Abstract
A new clinical grading system for ruptured cerebral aneurysms(Akita Nohken, 1982) has been used for evaluating operative indications and making the operative timing dicisions. The severity of patient condition is classified by their level of consciousness and signs of herniation. An accompanying conditions, which can include massive subarachnoid hemorrhage (SAH) shown by CT, intracerebral hematoma (ICH) with mass signs, such as midline shift and deformity of the ventricle, and vasospasm (VS) detected in angiography, reveal causes for severity and the pathophysiological condition of the patient.
In this study, a comparison will be made between the new Akita Nohken system and the Hunt and Hess system for grading and classification of ruptured aneurysms, and the clinical outcome of cases so evaluated will be examined. Subjects included 313 cases with ruptured aneurysms of the anterior communicating, internal carotid and middle cerebral arteries admitted within 7 days following the last attack. Excluded were those over 70 years of age, those who died of general complications, those deteriorated by operative or angiographic complications, patients with old strokes, and cases with fatal rebleeding attacks after admission. Two hundred and ninety-six cases were surgical; 17 were non-surgical.
Characteristics of the new classification system can be summarized in that mild cases, such as Grade 1 and 2 in Hunt's classification are placed in Grade 1; and severe cases are classified in detail according to the level of consciousness and signs of cerebral herniation; with labels such as Grade 4, 5 a, 5b and 6. The mortality of all cases was 8.9% and the morbidity was 11.8%. Severity of the clinical grades was well correlated with the clinical outcome. The incidence of accompanying conditions was higher in proportion to a worsening of the clinical grade. The number of cases with more than two accompanying conditions increased in severe cases with Grade 4 or more. “VS” and “SAH” resulted in a poor outcome in grade 2 and 3 patients due to cerebral ischemia following vasospasm. Clinical outcomes were poor in grade 4 and 5a patients with “VS.” Sixteen of 24 cases in Grade 5b and 6 were accompanied by “ICH,” and all of the conservatively treated cases in these grades died. As a result, cases without “VS” should be operated on as early as possible, and operations should be delayed in cases accompanied by “VS.”
