Predicting outcome in poor-grade patients with subarachnoid hemorrhage: a retrospective review of 159 aggressively managed cases

Anemia and transfusion after subarachnoid hemorrhage

Delayed cerebral ischemia after subarachnoid hemorrhage (SAH) may be affected by a number of factors, including cerebral blood flow and oxygen delivery. Anemia affects about half of patients with SAH and is associated with worse outcome. Anemia also may contribute to the development of or exacerbate delayed cerebral ischemia. This review was designed to examine the prevalence and impact of anemia in patients with SAH and to evaluate the effects of transfusion. A literature search was made to identify original research on anemia and transfusion in SAH patients. A total of 27 articles were identified that addressed the effects of red blood cell transfusion (RBCT) on brain physiology, anemia in SAH, and clinical management with RBCT or erythropoietin. Most studies provided retrospectively analyzed data of very low-quality according to the GRADE criteria. While RBCT can have beneficial effects on brain physiology, RBCT may be associated with medical complications, infection, vasospasm, and poor outcome after SAH. The effects may vary with disease severity or the presence of vasospasm, but it remains unclear whether RBCTs are a marker of disease severity or a cause of worse outcome. Erythropoietin data are limited. The literature review further suggests that the results of the Transfusion Requirements in Critical Care Trial and subsequent observational studies on RBCT in general critical care do not apply to SAH patients and that randomized trials to address the role of RBCT in SAH are required.

Predictors of outcome in World Federation of Neurologic Surgeons grade V aneurysmal subarachnoid hemorrhage patients

BACKGROUND

Only a small percentage of World Federation of Neurologic Surgeons grade V aneurysmal subarachnoid hemorrhage patients have a favorable outcome. The influence of clinical parameters on outcome was assessed.

METHODS

Retrospective evaluation of consecutive patients admitted from 2000-2007 with grade V subarachnoid hemorrhage at two institutions by evaluating, over time, the motor value of the Glasgow Coma Scale, effects of external ventricular drainage and rebleeding on outcome. Six-month outcome was assessed with the extended Glasgow Outcome Scale; favorable outcome was defined as good recovery or moderately disabled.

FINDINGS

Of 126 patients, 28 had absent brainstem reflexes, without improvement after external ventricular drainage. Rebleeding occurred in 26 patients, resulting in treatment withdrawal in 14. Only one patient had a favorable outcome after rebleeding. Of the 84 remaining patients, 61 improved at day 2 after subarachnoid hemorrhage to Glasgow Coma Scale motor value ≥4; 24 of these (39%) had a favorable outcome. All 23 patients with a Glasgow Coma Scale motor value ≤3 had an unfavorable outcome or died. Patients younger than 65 yrs of age had a better outcome (p < .03). Hydrocephalus was present in 71 of 84 patients. Favorable outcome was similar for patients with a positive external ventricular drainage response (8 of 28) as compared to no response to external ventricular drainage (12 of 43).

INTERPRETATION

The high rebleeding rate and subsequent poor outcome in World Federation of Neurologic Surgeons grade V patients warrants early treatment to secure the ruptured aneurysm. Favorable outcome was seen in 39% of patients with a Glasgow Coma Scale motor value ≥4 at day 2. In this study, patients with Glasgow Coma Scale motor value ≤3 at day 2 all had a very poor prognosis.

Risk profile of patients with poor-grade aneurysmal subarachnoid hemorrhage using early perfusion computed tomography

OBJECTIVE

To determine whether perfusion computed tomography (CT) is useful for identifying patients with poor-grade subarachnoid hemorrhage (SAH) with reversible etiologies and whether early obliteration in patients with poor-grade aneurysmal SAH leads to favorable outcomes.

METHODS

Patients with new-onset aneurysmal SAH in World Federation of Neurological Surgeons (WFNS) grade IV or V neurologic condition who had perfusion CT performed at admission were eligible for the study. The study retrospectively enrolled 38 patients seen between January 2007 and July 2009. The decision to perform an early obliteration was made by the family after a discussion with the neurosurgeons, neurointensivists, and interventional radiologists. The functional outcomes were correlated with the Glasgow Outcome Scale (GOS) at 6 months, and quantitative perfusion CT data were collected.

RESULTS

This study included 10 (26%) grade IV and 28 (74%) grade V patients. Favorable outcomes occurred in 19 (50%) patients, and 11 (29%) patients died. After a multivariate logistic regression analysis of the parameters, older age (odds ratio 1.104, P = 0.0317), bilateral prolonged mean transient time (MTT) at the thalami (odds ratio 4.155, P = 0.0362), and early obliteration (odds ratio 0.098, P = 0.003) were predictive of poor outcome.

CONCLUSIONS

Early bilateral prolonged MTT at the thalami and old age are associated with a poor outcome. Early obliteration benefits a significant portion of SAH patients.

Outcomes of Endovascular Coiling in Patients with Intracranial Aneurysms Presenting with Poor Clinical and SAH Grade

Although the treatment of intracranial aneurysms has made significant advances, prediction of outcomes in poor grades has always been difficult. We present our findings of patients in poor clinical and SAH grade treated with endovascular coiling. We aimed to evaluate the clinical outcomes in patients presenting with poorer neurological and SAH grades treated by endovascular techniques. Of 190 patients who presented with SAH over a period of nine years, 34 were of poorer clinical grade (Hunt & Hess Grades 4 and 5), of whom 30 presented with H&H grade 4 and four with grade 5. 44.1% of the 34 patients belonged to Fischer grade 4. We assessed the technical success and final outcomes based on the Glasgow outcome scale. Of the 30 patients with grade 4, 81.4% had a good outcome. Two out of four patients with grade 5 had a poor outcome. 82.5% of the patients with Fischer grade 4 had a good outcome. None of the poor outcomes were procedure-related. Endovascular treatment with its higher rates of technical success, lower complication rates and better outcomes should be recommended as the treatment of choice in patients with intracranial aneurysms even in patients with poorer clinical and SAH grades.

Development of a kit to treat subarachnoid hemorrhage by intrathecal simple urokinase infusion (ITSUKI) therapy: preliminary results in patients with World Federation of Neurological Surgery (WFNS) grade V subarachnoid hemorrhage

OBJECTIVE

To report the effectiveness of intrathecal selective administration of urokinase infusion (ITSUKI) therapy delivered via a special kit (ITSUKit), developed to prevent vasospasm in patients with ruptured aneurysms who had undergone Guglielmi detachable coil (GDC) placement, in patients with World Federation of Neurological Surgery (WFNS) grade V subarachnoid hemorrhage (SAH).

