Aneurysm surgery in poor grade patients. Results, and value of external ventricular drainage

The attitude concerning early clipping of aneurysms or generally aneurysm surgery in poor grade patients is controversial. There is no discussion about the space-occupying haematomas that must be removed urgently even in grade V patients if they have been admitted immediately after the acute event. Several patients in grade IV or V following a pure subarachnoid haemorrhage, can be improved by external ventricular drainage and thereafter their aneurysm operated upon with a better chance. Intelligible, the frequency of shunts needed is higher in poor than in good grade patients. Nevertheless, it can be reduced if the pressure, against what CSF is drained off, is kept on a higher level (about 20 cm H20) once the patient has stabilised. It also appears recommendable to operate upon aneurysms in patients who persist for several days in a condition no better than grade IV, rather than to assume an expectative attitude, for aneurysm rerupture mostly terminates the life of the patient, whereas clipping gives a change of recovery.