Risk factors influencing prognosis in surgical patients with poor-grade aneurysmal subarachnoid hemorrhage / 中国脑血管病杂志

Objective To investigate risk factors affecting prognosis in patients with poor-grade aneurysmal subarachnoid hemorrhage(aSAH) underwent surgical intervention. Methods From January 2015 to December 2017, 142 hospitalized patients with poor-grade (World Federation of Neurosurgery [WFNS] grade IV-V) a SAH were consecutively and retrospectively enrolled in the Department of Neurosurgery, the First Affiliated Hospital of Chongqing Medical University. All patients were diagnosed as spontaneous subarachnoid hemorrhage by head CT with intracranial aneurysm confirmed by CT angiography (CTA) or DSA. According to different therapeutic interventions, 142 cases were divided into the surgical treatment group (65 cases) and the conservative treatment group (77 cases). Baseline demographics,clinical data,concomitant symptoms and complications were recorded and compared between groups. Baseline demographics included sex, age, smoking history, drinking history, hypertension and diabetes mellitus; clinical data included WFNS classification, Fisher classification, pupil changes, intracerebral hematoma, intraventricular hemorrhage,aneurysm location,aneurysm diameter; concomitant symptoms of aSAH included in-hospital rebleeding,symptomatic vasospasm,symptomatic hydrocephalus,epilepsy,pulmonary infection; treatment-related complications included recurrent bleeding after discharge, cerebral infarction and intracranial infection. Risk factors affecting prognosis in surgical patients were determined using univariate analysis and multivariate Logistic regression analysis. Results (1) Lower age and proportion of ventricular hematoma were found in the surgical treatment group than the conservative treatment group,and the differences were statistically significanti [54 ± 9] years old vs. [60±12] years old.i = 2. 947; 55.4 % [36/65] vs. 77. 9% [60/77] x2 e8. 175; all P 0. 05). (2) In the terms of aneurysm re-rupture, symptomatic vasospasm, symptomatic hydrocephalus,epilepsy and pulmonary infection,no significant differences were found between the surgical treatment group and the conservative treatment group (a l l P > 0. 05). No recurrent rebleeding after discharge happened in the surgical treatment group but 13.0% (10/77) in conservative treatment group. There was significant difference between the two groups (P 0. 01). (3) Higher proportion of patients with favorable prognosis and lower mortality rate were found in the surgical treatment group than the conservative treatment group, and the differences were statistically significant (favorable prognosis rate; 60. 0% [39/65] vs. 26. 0% [20/77], x2 = 16. 803, P 0. 05). (5) Age (from low to high) and pupil changes (with or without) were analyzed using multivariate Logistic regression with unfavorable prognosis of the surgical patients as dependent variables. The results showed that advanced age (Oft = 1. 067, 9 5 % CI I. 006 - 1. 147) was an independent risk factor for unfavorable prognosis in surgical patients with poor-grade a S A H (P < 0. 05). Conclusions Compared with conservative treatment, surgical patients with poor-grade a S A H have advantages in reducing recurrent bleeding after discharge but may increase the risk of cerebral infarction and intracranial infection. However,the overall prognosis of surgical patients is better. Advanced age is an independent risk factor for unfavorable prognosis of surgical patients with poor-grade aSAH.

Safety of external ventricular drainage after stent-assisted embolization for poor-grade ruptured aneurysm / 医学研究生学报

Objective The management of poor-grade ruptured aneurysm is important and challenging in intravascular inter-vention. This study aimed to investigate the safety of external ventricular drainage(EVD)after stent-assisted embolization for patients with poor-grade ruptured aneurysm in the acute stage. Methods From January 2015 to July 2017,27 patients with poor-grade rup-tured aneurysm underwent EVD after endovascular embolization by stent-assisted coiling(n=14)or simple coiling(n=13). We com-pared the clinical data about and the postoperative complications between the two groups of patients. Results There were no statisti-cally significant differences in the patients'age,gender,Glasgow Coma Scale(GCS)scores before embolization and discharge,the in-terval between EVD and the end of embolization,preoperative intraventricular hemorrhage and hydrocephalus,puncture-related bleed-ing after EVD,catheter-indwelling time,perioperative bleeding in other parts,or poor prognosis between the stent-assisted coiling and simple coiling groups(all P>0.05). Conclusion EVD after stent-assisted embolization is a relatively safe strategy for the treatment of poor-grade ruptured aneurysm in the acute stage.

