Life After the Neurosurgical Ward in Sub-Saharan Africa: Neurosurgical Treatment and Outpatient Outcomes in Uganda.

BACKGROUND: In the past decade, neurosurgery in Uganda experienced increasing surgical volume and a new residency training program. Although research has examined surgical capacity, minimal data exist on the patient population treated by neurosurgery and their eventual outcomes in sub-Saharan Africa. METHODS: Patients admitted to Mulago National Referral Hospital neurosurgical ward over 2 years (2014 and 2015) were documented in a prospective database. In total, 1167 were discharged with documented phone numbers and thus eligible for follow-up. Phone surveys were developed and conducted in the participant's language to assess mortality, neurologic outcomes, and follow-up health care. RESULTS: During the study period, 2032 patients were admitted to the neurosurgical ward, 80% for traumatic brain injury. A total of 7.8% received surgical intervention. The in-hospital mortality rate was 18%. A total of 870 patients were reached for phone follow-up, a 75% response rate, and 30-day and 1-year mortality were 4% and 8%, respectively. Almost one-half of patients had not had subsequent health care after the initial encounter. Most patients had Glasgow Outcome Scale-Extended scores consistent with good recovery and mild disability, with patients experiencing trauma faring best and patients with tumor faring worst. A total of 85% felt they returned to baseline work performance, and 76% of guardians felt that children returned to baseline school performance. CONCLUSIONS: The neurosurgical service provided health care to a large proportion of nonoperative patients. Phone surveys captured data on patients in whom nearly one-half would be lost to subsequent health care. Although mortality during initial hospitalization was high, more than 90% of those discharged survived at 1-year follow up, and the vast majority returned to work and school.

Obstetric Anesthesia Liability Concerns.

Obstetric practice carries a high risk of medical liability and involves both obstetricians and anesthesiologists. Analysis of data from the Anesthesia Closed Claims Project database shows an increase in the proportion of anesthesia claims for maternal death and brain damage between the 1990s and 2000 and later, primarily due to hemorrhage. The proportion of claims for newborn brain damage remained unchanged while those for maternal nerve injury and minor injuries decreased. Use of massive transfusion protocols and clinical drills have been shown to improve outcomes from hemorrhage. Good communication and teamwork are critical for reducing obstetric liability.

Comparative Assessment of the Prognostic Value of Biomarkers in Traumatic Brain Injury Reveals an Independent Role for Serum Levels of Neurofilament Light.

Traumatic brain injury (TBI) is a common cause of death and disability, worldwide. Early determination of injury severity is essential to improve care. Neurofilament light (NF-L) has been introduced as a marker of neuroaxonal injury in neuroinflammatory/-degenerative diseases. In this study we determined the predictive power of serum (s-) and cerebrospinal fluid (CSF-) NF-L levels towards outcome, and explored their potential correlation to diffuse axonal injury (DAI). A total of 182 patients suffering from TBI admitted to the neurointensive care unit at a level 1 trauma center were included. S-NF-L levels were acquired, together with S100B and neuron-specific enolase (NSE). CSF-NF-L was measured in a subcohort (n = 84) with ventriculostomies. Clinical and neuro-radiological parameters, including computerized tomography (CT) and magnetic resonance imaging, were included in the analyses. Outcome was assessed 6 to 12 months after injury using the Glasgow Outcome Score (1-5). In univariate proportional odds analyses mean s-NF-L, -S100B and -NSE levels presented a pseudo-R2 Nagelkerke of 0.062, 0.214 and 0.074 in correlation to outcome, respectively. In a multivariate analysis, in addition to a model including core parameters (pseudo-R2 0.33 towards outcome; Age, Glasgow Coma Scale, pupil response, Stockholm CT score, abbreviated injury severity score, S100B), S-NF-L yielded an extra 0.023 pseudo-R2 and a significantly better model (p = 0.006) No correlation between DAI or CT assessed-intracranial damage and NF-L was found. Our study thus demonstrates that S-NF-L correlates to TBI outcome, even if used in models with S100B, indicating an independent contribution to the prediction, perhaps by reflecting different pathophysiological processes, not possible to monitor using conventional neuroradiology. Although we did not find a predictive value of NF-L for DAI, this cannot be completely excluded. We suggest further studies, with volume quantification of axonal injury, and a prolonged sampling time, in order to better determine the connection between NF-L and DAI.

