Outcome after urgent surgery for grade IV subarachnoid hemorrhage

Outcome after subarachnoid hemorrhage (SAH) in patients presenting with poor clinical grade has historically been dismal. As a result, many poor-grade patients have been excluded from early, aggressive surgery. We present a consecutive series of 27 patients with acute (less than 24 h since clinical onset) Grade IV SAH treated with early surgery.

All patients were treated with immediate ventricular drainage, rigid hemodynamic control, early angiography and surgery within 24 h of presentation. Patients were followed for a minimum of 6 months and their outcomes categorized using a four-tiered scale: 1) independent and working, 2) impaired but independent, 3) severely impaired and dependent, and 4) dead.

Seven patients died within 48 h of admission. The remaining 20 patients survived to discharge. At the time of discharge eight of these patients were considered to be impaired but independent and twelve were considered severely impaired and dependent. At follow-up, seven patients were independent and working, six were impaired but independent, five were severely impaired and dependent, and two severely impaired patients had subsequently died.

We conclude that urgent surgery for poor-grade SAH can produce quality survival for a higher percentage of patients than is historically reported with delayed surgery.