Influence of the timing of microsurgical clipping on the prognosis of patients with poor-grade aneurysmal subarachnoid hemorrhage / 中国脑血管病杂志

Objective To investigate the influence of different timing of surgery on patients with poor-grade intracranial aneurysm. Methods The clinical data of 86 patients with aneurysmal subarachnoid hemorrhage (Hunt-Hess gradeⅣ toⅤ)were analyzed retrospectively. The patients were divided into an ultra-early treatment group (the operative time within 24 h after onset;n=40),an early treatment group, (24 to 72 h after onset;n=27),and middle and late treatment group (>72 h after onset;n=19)according to the different timing of surgery. The prognosis of patients at 6 months after procedure was evaluated with the modified Rankin Scale (mRS)scores. The differences of the rate of good prognosis (mRS 0 to 2)and mortality in patients of the 3 groups were compared. Results (1 )The ratios of good prognosis in the ultra-early treatment group,early treatment group,and middle and late treatment group were 55. 0%(n=22),33. 3%(n=9),and 21. 1%(n=4),respectively. There were significant differences (P0. 05). The mortality ratios in patients of the 3 groups were 2/18,4/11,and 6/11,respectively. There were significant differences (P<0. 05). Conclusion Ultra-early operation may benefit part of the patients with poor-grade aneurysm,particularly in patients with gradeⅣ. As for the patients with grade Ⅴ, ultra-early operation may help to reduce short-term mortality rate,however,the rate of vegetative state is high.

Early Aneurysm Surgery using Eyebrow Incision for Poor Grade Patients

OBJECTIVE: This study is aimed to assess the clinical outcome in early and minimally invasive surgery using an eyebrow incision for the patients with poor grade aneurysm. METHODS: The authors retrospectively reviewed all 46 poor grade patients of Hunt and Hess(H-H) grade IV and V who suffered aneurysmal subarachnoid hemorrhage(SAH) between 1999 and 2004. All 35 patients harboring 43 aneurysms who underwent early surgery within 72 hours were included in this study. Clinical outcome was assessed by Glasgow outcome scale(GOS) and compared with that of conventional pterional approach. RESULTS: Twenty four patients were operated with conventional pterional approach and 11 with eyebrow approach within 72 hours after SAH. Seven multiple aneurysm patients harbor 15 aneurysms. Forty one aneurysms were treated with clippings. All 11 patients of eyebrow surgery group(ESG) were in H-H grade IV, 3 in Fisher grade III and 8 in Fisher grade IV. Among 24 patients of pterional approach group(PAG), 20 were in H-H grade IV and 4 in H-H grade V, 3 were in Fisher grade III and 21 in Fisher grade IV. Overall favorable outcome was achieved in 41.7% and 54.5% in PAG and ESG, respectively. Favorable outcome of H-H grade IV in PAG showed 45.0%. Overall mortality rate was 14.3%. CONCLUSION: It is concluded that the clinical outcome of early and minimally invasive aneurysmal surgery using eyebrow incision in the selected poor grade aneurysm patients can be compatible with that of conventional pterional surgery.

Clinical Analysis of Poor grade Subarachnoid Hemorrhage Patients / 대한뇌혈관외과학회지

PURPOSE: Subarachnoid hemorrhage (SAH) resulting from aneurysmal rupture carries a high rate of morbidity and mortality despite of intensive care. Owing to the advance in surgical techniques, the management results of good grade patients have shown better outcomes than the past, but those of poor grade patients have been still unsatisfactory. The aim of this study is to determine the treatment and the prognostic factors in the poor grade SAH patients. METHOD: We have analyzed 43 patients of Hunt & Hess (H&H) grade IV and V among 438 SAH patients treated between 1998 and 2004. The patients were divided into two groups (Good outcome group and Poor outcome group) according to the management outcomes. Each group was analyzed about the various prognosis factors; age, sex, H&H grade, Fisher grade, location and size of aneurysm, timing of operation, and complications. RESULTS: Among the various factors evaluated, the preoperative H&H grade only showed statistical significance (P value=0.0173). The better H&H grade seemed to show the more favorable outcome, especially surgically treated cases. CONCLUSIONS: An aggressive treatment including early surgery seems to contribute to a better outcome of poor grade SAH patients, especially H&H grade IV. But further clinical study should be researched to improve clinical outcomes in H&H grade V patients.