[Clinical profile in subjects with acquired brain injury in chronic phase in a social and health care center]. / Perfil del sujeto con daño cerebral adquirido en fase crónica en un recurso de atención sociosanitaria.

INTRODUCTION: There are few resources for acquired brain injury (ABI) in post-hospitalary phase in our country. At this level of carefulness, Personal Autonomy Promotion Center in Bergondo contemplates like a social and health care resource in order to facilitate community integration in subjects with ABI. AIMS. To describe clinical profile in the subjects admitted in our unit, and to assess intervention possibilities with clinico-functional recovery goals in the chronic phases in ABI. PATIENTS AND METHOD: . Sample of 105 subjects admitted in our center until December 2010. 86 men and 19 women, with a mean age of 32.16 years old and a most frequent evolution time of less than 5 years (64.76%). Variables collected were: sex, age, etiology, evolution time, personality changes diagnosis, admission FIM, previous participation in rehabilitation programmes and have recovery goals. RESULTS: The main etiology was traumatic brain injury (62.5%). The 54.28% of the subjects was taking physical rehabilitation at the moment of admission, while the 49.52% had participated in neuropsychological interventions. Physical recovery goals were identified in the 42.85% of the subjects and the 78.09% had goals in neuropsychology field. CONCLUSION: The clinical profile observed was young man with sequelae caused by a traumatic brain injury suffered in last five years, who has received poor neuropsychological care and that still takes physiotherapy treatment.

Early neurological deterioration within 24 hours after intravenous rt-PA therapy for stroke patients: the Stroke Acute Management with Urgent Risk Factor Assessment and Improvement rt-PA Registry.

BACKGROUND: The initial 24 h after thrombolysis are critical for patients' conditions, and continuous neurological assessment and blood pressure measurement are required during this time. The goal of this study was to identify the clinical factors associated with early neurological deterioration (END) within 24 h of stroke patients receiving intravenous recombinant tissue plasminogen activator (rt-PA) therapy and to clarify the effect of END on 3-month outcomes. METHODS: A retrospective, multicenter, observational study was conducted in 10 stroke centers in Japan. A total of 566 consecutive stroke patients [211 women, 72 ± 12 years old, the median initial NIH Stroke Scale (NIHSS) score of 13] treated with intravenous rt-PA (0.6 mg/kg alteplase) was studied. END was defined as a 4-point or greater increase in the NIHSS score at 24 h from the NIHSS score just before thrombolysis. RESULTS: END was present in 56 patients (9.9%, 18 women, 72 ± 10 years old) and was independently associated with higher blood glucose [odds ratio (OR) 1.17, 95% confidence intervals (CI) 1.07-1.28 per 1 mmol/l increase, p < 0.001], lower initial NIHSS score (OR 0.92, 95% CI 0.87-0.97 per 1-point increase, p = 0.002), and internal carotid artery (ICA) occlusion (OR 5.36, 95% CI 2.60-11.09, p < 0.001) on multivariate analysis. Symptomatic intracranial hemorrhage within the initial 36 h from thrombolysis was more common in patients with END than in the other patients (per NINDS/Cochrane protocol, OR 10.75, 95% CI 4.33-26.85, p < 0.001, and per SITS-MOST protocol, OR 12.90, 95% CI 2.76-67.41, p = 0.002). At 3 months, no patients with END had a modified Rankin Scale (mRS) score of 0-1. END was independently associated with death and dependency (mRS 3-6, OR 20.44, 95% CI 6.96-76.93, p < 0.001), as well as death (OR 19.43, 95% CI 7.75-51.44, p < 0.001), at 3 months. CONCLUSIONS: Hyperglycemia, lower baseline NIHSS score, and ICA occlusion were independently associated with END after rt-PA therapy. END was independently associated with poor 3-month stroke outcome after rt-PA therapy.

[Social impact of stroke due to atrial fibrillation]. / Impacto social del ictus producido por fibrilación auricular.

Atrial fibrillation (AF) is the most frequent heart arrhythmia and causes a substantial proportion of ischemic strokes. AF has a marked impact on stroke severity, as well as on morbidity and mortality in these patients. The importance of AF as an etiologic factor of stroke increases in the elderly and in the last few years its detection has increased. The presence of AF leads to more severe initial neurological involvement, longer hospitalization, greater disability and a lower probability of discharge to home. In addition, AF is an independent risk factor for mortality, especially in women and the elderly. All these factors lead to a higher social and economic impact among stroke patients with AF.

