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.

Cytokine Levels in Cerebrospinal Fluid and Delayed Ischemic Deficits in Patients with Aneurysmal Subarachnoid Hemorrhage

Subarachnoid hemorrhage (SAH) induces an inflammatory reaction and may lead to ischemic brain damage. The pathogenesis of brain dysfunction and delayed ischemic symptoms remain difficult to understand despite extensive surveys of such reactions. Cytokine production in the central nervous system following SAH and its relation with clinical outcome have hardly been studied. This study was aimed to determine whether the levels of IL-1 beta, IL-6 and TNF-alpha in the initial cerebrospinal fluid would increase following aneurysmal SAH, and be related with development of delayed ischemic deficit and clinical outcome. Nineteen patients suffering from aneurysmal SAH and 12 control volunteers were the subjects in this study. Cerebrospinal fluid samples were obtained on admission and the levels of each cytokine were determined with enzyme-linked immunosorbent assay. Patients with aneurysmal subarachnoid hemorrhage showed elevated levels of IL-1 beta, and TNF-alpha on admission. The patients with poor neurological status showed high levels of IL-1 beta, and IL-6. The patients who developed delayed ischemic deficit had high level of IL-6. We suggest that elevated level of IL-6 in cerebrospinal fluid of patients with aneurysmal SAH on admission can predict the high risk of delayed ischemic deficit.

A Study on the Usefulness of Acetazolamide Activated 99mTc-HMPAO SPECT in Subarachnoid Hemorrhage

Cerebral vascular reserve capacity was evaluated by acetazolamide activated 99m Tc-HMPAO brain SPECT in 17 patients with subarachnoid hemorrhage. Abnormal reactivity of the vascular reserve capacity correlated very well with the prognosis of these patients. This study would also help to make decision of the surgical timing for the ruptured aneurysm. In patients with normal response to acetazolamide activated vascular reactivity, vasodilatory drug such as calcium channel blocker is recommaned for the treatment of vasospasm. This study should be done as early as possible during the period of vasospasm to aid in the diagnosis, and in treating the vasospasm. Although this study has a minimal transient side effect of acetazolamide such as dizziness there was no major complication.

Effects of Nimodipine Treatment on Aneurysmal Subarachnoid Hemorrhage

Nimodipine, a potent, central active, calcium channel blocker, is known to relieve vasospasm, increase cerebral blood flow(CBF) and affect positively on clinical outcome in patients with subarachnoid hemorrhage. Experimentally, the potent effects on both vascular dilatation and increasing CBF were proven. However, there are still controversies and many debates at present about the actual clinical effects of nimodipine on subarachnoid hemorrhage. To evaluate the clinical effectiveness of nimodipine on aneurysmal subarachnoid hemorrhage in our series, we analyzed 122 consecutive patients with ruptured aneurysms who underwent operations between October, 1993 and June, 1995. These patients were grouped as follow: Group I consisted of 63 cases(52%) in which the patients were treated with nimodipine and Group II consisted of 59 cases(48%) in which the patients were treated conventionally. Administration of nimodipine was started immediately after the radiological diagnosis of ruptured aneurysm. The dose of nimodipine was 0.5microg/kg/min via continuous intravenous infusion for 7 to 10 days after the subarachnoid hemorrhage. After a course of intravenous treatment, oral administration of nimodipine was then continued for up to 21 days after subarachnoid hemorrhage in a dose of 60mg every four hours. We analyzed two groups based on patient's age, sex, aneurysmal location and size, timing of surgery, presence of hypertension, Hunt-Hess grade, presence of vasospasm on preoperative angiography and Fisher's CT classification. We also analyzed the incidence of delayed ischemic deficits(DID) and outcome(GOS) in each group. There were no significant differences in any of these parameters between nimodipine-treated group and the control group(p>0.05) and also, no significant differences in the distribution of DID or outcome between two groups (p>0.05). Based on these results, we conclude that nimodipine does not provide any significant beneficial effects on the prevention of DID and outcome in the patients with aneurysmal subarachnoid hemorrhage.

Overall Surgical Results and Causes of Unfavorable Outcome in Good Grade Patients with Intracranial Aneurysm

We analyzed the overall surgical results in 100 patients with intracranial aneurysms operated in Presbyterian Medical Center during the period from June 1990 to December 1993. Preoperatively, all patients were in Hunt and Hess grades I-III. Overall outcomes revealed 83 patients(83%) of good outcome, 10 patients(0%) of fair outcome. 3 patients(3%) of poor outcome, and 4 patients(4%) of dead outcome. The outcome was worse if surgery was performed in the 4 to 10 day post- bleed interval(P<0.05) and there was no statistical difference of the rate of good outcome between the parients operated at 0 to 3 days, and 11 day more after subarachnoid hemorrhage. In good grade patients, surgical trauma rather than delayed ischemic deficit was considered as the major cause of unfavorable outcome of aneurysm surgery. Intermedia to period operation increased the chance of postoperative delayed ischemic deficit. Systemic complications and vasospasm were the major causes of dead outcome in the oldaged patients.

