Anatomic predictors of unsatisfactory outcomes in surgical rejuvenation of the midface.

OBJECTIVE: To aid the aesthetic surgeon in midface analysis and selection of treatment plans offering the greatest likelihood of success in midface rejuvenation. METHODS: We performed a retrospective review of all patients who underwent surgical midface rejuvenation by a single surgeon. We recorded demographics, history, procedures, outcomes, and complications. Results of physical examination and photography were used to classify patients by volume loss, midface ptosis, skin elasticity, and skeletal anatomy. Outcome was determined by patient satisfaction at the 12-month follow-up; unsatisfactory results were further analyzed by a blinded independent expert with more than 15 years' experience. RESULTS: We included 150 patients. Mean patient age was 51 years; 93.3% were women, and 20.7% had undergone previous procedures, including malar implants, autologous fat grafting, rhytidectomy, midface-lift, and extended lower blepharoplasty. Multimodality treatment was used in 34.0%. Patient dissatisfaction was encountered in 14.0% of cases; the expert concurred in each case. Autologous fat grafting alone demonstrated the greatest propensity for dissatisfaction (4 of 12 cases [33%]). Rate of dissatisfaction was significantly higher with malar hypoplasia (41% vs 7%; P < .001) or loss of elasticity (16% vs 3%; P = .01) but was not highly correlated with age (r = 0.15). CONCLUSIONS: Successful midface rejuvenation requires accurate diagnosis and avoidance of anatomic pitfalls. Many patients require multimodality therapy, including lifting and volumizing techniques. Unsatisfactory results are most common when midfacial aging is accompanied by skeletal insufficiency or loss of elasticity. Respective consideration of these defects should be given to placement of malar implants and rhytidectomy approaches targeting the midface.

Persistent improvement in lower eyelid-cheek contour after a transtemporal midface lift.

BACKGROUND: This study aimed to assess quantitative changes in lower-eyelid aesthetics after a transtemporal midface lift concomitant with transconjunctival blepharoplasty and lower-eyelid skin pinch. METHODS: The study enrolled 55 consecutive patients who underwent a transtemporal midface lift and concurrent transconjunctival blepharoplasty with lower-eyelid skin pinch. All the surgeries were performed over a 2-year period by the senior author (A.A.J.). Patient demographics and surgical details were recorded. Standardized digital photographs were taken at baseline and then 12 months postoperatively. These were analyzed to assess changes in the vertical height of the lower eyelid and compared using within-subject analysis. RESULTS: The study cohort consisted of 50 women with a mean age of 54 years (range, 28-76 years). Five patients were lost to follow-up evaluation. The mean vertical height of the lower eyelid was 11.8 mm preoperatively and 9.3 mm postoperatively, giving an average difference of 2.5 mm at the 12-month follow-up assessment. The changes in lower-eyelid height were statistically significant (p = 0.0002), and the lower eyelid-cheek contour was improved in all cases. No major complications occurred during the study period, and no revision surgery was performed. Lower-eyelid height changes did not vary significantly with patient age. CONCLUSIONS: Age-related changes to the midface are marked by increased vertical height of the lower eyelid and a concomitant appearance of infraorbital hollowing. Separation of the lower eyelid-cheek complex causes the typical double-contour deformity. To the authors' knowledge, no study to date has reported the long-term effect of a midface lift on lower-eyelid aesthetics. The transtemporal midface lift not only repositions the malar fat pad but importantly also provides significant shortening of the lower eyelid at 12 months. This results in an improved midface contour. LEVEL OF EVIDENCE III: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Patient-specific rhytidectomy: finding the angle of maximal rejuvenation.