Risk in pediatric anesthesia.

Risk in pediatric anesthesia can be conveniently classified as minor or major. Major morbidity includes cardiac arrest, brain damage and death. Minor morbidity can be assessed by clinical audits with small patient samples. Major morbidity is rare. It is best assessed by very large clinical studies and by review of closed malpractice claims. Both minor and major morbidity occur most commonly in infants and children under three, especially those with severe co-morbidities. Knowledge of risk profiles in pediatric anesthesia is a starting point for the reduction of risk.

Occupational psychiatric disorders in Korea.

We searched databases and used various online resources to identify and systematically review all articles on occupational psychiatric disorders among Korean workers published in English and Korean before 2009. Three kinds of occupational psychiatric disorders were studied: disorders related to job stress and mental illness, psychiatric symptoms emerging in victims of industrial injuries, and occupational psychiatric disorders compensated by Industrial Accident Compensation Insurance (IACI). Korea does not maintain official statistical records for occupational psychiatric disorders, but several studies have estimated the number of occupational psychiatric disorders using the Korea Workers' Compensation and Welfare Service (COMWEL, formerly KLWC) database. The major compensated occupational psychiatric disorders in Korea were "personality and behavioral disorders due to brain disease, damage, and dysfunction", "other mental disorders due to brain damage and dysfunction and to physical diseases", "reactions to severe stress and adjustment disorders", and "depressive episodes". The most common work-related psychiatric disorders, excluding accidents, were "neurotic, stress-related, and somatoform disorders" followed by "mood disorders".

Stroke in under-75-year-olds: expectations, concerns and needs.

UNLABELLED: Most studies of functional outcomes in hemiplegic stroke patients use standard disability rating scales (such as the Barthel Index). However, planning the allocation of assistance and resources requires additional information about these patients' expectations and needs. AIMS OF THE STUDY: To assess functional independence in daily living and house holding, changes in home settings, type of technical aid and human helps, and expectations in hemiplegic patients 1 to 2 years after the stroke. METHODS: Sixty-one out of 94 patients admitted to the neurovascular unit of French university hospital for a first-ever documented stroke were consecutively enrolled. The study was restricted to patients under 75, since patients over 75 do not follow the same care network. Patients were examined at their homes or interviewed by phone 17 months (on average) after the stroke. Standard functional assessment tools (such as the Barthel Index and the instrumental activities of daily living [IADL] score) were recorded, along with descriptions of home settings and instrumental and human help. Lastly, patients and caregivers were asked to state their expectations and needs. RESULTS: Although only one person was living in a nursing home after the stroke, 23 (34%) of the other interviewees had needed to make home adjustments or move home. Seven patients (11%) were dependent in terms of the activities of daily living (a Barthel Index below 60) and 11 (18%) had difficulty in maintaining domestic activities and community living (an IADL score over 10). Although the remaining patients had made a good functional recovery, 23 were using technical aids and 28 needed family or caregiver assistance, including 23 patients with full functional independence scores. Twenty-five patients (42%) were suffering from depression as defined by the diagnosis and statistical manual of mental disorders (4th edition, text revision, DSM IV-R). The patients' prime concerns were related to recovery of independence, leisure activities and financial resources. Family members' expectations related to the complexity of administrative matters, lack of information and the delay in service delivery. DISCUSSION AND CONCLUSION: In under-75 hemiplegic stroke patients, high scores on standard disability rating scales do not always mean that no help is required.

Organizational and operational capabilities of specialist centres for children with psychomotor disability in Abidjan.