METHODS

A study of ITSUKI therapy with or without ventricular drainage enrolled 6 patients with WFNS grade V SAH owing to ruptured intracranial aneurysms who were eligible for coil embolization. The procedures were performed within 48 hours of the occurrence of aneurysmal SAH. The incidence of symptomatic vasospasm and the clinical outcomes based on the Glasgow Outcome Scale (GOS) were assessed at 6 months after SAH onset.

RESULTS

All patients underwent complete coil embolization. There were no side effects or adverse reactions attributable to ITSUKI therapy. Symptomatic vasospasm occurred in one patient (16.7%). There were no patients with hydrocephalus. Based on the GOS, one patient had a good outcome, two manifested moderate disability, and three manifested severe disability.

CONCLUSIONS

The results showed that the ITSUKit was useful for ITSUKI therapy. Although the combination of coil embolization and ITSUKI therapy did not completely eliminate WFNS grade V SAH, it significantly improved the treatment outcome in some patients.

Treatment Outcome of Aneurysmal Subarachnoid Hemorrhage in Patients Aged 70 Years and Older

BACKGROUND:

The incidence of subarachnoid hemorrhage is increasing, especially in the elderly as life expectancy increases. Aggressive treatment of aneurysms in the elderly is usually avoided because of a presumed poor prognosis.

OBJECTIVE:

The aim of this study was to assess the outcome of treatment in patients older than 70 years old.

METHODS:

We performed a retrospective chart review of 150 patients aged 70 years and older who were treated at Jefferson Hospital from 2004 to 2009. Data including World Federation of Neurological Surgeons grade and Hunt and Hess classification, specific management components, and treatment outcome on discharge were analyzed.

RESULTS:

One hundred ten patients had aneurysms coiled, 9 patients had aneurysms clipped, 11 patients had aneurysms that were not treated, and 20 patients had no visible aneurysms. Overall, increased World Federation of Neurological Surgeons grades correlated strongly with poor clinical outcome. Statistical tests indicate that patients who died (mean, 78.8, n = 35) or who went into rehabilitation (mean, 76.5, n = 81) were significantly older than patients who were discharged home (mean, 73.1, n = 20). However, day of presentation after initial symptom(s) of subarachnoid hemorrhage and placement of ventriculoperitoneal shunt also influenced clinical outcome. Patients who had a ventriculoperitoneal shunt were more likely to go into rehabilitation than patients who did not, and patients without a ventriculoperitoneal shunt were more likely to die.

CONCLUSION:

Older age should not preclude a patient from aneurysm treatment. Factors such as low Hunt and Hess or World Federation of Neurological Surgeons grades, earlier presentation to the hospital after initial symptoms, early shunting, prompt interventions, and tailored postoperative management can result in favorable clinical outcomes.

Intraventricular hemorrhage volume predicts poor outcomes but not delayed ischemic neurological deficits among patients with ruptured cerebral aneurysms

BACKGROUND

Intraventricular hemorrhage (IVH) predicts worse outcomes following aneurysmal subarachnoid hemorrhage (SAH). One potential mechanism is that IVH predisposes to the development of delayed ischemic neurological deficits (DINDs). No previous studies have evaluated the association between IVH volume (in milliliters) and subsequent development of DINDs or poor outcomes.

OBJECTIVE

To assess the association between the volume of IVH and the subsequent development of DINDs, delayed cerebral infarction, death, and poor neurological outcomes, specifically among patients with concomitant SAH and IVH.

METHODS

We performed a cohort study involving 152 consecutive patients with concomitant SAH and IVH. To determine volume of IVH, we used the IVH Score, shown to correlate well with computerized volumetric assessment. To determine the relative quantity of subarachnoid blood, we applied the SAH Sum Score. Multivariate logistic regression was used to adjust for potential confounders.

RESULTS

There was no significant association between IVH volume and the development of DINDs or delayed infarction. In contrast, patients with poor neurological outcomes had significantly larger baseline IVH volume (mean, 11.8 mL vs 3.8 mL, P = .001). In the multivariate analysis, IVH volume was an independent predictor of poor outcomes (OR per mL: 1.11 [1.04-1.18]). Patients in the highest quartile for IVH volume were far more likely to progress to poor outcome compared with those in the lowest quartile (OR 4.09 [1.32-12.65]). Interobserver agreement in the determination of IVH Score was moderate to good.

CONCLUSIONS

IVH volume is an independent predictor of poor neurological outcomes, even after adjusting for the amount of subarachnoid blood. The pathophysiology of this association does not appear to involve an increased risk of DINDs or delayed infarction. Measures aimed at accelerating IVH clearance, such as intraventricular thrombolysis, merit further evaluation.

Perfusion computed tomographic imaging and surgical selection with patients after poor-grade aneurysmal subarachnoid hemorrhage

BACKGROUND

Patients with ruptured aneurysms who present in coma have already experienced significant brain injury, require intensive resuscitation, have aneurysms that are difficult to treat, and generally fare poorly despite aggressive intervention.

OBJECTIVE

To determine whether surgical outcomes in comatose patients with ruptured aneurysms in a modern series might be better than previously reported because of changing surgical indications and multidisciplinary management, and to determine whether perfusion computed tomography (PCT) imaging might help select patients for surgery.

METHODS

A consecutive series of 78 patients with poor-grade aneurysms treated surgically was reviewed. Management consisted of resuscitation, early surgery, intracranial pressure control, comprehensive intensive care, and endovascular therapy for vasospasm. Cerebral blood flow (CBF), volume (CBV), and mean transit time (MTT) were measured on admission PCT studies and correlated with outcomes.

RESULTS

Among 58 grade IV patients (74%) and 20 grade V patients (26%), 44 patients (56%) had favorable outcomes (Glasgow Outcome Scale 5 and 4), and 34 patients (44%) had unfavorable outcomes. Favorable outcomes among grade IV patients were observed in 71%, whereas mortality among grade V patients was 60%. Sixteen patients (89%) with normal cerebral perfusion had favorable outcomes and all 13 patients with hemispheric or global hypoperfusion had unfavorable outcomes.

CONCLUSIONS

PCT provides physiological data that are immediately applicable and can guide decisions to aggressively manage comatose patients with ruptured aneurysms. Grade IV patients with normal or focally abnormal perfusion are good candidates for treatment, whereas grade V patients with hemispheric or global hypoperfusion are poor candidates. Surgery effectively excludes aneurysms with complex anatomy and relieves increased intracranial pressure with hematoma evacuation, lobectomy, and/or hemicraniectomy. Modern neurosurgical, endovascular, and neurointensive critical care produces favorable outcomes in a substantial percentage of carefully selected patients.

