Abstract
We analyzed clinical courses and overall management results in patients with severe subarachnoid hemorrhage of Grade IV or V (Hunt and Kosnik), on the basis of CT findings within 48 hours after the ictus. CT findings were classified into the following four types: Subarachnoid hemorrhage (SAH) only (Type I), with intraventricular hemorrhage (Type II), with intracerebral hematoma (Type III) and with acute subdural hematoma (Type IV).
Our policy of surgical treatment for patients in the acute stage was as follows: Clipping of aneurysm with removal of subarachnoid clots was performed in all cases within 48 hours after onset, except for Grade V cases not having middle cerebral aneurysms and for Grade IV and V cases with posterior circulation aneurysms. Surgery for these cases not included above was postponed until various conservative treatments brought about improvement in neurological conditions.
Thirty-five percent of the patients were Type I, 27%-Type II, 27%-Type III and 11%-Type IV. The mortality rate was 52% in Type I, 75% in Type II, 44% in Type III and 71% in Type IV. Type II and IV initial CT scans suggested a poor prognosis ending in death, while Type III suggested a good prognosis. In patients with Type I or II scans, the poor clinical results were attributable to diffuse acute brain swelling, postoperative vasospasm and systemic complications. Massive intracerebral hematoma or associated subdural hematoma was the major cause of poor outcome in patients with Type III or IV scans. Twenty-seven percent of patients operated on the day of admission (early surgery group) had a favorable outcome. On the other hand, 14% of patients whose surgery was delayed until their neurological conditions had improved (late surgery group) had favorable outcome. The mortality rate in the early surgery group was 43%, while that in the late surgery group was 50%.
It was suggested that our CT classification was clinically helpful in predicting prognosis of patients with severe SAH and for deciding surgical procedures. Moreover, our results suggest that early surgery might be indicated for critically-ill patients with SAH.