"Misery Collaterals" as Poor Angiographic Findings: Definition, Classification, and Practical Application

OBJECTIVE: Unique internal carotid artery angiographic findings have been found especially in very poor grade aneurysmal subarachnoid hemorrhage(SAH) patients before and during the endovascular coiling. The author investigates their patterns and classifies them into four subtypes. METHODS: Among Hunt&Hess grade IV, V SAH patients, the author could gather eight patients who showed abnormal intracranial circulation in cerebral catheter-based angiography. RESULTS: The author introduces new term 'misery collaterals' first and has classified them into four types with the case illustrations. Type 1 is the worst condition defined as almost no intracranial circulation. Type 2 is the condition of little intracranial circulation with contrast filling just only at vessels of brain base, type 3 is of no or little cortical circulation with contrast filling at bilateral large vessels of brain base through circle of Willis channel and type 4 is of visible bilateral cortical circulation but delayed intracranial circulation time. The prognosis of these eight patients showed misery collaterals were disappointed. CONCLUSION: These finding can be used as the supportive information in deciding a management plan in poor grade SAH patients.

Evaluation of Cerebral Vasomotor Reactivity using a Transcranial Doppler with Acetazolamide Test in Poor-grade Patients with Aneurysmal Subarachnoid Hemorrhage

OBJECTIVE: A greater reduction in cerebral blood flow has been shown in poor-grade patients with aneurysmal subarachnoid hemorrhage. The present study is designed to evaluate cerebral vasomotor reactivity(VMR) using a transcranial doppler(TCD) with acetazolamide(AZ) challenge in those patients and to investigate its predicting value for outcome. METHODS: Firstly, we compared the effect of AZ and most extensively using CO2 stimuli(breath-holding method) on middle cerebral artery flow velocity(FV) in the same control adults(n=12) to examine the reproducibility of AZ test. Secondly, the changes of FV of lesional and contralateral hemispheres after injection of AZ, which was measured one week after early surgery of poor-grade patients with aneurysmal subarachnoid hemorrhage, were compared between patients who showed good outcome(Group 1, n=22) and poor outcome(Group 2, n=22). RESULTS: There was a close correlation between both stimulation methods, indicating a strong similarity of the vasodilatory effects of CO2 and AZ. The FV at rest(lesional: 71.5+/-38.6cm/s, contralateral: 49.4+/-22.6cm/s) increased significantly after administration of AZ(lesional: 90.5+/-40.1cm/s, contralateral: 66.5+/-25.4cm/s, P<0.01, Student's t test) in Group 1. However, all had an insignificant increase of FV after AZ challenge compared with the baseline values in Group 2. The difference between the values at rest and after AZ had an increasing tendency but it was not significant, between Group 1 and 2(repeated measures ANOVA, P=0.06). CONCLUSION: These results demonstrate that the assessment of VMR by the change of FV using TCD together with AZ test in poor-grade patients with aneurysmal subarachnoid hemorrhage seems clinically helpful for predicting surgical outcome.

Analysis of Prognosis in Poor-grade Aneurysmal Subarachnoid Hemorrhage

OBJECTIVE: Although early surgery is a generally accepted in good grade subarachnoid hemorrhage(SAH), patients in a poor grade have been excluded from aggressive treatment due to severely damaged brain after attack. This study describes the prognosis and cause of poor outcome in poor-grade SAH patients excluding the effect of hydrocephlalus. METHODS: We analyzed 217 patients of Hunt & Hess(H&H) grade IV and V from 1997 to 2001. The prognosis according to the treatment modality, timing of operation, age, H&H grade, Fisher grade, location and size of aneurysm and the cause of poor outcome was analyzed retrospectively with literature review. Statistical analysis was performed using paired t-test with SPSS Ver 10.0 and considered significant for value less than 0.05. RESULTS: There were stastistical significance between age, Fisher grade and outcome. Good outcome was obtained about 25.2% in early surgery group and 23.4% in delayed surgery group. Patients who did not undergo clipping presented very poor outcome. The causes of poor outcome mainly composed of delayed ischemic deficit(DID) from vasospasm and direct effect from SAH. CONCLUSION: To improve outcome in poor-grade SAH patients, there must be more intensive care preventing DID from vasospasm.