Decompressive hemicraniectomy after aneurysmal subarachnoid hemorrhage

BACKGROUND

The aim of this study was to document the effects of decompressive hemicraniectomy (DHC) on neurologic outcome in patients treated for aneurysmal subarachnoid hemorrhage (SAH) and developing otherwise uncontrollable intracranial hypertension.

METHODS

Sixty-six of the 964 patients (6.8%) treated for aneurysmal SAH underwent DHC and were stratified as follows: Group 1, patients undergoing aneurysm clipping and DHC in one surgical sitting (i.e., primary DHC). Group 2, patients receiving aneurysm embolization and thereafter undergoing DHC. Group 3, patients undergoing standard aneurysm surgery and requiring DHC later in the post-SAH period. Group 4, patients with insufficient primary DHC and later requiring surgical enlargement of the craniectomy.

RESULTS

Outcome was not influenced by the timing of DHC, but depended on the pathology underlying intracranial hypertension (i.e., whether lesions were primary hemorrhagic or secondary ischemic in origin). Patients with large hematomas, undergoing primary, secondary, or repeat DHC (46/66) had significantly better outcomes than the 20 patients treated for edema and delayed ischemic infarctions. There were 16 (34.8%) of the 46 patients in the hematoma group, but only 2 (10.0%) of the 20 patients in the ischemia group had favorable neurologic outcomes, defined as modified Rankin Scale scores 0-3 (P value = 0.038).

CONCLUSIONS

In the largest series of SAH patients to date who received both microsurgical and endovascular treatment of ruptured aneurysms, and who underwent DHC for otherwise uncontrollable intracranial hypertension. Neurologic outcome was significantly correlated with the pathology underlying intracranial hypertension. DHC beneficially affected neurologic outcomes in patients with space-occupying hematomas, whereas patients suffering delayed ischemic strokes did not benefit to the same extent.

Acute-stage diffusion-weighted magnetic resonance imaging for predicting outcome of poor-grade aneurysmal subarachnoid hemorrhage

We investigated the role of acute-stage diffusion-weighted images (DWIs) for predicting outcome of poor-grade subarachnoid hemorrhage (SAH). This study included 38 patients with poor-grade SAH who underwent DWI within 24 h after onset. DWI findings were divided into three groups on the basis of lesion area: none (N), spotty (S, <or=10 mm(2)), or areal (A, >10 mm(2)). We evaluated the correlation between preoperative DWI findings and clinical outcome, and the characteristics of DWI abnormalities. DWI abnormalities were revealed in 81.6% of cases (group S 34.2%; group A 47.3%). All patients in groups N and S and 73.3% of patients in group A were treated radically. For those patients without rerupture, favorable outcomes were achieved in 100% of group N, 53.8% of group S, and 0% of group A. Abnormal lesions on initial DWI, which resulted in permanent lesions, showed a mean apparent diffusion coefficient ratio to the control value of 0.71, which was significantly lower than 0.95 observed in reversible lesions (P<0.01). We recommend radical treatment for even poor-grade SAH as long as the preoperative DWI shows no or only spotty lesions. DWI may provide an objective means to estimate the outcome of poor-grade SAH.

Patient Transport and Brain Oxygen in Comatose Patients

OBJECTIVE

Transport of critically ill intensive care unit patients may be hazardous. We examined whether brain oxygen (brain tissue oxygen partial pressure [PbtO2]) is influenced by transport to and from a follow-up head computed tomography (transport head computed tomography [tHCT]) scan.

METHODS

Forty-five patients (24 men, 21 women; Glasgow Coma Scale score ≤8; mean age, 47.3 ± 19.0 years) who had a traumatic brain injury (n = 26) or subarachnoid hemorrhage (n = 19) were retrospectively identified from a prospective observational cohort of PbtO2 monitoring in a neurosurgical intensive care unit at a university-based level I trauma center. PbtO2, intracranial pressure, and cerebral perfusion pressure were monitored continuously and compared during the 3 hours before and after 100 tHCT scans.

RESULTS

The mean PbtO2 before and after the tHCT scans for all 100 scans was 37.9 ± 19.8 mm Hg and 33.9 ± 17.2 mm Hg, respectively (P = .0001). A decrease in PbtO2 (&gt;5%) occurred after 54 tHCTs (54%) and in 36 patients (80%). In instances in which a decrease occurred, the average decrease in mean, minimum, and maximum PbtO2 was 23.6%, 29%, and 18.1%, respectively. This decrease was greater when PbtO2 was compromised (&lt;25 mm Hg) before tHCT. An episode of brain hypoxia (&lt;15 mm Hg) was identified in the 3 hours before tHCT in 9 and after tHCT in 19 instances. On average, an episode of brain hypoxia was 46.6 ± 16.0 (standard error) minutes longer after tHCT than before tHCT (P = .008). Multivariate analysis suggests that changes in lung function (PaO2/fraction of inspired oxygen [FiO2] ratio) may account for the reduced PbtO2 after tHCT (parameter estimate 0.45, 95% confidence interval: 0.024–0.871; P = .04).

CONCLUSION

These data suggest that transport to and from the intensive care unit may adversely affect PbtO2. This deleterious effect is greater when PbtO2 is already compromised and may be associated with lung function.

Cognitive Functioning and Health-Related Quality of Life 1 Year After Aneurysmal Subarachnoid Hemorrhage in Preoperative Comatose Patients (Hunt and Hess Grade V Patients)

OBJECTIVE

The objective of this study was to determine cognitive functioning and health-related quality of life 1 year after aneurysmal subarachnoid hemorrhage in preoperative comatose patients (Hunt and Hess Grade V patients).

METHODS

Patients who were comatose at hospital arrival and thereafter were investigated for 1 year using a comprehensive neuropsychological test battery and 2 HRQOL questionnaires.

RESULTS

Thirty-five of 70 patients survived the bleed, and 26 underwent neuropsychological testing. Two distinct patient groups emerged, one (n = 14) with good cognitive function, having mild deficits only, and the other (n = 12) with poor cognitive and poor motor function. Patients performing poorly were older (P = .04), had fewer years of education (P = .005) and larger preoperative ventricular scores, and were more often shunted (P = .02). There were also differences between the 2 groups in the Glasgow Outcome Scale (P = .001), the modified Rankin Scale (P = .001), and employment status. HRQOL was more reduced in patients with poor cognitive function.

CONCLUSION

A high fraction of survivors among preoperative comatose aneurysmal SAH patients (Hunt and Hess grade V) recover to good physical and cognitive function, enabling them to live a normal life.

Red Blood Cell Transfusion Is Associated With Infection and Extracerebral Complications After Subarachnoid Hemorrhage

OBJECTIVE

Red blood cell transfusion (RBCT) is associated with medical complications in general medical and surgical patients. We examined the hypothesis that RBCT during intensive care unit (ICU) care is associated with medical complications after subarachnoid hemorrhage (SAH).