BACKGROUND: Rhytidectomy is fundamentally an operation of tissue release and resuspension, although the manner and direction of suspension are subject to perpetual debate. OBJECTIVES: The authors describe a method for identifying the angle of maximal rejuvenation during rhytidectomy and quantify the resulting angle and its relationship to patient age. METHODS: Patients were prospectively enrolled; demographic data, history, and operative details were recorded. Rhytidectomies were performed by the senior author (AAJ). After complete elevation, the face-lift flap was rotated in a medially-based arc (0-90°) while attention was given to the submental area, jawline, and midface. The angle of maximal rejuvenation for each hemiface was identified as described, and the flap was resuspended. During redraping, measurements of vertical and horizontal skin excess were recorded in situ. The resulting angle of lift was then calculated for each hemiface using trigonometry. Symmetry between sides was determined, and the effect of patient age on this angle was assessed. RESULTS: Three hundred hemifaces were operated (147 women; 3 men). Mean age was 60 years (range, 37-80 years). Mean resulting angle for the cohort was 60° from horizontal (range, 46-77°). This was inversely correlated with patient age (r = -.3). Younger patients (<50 years, 64°) had a significantly more vertical angle than older patients (≥70 years, 56°; P < .0002). No significant intersubject difference was found between hemifaces (P = .53). CONCLUSIONS: The authors present a method for identifying the angle of maximal rejuvenation during rhytidectomy. This angle was more superior than posterior in all cases and is intimately related to patient age. Lasting results demand a detailed anatomical understanding and strict attention to the direction and degree of laxity.

Double-opposing rotation-advancement flaps for closure of forehead defects.

OBJECTIVE: To describe a local flap for closure of forehead defects of all sizes that does not alter the brow position or hairline. METHODS: Retrospective review of 16 cases in which the double-opposing rotation-advancement flaps were used for closure of small (<10 cm2), medium (10-20 cm2), and large (>20 cm2) forehead defects. This technique was developed from Orticochea's method for closure of large scalp wounds. RESULTS: All 16 patients underwent single-stage closure of forehead defects using our design. Six patients were men, 8 were women (mean age, 71 years). Preoperative defect sizes ranged from 3 to 30 cm2 (mean, 18 cm2). All wounds resulted from Mohs surgery for cutaneous malignant neoplasms; 2 were adjacent to previous reconstructions. No recurrence of tumor was seen during the study period. No permanent frontal branch injuries occurred. One patient developed a moderate cellulitis. Photographic analysis showed that brow position and hairline contour were maintained in all cases. CONCLUSIONS: The double-opposing rotation-advancement flap closure is a versatile reconstructive option for small, medium, and large forehead defects. The technique involves elevation of opposing, asymmetric flaps, with subsequent rotation of one side and advancement of the contralateral side. Single-stage closure may be accomplished without unappealing changes to the brow position or hairline.

Methicillin-resistant Staphylococcus aureus laryngitis: a report of two cases with different clinical presentations.

BACKGROUND: Methicillin-resistant Staphylococcus aureus (MRSA) infection has been described in multiple areas of the head and neck. Recently, otolaryngologists have recognized MRSA infection in the glottis. We describe 2 cases of MRSA laryngitis with divergent clinical presentations: acute airway obstruction and recalcitrant hoarseness. METHODS: Report of 2 cases and review of the literature. RESULTS: In the first case, a 44-year-old woman presented with near aphonia despite maximal medical therapy. Examination showed diffuse erythema and edema of the endolarynx with yellowish plaques lining the glottis and supraglottis. Complete resolution was achieved with long-term trimethoprim-sulfamethoxazole. In the second case, a 54-year-old woman presented with recent-onset hoarseness with rapid progression to respiratory distress and biphasic stridor. Endoscopy revealed exuberant granulation tissue in the glottis with a narrowed airway. Treatment required prolonged courses of antibiotics and steroids. Diagnosis in both cases was confirmed with biopsies taken during direct laryngoscopy. CONCLUSIONS: MRSA treatment is a growing part of otolaryngologic practice and should be included in the differential diagnosis of hoarseness and stridor.

Global and disease-specific health-related quality of life after complete endoscopic resection of anterior skull base neoplasms.