3-Dimensional Computed Tomography Angiography in Early Operation for Poor Grade Aneurysms

OBJECTIVE: The authors studied the feasibility of 3-Dimensional computed tomographic angiography(3-D CTA) in early surgery for poor grade patients with aneurysmal subarachnoid hemorrhage(SAH), therefore intended to verify the eligibility of this diagnostic tool in these special clinical settings. METHODS: During the period between July 1997 and December 2000, we studied 31 patients diagnosed as aneurysmal SAH that were classified as the Hunt-Hess grade IV or V and Fisher group III or IV. As the conventional angiography could not be conducted because of the patients' poor clinical conditions, we carried out early surgery on the same day of SAH solely based on the 3-D CTA. We compared the 3-D CTA features with intraoperative findings. RESULTS: Total of 33 aneurysms were found in preoperative 3-D CTA and, of them, all 31 ruptured aneurysms and additional another two unruptured ones were also. Undetected three aneurysms were found in the operative field(2 cases) and postoperative digital subtraction angiography(1 case). The sensitivity of 3-D CTA was 94.7% and specificity was 100%. CONCLUSION: According to our results, 3-D CTA might be sufficient for early surgery of intracranial aneurysms in poor grade SAH patients in urgent conditions.

Management Outcome of Poor Grade Patients with Aneurysmal Subarachnoid Hemorrhage

OBJECTIVE: The aim of this study is to determine the treatment strategies for the poor grade patients with aneurysmal subarachnoid hemorrhage(SAH) with respect to the timing of surgery. METHODS: We have analyzed 51 patients of Hunt and Hess grade IV and V at admission among 140 SAH patients who were managed during recent three years. They were devided into two groups according to the interval between SAH and surgery: 30 early treatment group(operated within 3 days) and 21 delayed treatment group(6 delayed operation cases and 15 unoperated cases). RESULTS: Clinical outcome of early surgery group was favorable(Good or Fair) in 23 cases(76.7%) and unfavorable in 7 cases(23.3%, 2 Poor, 5 Dead). On the contrary, those of delayed surgery group or without surgery group was favorable in 4 cases(19.1%) and unfavorable in 17 cases(80.9%, 1 Poor, 16 Dead). Overall management outcome of poor grade SAH patients was favorable in 27 cases(52.9%), unfavorable in 24 cases(47.1%) and mortality rate was 41.2%. Unfavorable outcome in poor grade SAH patients was largely affected by the initial hemorrhage and subsequent development of intractable intracranial hypertension(Hunt and Hess grade IV: 5 cases, grade V: 8 cases), cerebral infarction(grade IV: 3 cases, grade V: 1), rebleeding(grade IV: 3 cases), and surgical complication(4 cases). CONCLUSION: An active treatment policy including early surgery might achieve a better outcome of poor grade SAH patients.

Management Outcome of Poor Grade Patients with Aneurysmal Subarachnoid Hemorrhage

OBJECTIVE: The aim of this study is to determine the treatment strategies for the poor grade patients with aneurysmal subarachnoid hemorrhage(SAH) with respect to the timing of surgery. METHODS: We have analyzed 51 patients of Hunt and Hess grade IV and V at admission among 140 SAH patients who were managed during recent three years. They were devided into two groups according to the interval between SAH and surgery: 30 early treatment group(operated within 3 days) and 21 delayed treatment group(6 delayed operation cases and 15 unoperated cases). RESULTS: Clinical outcome of early surgery group was favorable(Good or Fair) in 23 cases(76.7%) and unfavorable in 7 cases(23.3%, 2 Poor, 5 Dead). On the contrary, those of delayed surgery group or without surgery group was favorable in 4 cases(19.1%) and unfavorable in 17 cases(80.9%, 1 Poor, 16 Dead). Overall management outcome of poor grade SAH patients was favorable in 27 cases(52.9%), unfavorable in 24 cases(47.1%) and mortality rate was 41.2%. Unfavorable outcome in poor grade SAH patients was largely affected by the initial hemorrhage and subsequent development of intractable intracranial hypertension(Hunt and Hess grade IV: 5 cases, grade V: 8 cases), cerebral infarction(grade IV: 3 cases, grade V: 1), rebleeding(grade IV: 3 cases), and surgical complication(4 cases). CONCLUSION: An active treatment policy including early surgery might achieve a better outcome of poor grade SAH patients.

