Abstract
During the last eight years, we have treated 318 patients with ruptured intracranial aneurysms who were admitted within 48 hours after subarachnoid hemorrhage. Forty-five of these were classified as Hunt and Kosnik neurological grade 4 and 77 were as grade 5. The authers surveyed the clinical results of the cases in poor neurological grades and discussed how to treat grade 4 and 5 patients at the acute stage.
In 38 of 45 patients in grade 4, aneurysm surgery was performed at the early stage and the results were good-excellent in 37%, fair in 18% and poor-dead in 45%. Three grade 4 patients were operated on at the late stage. One patient had a good and another a fair outcome, while the other died. The remaining four grade 4 patients did not undergo operations on aneurysms because one was not indicated for operation due to systemic complication and the others who had been considered candidates for delayed operation died from rebleeding or vasospasm while awaiting operation. The result was death in all four.
The influence of several clinical and therapeutic factors upon the outcome was examined in 38 early operation cases in grade 4. Younger patients tended to have more good outcomes. There was a trend to fewer good outcomes in those with intraventricular hemorrhage, with intracerebral hemorrhage, without cisternal drainage and without calcium antagonist, but it was not statistically significant.
Of 77 patients in grade 5, six underwent early operations for aneurysms and 42 were not treated surgically. All of these 48 patients died. Continuous ventricular drainage was performed in 29 grade 5 patients at the early stage. The majority of these patients died, whereas four impoved to grade 4. In these four patients, additional operations, i.e., aneurysm surgery in three and shunt operation in one, were performed. One patient who underwent aneurysm surgery had a good and another a fair recovery, while the other died. The patient who underwent the shunt operation also had a fair outcome.
Our conclusion is as follows. In grade 4 cases, early operation is considered the principle for surgical treatment and the use of cisternal drainage and/or calcium antagonist is recommended. In grade 5 cases, aneurysm surgery should be performed if the improvement of the neurological condition is observed during continuous ventricular drainage or medical treatment.