BACKGROUND: Minimally invasive surgery for neoplasms of the anterior skull base has revolutionized the treatment of these diseases. The relative effect of endoscopic procedures, however, has not been described in terms of disease-specific and global health-related quality of life (QoL). METHODS: A single-center longitudinal study was performed of patients undergoing complete endoscopic resection of anterior skull base neoplasms. Patients presenting between October 2009 and September 2010 were enrolled. QoL assessments were based on the 22-question Sinonasal Outcomes Test (SNOT-22), Health Utilities Index Mark II (HUI-2), and Short-Form 12 (SF-12) and were completed preoperatively and at 3, 6, and 12 months postoperatively. Comparisons over time were made within subjects. RESULTS: Fourteen patients were enrolled; 11 completed preoperative and postoperative assessments (79%). Our cohort consisted of five men and six women; mean age was 55 years. Six patients had malignant tumors; four required adjuvant therapy. SNOT-22 scores were stable or improved in 10 cases (91%), with a significant difference for the cohort (mean, -33 points; p < 0.01). Ten (91%) patients had stable or improved HUI-2 scores (mean utility change, +0.13). SF-12 scores were stable for both mental (p = 0.17) and physical (p = 0.26) components. Mean quality-adjusted life year gain over the study period was 0.07. CONCLUSION: Complete endoscopic resection of anterior skull base neoplasms is oncologically sound with anecdotal QoL improvements relative to open craniofacial resection. We show positive, quantifiable QoL results with validated global and disease-specific instruments. Additional work will help to improve outcomes in this population and will be used in formal cost-effectiveness analysis.

Quantifying osteotome sharpness: comparing the major manufacturers.

OBJECTIVE: (1) To develop a method for quantification of osteotome sharpness in a rhinoplasty model, using artificial bone; (2) to demonstrate changes in osteotome sharpness over multiple uses; and (3) to compare osteotomes from different manufacturers in terms of sharpness and cost. STUDY DESIGN: Prospective surgical model. SETTING: Academic hospital and engineering research facility. METHODS: Osteotomes were used to make 4-cm cuts through 4-mm wedges of artificial bone. Sharpness was assessed at baseline and following 1, 4, 7, and 10 uses by measuring the load required to cut a #2 Prolene suture. Changes in sharpness from baseline were measured over time, and comparison of manufacturers was performed using analysis of variance (ANOVA). Cost per use was computed for each osteotome. RESULTS: Five osteotomes were tested (Biomet, Black & Black, Miltex, NexEdge, Storz). At baseline, the Storz osteotome was sharpest (1.74 lb, P < .001), followed by Miltex and Biomet (2.50 lb, 2.68 lb) and NexEdge and Black & Black (3.48 lb, 3.40 lb). All osteotomes except NexEdge (P = .098) demonstrated significant decreases in sharpness over time (P = .02 to P < .001), although relative changes and absolute sharpness varied greatly. ANOVA demonstrated Storz to be significantly sharper at all time points (P < .001). Storz and Miltex were superior in cost-per-use analysis. CONCLUSION: Sharp osteotomes are important in cosmetic and functional rhinoplasty. Instruments may appear the same but can be quite dissimilar in efficacy and cost. Indeed, relative efficacy has not been previously tested. Quantitative analysis performance and cost-effectiveness analyses are reported here and can assist the surgeon in selection and maintenance of instruments.

Quantifying the sharpness of osteotomes for dorsal hump reduction.

OBJECTIVE: To assess the relative sharpness of osteotomes after multiple uses, routine maintenance, and sharpening. METHODS: This prospective clinical study and mechanical model quantified the relative sharpness of identical osteotomes at baseline; after 3, 6, and 9 uses; and after sharpening techniques compared with osteotomes from hospital central supply. The Instron universal tester developed a force-displacement curve as the osteotome blade cut a standardized suture. Force required to cut the suture is inversely proportional to osteotome sharpness. RESULTS: For osteotomes 1, 2, and 3, dullness occurred after 9 uses (4.836 lb; P < .001), 6 uses (4.431 lb; P < .005), and 3 uses (4.093 lb; P < .02), respectively. Osteotome 1 was professionally sharpened after 9 uses and retested (3.156 lb); results were similar to those for an osteotome used 6 times (3.160 lb). Additional sharpening showed significantly poorer performance (7.737 lb; P < .001 at baseline and after 9 uses). Osteotome 3 was hand sharpened after 6 uses and retested (7.750 lb; baseline P < .001). Two osteotomes from central supply required almost twice the cutting force relative to the senior author's osteotomes. CONCLUSIONS: Although osteotome performance decreased significantly over time, professional sharpening only achieved results similar to an osteotome used 3 to 6 times. Further resharpening seems detrimental to performance. Surgeons may want to consider osteotomes disposable instruments.

