Results of Surgical Ttreatment of Patients With Cerebral Aneurysms in the Acute Period of Hemorrhage Transported Over a Considerable Distance

Relevance. To provide emergency specialized neurosurgical care to patients living in rural areas, medical evacuation to a neurosurgical hospital is required. Despite the fact that medical evacuation is a necessary stage of medical care, there are not enough studies on the impact of transportation of patients with a ruptured cerebral aneurysm over long distances. There is little information about the time intervals for transportation, the timing of the start of treatment and the outcomes of the disease in patients who are at a considerable distance from the neurosurgical hospital.

Aim of the study. To analyze the impact on the extensive results of surgical treatment of patients with cerebral aneurysm rupture.

Material and methods. A retrospective analysis of the results of surgical treatment of 145 patients with cerebral aneurysm rupture in the acute period of hemorrhage, hospitalized in the regional vascular center of the State Budgetary Institution of the Sakha Republic (Yakutia) “Republican Hospital No. 2 — Center for Emergency Medical Aid” in the period from 01.01.2017 to 31.12.2018. Patients were divided into two groups: Group I — patients from remote areas of the Republic of Sakha (Yakutia) who underwent medical evacuation by the Disaster Medicine Service of the Sakha Republic (Yakutia); Group II — hospitalized from the territory of the city of Yakutsk and its nearest suburbs.

Results. 145 patients were hospitalized at the regional vascular center in Yakutsk. Sanaviation (Sanitary Aviation) delivered 91 patients from the districts of the republic to the regional vascular center (62.8% of the total number of patients) (Group I), 54 patients (37.2%) were hospitalized from the territory of the urban district of Yakutsk (Group II). The distance of transportation by ambulance aircraft in Group I ranged from 45 to 1330 kilometers. Deterioration from admission to the local medical organization to admission to the regional vascular center was noted in 8 patients (8.8%), improvement in the condition in 25 (27.5%) patients, there were no dynamics of changes in the state of 58 (63.7%) patients. The total number of deaths in two groups of patients was 11 (12.1%) patients. Postoperative mortality had no statistically significant differences between the two study groups: in Group I — 7.7% (7 patients), in Group II — 7.4% (4 observations) (p=1,000).

Conclusions. With an established system of medical evacuation, transportation over a considerable distance does not worsen the course of the disease and the results of surgical treatment of patients with cerebral aneurysm ruptures in the acute period of hemorrhage. 

1. Nieuwkamp DJ, Setz LE, Algra A, Linn FH, de Rooij NK, Rinkel GJ. Changes in case fatality of aneurysmal subarachnoid haemorrhage over time, according to age, sex, and region: a meta-analysis. Lancet. Neurol. 2009;8(7):635–642. PMID: 19501022 https://doi.org/10.1016/S1474-4422(09)70126-7

2. Suarez JI, Tarr RW, Selman WR. Aneurysmal subarachnoid hemorrhage. N Engl J Med. 2006;354(4):387–396. PMID:16436770 https://doi.org/10.1056/NEJMra052732

3. Larsen CC, Astrup J. Rebleeding after aneurysmal subarachnoid hemorrhage: a literature review. World Neurosurg. 2013;79(2):307–312. PMID: 22722033 https://doi.org/10.1016/j.wneu.2012.06.023

4. Naidech AM, Janjua N, Kreiter KT, Ostapkovich ND, Fitzsimmons B, Parra A, et al. Predictors and impact of aneurysm rebleeding after subarachnoid hemorrhage. Arch Neurol. 2005;62(3):410–416. PMID: 15767506 https://doi:10.1001/archneur.62.3.410

5. Biller J, Godersky JC, Adams HPJ. Management of aneurysmal subarachnoid hemorrhage. Stroke. 1988;19(10):1300–1305. PMID: 3176090 https://doi.org/10.1161/01.str.19.10.1300

6. Weyhenmeyer J, Guandique CF, Leibold A, Lehnert S, Parish J, Han W, et al. Effects of distance and transport method on intervention and mortality in aneurismal subarachnoid hemorrhage. J Neurosurg. 2018;128(2):490–498. PMID: 28186453 https://doi.org/10.3171/2016.9.JNS16668

7. Naval NS, Chang T, Caserta F, Kowalski RG, Carhuapoma JR, Tamargo RJ. Impact of pattern of admission on outcomes after aneurysmal subarachnoid hemorrhage. J Crit Care. 2012;27(5):532.e1–7. PMID: 22520493 https://doi.org/10.1016/j.jcrc.2012.03.006

8. Steiner T, Juvela S, Unterberg A, Jung C, Forsting M, Rinkel G. European Stroke Organization guidelines for the management of intracranial aneurysms and subarachnoid haemorrhage. Cerebrovascular Dis. (Basel, Switzerland). 2013;35(2):93–112. PMID:23406828 https://doi.org/10.1159/000346087

9. Konovalov AN, Krylov VV, Filatov UM, Eliava SS, Belousova OB, Tkachev VV, et al. Klinicheskie rekomendatsii lechenie bol’nykh s subarakhnoidal’nym krovoizliyaniem vsledstvie razryva anevrizm sosudov golovnogo mozga. Moscow; 2012. Available at: http://www.ruans.org/Text/Guidelines/aneurysms.pdf [Accessed 28 May 2021] (In Russ.)

