Early management in poor grade aneurysm patients

Safety and efficacy of endovascular embolization combined with external drainage for poor-grade ruptured cerebral aneurysms

PURPOSE

To investigate the safety and efficacy of endovascular embolization combined with external drainage for poor-grade ruptured cerebral aneurysms and risk factors.

MATERIALS AND METHODS

Forty-six patients with poor-grade ruptured cerebral aneurysms treated with endovascular embolization combined with decompressive craniectomy and drainage were retrospectively enrolled.

RESULTS

Coil embolization alone was performed in 29 (63.0%) patients, stent-assisted coiling in 14 (30.4%), and coiling with the assistance of two microcatheters in three (6.5%). Immediately after embolization, aneurysm occlusion degree was Raymond-Roy grade I in 88% (44/50), II in 8% (4/50), and III in 4% (2/50). Periprocedural complications occurred in four (8.7%) patients. Forty-two (91.3%) patients had lumbar cistern drainage (n = 29 or 63.0%), extraventricular drainage (n = 11 or 23.9%), or decompressive craniectomy (n = 2 or 4.3%). At discharge, six (13.0%) patients died, and hydrocephalus took place in 16 (34.8%) patients. Better outcomes (mRS 0-2) were achieved in 31 (67.4%), including 23 (50.0%) patients below 60 years and eight (17.4%) over 60 years. Better clinical outcomes were achieved in patients below 60 years and with lumbar cistern drainage, and age was the only significant independent risk factor for better clinical outcomes. Receiver characteristics curve analysis of age for better clinical outcomes revealed that the cutoff value was 61 years, with the AUC 0.73, sensitivity 0.69, and specificity 0.73.

CONCLUSION

Endovascular embolization combined with decompressive craniectomy and drainage may be safe and efficient for poor-grade ruptured cerebral aneurysms, and older age and drainage modality may significantly affect the clinical outcomes.

Length of Survival, Outcome, and Potential Predictors in Poor-Grade Aneurysmal Subarachnoid Hemorrhage Patients Treated with Microsurgical Clipping

BACKGROUND

Poor-grade aneurysmal subarachnoid hemorrhage (aSAH) has been associated with severe morbidity and high mortality. It has been demonstrated that early intervention is of paramount importance. The aim of our study is to evaluate the functional outcome and the overall survival of early microsurgically treated patients.

MATERIAL AND METHODS

Poor-grade aSAH patients admitted at our institution over fifteen years (January 2008 - December 2022) were included in our retrospective study. All participants underwent brain Computed Tomography Angiography (CTA). Fisher scale was used to assess the severity of hemorrhage. All our study participants underwent microsurgical clipping, and their functional outcome was assessed with the Glasgow Outcome Scale (GOS). We used logistic regression analysis to identify any parameters associated with a favorable outcome at 12 months. Cox proportional hazard analysis was also performed, identifying factors affecting the length of survival.

RESULTS

Our study included 39 patients with a mean age of 54 years. Thirty of our participants (76.9%) were Hunt and Hess grade V, while the vast majority (94.9%) were Fisher grade 4. The observed six-month mortality rate was 48.6%. The mean follow-up time was 18.6 months. The functional outcome at six months was favorable in 6 patients (16.2%), increased to 23.5% at 12 months. Our data analysis showed that the age, as well as the employment of temporary clipping during surgery, affected the overall outcome.

CONCLUSION

Management of poor-grade aSAH patients has been dramatically changed. Microsurgical clipping provides promising results in carefully selected younger patients.

Intermediate surgical outcome in patients suffering poor-grade aneurysmal subarachnoid hemorrhage. A single center experience

BACKGROUND

It is known that patients suffering poor-grade aneurysmal subarachnoid hemorrhage (aSAH) have a dismal prognosis. The importance of early intervention is well established in the pertinent literature. Our aim was to assess the functional outcome and overall survival of these patients undergoing surgical clipping.

MATERIAL AND METHODS

In the current retrospective study we included all consecutive poor-grade patients after spontaneous SAH who presented at our institution over an eight-year period. All participants suffering SAH underwent brain CT angiography (CTA) to identify the source of hemorrhage. We assessed the severity of hemorrhage according to the Fisher grade classification scale. All patients were surgically treated. The functional outcome was evaluated six months after the onset with the Glasgow Outcome Scale. Finally, we performed logistic and Cox regression analyses to identify potential prognostic risk factors.

RESULTS

Our study included twenty-three patients with a mean age of 53 years. Five (22%) patients presented with Hunt and Hess grade IV, and eighteen (78%) with grade V. The mean follow-up was 15.8 months, while the overall mortality rate was 48%. The six-month functional outcome was favorable in 6 (26%) patients. The vast majority of our patients died between the 15^th and the 60^th post-ictal days. We did not identify any statistically significant prognostic factors related to the patient's outcome and/or survival.

CONCLUSIONS

Poor-grade aSAH patients may have a favorable outcome with proper surgical management. Large-scale studies are necessary for accurately outlining the prognosis of this entity, and identifying parameters that could be predictive of outcome.

Survival and outcome in patients with aneurysmal subarachnoid hemorrhage in Glasgow coma score 3-5

BACKGROUND

Outcome of early, aggressive management of aneurysmal subarachnoid hemorrhage (aSAH) in patients with Hunt and Hess grade V is hitherto limited, and we therefore present our results.

METHODS

Retrospective study analyzing the medical data of 228 aSAH patients in Glasgow Coma Score 3-5 admitted to our hospital during the years 2002-2012. Background and treatment variables were registered. Outcome was evaluated after 3 and 12 months.