Concurrent structural fat grafting and carbon dioxide laser resurfacing for perioral and lower face rejuvenation.

OBJECTIVE: To quantitatively evaluate a dual-modality treatment that combines autologous structural fat grafting and carbon dioxide (CO(2)) laser resurfacing for perioral and lower face rejuvenation. METHOD: Retrospective review of patients undergoing rejuvenation by a single surgeon between 2005 and 2009. A blinded expert rated photographs on three scales, each with a range of 1 (no abnormality) to 5 (severe abnormality): (i) perioral fine rhytids; (ii) deep folds; and (iii) pigmentary or cutaneous abnormalities. Within-subject comparisons were generated. Results were correlated with skin type (Fitzpatrick) and baseline photodamage (Glogau). A test for effect of adjunctive procedures was performed. RESULTS: Seventeen patients were included (all female, mean age 61 years). Significant postoperative improvement was noted for perioral fine rhytids (3.1 to 1.7, p < 0.0001); deep folds (3.4 to 2.0, p < 0.00001); and pigmentation (2.5 to 1.9, p = 0.02). Fitzpatrick skin type was inversely correlated with improvement in pigmentation scores (r = -0.78), while the Glogau score correlated with improvement of fine rhytids (r = 0.76). No significant effect of adjunctive procedures was found. No complications occurred, though fat grafts resorbed in one patient. CONCLUSIONS: Concurrent structural fat grafting and CO(2) resurfacing result in quantifiable improvement of perioral and lower face aesthetics in relation to baseline characteristics and independent of adjunctive surgical procedures.

Reconstruction of alar defects.

With its complex symmetric contours and central facial location, the nose plays a key role in characterizing the face. Among the cosmetic subunits of the nose, the delicate nasal ala has a particularly marked influence on breathing and cosmetic appearance. Therefore, reconstruction of defects of the nasal ala requires careful attention to preserve and restore function and cosmesis. Reconstructive surgeons have a wide variety of options and techniques to repair specific defects of the nasal ala. Attention to detail, knowledge of the nasal anatomy, and precise surgical techniques allows for the optimum results with the lowest risk of complications.

Endoscopic transcranial and intracranial resection: case series and design of a perioperative management protocol.

Purely endoscopic resections of transcranial/intracranial pathology represent an exciting minimally invasive option for some patients. There is an abundance of literature on surgical techniques, though very little deals with perioperative management, which is critical for good outcomes. We present a detailed case review and a perioperative management protocol with specific reference to skull base and neuroanatomy. We performed a retrospective chart review and analysis of outcomes and complications by approach and design and prospective employment of a perioperative management protocol in a major tertiary care referral hospital. We included patients undergoing endoscopic skull base approaches by the two senior surgeons from September 2005 to April 2009, selecting of transcranial/intracranial cases for detailed review. Our main outcome measures included perioperative morbidity, mortality, and complications; degree of resection; recurrence rate; and survival. Fifteen patients met study criteria. No perioperative mortality occurred. There were two major and four minor complications. Mean follow-up was 15 months; 11/13 patients with malignancies had no evidence of disease. A perioperative management protocol was designed from these data and has resulted in decreased lumbar drainage and increased fluid/electrolyte monitoring. Endoscopic transcranial/intracranial anterior skull base surgery is both safe and effective when a complete understanding of the surgery and perioperative management is achieved.

Assessing risk/benefit of lumbar drain use for endoscopic skull-base surgery.