10. Upadhyayula PS, Yue JK, Yang J, Birk HS, Ciacciet JD. The Current State of Rural Neurosurgical Practice: An International Perspective. J Neuroscie Rural Pract. 2018;9(1):123–131. PMID: 29456356 https://doi.org/10.4103/jnrp.jnrp_273_17

11. Griswold D, Benet A, Tabani H, Lawton M.T, Meybodi A.M. “To Operate” Versus “Not to Operate” in Low-Resource Settings: Example of Aneurysm Surgery in Rural Iran and Impact of Mastery of Neurosurgical Anatomy. World Neurosurgery. 2017;100:628–631. PMID: 28179175 https://doi.org/10.1016/j.wneu.2017.01.111

12. Ohta H, Kawano S, Yamada H, Hashimoto M, Urasaki E, Yokota A. Treatment of subarachnoid hemorrhages in an isolated mountainous area. J UOEH. 2003;25(1):79–87. PMID: 12669629 https://doi.org/10.7888/juoeh.25.79

13. McNeill L, English SW, Borg N, Matta BF, Menon DK. Effects of institutional caseload of subarachnoid hemorrhage on mortality: a secondary analysis of administrative data. Stroke. 2013;44(3):647–652. PMID: 23362086 https://doi.org/10.1161/STROKEAHA.112.681254

14. Leake CB, Brinjikji W, Kallmes DF, Cloft HJ. Increasing treatment of ruptured cerebral aneurysms at high-volume centers in the United States. J Neurosurgery. 2011;115(6):1179–1183. PMID: 21961924 https://doi.org/10.3171/2011.7.JNS11590

15. Bardach NS, Zhao S, Gress DR, Lawton MT, Johnston SC. Association between subarachnoid hemorrhage outcomes and number of cases treated at California hospitals. Stroke. 2002;33(7):1851–1856. PMID: 12105365 https://doi.org/10.1161/01.STR.0000019126.43079.7B

16. Cross DT 3rd, Tirschwell DL, Clark MA, Tuden D, Derdeyn CP, Moran CJ, et al. Mortality rates after subarachnoid hemorrhage: variations according to hospital case volume in 18 states. J Neurosurgery. 2003;99(5):810– 817. PMID: 14609158 https://doi.org/10.3171/jns.2003.99.5.0810

17. Berman MF, Solomon RA, Mayer SA, Johnston SC, Yung PP. Impact of hospital-related factors on outcome after treatment of cerebral aneurysms. Stroke. 2003;34(9):2200–2207. PMID: 12907814 https://doi.org/10.1161/01.STR.0000086528.32334.06

18. Sorteberg A, Bredmose PP, Hansen AE, Sorteberg W. The path from ictus to Neurosurgery: chronology and transport logistics of patients with aneurysmal subarachnoid haemorrhage in the South-Eastern Norway Health Region. Acta Neurochir. 2019;161(8):1497–1506. PMID: 31197472 https://doi.org/10.1007/s00701-019-03971-9

19. Wilson TJ, Saadeh Y, Stetler WR Jr, Pandey AS, Gemmete JJ, Chaudhary N, et al. Transfer time to a high-volume center for patients with subarachnoid hemorrhage does not affect outcomes. J Stroke Cerebrovasc Dis. 2015;24(2):416–423. PMID: 25497722 https://doi.org/10.1016/j.jstr okecerebrovasdis.2014.09.009 20. Catalano AR, Winn HR, Gordon E, Frontera JA. Impact of interhospital transfer on complications and outcome after intracranial hemorrhage. Neurocrit Care. 2012;17(3):324–333. PMID: 22311233 https://doi.org/10.1007/s12028-012-9679-z

20. Boogaarts HD, van Amerongen MJ, de Vries J, Westert GP, Verbeek A, Grotenhuis JA, et al. Caseload as a factor for outcome in aneurysmal subarachnoid hemorrhage: a systematic review and meta-analysis. Journal of Neurosurgery. 2014;120(3):605–611. PMID: 24093633 https://doi.org/10.3171/2013.9.jns13640

21. Pandey AS, Gemmete JJ, Wilson TJ, Chaudhary N, Thompson BG, Morgenstern LB, et al. High Subarachnoid Hemorrhage Patient Volume Associated With Lower Mortality and Better Outcomes. Neurosurgery. 2015;77(3):462–470. PMID: 26110818 https://doi.org/10.1227/neu.0000000000000850

22. Rush B, Romano K, Ashkanani M, McDermid RC, Celi LA. Impact of hospital case-volume on subarachnoid hemorrhage outcomes: A nationwide analysis adjusting for hemorrhage severity. J Crit Care. 2017;37:240–243. PMID: 27663296 https://doi.org/10.1016/j.jcrc.2016.09.009

23. Yu W, Kavi T, Majic T, Alva K, Moheet A, Lyden P, et al. Treatment Modality and Quality Benchmarks of Aneurysmal Subarachnoid Hemorrhage at a Comprehensive Stroke Center. Front Neurol. 2018;9:152. PMID: 29599745 https://doi.org/10.3389/fneur.2018.00152

24. Ohkuma H, Tsurutani H, Suzuki S. Incidence and significance of early aneurysmal rebleeding before neurosurgical or neurological management. Stroke. 2001;32(5):1176–1180. PMID: 11340229 https://doi.org/10.1161/01.str.32.5.1176