Significance of Intracranial Pressure Monitoring in Early Surgery for Poor-Grade Aneurysm Patients

OBJECTIVE: Patients with poor grade aneurysm usually present with increased intracranial pressure(ICP), even those without an intracranial clot. Based on this fact, the present study investigated a significance of intracranial pressure monitoring in those patients. PATIENTS AND METHODS:A total of 60 patients with Hunt and Hess Grade IV(50 patients) or V(10 patients) were treated for aneurysmal subarachnoid hemorrhage(SAH) during a 3-year-period, and intraparenchymal ICP was measured in the majority, immediately after arrival to the emergency room. Early surgery including intraoperative ventriculostomy was undertaken within 3 days after SAH. An ultraearly surgery was performed without preceding angiogram or ICP monitoring in patients with large sylvian hematomas, highly suggestive of middle cerebral artery aneurysm. Outcomes were assessed by the Glasgow Outcome Scale(GOS) at 6 months. RESULTS: In overall, favorable outcome(GOS scores 1-2) was seen in 27(54.0%) of admission Grade IV and 1(10.0%) of admission Grade V patients. Of the 38 surgical patients with preoperative ICP monitorings, 25 patients (80.6%) exhibiting ICP values of less than 40mmHg showed favorable outcome, however, no patients with ICP values above 40mmHg recovered(Fisher's exact test, p=0.0001). CONCLUSION: It is concluded that a preoperative ICP above 40mmHg before ventriculostomy indicate significant vital brain destruction as intractable intracranial hypertension, and Grade IV patients at admission with an ICP below 40mmHg can be of benefit from early surgical intervention while Grade V patients still remains unfavorable.

Hemodynamics of Poor-grade Subarachnoid Hemorrhage

Patients who are devastated neurologically or medically after aneurysmal subarachnoid hemorrhage(SAH) are described as 'poor grade' patients. More recent studies have documented that the initial hemorrhage is by far the most important determinant of outcome after aneurysmal subarachnoid hemorrhage. This review mainly includes hemodynamics and suspected mechanisms of acute brain injury after aneurysmal SAH, particularly in special reference to increased intracranial pressure and cerebral ischemia during and after SAH.

Management of The Poor Grade Aneurysm Patient / 대한뇌혈관학회지

Patients who suffer a severe aneurysmal subarachnoid hemorrhage(SAH) and who have arrived in the emergency room with devastated neurological or medical condition by this event are categorized as poor grade(Grade IV or V) aneurysm patients. As the poor grade patients are more prone to develop rebleeding, acute hydrocephalus, intracerebral and intraventricular hematoma, and delayed ischemic neurological deficits, the management of these patients remains challenging and controversial. However, it is now becoming evident that a significant number of the poor grade patients can be salvaged with an aggressive management from the moment of patient's arrival to the hospital. Initial management for the poor grade patients should be directed to the life threatening conditions such as cardiopulmonary depression, seizure, acute intracranial hypertension and rebleeding. The authors suggest that: 1) the Grade IV patients should be treated aggressively with direct clipping for patients with non-complex aneurysms, acute hydrocephalus, or significant amount of intracerebral hematoma; 2) The Grade V patients who show neurological improvement with supportive care could be the patients for an aggressive management; 3) Intra-aneurysmal treatment with Guglielmi Detachable Coil would be an alternative therapeutic option in the poor grade patients with advanced age, poor general physical condition, or complex aneurysm such as aneurysm of the posterior circulation or paraclinoid segment of the internal carotid artery.