RESULTS

We intended to treat 176 (77.2%) patients, but only 146 went on to aneurysm repair. Of 52 patients managed conservatively, 27 had abolished cerebral circulation around arrival and 25 were deemed unsalvageable. One-year overall mortality was 65.8% and most (84.7%) of the fatalities occurred within 30 days. One-year mortality was higher in patients > 70 years. Without aneurysm repair, mortality was 100%. After 1 year, 21.9% of all patients lived independently and 4.8% lived permanently in an institution. Outcome in the 78 survivors (34.2%) was favorable in 64.1% in terms of modified Rankin Scale score 0-2, and 85.9% of survivors were able to live at home. Return to work was low for all 228 patients with 14.0% of those employed prior to the hemorrhage having returned to paid work, and respectively, 26.3% in the subgroup of survivors.

CONCLUSIONS

Even with aggressive, early treatment, 1-year mortality is high in comatose aSAH patients with 65.8%. A substantial portion of the survivors have a favorable outcome at 1 year (64.1%, corresponding to 21.9% of all patients admitted) and 85.9% of the survivors could live at home alone or aided.

High-Grade Aneurysmal Subarachnoid Hemorrhage: Predictors of Functional Outcome

BACKGROUND

Because the prognosis of high-grade aneurysmal subarachnoid hemorrhage (aSAH), classified as World Federation of Neurosurgical Societies (WFNS) grade IV-V, is generally poor, the functional outcomes of survivors have not been thoroughly explored. The aim of this retrospective cohort study is to determine predictors of functional independence in patients who survive a high-grade aSAH.

METHODS

We retrospectively evaluated consecutive patients with aSAH admitted to a single institution from January 2000 to April 2015. Adult (age ≥18 years) patients with WFNS grade IV-V aSAH were included for analysis. Patients without sufficient baseline data, those who died before discharge, and those without follow-up data were excluded. Univariable and multivariable logistic regression analyses were used to identify factors associated with functional independence, defined as a modified Rankin Scale score of 0-2, at last follow-up.

RESULTS

Of the 260 patients with a WFNS grade IV-V aSAH during the study period, 139 met the inclusion criteria. After a mean follow-up of 6.3 months, functional independence was achieved in 73% of high-grade aSAH survivors (101/139 patients) and in 39% of all high-grade aSAH cases (101/260 patients). Only a lack of cerebrospinal fluid shunt placement was found to be an independent predictor of functional independence in the multivariable analysis (odds ratio 0.28 [0.109-0.722]; P = 0.008).

CONCLUSIONS

Because functional independence can be achieved in the majority of high-grade aSAH survivors, aggressive initial management of high-grade aSAH is warranted. Strategies that reduce the need for permanent cerebrospinal fluid diversion may improve functional outcomes in survivors of high-grade aSAH.

Functional Outcome After Poor-Grade Subarachnoid Hemorrhage: A Single-Center Study and Systematic Literature Review

BACKGROUND AND PURPOSE

Poor-grade subarachnoid hemorrhage (SAH) (World Federation of Neurosurgical Societies grade 4 and 5) is associated with high mortality rates and unfavorable functional outcomes. We report a single-center cohort of poor-grade SAH patients, combined with a systematic review of studies reporting functional outcome in the poor-grade SAH population.

METHODS

Data on a cohort of poor-grade SAH patients treated between 2009 and 2013 were retrospectively collected and combined with a systematic review (from inception to November 2015; PubMed, Embase). Two reviewers assessed the studies independently based on predefined inclusion criteria: consecutive poor-grade SAH, functional outcome measured at least 3 months after hemorrhage, and the report of patients who died before aneurysm treatment.

RESULTS

The search yielded 329 publications, and 23 met our inclusion criteria with 2713 subjects enrolled from 1977 to 2014 in 10 countries (including 179 poor-grade patients from our cohort). Mortality rate was 60 % (1683 patients), of which 806 (29 %) died before and 877 (31 %) died after aneurysm treatment, respectively. Treatment was undertaken in 1775 patients (1775/2826-63 %): 1347 by surgical clipping (1347/1775-76 %) and 428 (428/1775-24 %) by endovascular methods. Outcome was favorable in 794 patients (28 %) and unfavorable in 1867 (66 %). When the studies were grouped into decades, favorable outcome increased from 13 % in the late 1970s to early 1980s to 35 % in the late 1980s to early 1990s, and remained unchanged thereafter.

CONCLUSION

Although mortality remains high in poor-grade SAH patients, a favorable functional outcome can be achieved in approximately one-third of patients. The development of new diagnostic methods and implementation of therapeutic approaches were probably responsible for the decrease in mortality and improvement in the functional outcome from 1970 to the 1990s. The plateau in functional outcome seen thereafter might be explained by the treatment of sicker and older patients and by the lack of new therapeutic interventions specific for SAH.

Factors affecting outcome in poor grade subarachnoid haemorrhage: An institutional study

Context:

Poor grade subarachnoid hemorrhage (SAH) is usually associated with unfavorable outcomes and optimal management is deemed complicated. Most centres follow an expectant management strategy or a less aggressive approach till patients improve to good clinical grades. This approach has been associated with higher mortality and morbidity. However, not all patients with poor clinical condition fare badly. Identification and early aggressive management of this select group of patients may lead to favorable outcomes.

Settings and Design:

Prospective non-randomized study.

Materials and Methods:

We prospectively analyzed 19 cases presented in WFNS grade 4 and 5 and factors affecting their outcome at a tertiary care centre in south India. This study was aimed at identifying those few poor grade patients who are probable candidates for a good outcome.

Statistical Analysis Used:

All the variables were analyzed for possible correlations with the SPSS version 13 software. The Chi-square test with a P < 0.05 was taken as statistically significant.

Results:

Of 19 cases, 13 were operated and good outcome was seen in 53.8% of the patients who underwent surgery and aggressive management. All 7 patients who were managed conservatively died. 15.8% of the patients had low density changes (P = 0.625). Absence of such changes was associated with a good long term outcome (P = 0.004). 9 patients had intraventricular hemorrhage at presentation and 5 patients having hydrocephalus underwent extra-ventricular drainage. Statistically significant factors precluding good outcome were the presence of infarcts and thick SAH in the cisterns.