METHODS

We retrospectively analyzed a prospective observational database containing 421 patients with SAH (mean age, 51.5 years; standard deviation, 14.6 years). Logistic regression models were used to adjust for age, admission hemoglobin (Hgb), clinical grade, average ICU Hgb, and symptomatic vasospasm.

RESULTS

Two hundred fourteen patients received an RBCT during their ICU stay. Medical complications were identified in 156 patients and were more common in those who received blood (46%) than in those who did not (29.8%) (P &lt; .001). Major medical complications (cardiac, pulmonary, renal, or hepatic) occurred in 111 patients, and minor complications (eg, skin rash, deep vein thrombosis) occurred in 45 patients. Any non–central nervous system infection (n = 183; P &lt; .001), including pneumonia (n = 103; P &lt; .001) or septicemia (n = 36; P = .02), was more common with RBCT. Central nervous system infections (meningitis, cranial wound, n = 15) also were associated with RBCT (P = .03). Mechanically ventilated patients (n = 259) were more likely to have received an RBCT than those who did not (P &lt; .001). When logistic regression was used to control for age, admission clinical grade and Hgb, average ICU Hgb, symptomatic vasospasm, and other admission variables associated with outcome, the following factors (odds ratio; 95% confidence interval) were associated with RBCT: any medical complication (1.8; 1.1–3.0), major medical complications (2.1; 1.2–3.7), any infection (2.8; 1.7–4.5), pneumonia (2.6; 1.5–4.7), septicemia (2.9; 1.2–6.8), and need for mechanical ventilation (2.8; 1.5–5.1).

CONCLUSION

These data suggest that RBCTs are associated with medical complications after SAH. However, the data do not infer causation, and further study is necessary to better define the indications for transfusion after SAH.

Ultra-early surgery for poor-grade intracranial aneurysmal subarachnoid hemorrhage: a preliminary study

PURPOSE

To describe the therapeutic effect and possibility of the ultra-early surgery for poor-grade aneurysmal subarachnoid hemorrhage (Hunt-Hess grades IV-V).

MATERIALS AND METHODS

Nine cases with intracranial aneurysms, demonstrated by computed tomographic angiography (CTA), were treated by ultra-early surgery under general anesthesia within 24 hours from subarachnoid hemorrhage (SAH), 5 cases were treated within 6 hours and 4 cases in 6 - 24 hours. Preoperative Hunt-Hess grade: 6 cases were IV and 3 cases were V. The clinical outcome was evaluated by Glasgow Outcome Scores (GOS).

RESULTS

In operation, difficult dissection occurred in 5 cases (55.6%), and rupture of aneurysm occurred and temporary obstructions were performed in 4 cases (44.4%). After clipping of aneurysm, 2 cases underwent V-P shunt because of hydrocephalus, pulmonary infection occurred in 3 cases, hypothalamus reaction accompanied with upper gastrointestinal hemorrhage in 2 cases. The clinical outcome were favorable (GOS 4-5) in 4 cases (44.4%), dissatisfied (GOS 2-3) in 3 cases (33.3%), and dead (GOS 1) in 2 cases (22.2%) when patients departed from our hospital.

CONCLUSION

The ultra-early surgery can avoid early rebleeding of intracranial aneurysm, therefore, should be considered in the treatment of Hunt-Hess grade IV-V intracranial aneurysms. The appliance of CTA can make it possible to use of ultra-early surgery and improve the therapeutic effect.

CLASSIFICATION OF CEREBRAL INFARCTION AFTER SUBARACHNOID HEMORRHAGE IMPACTS OUTCOME

OBJECTIVE

Cerebral infarction (CI) after subarachnoid hemorrhage (SAH) is well described, but there is no validated classification.

METHODS

We prospectively enrolled 119 consecutive patients with SAH. We recorded admission World Federation of Neurological Societies grade and Columbia computed tomographic scores. Vasospasm was defined as transcranial Doppler of greater than 120 cm/second or typical clinical symptoms. CI was defined by computed tomographic or magnetic resonance imaging scan, and the date of discovery was recorded. CI was classified by a previously published method (single versus multiple, cortical versus deep versus combined). Outcomes were assessed at 14 days or discharge with the National Institutes of Health Stroke Scale and modified Rankin Scale (mRS), and at 28 days and 3 months with the mRS.

RESULTS

Vasospasm was associated with a higher risk of CI (odds ratio, 2.6; 95% confidence interval, 1.3–5.6; P = 0.01). The median time to detection was 4.2 days (interquartile range, 1.6–7.6 days) after SAH onset. CI classification was associated with the National Institutes of Health Stroke Scale score at 14 days (P = 0.002) and intensive care unit length of stay (P = 0.001). CI location (cortical, deep, or combined) was associated with National Institutes of Health Stroke Scale and mRS score at 14 days, and mRS score at 28 days and 3 months (P ≤ 0.02 for all). In a multiple logistic regression model, CI classification, World Federation of Neurological Societies grade, aneurysm diameter, and age were all associated with mRS score at 28 days and 3 months (P ≤ 0.05). Combined cortical and deep CI was associated with less improvement and poor outcome.

CONCLUSION

CI classification predicts outcomes after SAH. Future reports of CI after SAH should include this or similar descriptive information.

Hemoglobin Concentration and Cerebral Metabolism in Patients With Aneurysmal Subarachnoid Hemorrhage

Background and Purpose— The optimal hemoglobin (Hgb) target after aneurysmal subarachnoid hemorrhage is not precisely known. We sought to examine the threshold of Hgb concentration associated with an increased risk of cerebral metabolic dysfunction in patients with poor-grade subarachnoid hemorrhage.

Methods— Twenty consecutive patients with poor-grade subarachnoid hemorrhage who underwent multimodality neuromonitoring (intracranial pressure, brain tissue oxygen tension, cerebral microdialysis) were studied prospectively. Brain tissue oxygen tension and extracellular lactate/pyruvate ratio were used as markers of cerebral metabolic dysfunction and the relationship between Hgb concentrations and the incidence of brain hypoxia (defined by a brain tissue oxygen tension <20 mm Hg) and cell energy dysfunction (defined by a lactate/pyruvate ratio >40) was analyzed.