Management of Poor-grade Patients with Ruptured Intracranial Aneurysm

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 aneurysmal SAH patients admitted during the past 5 years. Causes for unfavorable outcome(poor or dead) in these 166 patients were carefully evaluated to improve the management outcome. Overall management results were favorable(good or fair) in 71(42.8%), and unfavorable in 95(78 dead, 17 poor). Direct clipping was performed in 90 patients, and the surgical results were favorable in 69(76.7%) and unfavorable in 21(23.3%). Surgery was not performed in 76 patients because of moribund state on arrival in 41, neurological deterioration due to rebleeding in 15, massive brain swelling in seven, serious medical illness in five, severe delayed ischemic deficit in one, and massive cerebral infarction following angiography in one, and refused surgery in six. Seven patients survived from non-surgery group(2 fair, 5 poor). Direct effects of aneurysm rupture(34.8%) and early rebleeding(34.8%) were the 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 since rebleeding is the only preventable factor of unfavorable outcome, urgent management seems 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 with coil embolization for complex aneurysms without hematoma.

Analysis on the Early Surgical Results of Patients with Poor-grade Anterior Communicating Artery Aneurysms via Frontotemporal-transorbital Approach

Anterior communicating artery aneurysm is located in the deep area of the brain base around the important midline structure. It has adjacent complex arterial anatomy and multidirectionally projected aneurysm fundus. For these reasons, various surgical approaches including anterior interhemispheric and pterional approaches to the anterior communicating artery aneurysm have been introduced, but none of them are thought to be completely adequate for large and complex anterior communicating artery aneurysm. In the acute stage when brain edema is very severe, poor-grade anterior communicating artery aneurysm is more difficult to treat surgically and represents higher morbidity and mortality. In our hospital, forty one patients with Hunt-Hess grade IV-V anterior communicating artery aneurysms were operated on via frontotemporal-transorbital approach within 72 hours after onset of subarachnoid hemorrhage from May 1, 1990 to April 30, 1996. The frontotemporal-transorbital approach was found to have many advantages in the surgery of these poor-grade anterior communicating artery aneurysms, i.e., providing multidirectional surgical dissection and aneurysmal viewing, mininal brain retraction, wider basal exposure, shortest distance to the lesion, and preservation of the nerve and vascular supply to the frontotemporal muscle. The results of the early surgery for poor-grade anterior communicating artery aneurysm via frontotemporal-transorbital approach represented reduced morbidity(31.7%) and mortality(22.0%).

Early Surgery for Poor-Grade Aneurysmal Subarachnoid Hemorrhage

In order to determine the effect of early surgery on poor grade subarachnoid hemorrhage(SAH) patients. 88 such patients were evaluated between January, 1990 and January, 1996. Clinical grade on admission was Hunt-Hess grade IV(n=58) and V(n=30). The protocol involved the use of computed tomography(CT) scanning to diagnose SAH and to obtain evidence of the destruction of vital brain function, involving massive cerebral infarction with midline shift, dominant basal ganglia or brain stem hematoma. Patients were assigned to either the early surgery group(n=54: surgery performed within 3 days of the first hemorrhage) or the non-surgical group(n=33). In seventeen of 58 in Hunt-Hess grade IV patients, the outcome was good(GOS 4 and 5); 15 of these were in the early surgery group. In only one of 30 Hunt Hess grade V patients was there a good outcome, however. Among Hunt-Hess grade IV patients, mortality was 36.8% in the early surgery group and 60% in the non-surgical group; in the Hunt-Hess grade V group, the corresponding figures were 75% and 100%. In conclusion, it is recommended that to prevent rebleeding and other complications, Hunt-Hess grade IV patients, especially those that showing destruction of vital brain function, should undergo early surgery. With regard to early surgery, non-operation and the existence of evidence of destruction of vital brain function, grade V patients showed no difference in terms of their mortality and morbidity rate.

