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Management of poor-grade patients with ruptured intracranial aneurysm
1Department of Neurosurgery, Yonsei University College of Medicine, Seoul, Korea.
Insights
Urgent management is crucial for poor-grade patients with aneurysmal subarachnoid hemorrhage (SAH). Early intervention, especially for Grade IV patients, can prevent rebleeding and improve outcomes, with aggressive treatment strategies recommended.
Area of Science:
- Neurosurgery
- Neurology
- Critical Care Medicine
Background:
- Aneurysmal subarachnoid hemorrhage (SAH) presents a significant challenge, particularly in poor-grade patients (Hunt and Hess Grade IV-V).
- Understanding the causes of unfavorable outcomes is essential for developing effective treatment strategies.
Purpose of the Study:
- To analyze the causes of unfavorable outcomes in poor-grade SAH patients.
- To formulate improved treatment strategies for this patient cohort.
Main Methods:
- Retrospective analysis of medical records for 166 poor-grade SAH patients (Hunt and Hess Grade IV-V) from 588 consecutive cases.
- Evaluation of causes of unfavorable outcomes and comparison of management results between surgical and non-surgical groups.
Main Results:
- Overall favorable outcomes were achieved in 42.8% of poor-grade patients.
- Direct aneurysm clipping yielded favorable results in 76.7% of cases.
- Direct effects of aneurysm rupture and early rebleeding were primary causes of unfavorable outcomes, particularly in Grade IV patients.
Conclusions:
- Rebleeding is the only preventable cause of unfavorable outcomes in SAH patients.
- Urgent management is necessary to prevent rebleeding, especially in Grade IV patients.
- Aggressive treatment, including direct clipping or coil embolization based on aneurysm complexity and presence of hematoma, is recommended for Grade IV patients.
Abstract:
To formulate treatment strategies for poor-grade patients after aneurysmal subarachnoid hemorrhage (SAH), medical records were analyzed for 166 patients who were in Hunt and Hess Grade IV or V among 588 consecutive cases with ruptured intracranial aneurysm admitted during the past 5 years. Causes of unfavorable outcome (poor or dead) in those 166 patients were evaluated to improve the management outcome. Overall management results of the 166 poor-grade patients were favorable (good or fair) in 71 (42.8%), unfavorable in 95 (78 dead, 17 poor). Direct clipping was performed in 90 patients, and the results were favorable in 69 (76.7%) and unfavorable in 21 (23.3%). Surgery was not done in 76 patients because 41 were moribund on arrival, 15 deterioration due to rebleeding, 7 severe brain swelling, 5 serious medical illness, one severe delayed ischemic deficit (DID), and one cerebral infarction following angiography, and 6 refused surgery. Seven patients survived in non-surgery group (2 fair, 5 poor). Direct effects of aneurysm rupture (34.8%) and early rebleeding (34.8%) were the major causes of unfavorable outcome in Grade IV patients, while it was direct effect of aneurysm rupture (91.8%) in Grade V patients. It is suggested that as rebleeding is the only preventable cause of unfavorable outcome, urgent management is necessary to prevent rebleeding, especially for Grade IV patients. Grade IV patients should be treated aggressively with direct clipping for non-complex aneurysms or for patients with hematoma, and coil embolization for complex aneurysms without hematoma.