Conclusions:

Poor grade (WFNS 4 and 5) SAH patients with or without ICH, IVH, if operated within 3 days can give rise to favorable outcome in around 50%. However, presence of patchy infarcts associated with thick subarachnoid blood (Fisher grade 3) precludes long term survival or meaningful recovery. Hence, aggressive management is unlikely to alter the natural history of such patients.

Variation in Patient Characteristics and Outcomes Between Early and Delayed Surgery in Poor-Grade Aneurysmal Subarachnoid Hemorrhage

BACKGROUND

There is no consensus regarding the optimal timing for surgery for poor-grade aneurysmal subarachnoid hemorrhage.

OBJECTIVE

To retrospectively evaluate variation in patient characteristics and outcomes between early and delayed surgery groups.

METHODS

Poor-grade aneurysmal subarachnoid hemorrhage was defined as a World Federation of Neurosurgical Societies grade of IV or V after resuscitation. Early surgery was defined as surgery performed within 72 hours of ictus, and delayed surgery was defined as surgery after 72 hours. Outcomes were assessed by modified Rankin score. The mean time of follow-up was 12.5 ± 3.4 months.

RESULTS

Of the 118 patients included in the study, 80 (68%) underwent early surgery and 38 (32%) underwent delayed surgery. Patients with brain herniation (P < .001) and a lower Fisher grade (P = .02) more often underwent early surgery. Patients in the early group more often underwent decompressive craniectomy (P < .001). Postoperative complications and length of hospital stay did not differ, and outcomes were similar between the 2 groups. Forty (34%) patients had an excellent outcome (modified Rankin score 0-1). Multivariate analysis showed a slight trend toward an excellent outcome in the early surgery group. Younger age, World Federation of Neurosurgical Societies grade IV after resuscitation, and middle cerebral artery aneurysms were independent predictors of an excellent outcome.

CONCLUSION

Although patients with brain herniation and a lower Fisher grade were more likely to undergo early surgery, there was a slight trend toward an excellent outcome in the early surgery group. Patients with a younger age, World Federation of Neurosurgical Societies grade IV after resuscitation, and middle cerebral artery aneurysms were more likely to experience an excellent outcome.

A Multicenter Analysis of Computed Tomography Angiography Alone Versus Digital Subtraction Angiography for the Surgical Treatment of Poor-Grade Aneurysmal Subarachnoid Hemorrhage

BACKGROUND

Poor-grade aneurysmal subarachnoid hemorrhage (aSAH) is associated with increased intracranial pressure, and these patients are unstable with a high risk of rebleeding. Computed tomography angiography (CTA) has been proposed as an examination tool for the rapid detection of ruptured aneurysms. We aimed to determine the safety and efficacy of CTA alone for surgical treatment of poor-grade aSAH compared with digital subtraction angiography (DSA).

METHODS

We conducted a multicenter retrospective analysis of 144 patients with poor-grade aSAH who underwent surgical treatment for 2 different cohorts. Patients were grouped into CTA alone and DSA groups. Baseline characteristics, postoperative complications, and clinical outcomes at discharge and at last follow-up were compared between the 2 groups. Multivariate logistic regression models were used to assess the association between CTA alone and clinical outcomes after we adjusted for potential confounders.

RESULTS

Of the 116 patients included, 42 (36.2%) patents received CTA alone and 74 patients (63.7%), including 12 patients with CTA and DSA and 62 patients with DSA alone, received DSA before surgical treatment. Patients with larger ruptured aneurysms (P = 0.006), aneurysm sizes of larger than 5 mm (P = 0.025), presence of single aneurysms (P = 0.018), and presence of intraventricular hemorrhage (P = 0.019) more often received CTA alone. All ruptured aneurysms were clipped successfully during surgery. There were no statistically significant differences in postoperative complications and clinical outcomes between the 2 groups.

CONCLUSIONS

Although CTA alone can be safely and effectively used in most patients requiring surgical treatment, additional DSA may be considered in patients with smaller ruptured aneurysms or in those with multiple aneurysms.

Ultra-early microsurgical treatment within 24 h of SAH improves prognosis of poor-grade aneurysm combined with intracerebral hematoma

Spontaneous subarachnoid hemorrhage (SAH) is the most common cerebrovascular disease. The conventional treatment for SAH is usually associated with high mortality. The present study aims to assess the prognosis of microsurgical treatment for patients with poor-grade aneurysm (Hunt and Hess grades IV-V) associated with intracerebral hematoma. A total of 18 consecutive patients who were diagnosed with poor-grade aneurysm accompanied with intracerebral hematoma were retrospectively recruited. All patients underwent microsurgical treatment between April 2010 and June 2013 at The 101st Hospital of Chinese People's Liberation Army (Wuxi, China). Among them, 15 cases underwent microsurgery within 24 h of SAH, and 3 cases underwent microsurgery 24 h following SAH. All 18 cases were examined by computed tomography angiography (CTA). The outcome was assessed during a follow-up time of 6-36 months. According to the Glasgow Outcome Scale, 4 patients experienced a good recovery, 6 were dissatisfied with the outcome, 4 were in vegetative state and 4 succumbed to disease. Poor outcome occurred in patients with an aneurysm diameter >10 mm, exhibited >50 ml volume of intracerebral hematoma or presented cerebral hernia prior to the surgical operation. The outcome of ultra-early surgery (within 24 h of SAH) was improved, compared with that of surgery following 24 h of SAH (P=0.005). Among 7 patients who accepted extraventricular drainage, good outcomes were achieved in 4 of them, whereas dissatisfaction and mortality occurred in 2 and 1 patients, respectively. Therefore, ultra-early microsurgery (within 24 h of SAH) combined with extraventricular drainage may improve the prognosis of patients with poor-grade aneurysm.

Ventriculoperitoneal shunt placement in poor-grade patients with chronic normal pressure hydrocephalus after aneurysmal subarachnoid haemorrhage

OBJECTIVE

The aim of this study was to analyse the shunt placement in patients who had normal pressure hydrocephalus after poor-grade aneurysmal subarachnoid haemorrhage (aSAH).