OBJECTIVE: To describe the organizational and operational capabilities of specialized centres for children with psychomotor disability in Abidjan, Republic of Côte d'Ivoire. MATERIALS AND METHODS: This descriptive study was carried out from February to May, 2006 at the various specialized centres for children with psychomotor disability that exist in the district of Abidjan. The procedure comprised a clinical description of the disabled children admitted to these centres and an assessment of the centres' organization and operational capabilities. RESULTS AND COMMENTS: Six specialist centres for children with psychomotor disability were identified, namely the Infant Guidance Centre, the Awakening and Stimulation Centre for disabled Children, the "Sainte-Magdeleine" Centre, the Medical and Training Institute, the "Page Blanche" institute and the "Colombes Notre Dame de la Paix" Centre. Among the children, 97.15% were day patients, 66.37% were mentally challenged, 30.96% had psychomotor impairment and 2.66% had motor impairments. The level of organization varied but the centres nevertheless had operational administrative, medical and paramedical staff, despite the absence of certain specialties. However, the lack of personnel, equipment and infrastructure is hindering the delivery of adequate services to the children. CONCLUSION: In Abidjan District, reception centres for children with psychomotor impairments are essentially privately run. Organizational and operational performances were suboptimal, with a low carer-to-patient ratio. Reinforcement of the centres' operational capabilities appears to be necessary.

Approaches to neurodevelopmental assessment in congenital diaphragmatic hernia survivors.

BACKGROUND: Infants with congenital diaphragmatic hernia require complex surgical care and may have neurodevelopmental morbidity. We examined the performance of reports of motor functioning in 25 congenital diaphragmatic hernia survivors using the parent-completed Developmental Profile-II and a clinical evaluation by a neurodevelopmental pediatrician (MD) measured against the Bayley motor scale. METHODS: Bayley motor scores were dichotomized as normal or abnormal. Sensitivity and specificity were calculated for each test. RESULTS: The median age at assessment was 25 months. Bayley motor scores were abnormal in 77% of infants tested (10/13). The MD examinations detected motor problems in 92% (12/13). Sensitivity and specificity of the MD examination were 1.0 and 0.33, respectively. Developmental Profile-II physical scores were abnormal in 15% (2/13); sensitivity and specificity were 0.2 and 1.0, respectively. CONCLUSIONS: The high rate of abnormal motor findings in this study supports the need for ongoing screening and evaluation. The sensitivity of MD examinations was excellent, but hypotonia findings were not universally corroborated by the Bayley. Although specificity of parent-reported motor findings was high, parents underreported abnormal motor findings. Parental reports of neurodevelopmental problems should be heeded, and physicians should perform screening motor examinations. Bayley assessments may be warranted to determine the functional implications of observed abnormalities.

Trends in anesthesia-related death and brain damage: A closed claims analysis.

BACKGROUND: The authors used the American Society of Anesthesiologists Closed Claims Project database to determine changes in the proportion of claims for death or permanent brain damage over a 26-yr period and to identify factors associated with the observed changes. METHODS: The Closed Claims Project is a structured evaluation of adverse outcomes from 6,894 closed anesthesia malpractice claims. Trends in the proportion of claims for death or permanent brain damage between 1975 and 2000 were analyzed. RESULTS: Claims for death or brain damage decreased between 1975 and 2000 (odds ratio, 0.95 per year; 95% confidence interval, 0.94-0.96; P < 0.01). The overall downward trend did not seem to be affected by the use of pulse oximetry and end-tidal carbon dioxide monitoring, which began in 1986. The use of these monitors increased from 6% in 1985 to 70% in 1989, and thereafter varied from 63% to 83% through the year 2000. During 1986-2000, respiratory damaging events decreased while cardiovascular damaging events increased, so that by 1992, respiratory and cardiovascular damaging events occurred in approximately the same proportion (28%), a trend that continued through 2000. CONCLUSION: The significant decrease in the proportion of claims for death or permanent brain damage from 1975 through 2000 seems to be unrelated to a marked increase in the proportion of claims where pulse oximetry and end-tidal carbon dioxide monitoring were used. After the introduction and use of these monitors, there was a significant reduction in the proportion of respiratory and an increase in the proportion of cardiovascular damaging events responsible for death or permanent brain damage.

Incidence of pediatric traumatic brain injury and associated hospital resource utilization in the United States.

