Abstract
Management outcome in poor-grade patients with ruptured cerebral aneurysms has been unsatisfactory. In the present study, we discuss how to manage patients with Hunt and Hess Grade IV or V, and their surgical indications at the acute stage.
Of the 35 patients with admission Grade N, 25 (71%) were surgically treated for ruptured aneurysms at the acute stage. The clinical grade of 11 of these 25 patients improved spontaneously from IV to III before surgery, and none of them had a vegetative state or died. Ten (40%) of the 25 patients who were surgically treated had good recovery, and only 1 (4%) patient died. Ten patients were not treated surgically, because of deterioration due to rerupture in 5, old age (over 80 years) in 4, and no detection of ruptured aneurysm in 1. Of the 58 patients with admission Grade V, 12 (21%) were operated on at the acute stage. In six of the 12 patients, the clinical grade improved to III or IV before surgery; 2 had a good recovery, and 4 had severe disability. The surgical outcome of the other 6 patients, in whom the clinical grade had not improved preoperatively, was vegetative state or death.
Emergency ventricular drainage was performed in 25 of the 58 patients with admission Grade V. The clinical grade improved in 36% (9) of these patients, which was significantly higher than the 12% (4 out of 33) in patients without ventricular drainage (p=0.033).
In conclusion, in patients with admission Grade IV, acute stage surgery for ruptured aneurysms is indicated for those aged under 80 years. In patients with admission Grade V, if their clinical grade improves spontaneously or in response to emergency ventricular drainage, surgery for ruptured aneurysm is indicated. Surgical outcome in poor-grade patients whose clinical grade improved before surgery was not necessarily unfavorable.
