"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.

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.