METHODS

Patients diagnosed with NPH after poor-grade aSAH were divided into a treatment group and control group, based on whether they had received ventriculoperitoneal shunt placement. The treatment group was then divided into an improvement group and non-improvement group according to their recovery. The Glasgow Outcome Scale and Mini Mental Scale Examination were used for 3 month and 1 year follow-up rehabilitation measures.

RESULTS

Of the 46 total patients, significant improvement was observed at the 3 month and 1 year follow-ups (p < 0.01) after shunt implantation in the treatment group compared to the control group. Furthermore, patients who were younger (p = 0.022), had better neurological function (higher Glasgow Coma Score, p < 0.01) and less severe hydrocephalus (lower EI, p < 0.01) appears to be more likely to benefit from the shunt.

CONCLUSIONS

Patients who had NPH due to poor-grade aSAH would benefit from shunt placement when given the correct candidates and timely management of shunt malfunction. Additionally, the curative effect of the shunt should have been regarded as a long-term goal of rehabilitation in these patients.

Intracranial pressure and cerebral perfusion pressure monitoring in non-TBI patients: special considerations

The effect of intracranial pressure (ICP) and the role of ICP monitoring are best studied in traumatic brain injury (TBI). However, a variety of acute neurologic illnesses e.g., subarachnoid hemorrhage, intracerebral hemorrhage, ischemic stroke, meningitis/encephalitis, and select metabolic disorders, e.g., liver failure and malignant, brain tumors can affect ICP. The purpose of this paper is to review the literature about ICP monitoring in conditions other than TBI and to provide recommendations how the technique may be used in patient management. A PubMed search between 1980 and September 2013 identified 989 articles; 225 of which were reviewed in detail. The technique used to monitor ICP in non-TBI conditions is similar to that used in TBI; however, indications for ICP monitoring often are intertwined with the presence of obstructive hydrocephalus and hence the use of ventricular catheters is more frequent. Increased ICP can adversely affect outcome, particularly when it fails to respond to treatment. However, patients with elevated ICP can still have favorable outcomes. Although the influence of ICP-based care on outcome in non-TBI conditions appears less robust than in TBI, monitoring ICP and cerebral perfusion pressure can play a role in guiding therapy in select patients.

Complications and outcomes after early surgical treatment for poor-grade ruptured intracranial aneurysms: A multicenter retrospective cohort

INTRODUCTION

Early surgical treatment has been proposed to improve outcomes of selected patients with poor-grade ruptured intracranial aneurysms. We performed a multicenter retrospective analysis to identify complications and outcomes after early surgery.

METHODS

We analyzed data from the two cohorts of patients with poor-grade ruptured aneurysms. Poor-grade aneurysm was defined as a World Federation of Neurosurgical Society (WFNS) grade of IV or V after resuscitation. Early surgery was defined as surgery performed within 72 h after poor-grade condition.

RESULTS

Of the 144 patients who underwent surgical treatment for poor-grade aneurysm, 80 underwent early surgery and were included in this report. Forty-one (51%) patients presented with a WFNS grade of IV and 39 (49%) presented with a WFNS grade of V. Cerebral infarction occurred in 17 (21%) patients and was the most common complication except for pneumonia. No patients had a good outcome after postoperative aneurysm rebleeding. At follow-up (mean 12.6 months), 37 (46%) patients had a good outcome after early surgery. Multivariate analysis showed that a WFNS grade of V, presence of intraventricular hemorrhage, brain herniation were independent predictors of poor outcome after early surgery. Patients with WFNS grade V more often had a poor outcome after postoperative cerebral infarction, rebleeding or symptomatic vasospasm.

CONCLUSIONS

Patients with a WFNS grade of V, intraventricular hemorrhage, brain herniation were more likely to have a poor outcome after early surgery. Postoperative complications, including rebleeding and cerebral infraction, should be prevented and treated aggressively to maximize the chance of good outcome in poor-grade patients.

[The use of transcallosal ventriculostomy to treat complicated forms of aneurismal intracranial hemorrhages]

The present paper reports two cases of successful use of the anterior interhemispheric transcallosal approach during ultra-early surgery in patients in decompensated condition with severe intraventricular hemorrhage caused by rupture of cerebral aneurysms.

Factors and outcomes associated with ultra-early surgery for poor-grade aneurysmal subarachnoid haemorrhage: a multicentre retrospective analysis

OBJECTIVE

To determine factors and outcomes associated with ultra-early surgery for poor-grade aneurysmal subarachnoid haemorrhage (aSAH).

DESIGN

A multicentre retrospective analysis, observational study.

SETTING

High-volume teaching hospitals (more than 150 aSAH cases per year).

PARTICIPANTS

118 patients with World Federation of Neurosurgical Societies (WFNS) grades IV and V underwent surgical treatment. Ultra-early surgery was defined as surgery performed within 24 h of aSAH, and delayed surgery as surgery performed after 24 h. Outcome was assessed by modified Rankin Scale (mRS). The mean time of follow-up was 12.5±3.4 months (range 6-28 months).

RESULTS

47 (40%) patients underwent ultra-early surgery, and 71 (60%) patients underwent delayed surgery. Patients with WFNS grade V (p=0.011) and brain herniation (p=0.004) more often underwent ultra-early surgery. Postoperative complications were similar in ultra-early and delayed surgery groups. Adjusted multivariate analysis showed the outcomes were similar between the two groups. Multivariate analysis of predictors of poor outcome, ultraearly surgery was not an independent predictor of poor outcome, while advanced age, postresuscitation WFNS V grade, intraventricular haemorrhage, brain herniation and non-middle cerebral artery (MCA) aneurysms were associated with poor outcome.