Results— Compared with higher Hgb concentrations, a Hgb concentration <9 g/dL was associated with lower brain tissue oxygen tension (27.2 [interquartile range, 21.2 to 33.1] versus 19.9 [interquartile range, 7.1 to 33.1] mm Hg, P =0.02), higher lactate/pyruvate ratio (29 [interquartile range, 25 to 38] versus 36 [interquartile range, 26 to 59], P =0.16), and an increased incidence of brain hypoxia (21% versus 52%, P <0.01) and cell energy dysfunction (23% versus 43%, P =0.03). On multivariable analysis, a Hgb concentration <9 g/dL was associated with a higher risk of brain hypoxia (OR, 7.92; 95% CI, 2.32 to 27.09; P <0.01) and cell energy dysfunction (OR, 4.24; 95% CI, 1.33 to 13.55; P =0.02) after adjusting for cerebral perfusion pressure, central venous pressure, PaO 2 /FIO 2 ratio, and symptomatic vasospasm.

Conclusions— A Hgb concentration <9 g/dL is associated with an increased incidence of brain hypoxia and cell energy dysfunction in patients with poor-grade subarachnoid hemorrhage.

Follow-up of Large Aneurysms Treated with Coil Embolization at an Acute Stage in Patients with Poor-Grade Subarachnoid Hemorrhage

SUMMARY

This study evaluated the clinical and angiographic outcome of large aneurysms treated with coil embolization at an acute stage in patients with poor-grade subarachnoid hemorrhage (SAH). Between July 1, 2001 and June 30, 2004, eight consecutive WFNS grade 5 patients with large aneurysms (15~23 mm) were treated with endovascular coil embolization within two days and followed for at least 30 months. There were three middle cerebral and five internal carotid artery aneurysms. No patients were treated by craniotomy and none survived without treatment. Two patients died of primary brain damage or cerebral vasospasm within one month. One patient died of pneumonia at 24 months. Four patients were alive with good recovery or moderate disability at the time of final follow-up (30~66 months). Angiography immediately after the procedure showed complete occlusion in three, neck remnant in four, and body filling in one patient. No complication was seen related to the procedure. Three aneurysms that were initially neck remnant developed body filling due to coil compaction. Two were re-treated with coils at six and 12 months and resulted in neck remnant. One patient refused re-treatment and died of re-bleeding. Endovascular coil embolization can be selected at an acute stage for the treatment of aneurysms in patients with poor-grade SAH without intraparenchymal hematoma even if the aneur-ysm is large. Serial follow up by MRA/angiography is necessary for at least 12 months.

RESUSCITATION AND CRITICAL CARE OF POOR-GRADE SUBARACHNOID HEMORRHAGE

AS OUTCOMES HAVE improved for patients with aneurysmal subarachnoid hemorrhage, most mortality and morbidity that occur today are the result of severe diffuse brain injury in poor-grade patients. The premise of this review is that aggressive emergency cardiopulmonary and neurological resuscitation, coupled with early aneurysm repair and advanced multimodality monitoring in a specialized neurocritical care unit, offers the best approach for achieving further improvements in subarachnoid hemorrhage outcomes. Emergency care should focus on control of elevated intracranial pressure, optimization of cerebral perfusion and oxygenation, and medical and surgical therapy to prevent rebleeding. In the postoperative period, advanced monitoring techniques such as continuous electroencephalography, brain tissue oxygen monitoring, and microdialysis can detect harmful secondary insults, and may eventually be used as end points for goal-directed therapy, with the aim of creating an optimal physiological environment for the comatose injured brain. As part of this paradigm shift, it is essential that aggressive surgical and medical support be linked to compassionate end-of-life care. As neurosurgeons become confident that comfort care can be implemented in a straightforward fashion after a failed trial of early maximal intervention, the usual justification for withholding treatment (survival with neurological devastation) becomes less relevant, and lives may be saved as more patients recover beyond expectations.

Emergent Clipping without Prophylactic Decompressive Craniectomy in Patients with a Large Aneurysmal Intracerebral Hematoma

OBJECTIVE

Many vascular neurosurgeons tend to remove bone flap in patients with large aneurysmal intracerebral hematomas (ICH). However, relatively little work has been done regarding the effectiveness of prophylactic decompressive craniectomy in a patient with a large aneurysmal ICH.

METHODS

Large ICH was defined as hematoma when its volume exceeded 25 mL, ipsilateral to aneurysms. The patients were divided into two groups; aneurysmal subarachnoid hemorrhage (SAH) associated with large ICH, January, 1994 - December, 1999 (Group A, 41 patients), aneurysmal SAH associated with large ICH, January, 2000 - May, 2005 (Group B, 27 patients). Demographic and clinical variables including age, sex, hypertension, vasospasm, rebleeding, Hunt-Hess grade, aneurysm location, aneurysm size, and outcome were compared between two groups, and also compared between craniotomy and craniectomy patients in Group A.

RESULTS

In Group A, 21 of 41 patients underwent prophylactic decompressive craniectomy. In Group B, only two patients underwent craniectomy. Surgical outcome in Group A (good 23, poor 18) was statistically not different from Group B (good 15, poor 12). Surgical outcomes between craniectomy (good 12, poor 9) and craniotomy cases (good 11, poor 9) in Group A were also comparable.

CONCLUSION

We recommend that a craniotomy can be carried out safely without prophylactic craniectomy in patients with a large aneurysmal ICH if intracranial pressure is controllable with hematoma evacuation.

Brain oxygen tension and outcome in patients with aneurysmal subarachnoid hemorrhage

Object

Poor outcome is common after aneurysmal subarachnoid hemorrhage (SAH). Clinical studies suggest that cerebral hypoxia after traumatic brain injury is associated with poor outcome. In this study we examined the relationship between brain oxygen tension (PbtO2) and death after aneurysmal SAH.

Methods

Forty-six patients, including 34 women and 12 men (Glasgow Coma Scale Score ≤ 8 and median age 58.5 years) who underwent PbtO2 monitoring were studied prospectively during a 2-year period in a neurosurgical intensive care unit at a University Level I Trauma Center. Brain oxygen tension, intracranial pressure (ICP), mean arterial pressure, cerebral perfusion pressure (CPP), and brain temperature were continuously monitored, and treatment was directed toward ICP, CPP, and PbtO2 targets. The relationship between PbtO2 and 1-month survival was examined.

Results

Data were available from 5424 hours of PbtO2 monitoring. For the entire cohort the mean ICP, CPP, and PbtO2 were 13.85 ± 2.40, 84.05 ± 3.41, and 30.79 ± 1.91 mm Hg, respectively. Twenty-five patients died (54%). The mean daily PbtO2 was higher in survivors than nonsurvivors (33.94 ± 2.74 vs 28.14 ± 2.59 mm Hg; p = 0.05). In addition, survivors had significantly shorter episodes of compromised PbtO2 (defined as 15–25 mm Hg) than nonsurvivors (125.85 ± 15.44 vs 271.14 ± 55.23 minutes; p < 0.01). Intracranial pressure was similar in survivors and nonsurvivors. In contrast, the average CPP was significantly lower in nonsurvivors than survivors (76.96 ± 5.50 vs 92.49 ± 2.75 mm Hg; p = 0.01). When PbtO2 was stratified according to CPP level, survivors had higher PbtO2 levels. Following logistic regression, the number of episodes of compromised PbtO2 (odds ratio 1.1, 95% confidence interval 1.003–1.2) and number of episodes of cerebral hypoxia (< 15 mm Hg; odds ratio 1.3, 95% confidence interval 1.0–1.7) were more frequent in those who died.

