supratentorial meningioma aged 80 years or older, to identify factors associated with outcome, and to validate a previously proposed decision support tool. METHODS: Neurofunctional status was assessed by the Karnofsky Performance Scale (KPS). Patients were categorized in poor (KPS ≤40), intermediate (KPS 50-70), and good (KPS ≥80) preoperative subgroups. Volumetric analyses of tumor and peritumoral brain edema (PTBE) were performed; volumes were scored as small (<10 cm 3 ), medium (10-50 cm 3 ), and large (>50 cm 3 ). RESULTS: The study population consisted of 262 patients, and the median age at surgery was 83.0 years. The median preoperative KPS was 70; 117 (44.7%) patients were allotted to the good, 113 (43.1%) to the intermediate, and 32 (12.2%) to the poor subgroup. The median tumor and PTBE volumes were 30.2 cm 3 and 27.3 cm 3 ; large PTBE volume correlated with poor preoperative KPS status ( P = .008). The 90-day and 1-year mortality rates were 9.0% and 13.2%, respectively. Within the first postoperative year, 101 (38.5%) patients improved, 87 (33.2%) were unchanged, and 74 (28.2%) were functionally worse (including deaths). Each year increase of age associated with 44% (23%-70%) increased risk of 90-day and 1-year mortality. In total, 111 (42.4%) patients suffered from surgery-associated complications. Maximum tumor diameter ≥5 cm (odds ratio 1.87 [1.12-3.13]) and large tumor volume (odds ratio 2.35 [1.01-5.50]) associated with increased risk of complications. Among patients with poor preoperative status and large PTBE, most (58.3%) benefited from surgery. CONCLUSION: Patients with poor preoperative neurofunctional status and large PTBE most often showed postoperative improvements. The decision support tool may be of help in identifying cases that most likely benefit from surgery.

Case Fatality of Aneurysmal Subarachnoid Hemorrhage Varies by Geographic Region Within Finland: A Nationwide Register-Based Study.

BACKGROUND AND OBJECTIVES: Previous studies have reported a substantial between-country variation in the case fatality rates (CFRs) of aneurysmal subarachnoid hemorrhage (SAH). However, contrary to comparisons among countries, nationwide comparisons within countries that focus on populations with equal access to health care and include out-of-hospital deaths in analyses are lacking. Thus, we aimed to investigate whether the SAH CFRs vary between geographic regions within Finland. METHODS: We identified all hospitalized and nonhospitalized (sudden-death) cases with aneurysmal SAH in Finland during 1998-2017 through 2 externally validated nationwide registers. According to the municipality of residence, we divided the cases with SAH into 5 geographic regions: Southern, Central, Western, Northern, and Eastern Finland, each served by a University Central Hospital with a neurosurgical service. In addition to overall 30-day CFRs, we computed sudden death rates and 30-day CFRs after hospitalization for each region. Using logistic and Poisson regression models, we calculated regional age-adjusted, sex-adjusted, and year-adjusted odds ratios and annual percent changes with 95% CIs for CFRs. RESULTS: During 1998-2017, we identified a total of 9,443 cases with SAH, of which 3,484 (36.9%) occurred in Southern Finland. In comparison with the overall 30-day CFR of Southern Finland (35.1%), the age-adjusted, sex-adjusted, and study year-adjusted odds of SAH death were 32% (16%-50%) higher in Central Finland (42.7%), 39% (23%-58%) higher in Eastern Finland (43.4%), and 52% (33%-74%) higher in Western Finland (47.1%). The regional differences were present among both sexes, in all age groups, in sudden death rates, and in 30-day CFRs after hospitalization. Between 1998 and 2017, the overall 30-day CFRs decreased in Central (2.4% [1.0%-3.8%] per year) and Southern (1.2% [0.2%-2.2%] per year) Finland, whereas CFRs remained stable in the other regions. In the last 4 years of the study period (2014-2017), Southern Finland had the lowest 30-day CFR (16.5%) among hospitalized patients. DISCUSSION: SAH CFRs seem to vary significantly even within a country with relatively equal access to health care. Future studies with detailed individual-level data are needed to explore whether health inequities explain the reported findings.

