AIM To investigate our clinical practices with the aim of identifying opportunities to improve the medico-surgical management of spontaneous subarachnoid haemorrhages (SAH).

PATIENTS AND METHODS A prospective, longitudinal cohort study was conducted of the cases of SAH attended consecutively in the critical care and emergency services in 29 public hospitals in Andalusia over a period of 20 months, between the years 2000 and 2002. SAH were considered to be acute haemorrhagic cerebrovascular accidents diagnosed as such by imaging. Results at 12 months and care management (medical and surgical therapy, diagnostic techniques, care times and specific neurological complications) were analysed and the latter was then compared with the clinical practices that scientific evidence has proved to be the most useful. Deaths due to rebleeding in patients with no arteriographic study or without exclusion of the aneurysm were catalogued as potentially avoidable deaths.

RESULTS A total of 506 SAH were included. During the follow-up 5% of the sample were lost. In all 155 patients died. The non-modifiable independent risk variables for mortality were: age, being male, history of arterial hypertension, coma on arrival at the hospital and hydrocephalus. The independent risk variables for death that can be influenced were: absence of urgent analgesic, no arteriographic diagnosis, appearance of ischaemic neurological impairment and rebleeding. Twenty per cent of the overall mortality could be considered potentially avoidable.

CONCLUSIONS Although fatality is mostly dependent on variables that cannot be influenced (sex, age, history, clinical severity and hydrocephalus), 20% of deaths are associated to modifiable factors.

Objetivo Investigar nuestras prácticas clínicas, a fin de identificar oportunidades de mejora en el manejo medicoquirúrgico de las hemorragias subaracnoideas (HSA) espontáneas.

Pacientes y métodos Estudio de cohortes, longitudinal, prospectivo, de las HSA atendidas consecutivamente en los servicios de cuidados críticos y urgencias de 29 hospitales públicos de Andalucía durante 20 meses, de 2000 a 2002. Se consideraron HSA los accidentes cerebrovasculares hemorrágicos agudos con este diagnóstico tomográfico. Se analizaron los resultados a 12 meses y el manejo asistencial (terapéutica médica y quirúrgica, técnicas diagnósticas, tiempos asistenciales y complicaciones neurológicas específicas), comparándolo con las prácticas clínicas que la evidencia científica ha demostrado de mayor utilidad. Se catalogaron como muertes potencialmente evitables los óbitos por resangrado en pacientes sin estudio arteriográfico o sin exclusión del aneurisma.

Resultados Se incluyeron 506 HSA. Se perdió durante el seguimiento el 5% de la muestra. Fallecieron 155 enfermos. Las variables no modificables de riesgo independiente para la mortalidad fueron: edad, género masculino, antecedente de hipertensión arterial, coma a la recepción hospitalaria e hidrocefalia. Las variables influenciables de riesgo independiente para fallecer resultaron ser: ausencia de analgesia urgente, carencia de diagnóstico arteriográfico, aparición de deterioro neurológico isquémico y resangrado. El 20% de la mortalidad global podría considerarse potencialmente evitable.

Conclusiones Aunque la letalidad es mayoritariamente dependiente de variables médicamente no influenciables (sexo, edad, antecedentes, gravedad clínica e hidrocefalia), los decesos, en un 20%, están asociados a factores modificables.