OBJECTIVE: The goal was to examine the influence of sociodemographic characteristics and health care system factors on the utilization of hospital resources by US children < or = 17 years of age with a diagnosis of traumatic brain injury. METHODS: A retrospective analysis of data from the Healthcare Cost and Utilization Project Kids' Inpatient Database, from January 1, 2000, to December 31, 2000, was performed. National estimates of traumatic brain injury-associated hospitalization rates and resource use were calculated with Kids' Inpatient Database sample weighting methods. RESULTS: Of 2,516,833 encounters between January 1, 2000, and December 31, 2000, 25,783 cases involved patients < or = 17 years of age with a recorded diagnosis of traumatic brain injury. On the basis of these data, there were an estimated 50,658 traumatic brain injury-associated hospitalizations among children < or = 17 years of age in the United States in 2000. The traumatic brain injury-associated hospitalization rate was 70 cases per 100,000 children < or = 17 years of age per year; 15- to 17-year-old patients had the highest hospitalization rate (125 cases per 100,000 children per year). Pediatric inpatients accrued more than $1 billion in total charges for traumatic brain injury-associated hospitalizations in this study. In the multivariate regression models, older age, Medicaid insurance status, and admission to any type of children's hospital were associated with a longer length of stay for pediatric traumatic brain injury-associated hospitalizations. Older age, longer length of stay, and in-hospital death predicted higher total charges for traumatic brain injury-associated hospitalizations. CONCLUSION: Pediatric traumatic brain injury is a substantial contributor to the health resource burden in the United States, accounting for more than $1 billion in total hospital charges annually.

Neurobehavioral assessment predicts differential outcome between VLBW and ELBW preterm infants.

OBJECTIVE: To evaluate the impact of birth weight on development of very low birth weight (VLBW) infants using the Neurobehavioral Assessment of the Preterm Infant (NAPI) before hospital discharge, and to show the relation to follow-up outcomes at 12, 18 and 30 months of age. STUDY DESIGN: In total, 113 preterm infants were assessed with the NAPI at 36 weeks postmenstrual age. Later, neurodevelopment was examined using the Bayley Infant Neurodevelopmental Screener (BINS) at 12 months and the Bayley Scales of Infant Development, at 18 and 30 months. The cohort was divided into two groups, based on birth weight, extremely low birth weight (ELBW) (<1000 g) and VLBW (1000 to 1500 g). RESULTS: ELBW infants showed significantly lower NAPI scores compared with VLBW infants at 36 weeks. The predischarge NAPI scores correlated with the 12, 18 and 30 months scores when the ELBW infants continue to have lower performance than the VLBW infants. In all, 14 infants developed cerebral palsy. These infants had significantly lower NAPI, BINS and Bayley scores compared with all other preterm infants. CONCLUSION: NAPI before discharge provides clinically meaningful information related to later neurodevelopmental outcome.

Amiel-Tison Neurological Assessment at term age: clinical application, correlation with other methods, and outcome at 12 to 15 months.

The aims of this study were: (1) to perform the Amiel-Tison Neurological Assessment (ATNA) in a group of infants with different risk factors for brain damage; (2) to analyze the results of the examinations in light of the risk factors and presumed aetiology; (3) to compare results of examinations with results of cranial ultrasound, electroencephalography (EEG), and cerebral function monitoring (CFM); and (4) to evaluate neurological outcome at 12 to 15 months of age using the Amiel-Tison and Gosselin method, and developmental outcome using the Bayley Scales of Infant Development. Participants were 52 term, newborn infants (31 males, 21 females) with risk factors for brain damage. Mean birthweight was 3288g (SD 661g) and mean gestational age was 39.4wks (SD 1.2wks); range 38 to 41.3wks. Mean age at admission to a neonatal special care unit was 75h, (SD 13.7h). The group with a dynamic (evolving) clinical profile differed significantly from the group with a static (stable) profile in terms of aetiology, while the group with signs of prenatal brain damage differed from the group without these signs regarding aetiology and the level of severity of neurological signs. Sensitivity of the ATNA to detect infants with abnormal ultrasound was 0.97, with EEG 0.89, and with CFM 0.88. At follow-up at 12 to 15 months 47 children were examined: neurological examination was normal in 25 and five children had a minor, five a moderate, and 12 a severe neurological deficit. Agreement of the ATNA with neurological and developmental assessment at follow-up was very good. Our findings suggest that the ATNA is also of value in assessing aetiology and timing of brain lesions.

Assessment practices of clinical neuropsychologists in the United States and Canada: a survey of INS, NAN, and APA Division 40 members.