Conclusions

Patient deaths after SAH may be associated with a lower mean PbtO2 and longer periods of compromised cerebral oxygenation than in survivors. This knowledge may be used to help direct therapy.

Effects of admission glucose level on mortality after subarachnoid hemorrhage: a comparison between short-term and long-term mortality

BACKGROUND

Admission hyperglycemia is associated with poor functional outcomes and risk of death in nondiabetic patients with acute ischemic stroke. However, there is still some debate about the effects of hyperglycemia in subarachnoid hemorrhage (SAH) patients. The purpose of this study was to assess whether the admission glucose level in patients with SAH is associated with short- and/or long-term mortality.

METHODS

A consecutive data set of SAH patients without diabetes was obtained from a prospective multicenter cohort of hemorrhagic stroke patients. The effects of glucose level were examined in relation to short- (30 days) or long-term mortality using Cox regression analysis. To eliminate the short-term effects of glucose level, the long-term effects were analyzed in the patients who survived for more than 30 days.

RESULTS

A total of 803 SAH patients were followed up in this study. The 30-day and final mortalities were 7.6% and 12.0%, respectively. Throughout the entire follow-up period, glucose level was found to be significantly associated with final mortality after adjusting for potential confounders (adjusted HR, 1.10; 95% CI, 1.01 to 1.19). Moreover, glucose level was found to be associated with short-term mortality (adjusted HR, 1.15; 95% CI, 1.05 to 1.27), but not with long-term mortality (adjusted HR, 0.97; 95% CI, 0.82 to 1.14).

CONCLUSIONS

We demonstrated that admission hyperglycemia has a harmful effect on short-term mortality, but not with long-term mortality in SAH patients without diabetes. Our results may be used as further evidence to support a hypothesis of harmful effects of hyperglycemia in SAH patients.

Comparisons of risk-adjusted clinical outcomes for patients with aneurysmal subarachnoid haemorrhage across eight teaching hospitals in Japan

OBJECTIVES

To assess predictive value of patient characteristics and severity of aneurysmal subarachnoid haemorrhage (SAH) patients for clinical outcomes, and thereby estimate risk-adjusted clinical outcomes and compare the outcomes across hospitals.

METHODS

We selected 256 aneurysmal SAH patients from eight teaching hospitals in Japan. The clinical outcomes of patients at the time of discharge were assessed by the Glasgow Outcome Scale (GOS). A multiple logistic regression analysis was performed to identify predictors for the GOS status at the time of discharge. The risk-adjusted proportion of patients with a favourable GOS outcome was then estimated for each facility and compared across hospitals.

RESULTS

The logistic regression analysis revealed that younger age (P < 0.001), patients with good World Federations of Neurological Surgeons grade at admission (P < 0.001) and absence of chronic renal failure or ischaemic heart disease as a comorbid condition (P < 0.001) were identified as significant predictors for favourable GOS outcome at the time of discharge among aneurysmal SAH patients (C statistic = 0.88). We found that one hospital had significantly better outcomes than the others.

CONCLUSION

After comparison of risk-adjusted values across hospitals, the clinical management methods of the hospital that showed the best performance were examined and shared among providers.

Endovascular therapy of distal anterior cerebral artery aneurysms-an effective treatment option

BACKGROUND

Surgical treatment of APAs is associated with relatively high morbidity and mortality. The aim of this study was to illustrate the technical achievements of endovascular procedures in the distal anterior cerebral artery area, technical difficulties and how they can be overcome, and the outcome of endovascular treatment of APAs.

METHODS

Between 1997 and 2006, of 49 patients with APAs at our institution, 29 were treated endovascularly (4.1% of all endovascularly treated aneurysms; F:M = 3.8; mean age, 52.8 +/- 11.5 years), and 12 were treated surgically. Twenty-one (72.4%) of the endovascularly treated patients had a subarachnoid hemorrhage. The mean observation period was 25 +/- 22.8 months.

RESULTS

In 27 (93.1%) cases, complete occlusion of the aneurysm was achieved. The intervention led to 5 (17.2%) cases of minor complications with no neurologic deficits: 2 thromboembolisms, 1 local thrombus, 1 occlusion, and 1 recurrent hemorrhage. Mortality related to the intervention was 3.4%. There was no morbidity associated with the elective procedures. The dome-to-neck ratio is the main predictor of reperfusion. The most important factor impairing the outcome in terms of the GOS status is the presence of an intraparenchymal hematoma, followed by thrombembolic complications.

CONCLUSION

Endovascular treatment of APAs is feasible, safe, and effective. Mortality and morbidity are comparable with surgical therapy. An intraparenchymal hematoma has a severe negative influence on the patient's condition after rehabilitation. In these cases, surgical intervention should be considered. In case of incomplete occlusion of the aneurysm, prompt reintervention is required.

Neurological impairment in rats after subarachnoid hemorrhage--a comparison of functional tests

Functional outcome has become a key parameter for the determination of the efficacy of therapeutic interventions. Unfortunately, functional tests are not established for filament perforation induced subarachnoid hemorrhage (SAH). Therefore, we evaluated generally applied functional tasks for their potential to discriminate between various degrees of neuronal damage. Rats were subjected to SAH by an endovascular filament and were randomly assigned to controls treated with 0.9% NaCl, moderately neuroprotective therapy with 7.5% NaCl, and highly effective neuroprotection by 7.5% NaCl+6% dextran 70 (HSD). Functional deficit was quantified daily using beam balance task, prehensile traction task, rotarod, a 6-point motor function score and a general neurological 100-point score. Only the HSD group exhibited significantly more surviving neurons at postoperative day 7. Despite significant variations in histomorphometry, beam balance, prehensile traction and rotarod failed to distinguish between groups. On the other hand, the 100-point neuroscore showed improved neurological recovery on postoperative day 1 for HSD. The 100-point neuroscore failed to discriminate between treatment arms at later time points and therefore seems to reflect predominantly early neurological dysfunction. In conclusion, the results of pure motor tasks after experimental SAH in rats should be carefully interpreted. The integration of a test regimen to examine long term cognitive deficits after rat SAH might be valuable to gain additional information about the functional consequences of morphological damage.