BACKGROUND: Lumbar drains (LD) are frequently employed with the goal of postoperative cerebrospinal fluid (CSF) leak prevention. LD placement is not without risk, however, and complications can significantly increase patient discomfort and resource utilization. The objective of this work was to characterize the risks, benefits, and resource utilization associated with LD use in endoscopic anterior skull-base surgery. METHODS: A retrospective review of endoscopic anterior skull-base surgeries performed by the senior authors over the past 5 years was done. Cases with prospective LD were selected using anesthesia and billing records. Analysis was done of indications, LD duration, complications, revisions, and additional care required. RESULTS: A total of 65 patients had LD placed prospectively at the time of surgery. LD were in place for an average of 63 ± 38 hours. Four cases (6.2%) required revision surgery for postoperative CSF leak. Leak rates did not differ between patients with neoplasm (7.7%) and without neoplasm (5.8%; p = 0.80). One readmission was attributable to a recurrent leak. Nine LD complications occurred in 8 patients (12.3%). Overall, 6 blood patches, 3 head computed tomography (CT) scans, 1 open removal of retained catheter fragments, 1 spine CT, and an infectious disease workup were required. Three readmissions and 10 additional hospital days were attributable to LD complications. No relationship was found between patient demographics or comorbidities and LD complications. Regression analysis showed no significant effect of body mass index (odds ratio [OR], 1.01; 95% confidence interval [CI], 0.89-1.14; p = 0.87) or duration of LD (OR, 1.00; 95% CI, 0.98-1.02; p = 0.85) on complication risk. Diagnosis of neoplasm was associated with a significant increase in likelihood of complication (OR, 5.33; 95% CI, 1.11-25.64; p < 0.04). CONCLUSION: Complications of LD may be more frequent than postoperative CSF leaks, adding significantly to health care resource utilization. It is difficult to predict which patients will suffer LD complications. Reduction of prospective LD use may avoid unnecessary morbidity and resource utilization.

Prevention and management of complications in intracranial endoscopic skull base surgery.

Development of minimally invasive approaches has become a significant driver across surgical specialties in recent years. Purely endoscopic resections with proper attention to oncologic margins are now possible, with the potential benefit of decreased perioperative morbidity and improved cosmesis compared with traditional open transfacial or craniofacial approaches. Efforts to reduce perioperative morbidity and mortality have been applied with increasing sophistication in the most complex anatomic regions of the human body, including the head and neck. These efforts have resulted in an expanded role of purely endoscopic approaches to the paranasal sinuses, the anterior skull base, and the anterior cranial fossa. This article reviews the current understanding and available literature regarding the diagnosis and management of complications associated with endoscopic anterior skull base surgery.

Concurrent Cochlear Implantation with Resection of Skull Base Hemangiopericytoma following Sudden Deafness in an Only Hearing Ear.

A 72-year-old man with a known left acoustic neuroma, left-sided deafness, and a recently diagnosed right infratemporal fossa (ITF) hemangiopericytoma, presented with sudden deafness in his right ear. Imaging revealed right-sided skull base extension and a large intracranial tumor component. The patient underwent a frontotemporal crainiotomy with concomitant ITF approach. Complete tumor resection was possible, though invasion of the otic capsule was present. Immediately postresection, a cochlear implant (CI) was performed via a transmastoid approach. Full electrode insertion was achieved and confirmed by visualization through the dehiscent middle fossa floor. Mastoid obliteration was then performed with a free fat graft. Postoperative imaging confirmed complete tumor resection (Simpson grade I) and adequate CI placement. Follow-up magnetic resonance imaging was performed at 6 and 12 months, and no tumor recurrence was seen. Prior to CI activation, the patient was completely deaf bilaterally. At 18-month follow-up, however, excellent hearing was achieved with the right CI (16 of 22 electrodes active), and the patient is now conversational with no obvious deficit. His cognitive function is excellent, corresponding to preoperative status, and he is independent in his activities of daily living. Following adjuvant radiation, our patient remains disease free at 18 months.

Microdebrider resection of acquired subglottic cysts: case series and review of the literature.