The present study surveyed assessment practices and test usage patterns among clinical neuropsychologists. Respondents were 747 North American, doctorate-level psychologists (40% usable response rate) affiliated with Division 40 of the American Psychological Association (APA), the National Academy of Neuropsychology (NAN), or the International Neuropsychological Society (INS). Respondents first provided basic demographic and practice-related information and reported their most frequently utilized instruments. Overall, the Wechsler Adult Intelligence Scales and Wechsler Memory Scales were most frequently used, followed by the Trail Making Test, California Verbal Learning Test, and Wechsler Intelligence Scale for Children. Respondents also reviewed a vignette about a traumatic brain injury patient, and then reported the instruments they would use to assess this patient's specific cognitive symptomatology, general cognitive ability, and capacity to return to work. Particular attention was paid to the areas of memory, attention, and executive functioning. The current study represents the largest and most comprehensive test usage survey conducted to date within the field of clinical neuropsychology. Survey results update and greatly expand knowledge about neuropsychologists' assessment practices. Following a review of findings, results are compared to those obtained in prior surveys and implications for the field of neuropsychology are discussed.

Assessment of seizures and related symptomatology in persons with mental retardation.

Seizures can be debilitating across a number of physical, social, occupational, and personal variables. Given the deficits in all of these areas frequently present in persons with mental retardation, effective assessment and subsequent treatment of seizures is a primary goal for individuals with both mental retardation and epilepsy. To thoroughly address the behavioral domains related to seizures in persons with mental retardation and epilepsy, areas of assessment should include seizure behavior, triggering stimuli, reinforcing consequences, and antiepileptic medication side effects. Assessment of these areas in this population often deviates from methods typically used with persons of normal intelligence. Specifically, direct behavioral observation and third-party report with structured interviews are the most viable and accessible means of assessment, and efforts to establish reliable and valid protocols have been successful in some areas. This article reviews this assessment methodology and discusses the extant issues in establishing and proliferating such approaches.

Injuries associated with regional anesthesia in the 1980s and 1990s: a closed claims analysis.

BACKGROUND: The authors used the American Society of Anesthesiologists Closed Claims Project database to identify specific patterns of injury and legal liability associated with regional anesthesia. Because obstetrics represents a unique subset of patients, claims with neuraxial blockade were divided into obstetric and nonobstetric groups for comparison. METHODS: The American Society of Anesthesiologists Closed Claims Project is a structured evaluation of adverse anesthetic outcomes collected from closed anesthesia malpractice insurance claims of professional liability companies. An in-depth analysis of 1980-1999 regional anesthesia claims was performed with a subset comparison between obstetric and nonobstetric neuraxial anesthesia claims. RESULTS: Of the total 1,005 regional anesthesia claims, neuraxial blockade was used in 368 obstetric claims and 453 of 637 nonobstetric claims (71%). Damaging events in 51% of obstetric and 41% of nonobstetric neuraxial anesthesia claims were block related. Obstetrics had a higher proportion of neuraxial anesthesia claims with temporary and low-severity injuries (71%) compared with the nonobstetric group (38%; P

Yield of screening for new aneurysms after treatment for subarachnoid hemorrhage.

OBJECTIVE: Patients who have been successfully treated for subarachnoid hemorrhage (SAH) are at risk for new episodes. The authors studied the effect of screening with CT angiography (CTA) for new aneurysms. METHODS: In a decision model, the authors compared the strategies "screening" and "no screening" after SAH. A literature review yielded the risks of aneurysm recurrence, complications of CTA, and re-treatment. The authors estimated the expected number of quality-adjusted life-years (QALYs), the number of SAH, and the mortality and disability rates for both strategies. They evaluated screening at intervals of 2, 5, and 10 years after SAH, using 10 years and remaining life expectancy as time horizon. RESULTS: The expected number of QALYs 10 years after clipping was virtually the same for no screening (8.33), screening once after 5 years (8.28), and screening every 2 years (8.27). With screening every 2 years, the expected rate of new SAH decreased from 1.9 to 0.5%, and mortality decreased from 0.9 to 0.6%; however, the disability rate increased from 0.5 to 1.9%. Results were comparable with remaining life expectancy as time horizon and for screening after initial treatment with coils. The key estimates of the analyses were the incidence and rupture rate of new aneurysms, the risk of dying from recurrent SAH, the utility of disability, and the risk of complications from DSA and re-treatment. CONCLUSIONS: Presently, screening for new aneurysms after subarachnoid hemorrhage cannot be recommended. Screening may prevent new episodes of subarachnoid hemorrhage but with too high a cost in terms of complications from preventive treatment.