CONCLUSIONS

Although patients with WFNS grade V and brain herniation more often undergo ultra-early surgery, postoperative complications and outcomes in selected patients were similar in the two groups. Patients of younger age, WFNS grade IV, absence of intraventricular haemorrhage, absence of brain herniation and MCA aneurysms are more likely to have a good outcome. Ultra-early surgery could improve outcomes in carefully selected patients with poor-grade aSAH.

Vasospasm: A friend or foe - initial experience

Background

The optimal time to operate on an intracranial aneurysm eludes a satisfactory answer. While most surgeons would agree to operate early in young and neurologically intact patients, the ideal timing in older and neurologically impaired patients is debatable. In India, the majority of centers operate on patients in Hunt and Hess grades I-III, but is circumspect about grades IV and V.

Purpose

The following study was carried out to check the effect of vasospasm on mortality rates and time of surgery being performed on the patient after having the same in patients coming under criteria of Hunt and Hess grades IV and V

Methods

We undertook a prospective evaluation of 171 consecutive patients of aneurysms operated during the last 9 years irrespective of their age, neurological grade, and time of presentation or vasospasm in an attempt to resolve this issue. The influence of vasospasm on each neurological grade was examined.

Results

It appears that concomitant presence of vasospasm in grade III, IV and V patients indicates a possible “reversible” cause of the poor neurological status, while its absence may indicate an irreversible or more extensive primary insult.

Conclusion

The presence of vasospasm in poor grade patients appears to be a better prognostic indicator.

A Multicenter prospective study of poor-grade aneurysmal subarachnoid hemorrhage (AMPAS): observational registry study

Background

Poor-grade aneurysmal subarachnoid hemorrhage (aSAH) is associated with very high mortality and morbidity. Our limited knowledge on predictors of long-term outcome in poor-grade patients with aSAH definitively managed comes from retrospective and prospective studies of small case series of patients in single center. The purpose of the AMPAS is to determine the long-term outcomes in poor-grade patients with different managements within different time after aSAH, and identify the independent predictors of the outcome that help guide the decision on definitive management.

Methods/design

The AMPAS study is a prospective, multicenter, observational registry of consecutive hospitalized patients with poor grade aSAH (WFNS grade IV and V). The aim is to enroll at least 226 poor-grade patients in 11 high-volume medical centers (eg, >150 aSAH cases per year) affiliated to different universities in China. This study will describe poor grade patients and aneurysm characteristics, treatment strategies (modality and time of definitive management), hospitalization complications and outcomes evolve over time. The definitive management is ruptured aneurysm treatment. Outcomes at 3, 6, 12 months after the management were measured using the Glasgow Outcome Scale and the Modified Rankin Scale.

Discussion

The AMPAS is the first prospective, multicenter, observational registry of poor grade aSAH with any management. This study will contribute to a better understanding of significant predictors of outcome in poor grade patients and help guide future treatment of the worst patients after aSAH.

Trial registration

Chinese Clinical Trial Registry: ChiCTR-TNRC-10001041.

Comparison of microsurgery and endovascular treatment on clinical outcome following poor-grade subarachnoid hemorrhage

Poor-grade (World Federation of Neurological Surgeons [WFNS] clinical grading scale grades IV and V) subarachnoid hemorrhage (SAH) is associated with significant morbidity and mortality. However, the correlation between the timing, modality of intervention (clipping or coiling) and the clinical outcome is not clear. This study aims to examine this correlation. Patients presenting with WFNS grades IV and V aneurysmal SAH between 1997 and 2008 to a single centre were studied. An aggressive policy of early intervention was followed, and the selection of endovascular versus microsurgical intervention was made according to angiographic rather than clinical features. Clinical outcomes were graded using the modified Rankin scale (mRS) at 6 month follow-up. One hundred and forty-three poor-grade patients (23.9% of all 598 aneurysmal SAH patients) were studied. Treatment was microsurgical in 83 (58.0%) and endovascular in 60 (42%) patients. Twenty patients (14.0%) were lost to follow-up. Good outcome (mRS 0-2) at 6 months was found in 45 microsurgical patients (63.3%) and 24 endovascular patients (46.1%). This trend towards better clinical outcomes in the microsurgical group was not statistically significant. With an aggressive early treatment policy more than half of the poor-grade SAH patients demonstrated a good clinical outcome. Microsurgery and endovascular treatment, when selected primarily according to angiographic features, were equally likely to achieve good outcome.

Management of Patients Presenting with Acute Subdural Hematoma due to Ruptured Intracranial Aneurysm

Acute subdural hematoma is a rare presentation of ruptured aneurysms. The rarity of the disease makes it difficult to establish reliable clinical guidelines. Many patients present comatose and differential diagnosis is complicated due to aneurysm rupture results in or mimics traumatic brain injury. Fast decision-making is required to treat this life-threatening condition. Determining initial diagnostic studies, as well as making treatment decisions, can be complicated by rapid deterioration of the patient, and the mixture of symptoms due to the subarachnoid hemorrhage or mass effect of the hematoma. This paper reviews initial clinical and radiological findings, diagnostic approaches, treatment modalities, and outcome of patients presenting with aneurysmal subarachnoid hemorrhage complicated by acute subdural hematoma. Clinical strategies used by several authors over the past 20 years are discussed and summarized in a proposed treatment flowchart.

Outcomes of Endovascular Coiling in Patients with Intracranial Aneurysms Presenting with Poor Clinical and SAH Grade

Although the treatment of intracranial aneurysms has made significant advances, prediction of outcomes in poor grades has always been difficult. We present our findings of patients in poor clinical and SAH grade treated with endovascular coiling. We aimed to evaluate the clinical outcomes in patients presenting with poorer neurological and SAH grades treated by endovascular techniques. Of 190 patients who presented with SAH over a period of nine years, 34 were of poorer clinical grade (Hunt & Hess Grades 4 and 5), of whom 30 presented with H&H grade 4 and four with grade 5. 44.1% of the 34 patients belonged to Fischer grade 4. We assessed the technical success and final outcomes based on the Glasgow outcome scale. Of the 30 patients with grade 4, 81.4% had a good outcome. Two out of four patients with grade 5 had a poor outcome. 82.5% of the patients with Fischer grade 4 had a good outcome. None of the poor outcomes were procedure-related. Endovascular treatment with its higher rates of technical success, lower complication rates and better outcomes should be recommended as the treatment of choice in patients with intracranial aneurysms even in patients with poorer clinical and SAH grades.