Case Fatality in Patients With Aneurysmal Subarachnoid Hemorrhage in Finland: A Nationwide Register-Based Study.

BACKGROUND AND OBJECTIVES: Although single-center studies have reported declining case fatality rates (CFRs) of aneurysmal subarachnoid hemorrhage (SAH), nationwide reports that also include sudden-death SAHs with long uninterrupted study periods have remained limited. Moreover, little is known about whether the time-dependent trends of SAH CFR differ by age and/or sex. Thus, we aimed to characterize the nationwide changes of SAH CFRs in Finland between 1998 and 2017. METHODS: We used 2 externally validated nationwide registers to identify all hospitalized and nonhospitalized (sudden-death) aneurysmal SAH events in Finland during 1998-2017. In addition to overall 30-day CFRs, we determined annual proportions of sudden-death and 30-day CFRs among hospitalized patients with SAH. To estimate time-dependent trends, we calculated annual age-adjusted and sex-adjusted CFR changes (percent with 95% CIs). RESULTS: Between 1998 and 2017, we identified 9,443 cases with SAH (57.6% women), of which 2,245 (23.8%) died before hospitalization and 3,715 (39.3%) died within 30 days after SAH. Among the 7,198 hospitalized patients with SAH, the 30-day CFR was 20.4%. During the study period, the overall age-adjusted and sex-adjusted CFR declined by an average of 1.8% (1.1%-2.6%) per year. The decreases were especially notable in the proportion of sudden deaths among middle-aged (aged 40-64 years) and older (aged 65 years or older) women (2.9% [1.1%-4.7%] and 2.3% [0.7%-4.0%] per year, respectively) and in the CFRs of hospitalized young (younger than 40 years) and middle-aged women (9.1% [2.3%-15.7%] and 4.3% [2.3%-6.5%] per year, respectively). On the contrary, the 30-day CFR of older (aged 65 years or older) hospitalized men increased by 3.5% (0.7%-6.3%) per year, while the proportions of older men who died before hospitalization remained unchanged. DISCUSSION: The overall CFR of SAH seems to be decreasing, at least among women. The continued high CFR of hospitalized older men requires attention from clinicians and epidemiologists, especially if this trend is also common in other countries.

Body Mass Index and the Risk of Poor Outcome in Surgically Treated Patients With Good-Grade Aneurysmal Subarachnoid Hemorrhage.

BACKGROUND: Heterogeneity among study populations and treatment procedures has led to conflicting results on outcome predictors for patients with aneurysmal subarachnoid hemorrhage (aSAH). One such conflicting predictor is body mass index (BMI). OBJECTIVE: To clarify whether high BMI values protect patients from poor outcome after aSAH, as previously suggested. METHODS: We surveyed 6 prospective studies conducted in 14 different countries (93 healthcare units) between 1985 and 2016 and pooled the data on surgically treated patients with good-grade (Glasgow Coma Scale 13-15 on admission) aSAH. We calculated BMI for each patient and created 4 balanced categories based on the BMI quartiles of each cohort. We calculated adjusted odds ratios (ORs) with 95% CIs for the 3-month poor outcome (Glasgow Outcome Scale 1-3) by BMI. RESULTS: The pooled study cohort included 1692 patients with good-grade aSAH (mean age 51 years; 64% female). At 3 months, 288 (17%) had poor outcomes. The risk for poor outcomes increased with increasing BMI values (OR = 1.15 [1.02-1.31] per each standard deviation increase of BMI). The risk for poor outcome was over 1.6 times higher (OR = 1.66 [1.13-2.43]) in the highest BMI category (range 27.1-69.2) compared with the lowest BMI category (range 14.4-23.8). These associations were found in each of the 6 study cohorts in both men and women, regardless of age. CONCLUSION: Because higher BMI values seem to associate with poor outcomes in surgically treated patients with good-grade aSAH, it seems unlikely that obesity protects patients with aSAH from poor outcomes.