OBJECTIVE: Pediatric subglottic cysts (SGC) are a rare but curable cause of respiratory distress. Previous studies have described microsurgical marsupialization and carbon dioxide laser ablation to treat SGC. In this report we describe our experience performing endoscopic resection of SGC with a laryngeal microdebrider. METHODS: A retrospective review of all patients who underwent endoscopic resection of SGC with a laryngeal microdebrider between January 2004 and October 2008 at a tertiary care children's hospital was performed. RESULTS: Eight patients with one or more SGC were treated with microdebrider resection. All patients presented with stridor or respiratory distress, were born prematurely (mean gestational age 27 weeks), and had been intubated for between 1 and 91 days (mean 33 days). In all cases, suspension laryngoscopy was performed under general anesthesia. The SGC was visualized using a 4.0-mm Hopkins rod telescope and excised using a 2.9-mm diameter laryngeal microdebrider (skimmer blade). No patient experienced significant bleeding following excision. Mean surgical time was 36 min (range 26-59 min). Seven of eight patients (87.5%) were extubated by post-operative day 1. All patients had a follow-up bronchoscopy within 10 weeks. Six of eight patients (75%) had a single treatment, while two patients (25%) required a second resection. One patient had a symptomatic recurrence (12.5%). All eight patients are now free of disease with a mean follow-up of 21 months. No patient developed clinically significant scarring or subglottic stenosis. CONCLUSIONS: The laryngeal microdebrider offers a safe and effective way to remove SGC with a low recurrence rate.

External ventricular drainage response in poor grade aneurysmal subarachnoid hemorrhage: effect on preoperative grading and prognosis.

INTRODUCTION: The importance of preoperative response to external ventricular drainage (EVD) for treatment of acute hydrocephalus (HCP) following poor grade (Hunt & Hess grade IV or V) aneurysmal subarachnoid hemorrhage (aSAH) has not been clearly defined. The effect of EVD response on preoperative grade and prognosis is described. METHODS: Fifty-nine poor grade patients had an EVD placed preoperatively and underwent definitive aneurysm treatment between September 1996 and March 2002. Patients improving > or = one Hunt and Hess grade were considered responders. Case-control comparisons were completed for each responder, based on clinical grade; the pre-EVD grade and the post-EVD (response) grade were used to generate two independent control cohorts. Logistic regression was used to evaluate the relationship of 12-month modified Rankin disability score (mRS) to clinical grade. RESULTS: Nineteen (32%) responders were identified, and were less likely Grade V (p < 0.05), and more often had smaller (<13 mm, p < 0.01) and posterior circulation (p < 0.03) aneurysms. The frequency of favorable outcome (mRS < or= 3) was greater in responders than non-responders (68% vs. 28%, p < 0.001). Responders had a similar incidence of favorable outcome as response-grade controls (74%), and a higher incidence of favorable outcome than pre-EVD controls (47%). Regression analysis identified the post-EVD grade, but not the pre-EVD grade, as significantly predictive of long-term outcome (p < 0.04). CONCLUSION: Long-term outcomes in poor grade patients who improve after EVD placement are similar to patients with lower grade hemorrhages. When an EVD is placed preoperatively in a poor grade aSAH patient, the neurological status after EVD determines the clinical grade.

2-Hexyl cyanoacrylate (neuracryl M) embolization of cerebral arteriovenous malformations.

OBJECTIVE: Neuracryl M is a newly designed liquid embolic agent. In an attempt to verify the safety and efficacy of neuracryl M, we participated in the PROVASIS Trial, a pilot study using this agent in the preoperative treatment of cerebral arteriovenous malformations (AVMs). Because the trial was prematurely terminated by the sponsoring company because of financial considerations, we now present our data as a single center series. METHODS: Between November 2002 and December 2003, six patients were enrolled in the PROVASIS trial at our institution, and four of these patients were randomized to treatment with neuracryl M. The patients were a 30-year-old man with a right frontal lobe AVM, a 20-year-old man with a right cerebellar AVM, a 26-year-old woman with a midline cerebellar AVM, and a 47-year-old man with a left parietotemporal lobe AVM. All patients underwent AVM embolization with neuracryl M, followed by definitive treatment, either open surgery or radiosurgery. RESULTS: In each case, there were no permanent complications, and blood loss was minimal. Follow-up imaging demonstrated either complete AVM obliteration (open surgery) or substantial diminution in AVM size (radiosurgery). CONCLUSION: Our data provide preliminary evidence supporting the thesis that neuracryl M is a safe and effective liquid embolic agent for the preoperative embolization of cerebral AVMs. Larger trials and continued experience using this novel liquid embolic agent are warranted.