Development of a kit to treat subarachnoid hemorrhage by intrathecal simple urokinase infusion (ITSUKI) therapy: preliminary results in patients with World Federation of Neurological Surgery (WFNS) grade V subarachnoid hemorrhage

OBJECTIVE

To report the effectiveness of intrathecal selective administration of urokinase infusion (ITSUKI) therapy delivered via a special kit (ITSUKit), developed to prevent vasospasm in patients with ruptured aneurysms who had undergone Guglielmi detachable coil (GDC) placement, in patients with World Federation of Neurological Surgery (WFNS) grade V subarachnoid hemorrhage (SAH).

METHODS

A study of ITSUKI therapy with or without ventricular drainage enrolled 6 patients with WFNS grade V SAH owing to ruptured intracranial aneurysms who were eligible for coil embolization. The procedures were performed within 48 hours of the occurrence of aneurysmal SAH. The incidence of symptomatic vasospasm and the clinical outcomes based on the Glasgow Outcome Scale (GOS) were assessed at 6 months after SAH onset.

RESULTS

All patients underwent complete coil embolization. There were no side effects or adverse reactions attributable to ITSUKI therapy. Symptomatic vasospasm occurred in one patient (16.7%). There were no patients with hydrocephalus. Based on the GOS, one patient had a good outcome, two manifested moderate disability, and three manifested severe disability.

CONCLUSIONS

The results showed that the ITSUKit was useful for ITSUKI therapy. Although the combination of coil embolization and ITSUKI therapy did not completely eliminate WFNS grade V SAH, it significantly improved the treatment outcome in some patients.

Perfusion computed tomographic imaging and surgical selection with patients after poor-grade aneurysmal subarachnoid hemorrhage

BACKGROUND

Patients with ruptured aneurysms who present in coma have already experienced significant brain injury, require intensive resuscitation, have aneurysms that are difficult to treat, and generally fare poorly despite aggressive intervention.

OBJECTIVE

To determine whether surgical outcomes in comatose patients with ruptured aneurysms in a modern series might be better than previously reported because of changing surgical indications and multidisciplinary management, and to determine whether perfusion computed tomography (PCT) imaging might help select patients for surgery.

METHODS

A consecutive series of 78 patients with poor-grade aneurysms treated surgically was reviewed. Management consisted of resuscitation, early surgery, intracranial pressure control, comprehensive intensive care, and endovascular therapy for vasospasm. Cerebral blood flow (CBF), volume (CBV), and mean transit time (MTT) were measured on admission PCT studies and correlated with outcomes.

RESULTS

Among 58 grade IV patients (74%) and 20 grade V patients (26%), 44 patients (56%) had favorable outcomes (Glasgow Outcome Scale 5 and 4), and 34 patients (44%) had unfavorable outcomes. Favorable outcomes among grade IV patients were observed in 71%, whereas mortality among grade V patients was 60%. Sixteen patients (89%) with normal cerebral perfusion had favorable outcomes and all 13 patients with hemispheric or global hypoperfusion had unfavorable outcomes.

CONCLUSIONS

PCT provides physiological data that are immediately applicable and can guide decisions to aggressively manage comatose patients with ruptured aneurysms. Grade IV patients with normal or focally abnormal perfusion are good candidates for treatment, whereas grade V patients with hemispheric or global hypoperfusion are poor candidates. Surgery effectively excludes aneurysms with complex anatomy and relieves increased intracranial pressure with hematoma evacuation, lobectomy, and/or hemicraniectomy. Modern neurosurgical, endovascular, and neurointensive critical care produces favorable outcomes in a substantial percentage of carefully selected patients.

Cognitive Functioning and Health-Related Quality of Life 1 Year After Aneurysmal Subarachnoid Hemorrhage in Preoperative Comatose Patients (Hunt and Hess Grade V Patients)

OBJECTIVE

The objective of this study was to determine cognitive functioning and health-related quality of life 1 year after aneurysmal subarachnoid hemorrhage in preoperative comatose patients (Hunt and Hess Grade V patients).

METHODS

Patients who were comatose at hospital arrival and thereafter were investigated for 1 year using a comprehensive neuropsychological test battery and 2 HRQOL questionnaires.

RESULTS

Thirty-five of 70 patients survived the bleed, and 26 underwent neuropsychological testing. Two distinct patient groups emerged, one (n = 14) with good cognitive function, having mild deficits only, and the other (n = 12) with poor cognitive and poor motor function. Patients performing poorly were older (P = .04), had fewer years of education (P = .005) and larger preoperative ventricular scores, and were more often shunted (P = .02). There were also differences between the 2 groups in the Glasgow Outcome Scale (P = .001), the modified Rankin Scale (P = .001), and employment status. HRQOL was more reduced in patients with poor cognitive function.

CONCLUSION

A high fraction of survivors among preoperative comatose aneurysmal SAH patients (Hunt and Hess grade V) recover to good physical and cognitive function, enabling them to live a normal life.

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.

Contribution of endovascular therapy to the management of poor-grade aneurysmal subarachnoid hemorrhage: Clinical and angiographic outcomes

OBJECT

Treatment of patients presenting with poor-grade (Hunt and Hess Grade IV or V) subarachnoid hemorrhage (SAH) is controversial. Endovascular coil embolization has been considered a valuable therapeutic alternative to surgical clip placement for this kind of patient. The aim of the present study was to evaluate immediate and long-term angiographic and clinical outcomes in patients with poor-grade SAH treated by endovascular embolization.