Outcome of Nimodipine Treatment on the Surgical Cases of Aneurysmal Subarachnoid Hemorrhage

In order to elucidate the clinical effectiveness of nimodipine treatment, we analyzed 322 consecutive patients with the aneurysmal subarachnoid hemorrhage operated between September, 1987 and December, 1991. The nimodipine treatment group of one hundred and forty-two patients(44.1%) was compared with the control group of one hundred and eighty patients(55.9%) treated without nimodipine during this period. The patients were randomly allocated to either group. The nimodipine was infused intravenously at 30 microgram/Kg/hr for the first week beginning on the day of admission and then given orally at 360 mg/day for the following two weeks. Statistical anayses were done using the Student's t-test and clinical variables were compared using the chi-square, Mantel-Haenszel chi-square, two-tailed Fisher's exact test. There was no difference in clinical and radiological variables known to influence the outcome of the disease, such as age, sex, presence of hypertension, history of previous subarachnoid hemorrhage, preoperative categorization by Hunt and Hess grade and Fisher's classification, presence of hydrocephalus, location of aneurysm, multiplicity and vasospasm on preoperative angiography(p>0.05). The only difference was in the timing of surgery(p0.05, respectively). The number of patients with good functional recovery and the number of who developed delayed ischemic deficit(DID) were not significantly different between the group (P>0.05), respectively. Nimodipine treatment did not improve the rate of good outcome in the aneurysmal subarachnoid hemorrhage in our study.

Role of Transcranial Doppler Study in the Patients with Ruptured Cerebral Aneurysm

The authors performed prospectively the transcranial Doppler monitoring of middle cerebral arteries in 37 patients with ruptured cerebral aneurysm. The entry criteria for the study were confined to the patients who had clinical Grades of 1, 2, or 3, and were operated within 4 days after bleeding. There were several sonographic risk factors of developing delayed ischemic deficits; 1) An early steep increase of flow velocity exceeding 120 cm/sec. 2) An increase of maximum flow velocity more than 140 cm/sec. 3) The flow velocity increasing simultaneously with the onset of delayed ischemic deficit in which case preventive treatment was impossible. 4) Prolonged elevation of flow velocity for more than 7 days despite of aggressive treatment. It seemed to be mandatory to start preventive and aggressive treatment for the asymptomatic patients who showed higher flow velocity than 140 cm/sec. Transcranial Doppler sonography has another potential on deciding the timing of surgery.

The Therapeutic Effect of Nizofenone in the Acute Stage Following Subarachnoid Hemorrhage

We administered new imidazole dervative, nizofenone, to 15 cases in the acute stage following subarachnoid hemorrhage between December, 1990 and March, 1991 to determine its therapeutic value of ischemic protection. The appearance of delayed ischemic deficit was not prevented, but its prognostic adverse effect was ameliorated. The ability to perform the normal activity was 67% in the group which did not show the delayed ischemi deficit. And the ability to perform the normal activity was also 67% in the group whih showed the delayed ischemic deficit. No significant side effect was seen in the end of its administration. But in 6 cases, the administration was stopped because of deterioration of patient' consciousness level despite its administration. No therapeutic value was observed in the poor grade(Hunt and Hess grade III-IV) patients. The ability to perform the normal activity was still 29% in the poor grade group. The mortality was 13% despite nizofenone. In this clinical trial, we concluded that nizofenone had the ameliorating effect to the adverse effect of the delayed ischemic deficit in the good grade(Hunt and Hess grade I-II) patients. But the effect to the poor grade patients was not observed. So large scaled controlld study would be necessary to verify its good therapeutic effect to the whole population of subarachnoid hemorrhage patients.

Delayed Ischemic Deficit following Spontaneous Subarachnoid Homorrhage

Of 286 patients with spontaneous subarachnoid hemorrhage over the past 5 years, 201 patients underwent operation after confirming the ruptured aneurysms. Among the operated patients, 31 developed dealyed ischemic deficit(DID) pre-or post-operatively. DID developed as early as 4 dyas and as late as 29 dyas after the subarachnoid hemorrhage. The severity of hemorrhage based on Fisher group, subarachnoid hemorrhage assoicated with intracerebral hemorrhage and/or intraventricular hemorrhage, surgery within 3 days after the subarachnoid hemorrhage were closely related with higher incidence of DID. Inspite of vigorous therapy, 3 died but 23 recovered satisfactorily.

Study on Timing of Surgery for Ruptured Intracranial Aneurysms

The optimum timing of surgery for ruptured intracranial aneurysms still remains controversial. In order to compare the total management outcome between early and late surgery a retrospective analysis was carried out. Of 159 patients, 97 patients were selected according to the entry criteria and were divided into two groups ; group I(46pts.) was early surgery planned patients and group II(51 pts.) was late surgery planned patients. The results obtained are as follows ; 1) The incidence of a good recovery for the early surgery planned group was 74%, and that of the late surgery planned group was 67%, but there was no statistically significant difference between two groups. 2) The incidence of a delayed ischemic deficit was 24% for the early surgery planned group, and 29% for the late surgery planned group, with no statistically significant difference. But, the incidence of rebleeding was 2% for the early surgery group, and 14% for the late surgery planned group, so there was a statistically significant difference here. 3) The total management outcome of the early and late surgery planned group was similar, but early surgery was advantageous for the prevention of rebleeding.

Electrolyte Imbalance after Aneurysmal Subarachnoid Hemorrhage

Authors analyzed 173 patients diagnosed as and treated for aneurysmal subarachnoid hemorrhage at the Department of Neurosurgery in Presbyterian Medical Center, Chonju and Yonsei University College of Medicine, Seoul, from January 1, 1985 to December 31, 1986. Results of the analysis are summarized as follows; 1) The electrolyte imbalance and delayed ischemic deficit have significant relationships. They have higher incidence in ruptured aneurysms adjascent to hypothalamus, onset at similar time and have tendency to accompany each other. 2) The precipitating factors of vasopasm and electrolyte imbalance have significant relationships. The incidence of electrolyte imbalance is higher in the group of high Hunt & Hess grade, high Fisher grade, presence of basal cistern hemorrhage. 3) Inspite of ordinary fluid and sodium supplement, the hyponatremia group has the same prognosis as group with normal electrolyte concentration, and duration of hyponatremia is not prolonged compared to the group with strict fluid restriction as presented by other authors.