Clinical Significance of Hemorrhage Location in Poor Grade Aneurysm Patients

Many factors contributing to outcome of aneurysmal rupture patients have been studied but clinical significance of hemorrhage location based on CT in poor grade aneurysm(Hunt-Hess grade IV or V) patients is still unclear. The study was undertaken in order to try to outline the relative influence of hemorrhage location upon eventual outcome in poor grade patients with aneurysmal subarachnoid hemorrhage(SAH). Sixty-six SAH patients with early aneurysm surgery during the recent 3.5-year period, who were grouped into patients with intraventricular hemorrhage(IVH), intracerebral hematoma(ICH), ICH combined with IVH(ICH+IVH), and SAH according to hemorrhage locations were comparatively analyzed. Most of the poor grade patients(84.8%) were associated with ICH or IVH and the high frequency(67.9%) of IVH patients had an associated with ICH in contrast with the small number(32.1%) of pure IVH. Outcome was good in 26(39.4%) and poor in 40(60.6%). The presence of ICH on initial CT revealed better outcome compared to patients without ICH(60.7% vs 23.7%) However, ICH+IVH revealed poor outcome compared to patients without ICH+IVH(100% vs 44.7%). Ruptured anterior cerebral aneurysm caused an ICH+IVH more frequently and consequently more poor outcome than aneurysms in other anterior circulation. Additionally we relatively compared surgical outcome between aneurysmal sylvian or temporoparietal hematoma(ICH+sylvian or t-p) and hypertensive putaminal hematoma(H-ICH-putamen) sampled randomly under the similar conditions as much as motor weakness)was significantly lower in patients with aneurysmal ICH-sylvian or t-p(8.7% vs 50.0%). Overall results suggest that in Hunt-Hess IV-V aneurysm patients IVH itself does not independently correlate with prognosis, but when associated with an ICH it is related to a grave prognostic significance, and aggressive surgery for ICH lead to a better outcome with less morbidity.

Clinical Parameters Associated with Vasospasm in Early-Operated Aneurysmal Subarachnoid Hemorrhage

Much controversies still exist with respect to the risk factors influencing symptomatic cerebral vasospasm. In our study, the patient group had some unique characteristics, ie.:42.5%(65) of the 153 patients were aged 60 years or older(mean;55.6 years) and consequently the proportion of Hunt-Hess grade 3-5 was higher than grade 1-2(57.5% vs 42.5%). The authors analyzed the relationship between vasospasm and Hunt & Hess grade, Fisher grade, hydrocehalus, age & hypertension among these 153 early operative cases after a 3 year follow up study. The incidence of vasospasm was significantly higher in the Hunt-Hess grade III, IV, V and the Fisher grade III, IV, compared to grade I & II, and also in preoperative hydrocehalus but it was insignificant in old and hypertensive patients. These results suggest initial severe direct insults and complicating preoperative hydrocephalus increase the chance of postoperative symptomatic vasospasm in this older aged, poorer grade study group.

Outcome of Poor Grade Subarachnoid Hemorrhage Patients:Relationship to Timing of Surgery

In order to define the hospital course and the best surgical timing for the poor grade subarachnoid hemorrhage(SAH) patients, 131 patients(from 1989 to 1991) whose clinical grade on admission were Hunt and Hess grade III to V were analyzed. Their admission grades was III(90 patients), IV(30 patients), and V(11 patients). Patients were grouped into the early surgery group(within 3 days of the last hemorrhage), the intermediate group(4 to 14 days), the late surgery group(14 days after the last hemorrhage), and non-surgical group. Early surgery was performed on 17 patients, intermediate on 31 patients, and late on 54 paients. Twenty-nine patients did not undergo surgery. This non-surgical group had a high mortality rate(72.4%). During the waiting period for a delayed surgery(later than 3 days), 21% improved their clinical state, 53.5% were stationary and 25.5% became worse. Morbidity and mortality were compated among these three surgical groups and the non-surgical group, with sratistical analysis using chi square test and Fisher's exact test. No statistical differences were noted between the management groups in terms of associated disease, location of aneurysms, Fisher's grade, occurrence of hydrocephalus or symptomatic vasospasm. The mortality rate was significantly lower in the combined surgical groups than in the non-surgical group(p<0.05). Mortality was related to the timing of surgery. It was higher after early surgery than in the other two gorups, but it was not different between the intermediate and late surgery groups. Morbidity was not different among the three surgery groups. The major cause of morbidity and mortality in the early surgery group was brain swelling, while rebleeding, hydrocephalus, and vasospasm, were the main causes in the intermediate and delayed surgery groups. It is concluded that it is not recommended that early surgery must be done in all the poor grade SAH patients. However three days after the last hemorrhage, it is better to perform surgery as soon as possible, because there were no statistically significant differences between the intermediate group and the late surgery groups in the mortality and the morbidity rates.