Abstract
We analyzed 49 consecutive poor-grade patients with subarachnoid hemorrhage (SAH) treated over 5 years from 1990 to 1994. The preoperative Hunt & Kosnik (H & K) Grade was IV or V for all 49 after introduction of Ca2+ antagonist.
The H & K Grade IV patients were sub-classified in IVa and IVb, depending on whether consciousness was present or not. Eight patients were classified in Grade IV a, 16 patients were classified in Grade IVb, and 25 patients were classified in Grade V. Twenty-six patients had direct aneurysmal surgery within 48 hours. Their condition was evaluated on the Glasgow Outcome Scale (GOS) at 3 months after operation with the following results: Good recovery (GR) in 6, moderate disability (MD) in 3, severe disability (SD) in 7, persistent vegetative state (PVS) in 6 and death (D) in 27. The 23 inoperable patients and 3 patients who had minor operations all died.
Primary brain damage (23/49, 45%) was the major poor prognostic factor. Rebleeding (21/49, 43%) was the second important factor (GR, 4; MD, 3; SD, 1; PVS, 0; D, 13). Three patients (12%) had permanent neurological deficits but there were no deaths due to vasospasm. The operative procedures adversely affected 2 patients (delayed intracerebral hematoma in venous origin) of poor prognosis. Twelve patients aged more than 70 years old also had a poor prognosis (SD, 2; PVS, 3; D, 7). In Grade IVb, 2 patients of intracerebral hematoma and 1 patient of hydrocephalus had a good prognosis when immediate decompression was performed. No patients died due to vasospasm, but the rate of patients with poor prognosis was still high (82%of over all patients and 65%of clipping patients) in poor-grade patients.
