Conventional grading system in subarachnoid hemorrhage (SAH) patients was not really useful in forecasting to what extent delayed vasospasm developed and in assessing the risk for vasospasm (spasm risk). This study is to assess the spasm risk in SAH patients by grading the severity of cisternal high density on CT.
Natural course of vasospasm was difficult to assess in patients with grade IV, V or fatal hemorrhage, and was significantly modified in patients who underwent surgery in the acute or subacute stage of SAH. These patients as well as patients with various complications including rebleeding of the aneurysm were therefore all excluded from this study. And 120 patients with grade I-III on admission within 24 hours of SAH were included who presented natural course of vasospasm either by undergoing uncomplicated delayed operation or by resulting without operation in severe disability or death.
In all patients CT scanning was done within 24 hours of SAH, and severity of subarachnoid hemorrhage was scored from 1 to 4. SAH score 1: mild high density (attenuation number less than 60) in the basal cistern, SAH score 2: moderate (attenuation number 60-69), SAH score 3: local severe (attenuation number 70 or more), SAH score 4: diffuse severe. Intracerebral and intraventricular hemorrhage was not included in this scoring system and discussed separately.
In patients with SAH score 1, no clinical vasospasm was observed in 44/46 (96%) and good recovery from vasospasm obtained in the remaining 2 patients. Patients with SAH score 2 showed no vasospasm in 35/53 (66%), good recovery in 16/53 (30%), and fair recovery in 2 /53 (4%). Patients with SAH score 3 presented fair recovery in 4/15 (27%), severe disability in 2/15 (13%), and death in 9/15 (60%). Patients with SAH score 4 were severely disabled in 1/6 (17%) and dead in 5/6 (83%).
26 patients were associated with intracerebral hemorrhage (ICH) and 13 patients with intraventricular hemorrhage (IVH). ICH patients showed no vasospasm in 14, good recovery in 6, fair recovery in 3, and death in 3. IVH patients presented no vasospasm in 6, good recovery in 3,fair recovery in 1, severe disability in 2, and death in 1. Generally speaking, grade I-III patients with ICH or IVH showed fairly good recovery from vasospasm, and severity of vasospasm in these patients was primarily determined by SAH score.
These results suggested that SAH score is very helpful in assessing spasm risk in SAH patients, and that efficacy of various treatment for vasospasm including that of early operation should be assessed by grading the patients according to the severity of cisternal high density on CT.