METHODS

One hundred eleven patients with Hunt and Hess Grade IV or V SAH were treated with endovascular embolization at the University of California at Los Angeles Medical Center between October 1990 and December 2004. Eighty patients harbored Grade IV hemorrhages and 31 patients had Grade V ones. Immediate and long-term anatomical and clinical outcomes were evaluated in all patients. Long-term clinical outcome assessments were based on follow-up data obtained over an average of 32 months posttherapy. Technical complications occurred in 15 patients (13.5%). Immediate complete aneurysm occlusion was observed in 51.4% of aneurysms. Angiographic, long-term follow-up review revealed aneurysm recanalization in 16.2% of cases. Thirty-nine patients (35.1%) demonstrated a favorable long-term clinical outcome. The overall mortality rate in this patient series was 32.4%. The mortality rate associated with vasospasm was significantly higher in patients with Grade IV SAHs than in those with Grade V hemorrhages.

CONCLUSIONS

The results of this study demonstrate a valuable contribution of endovascular therapy of ruptured intracranial aneurysms in patients with Hunt and Hess Grade IV or V SAH. This technique was successful in decreasing repeated aneurysm rupture and in enabling aggressive medical management during the acute phase of SAH. This is particularly important in patients with Grade IV SAH because of their potential for obtaining higher physical and functional recoveries.

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.

One-stage embolization in patients with acutely ruptured poor-grade aneurysm

BACKGROUND

Early or ultra-early surgery for patients in poor neurological condition (Hunt and Hess grade IV or V) after ictus of aneurysmal subarachnoid hemorrhage is increasingly reported to prevent early rebleeding. To prevent any rebleeding after hospital admission, we have treated patients with poor-grade aneurysm during the same session as when diagnostic angiography is performed ("one-stage embolization"). The aim of the present study is to determine whether this treatment modality is a viable management option for this group of patients.

METHODS

We retrospectively reviewed 18 consecutive patients who presented with acutely ruptured aneurysms and were in very poor neurological condition and who were treated with one-stage embolization.

RESULTS

We observed 2 complications related to the endovascular procedure: partial occlusion of the parent artery and aneurysm rupture during the procedure. According to the Glasgow Outcome Scale, good recovery occurred in 8 patients, and moderate and severe disabilities occurred in 4 and 3 patients, respectively, and 3 patients died. No rebleeding occurred after the procedure. The mean follow-up of the surviving patients (those who were alive more than 30 days after embolization) was 13.7 months (4-25 months). Three patients had surgery after endovascular procedure: 2 surgical clipping of failed or partial aneurysm embolization and 1 emergency coil removal with clipping. A permanent ventriculoperitoneal shunt was placed in 11 patients.

CONCLUSIONS

We achieved promising results by using one-stage embolization to prevent ultra-early rebleeding followed by aggressive resuscitation. The active involvement of the endovascular team from the stage of diagnostic angiogram is a prerequisite for this treatment strategy.

Management of poor-grade patients with aneurysmal subarachnoid hemorrhage in the acute stage: Importance of close monitoring for neurological grade changes

BACKGROUND

The optimal management of poor-grade patients with aneurysmal subarachnoid hemorrhage (SAH) remains controversial. We evaluated therapeutic outcomes to identify appropriate treatments for SAH patients admitted with a poor grade.

METHODS

We retrospectively studied 136 patients admitted within 6 hours after SAH onset with a poor Hunt & Kosnik Grade (IV and V).

RESULTS

Of 136 poor-grade patients, 20 with massive intracerebral or subdural hematoma underwent urgent hematoma evacuation and aneurysmal neck clipping. Seven of these achieved a favorable outcome (good recovery or moderate disability). Another 7 patients with prominent hydrocephalus or massive intraventricular hematoma underwent urgent continuous ventricular drainage. Of these, 4 manifested spontaneous grade improvement and underwent neck clipping; the other 3 died resulting from rebleeding. The remaining 109 patients whose poor grade was primarily because of SAH were observed without immediate surgery. In 43 patients of 109, the grade improved within 24 hours after hospitalization and within 38 hours in the other 4 patients. Aneurysmal neck clipping was performed in these 47 patients and a favorable outcome was achieved in 25 patients. The remaining 62 patients did not improve and the outcome was unfavorable.

CONCLUSIONS

Poor-grade SAH patients should be treated according to the pathogenesis underlying their poor grade. Close monitoring for a grade change over the first 24 hours after hospitalization is mandatory in patients whose poor grade is primarily because of the SAH and helps to determine the appropriateness of surgery.

Angiographic assessment of cerebral circulation time for outcome prediction in patients with subarachnoid hemorrhage

BACKGROUND

In the acute stage following subarachnoid hemorrhage (SAH), prolonged cerebral circulation time reflects increased intracranial pressure (ICP), which can lead to irreversible brain damage. We evaluated the ability of cerebral circulation time to predict outcome in SAH patients.

METHODS

We prospectively studied 40 consecutive patients treated for SAH according to standard intensive care guidelines. Lateral views in preoperative carotid digital subtraction arteriograms (DSA) were used to determine arteriovenous transit time (AVTT), defined as interval from initial opacification of the intracranial internal carotid artery to that of the Rolandic vein. We then analyzed relationship of AVTT to other prognostic parameters and outcome.

RESULTS

AVTT depended on initial Glasgow Coma Scale score (GCS), ranging from 3.4 to 8.0 seconds (mean: 5.4) when initial GCS was 13 to 15; from 4.5 to 8.7 seconds (mean: 6.4) when initial GCS was 7 to 12; and from 5.8 to 15.0 seconds (mean: 9.1 seconds, excluding angiograms with nonfilling) when initial GCS was 3 to 6. AVTT correlated significantly with prognosis, longer AVTT predicting poorer outcome. No patient with an AVTT above 12 seconds recovered to a functioning state.

CONCLUSIONS

AVTT obtained from routinely performed acute-phase DSA in SAH patients reflects ICP and functional prognosis, representing a cost-effective, practical, and reliable outcome predictor.

