We retrospectively analyzed and compared overall outcome of poor-grade patients (WFNS Grade IV, V, and cardiopulmonary arrest on arrival |CPAOA|) with subarachnoid hemorrhage (SAH) in 2 study periods. The first was from July 1993 to June 1994 and the second from July 1998 to June 1999. A total of 20 patients, 7 with Grade IV, 5 with Grade V, and 8 with CPAOA were included in the first period; and a total of 36 patients, 6 with Grade IV, 21 with Grade V, and 9 with CPAOA, in the second period. The major recent changes in the treatment protocol were 1) deep sedation, intensive control of blood pressure, and endotracheal intubation in the emergency room in the resuscitative phase; 2) immediate cerebral angiography under general anesthesia after diagnosis of SAH; 3) aneurysm obliteration by Guglielmi detachable coil (GDC) as an option; and 4) early enteric feeding and tracheostomy for patients in a prolonged comatose state. Therapeutic mild brain hypothermia was conducted in 3 Grade V patients in the second-period study. Aneurysm was obliterated by clipping in 7 and 18 patients in each period and by GDC in 4 patients in the second period. The median time from onset to admission, to angiography, and to surgery was 29, 440, and 797.5 minutes, respectively, in the first period, and 32, 99, and 210 minutes, respectively, in the second period. Overall outcome assessed at 3 months by the Glasgow Outcome Scale was; GR: 2 (10%), MD: 0 (0%), SD: 1 (5%), VS: 2 (10%), D: 15 (75%) for the first period and GR: 5 (13.9%), MD: 3 (8.3%), SD: 7 (19.4%), VS: 1 (2.8%), D: 20 (55.6%) for the second period. A favorable outcome (GR+MD) increased from 10% to 22.2%, and deaths were reduced from 75% to 55.6% (P=0.02, chi-square test). Angiography and surgical intervention immediately after resuscitation produce a more favorable outcome for severe SAH patients without increasing the risk of rerupture.