Outcomes of ruptured intracranial aneurysms treated by microsurgical clipping and endovascular coiling in a high-volume center

BACKGROUND AND PURPOSE

The purpose of this study was to analyze the 3-month outcomes of patients with aneurysmal subarachnoid hemorrhage (SAH) treated from January 2005 to June 2006. This paper describes the outcomes after treatment of aneurysmal SAH and comparison between patients treated by clipping or coiling in a high volume center.

MATERIALS AND METHODS

A retrospective chart review was performed of records of 195 consecutive patients with SAH. The overall outcome and the pretreatment variables predicting outcomes and the difference between the clipping and coiling groups were analyzed by logistic regression analysis.

RESULTS

A total of 105 (55%) patients had microsurgical clipping and 87 (45%) had endovascular coiling. At 3 months, 69% of patients recovered with no or mild disability. The predictors of a 3-month modified Rankin Scale (mRS) were Hunt and Hess (HH) grade on admission and the presence of intracerebral hemorrhage (ICH). Patients in the coiling group had worse admission grades; they had worse 3-month mRS (2.28 vs 1.73), but this was not significant when the groups were matched (P = .38). Vasospasm rate was significantly higher in the clipping group (66% vs 52%). The immediate incomplete occlusion rate of aneurysms was higher (21.7% vs 7.6%) in the coiling group.

CONCLUSION

The overall results of treatment of aneurysmal SAH have improved. There is no significant difference in the outcomes between the patients in the clipping and coiling groups.

CHARACTERISTICS OF NONTRAUMATIC SUBARACHNOID HEMORRHAGE IN THE UNITED STATES IN 2003

OBJECTIVE

Substantial progress has been made in the diagnosis and treatment of subarachnoid hemorrhage (SAH). However, studies of SAH in the United States do not include information more recent than 2001, precluding analysis of shifts in treatment methods. We examined the epidemiology and in-hospital outcomes of nontraumatic SAH in the United States.

METHODS

We analyzed nationally representative data from the 2003 Nationwide Inpatient Sample of the Healthcare Cost and Utilization Project to determine demographic and hospital characteristics, treatments, and in-hospital outcomes of patients with nontraumatic SAH.

RESULTS

In 2003, there were an estimated 31,476 discharges for nontraumatic SAH among patients aged 17 years or older, or 14.5 discharges per 100,000 adults. The in-hospital mortality rate was 25.3%. Microvascular clipping was performed in 7513 discharges, or 23.9% of inpatients with nontraumatic SAH; endovascular coiling was performed in 2849 discharges (9.1%). Adjusted odds of treatment with either procedure were significantly higher in urban teaching hospitals compared with urban nonteaching hospitals (odds ratio, 1.62; 95% confidence interval, 1.00–2.62) or rural hospitals (odds ratio, 3.08; 95% confidence interval, 1.93–4.91).

CONCLUSION

The in-hospital mortality rate associated with nontraumatic SAH continues to exceed 25%. Although it is unclear how many patients with nontraumatic SAH were actually diagnosed with a cerebral aneurysm, this study suggests that less than one-third of patients hospitalized for SAH receive surgical or endovascular treatment. Prospective studies are needed to elucidate either what systematic coding error is occurring in the national database or why patients may not receive treatment to secure a ruptured aneurysm.

Severe intracranial bleedings during endovascular procedures: outcome of surgically treated patients

OBJECTIVE

Severe intracranial bleedings (SIBs) during endovascular procedures (EPs) are accompanied by acute intracranial hypertension and brain herniation signs. The purpose of this study was to determine the effectiveness of urgent surgical management and its related patient outcome in cases with such a fatal complication.

METHOD

Medical records were reviewed retrospectively for the last 750 patients treated in our department in the past 12 years with acute non-traumatic intracranial bleeding, who underwent a diagnostic or therapeutic EP. Patients with a severe intra-procedural bleeding episode undergoing urgent surgical management (within 30 minutes after bleeding) were analysed.

RESULTS

Fourteen of 750 patients with ruptured vascular malformations presented a new SIB during EP. In nine patients, this occurred during initial angiography, two during aneurysm coiling, two during balloon angioplasty and one during arteriovenous malformation (AVM) embolization. The neurological condition 6 months later was good (independents patients) in seven cases with only a mild disability in two of them. Two patients showed a severe disability. Four patients died without recovering their consciousness. One patient presented a satisfactorily course but died weeks later owing to a pulmonary embolism.

CONCLUSION

Despite the fatal spontaneous prognosis of severe intracranial bleeding occurring during endovascular diagnostic or therapeutic procedures, a favorable outcome can be expected if an appropriated treatment was set within 30 minutes of the bleeding.

Inhibition of lipopolysaccharide stimulated interleukin-1beta production after subarachnoid hemorrhage

PURPOSE

To identify the characteristics of cytokine production from peripheral blood mononuclear cells (PBMCs) in response to lipopolysaccharide (LPS) in patients with subarachnoid hemorrhage (SAH).

METHODS

Blood samples were collected on the first day and 3 days after SAH (n = 12) to measure plasma concentrations of catecholamines, tumor necrosis factor-alpha (TNF-alpha), interleukin (IL)-1beta and IL-10. PBMCs from SAH patients or healthy volunteers were incubated with LPS (1 microg) for 24 hours. In the second phase, PBMCs from healthy volunteers (n = 6) were incubated with or without catecholamine (10 micromol/1) for 6 hours. After pre-treatment, the cells were treated with LPS (1 microg) for 18 hours. Supernatants were extracted and subjected to measurement by enzyme-linked immunosorbent assay.

RESULTS

Plasma concentrations of epinephrine or dopamine prolong increased significantly 3 days after SAH, involved in elevation of plasma IL-10. In the PBMCs from the SAH patients, LPS-stimulated IL- 10 production was inhibited significantly. Pre-treatment with epinephrine or dopamine inhibited LPS-stimulated IL-1beta production significantly in the PBMCs from the healthy volunteers.

CONCLUSIONS

The initial SAH involved in an impaired production of pro-inflammatory cytokines in response to LPS with an elevation of plasma epinephrine, dopamine and IL-10 after acute stressful conditions. This phenomenon may play an important role of an early immnosupression in patients with poor grade SAH.

Predictors of cerebral infarction in patients with aneurysmal subarachnoid hemorrhage

OBJECTIVE

Cerebral infarction would be expected to be associated with poor outcome after aneurysmal subarachnoid hemorrhage (SAH), although there are few data on which to base this assumption. The goals of this study were to determine the impact of cerebral infarction on outcome and to examine predictors of infarction in these patients.