Poor-grade aneurysmal subarachnoid hemorrhage: outcome after treatment with urgent surgery

OBJECTIVE

We sought to determine whether the rebleeding rate in poor-grade patients justified a period of supportive observation before selective treatment and whether unselected ultraearly surgery would lead to acceptable results.

METHODS

A prospectively audited, nonselected series of 177 consecutive poor-grade (i.e., World Federation of Neurological Surgeons Grades IV and V) patients with aneurysmal subarachnoid hemorrhage managed during a 9-year period was analyzed. A management policy of aggressive ultraearly surgery (not selected by age or by grade) was followed. Coiling was not available. Outcomes were assessed at 3 months.

RESULTS

Despite the aggressive management policy, surgery could be performed in only 132 poor-grade patients (75%). Twenty percent of all patients were 70 years of age or older (15% of the surgical cases). All surgery was performed within 12 hours of subarachnoid hemorrhage (majority <6 h). Preoperative rebleeding occurred within the first 12 hours (>85% within 6 h) in 20% of the patients, which is four times the rate found in good-grade patients managed according to the same policy. Outcome assessment performed at 3 months in the 132 poor-grade surgical patients revealed that 40% were independent, 15% were dependent, and 45% had died. There was no significant difference in outcomes for young and old (70+ yr) poor-grade surgical patients (P > 0.05).

CONCLUSION

The high ultraearly rebleeding rate indicates a need to urgently secure the ruptured aneurysm by performing surgery or coiling, and this indication is more pronounced for poor-grade patients than for good-grade patients. The outcome results of ultraearly surgery indicate that a nonselective policy does not lead to a large number of dependent survivors, even among elderly poor-grade patients.

Management of intracranial aneurysms: factors that influence clinical grade and surgical outcome

BACKGROUND

We report the experience in managing intracranial aneurysms at our medical center.

METHODS

We retrospectively analyzed 297 intracranial aneurysms managed during a 6-year period. Risk factors were analyzed with respect to their influence on outcome after surgery as measured by Glasgow Outcome Scale score.

RESULTS

Fifty-eight patients had multiple aneurysms. Of all aneurysms, 83% were in the anterior circulation, 37% were unruptured, and 59% were larger than 10 mm in size. Good outcomewas achieved in 75% of patients, and another 16% had fair outcomes. The mortality rate was 4%, and significant morbidity occurred in 5% of patients. Significant indicators of poor outcome were worsened clinical grade, posterior aneurysm location, and large aneurysm size.

CONCLUSION

Hypertensive patients, older patients, and patients with posterior circulation aneurysms had poorer neurologic status, which significantly influenced outcome. Larger aneurysms and vertebrobasilar aneurysms were associated with poor outcomes.

Third ventriculostomy through the lamina terminalis for intracranial pressure monitoring after aneurysm surgery: technical note

OBJECTIVE

A new ventriculostomy technique through the lamina terminalis is described. This technique is applied mainly during aneurysm surgery at the acute stage.

METHOD

Thirteen patients were operated on intracranial aneurysms and, during the procedure, had the lamina terminalis fenestrated. A ventricular catheter was inserted into the third ventricule, left in place and connected to an external drainage system for further intracranial pressure (ICP) monitoring and/or cerebrospinal fluid (CSF) drainage.

RESULTS

ICP readings and CSF drainage were obtained in all cases. No complication was recorded.

CONCLUSION

Third ventriculostomy through the lamina terminalis is a simple and easy technique that can be used as an alternative to conventional ventriculostomy. This procedure can be indicated in cases where the ventricule is not reached by means of another technique, and when the decision to perform ventriculostomy is made at the end of aneurysm surgery.

Prognostic value of SSEP in early aneurysm surgery after SAH in poor-grade patients

We evaluate the prognostic value of somatosensory evoked potentials (SSEP) in poor-grade patients after early surgery for aneurysmal subarachnoid hemorrhage compared to the Hunt and Hess (H&H) and WFNS scales. Ninety patients with angiographically proven aneurysms graded H&H IV or V were evaluated retrospectively. The aneurysms of 72 patients were clipped. In 53 out of 72 patients 147 SSEP examinations were recorded. The SSEP were classified according to the central conduction time (CCT) and the number of cortical potentials. Outcome was determined according to the Glasgow Outcome Scale. To evaluate the predictability of the SSEP to clinical grading scales receiver operating characteristic (ROC) analysis was done. The H&H scale did not demonstrate statistically significant predictability for poor-grade patients. The WFNS scale predicted the outcome for only one group (survival/death) (p = 0.035). Predictability of outcome by the SSEP was statistically confirmed. Normal CCT indicated a potential for a good recovery, but not consistently so. Bilaterally enhanced CCT was predictive of a poor outcome. Bilateral lack of cortical responses was always related to fatal outcome. ROC analysis confirmed that SSEP are superior to clinical grading scales in determining prognosis in poor-grade patients. In doubt, whether early aneurysm surgery or conservative treatment in a poor-grade patient should be done, SSEP will be helpful.

Impact of early endovascular aneurysmal occlusion on outcome of patients in poor grade after subarachnoid haemorrhage: a prospective, consecutive study

Patients in poor grade (WFNS IV and V) after aneurysmal subarachnoid hemorrhage (SAH) often have a bad outcome. To evaluate early GDC embolisation on such patients a prospective observational study, with comparison to a historical cohort was performed. From January 1996 to December 1998 113 patients were admitted to the Department of Clinical Neurosciences in poor grade after SAH (45 WFNS IV and 68 WFNS V). Eighty-one patients were managed actively with endovascular occlusion of the aneurysm (n = 42) where possible and delayed clipping (n = 16) where not. On an intention to treat basis, 46% had a favourable outcome (Glasgow Outcome Score IV or V) and 48% had died by 3 months. Compared to an historical cohort managed in the same unit between 1992 and 1995 (n = 62, 52% favourable outcome) these results suggest that early GDC aneurysmal occlusion has had a minimal impact on overall outcome.