Long-term domain-specific improvement following poor grade aneurysmal subarachnoid hemorrhage.

BACKGROUND: While efforts have been made to document short-term outcomes following poor grade aneurysmal subarachnoid hemorrhage (aSAH), no data exist concerning the degree of delayed improvement in neurological function. Here we assess cognitive function, level of independence, and quality of life (QoL) over 12 months following poor grade aSAH. METHODS: Data on definitively treated poor grade patients (Hunt and Hess grade IV or V) surviving 12 months post-aSAH were obtained through a prospectively maintained SAH database. Demographic information, medical history, and clinical course were analyzed. Health outcomes assessments completed by surviving patients at discharge (DC), three months (3 M) and 12 months (12 M) follow-up, including the Telephone Interview for Cognitive Status (TICS), Barthel Index (BI), and Sickness Impact Profile (SIP), were used to evaluate cognitive function, level of independence, and QoL. FINDINGS: Fifty-six poor grade patients underwent aneurysm-securing intervention and survived at least 12 months post-aSAH. Thirty-five (63%) surviving patients underwent health outcomes assessments at DC, 3 M and 12 M post-aSAH. A majority of patients had improved scores on the TICS (DC to 3 M: 91%; 3 M to 12 M: 82%), BI (DC to 3 M: 96%; 3 M to 12 M: 92%), and SIP (3 M to 12 M: 80%) following aSAH. Using paired-sample analyses, significant improvement on each test was observed. CONCLUSION: A substantial portion of patients experience cognitive recovery, increased independence, and improved QoL following poor grade aSAH. Delayed follow-up assessments are necessary when evaluating functional recovery in this population. These findings have the potential to impact poor grade aSAH management and prognosis.

Preoperative prediction of long-term outcome in poor-grade aneurysmal subarachnoid hemorrhage.

OBJECTIVE: To evaluate which presentation indices, demographics, and clinical information predict 12-month outcome in poor-grade aneurysmal subarachnoid hemorrhage (SAH), and to provide a preoperative index of prognosis. METHODS: Data were obtained on all patients with poor-grade (Hunt and Hess Grades IV and V) aneurysmal SAH from a prospectively maintained SAH database and health outcomes project. Demographics, medical history, presenting clinical condition, and health outcomes were analyzed. Survival analysis was performed and Kaplan-Meier curves were generated. Multivariable logistic regression analysis was used to identify significant predictors of poor outcome at 12 months after hemorrhage, as measured by the modified Rankin disability scale. RESULTS: Survival curves for open surgery and endovascular treatment did not differ significantly. Overall, 40% of the 98 definitively treated patients had a favorable outcome at 12 months. Multivariable analysis identified patient age older than 65 years (P < 0.001), hyperglycemia (P < 0.03), worst preoperative Hunt and Hess Grade V (P < 0.0001), and aneurysm size of at least 13 mm (P < 0.002) as significant predictors of poor outcome. These variables were weighted and used to compute a poor-grade aneurysmal SAH Prognosis Score (hereafter, Prognosis Score) for each patient. A Prognosis Score of 0 was associated with a 90% favorable outcome; Prognosis Score of 1 with 83%; Prognosis Score of 2 with 43%; Prognosis Score of 3 with 8%; Prognosis Score of 4 with 7%; and a Prognosis Score of 5 with 0%. CONCLUSION: Outcome in poor-grade aneurysmal SAH is strongly predicted by patient age, worst preoperative Hunt and Hess clinical grade, and aneurysm size. Hyperglycemia on admission after poor-grade aneurysmal SAH increases the likelihood of poor outcome, and is a potentially modifiable risk factor. The Prognosis Score is a useful tool for preoperatively assessing the likelihood of a favorable outcome for poor-grade aneurysmal SAH patients.