METHODS

Univariate and multivariable statistical methods were used to examine the impact of cerebral infarction on the Glasgow Outcome Scale score 3 months after SAH among 3567 patients entered into four prospective, randomized, double-blind, placebo-controlled trials of tirilazad conducted in neurosurgical centers around the world between 1991 and 1997. Patient demographics, clinical variables, radiographic characteristics, and treatment variables associated with cerebral infarction were also determined by the same methods.

RESULTS

Seven hundred and seven (26%) out of 2741 patients with complete data had cerebral infarction on computed tomographic scans 6 weeks after SAH. Multivariable logistic regression showed that cerebral infarction increased the odds of unfavorable outcome by a factor of 5.4 (adjusted odds ratio, 5.4; 95% confidence interval, 4.2-6.8; P < 0.0001), which was a higher odds ratio than all other factors associated with outcome. The proportion of explained variance in outcome was also highest for cerebral infarction and accounted for 39% of the explained variance. Multivariable analysis found that cerebral infarction was significantly associated with increasing patient age, worse neurological grade on admission, history of hypertension or diabetes mellitus, larger aneurysm, use of prophylactically or therapeutically induced hypertension, temperature more than 38 degrees C 8 days after SAH, and symptomatic vasospasm.

CONCLUSION

Cerebral infarction was strongly associated with poor outcome after aneurysmal SAH. The most important potentially treatable factor associated with infarction was symptomatic vasospasm.

External ventricular drainage response in poor grade aneurysmal subarachnoid hemorrhage: effect on preoperative grading and prognosis

INTRODUCTION

The importance of preoperative response to external ventricular drainage (EVD) for treatment of acute hydrocephalus (HCP) following poor grade (Hunt & Hess grade IV or V) aneurysmal subarachnoid hemorrhage (aSAH) has not been clearly defined. The effect of EVD response on preoperative grade and prognosis is described.

METHODS

Fifty-nine poor grade patients had an EVD placed preoperatively and underwent definitive aneurysm treatment between September 1996 and March 2002. Patients improving > or = one Hunt and Hess grade were considered responders. Case-control comparisons were completed for each responder, based on clinical grade; the pre-EVD grade and the post-EVD (response) grade were used to generate two independent control cohorts. Logistic regression was used to evaluate the relationship of 12-month modified Rankin disability score (mRS) to clinical grade.

RESULTS

Nineteen (32%) responders were identified, and were less likely Grade V (p < 0.05), and more often had smaller (<13 mm, p < 0.01) and posterior circulation (p < 0.03) aneurysms. The frequency of favorable outcome (mRS < or= 3) was greater in responders than non-responders (68% vs. 28%, p < 0.001). Responders had a similar incidence of favorable outcome as response-grade controls (74%), and a higher incidence of favorable outcome than pre-EVD controls (47%). Regression analysis identified the post-EVD grade, but not the pre-EVD grade, as significantly predictive of long-term outcome (p < 0.04).

CONCLUSION

Long-term outcomes in poor grade patients who improve after EVD placement are similar to patients with lower grade hemorrhages. When an EVD is placed preoperatively in a poor grade aSAH patient, the neurological status after EVD determines the clinical grade.

Contribution of endovascular therapy to the management of poor-grade aneurysmal subarachnoid hemorrhage: Clinical and angiographic outcomes

OBJECT

Treatment of patients presenting with poor-grade (Hunt and Hess Grade IV or V) subarachnoid hemorrhage (SAH) is controversial. Endovascular coil embolization has been considered a valuable therapeutic alternative to surgical clip placement for this kind of patient. The aim of the present study was to evaluate immediate and long-term angiographic and clinical outcomes in patients with poor-grade SAH treated by endovascular embolization.

METHODS

One hundred eleven patients with Hunt and Hess Grade IV or V SAH were treated with endovascular embolization at the University of California at Los Angeles Medical Center between October 1990 and December 2004. Eighty patients harbored Grade IV hemorrhages and 31 patients had Grade V ones. Immediate and long-term anatomical and clinical outcomes were evaluated in all patients. Long-term clinical outcome assessments were based on follow-up data obtained over an average of 32 months posttherapy. Technical complications occurred in 15 patients (13.5%). Immediate complete aneurysm occlusion was observed in 51.4% of aneurysms. Angiographic, long-term follow-up review revealed aneurysm recanalization in 16.2% of cases. Thirty-nine patients (35.1%) demonstrated a favorable long-term clinical outcome. The overall mortality rate in this patient series was 32.4%. The mortality rate associated with vasospasm was significantly higher in patients with Grade IV SAHs than in those with Grade V hemorrhages.

CONCLUSIONS

The results of this study demonstrate a valuable contribution of endovascular therapy of ruptured intracranial aneurysms in patients with Hunt and Hess Grade IV or V SAH. This technique was successful in decreasing repeated aneurysm rupture and in enabling aggressive medical management during the acute phase of SAH. This is particularly important in patients with Grade IV SAH because of their potential for obtaining higher physical and functional recoveries.

Long-term domain-specific improvement following poor grade aneurysmal subarachnoid hemorrhage

BACKGROUND

While efforts have been made to document short-term outcomes following poor grade aneurysmal subarachnoid hemorrhage (aSAH), no data exist concerning the degree of delayed improvement in neurological function. Here we assess cognitive function, level of independence, and quality of life (QoL) over 12 months following poor grade aSAH.

METHODS

Data on definitively treated poor grade patients (Hunt and Hess grade IV or V) surviving 12 months post-aSAH were obtained through a prospectively maintained SAH database. Demographic information, medical history, and clinical course were analyzed. Health outcomes assessments completed by surviving patients at discharge (DC), three months (3 M) and 12 months (12 M) follow-up, including the Telephone Interview for Cognitive Status (TICS), Barthel Index (BI), and Sickness Impact Profile (SIP), were used to evaluate cognitive function, level of independence, and QoL.

FINDINGS

Fifty-six poor grade patients underwent aneurysm-securing intervention and survived at least 12 months post-aSAH. Thirty-five (63%) surviving patients underwent health outcomes assessments at DC, 3 M and 12 M post-aSAH. A majority of patients had improved scores on the TICS (DC to 3 M: 91%; 3 M to 12 M: 82%), BI (DC to 3 M: 96%; 3 M to 12 M: 92%), and SIP (3 M to 12 M: 80%) following aSAH. Using paired-sample analyses, significant improvement on each test was observed.

CONCLUSION

A substantial portion of patients experience cognitive recovery, increased independence, and improved QoL following poor grade aSAH. Delayed follow-up assessments are necessary when evaluating functional recovery in this population. These findings have the potential to impact poor grade aSAH management and prognosis.