The optimum management for patients with severe aneurysmal subarachnoid hemorrhage (SAH) remains controversial. Previous studies have used different clinical grading systems or different timings for grading when using the same classification. Therefore, the present study tried to identify the prognostic factors and indications for active treatment. Patient management and outcome were retrospectively reviewed in 146 cases of severe SAH classified into Hunt and Kosnik grades IV and V. The general condition of the patient was not considered at grading. There were 131 patients in grade IV (JCS 30-200,GCS 4-10) and 15 patients in grade V (JCS 300,GCS 3). This study found that surgical treatment in the early stage, within 24 hours after onset, is essential for patients in grade IV aged less than 80 years leading a normal life before onset without severe systemic disease. However, there is no indication for surgery in patients with grade V SAH.

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Treatment strategy for poor-grade subarachnoid hemorrhage (SAH) cases is reviewed paying attention to the controversies on the decision making and its evidence. Among the consecutive 1,012 cases of SAH experienced at the Kyorin University Hospital, the authors prospectively studied several clinical characteristics and defined the significant factors contributing to a poor outcome, such as bilaterally dilated pupils, apnea, cardiac arrest and abnormal blood pressure (systolic pressure <100 mmHg, >200 mmHg). Theoretically, good candidates for aggressive treatment are those who had reversible primary brain damage, however, any reviewed characteristics failed to show definite evidence of this. The authors currently proposed the treatment strategy for poor-grade SAH is as follows : 1.) in some cases, evaluated as exaggeratory, demonstrated a poor-condition on very early admission or a relatively small amount of SAH on CT, and some of the primary damage contributing to an increased intracranial pressure could be controlled, such as acute hydrocephalus and intracerebral hematoma, 2.) absolute contraindications for treatment are the loss of brainstem function and anoxic and/or ischemic insult to the whole brain, and 3.) evaluation of a patient's condition on their admission followed by deep sedation is reasonable to avoid losing curable candidates who are missed under a wait-and-see policy.

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The outcome of poor-grade [Hunt & Kosnik (H & K) grade IV, V]subarachnoid hemorrhage (SAH) patients is still unsatisfactory. However, there are some patients who can be saved with aggressive treatment. In our clinic, we have operated on those poor-grade patients who did not show total cerebral ischemia, and who had spontaneous breathing. In our 723 operated (clipping) cases, there were 105 (14.5%) H & K grade IV patients and 30 (4.1%) H & K grade V patients. The GOS of these operated patients was as follows : In grade IV, good recovery (GR) 13%, moderate disability (MD) 13%, severe disability (SD) 20%, persistent vegetative state (V) 10%, death (D) 44% and in grade V, GR 7%, MD 3%, SD 10%, V 23%, D 57%, respectively. The most frequent cause of death among the operated cases was pneumonia, at 63% and 59%, respectively. On the other hand, the mortality rate for non-operated patients was as high as 96% in grade IV, and 98% in grade V. Although the patients' profiles are different in these two groups (operated vs. non-operated), the outcome of the operated group seems better than that of the other, when we consider the high mortality of the non-operated group. With the developments of 3D-CT angiography (3D=CTA), or the technique of inducing mild hypothermia (32-33 degree C), we can accomplish a direct operation for more patients these days than before. We should never give up on positive surgical treatment for those patients. We should establish criteria to select patients for aggressive treatment and do direct clipping for them with the help of induced mild hypothermia. The patients who are indicated for the surgery, are those who do not show total cerebral ischemia (that is, who are not under a long period of hypoxemia or general hypotension), and those who breathe spontaneously, indicating no complete brain herniation yet. Aged patients should never be omitted from those positive surgical treatments based solely on that lone criterior. Those poor-grade patients must be examined promptly and adequately, and be operated on by skilled neurosurgeons, although less invasively. Intraoperative intensive monitoring of the patients' general condition is also important, and postoperative intensive and adequate management, especially of the water balance and early mobilization of the patients, is mandatory. The operative results can also be improved if cisternal irrigation with urokinase is applied to prevent the development of vasospasm. All of these efforts mentioned can achieve better postoperative outcomes for poor-grade SAH patients.

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Object : Controversy persists regarding the optimal management of poor-grade patients with severe subarachnoid hemorrhage (SAH). The aim of this study is to clarify the time course of consciousness and its significance in poor-grade SAH patients. Methods : One hundred and two poor-grade patients without massive hematoma, who were admitted within 6 hours after the onset of SAH, were studied retrospectively. At the time of admission, 26 patients were grade IV and 76 were grade V. The patients were observed without performing urgent surgery for the time being. Results : Of the 102 patients, 44 improved their grades in the acute stage after admission ; 17 (65%) in grade IV and 27 (36%) in grade V. Forty-one of the 44 patients (93%) improved within 24 hours after admission and the remaining 3 (7%) within 48 hours. Acute surgery was performed in 42 patients and chronic surgery in 2. At the time of discharge, 11 patients with grade IV and 13 patients with grade V were in good recovery or moderate disability, that is, 24 patients with poor-grade (24%) showed favorable outcomes. The remaining 58 patients showed no change or aggravation of their grades. Conclusion : These results suggest that close observation of the neurological grade for 24 hours after admission is useful in deciding surgical indication for poor-grade SAH patients without massive hematoma.

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Surgical approaches to a petroclival lesion basically include the anterior transpetrosal, posterior transpetrosal and lateral suboccipital approaches. In this paper, the posterior transpetrosal approach is described. The posterior transpetrosal approach, in which the lesion is reached by drilling the posterior lateral part of the pyramid bone, posterior to the arcuate eminence, can obtain a wider operative field from the Meckel's cave to the jugular foramen without excessive brain retraction. As this approach requires a mastoidectomy, full understanding of the microsurgical anatomy of the mastoid bone is essential. The preoperative evaluation of the venous system including the vein of Labbe is also important. Surgical technical points are described by showing a representative case.

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Indications and limitations for the anterior petrosal approach for petroclival meningioma were discussed. We selected the anterior petrosal approach for tumors with an anterior extension into the Meckel's cave. Lateral and inferior limitations of this approach were the internal acoustic meatus and the inferior petrosal sinus, respectively. Tumors with an extension beyond the lateral or inferior limitation were resected using a combined petrosal approach. One of the anterior limitations was the cavernous sinus. Tumors in the cavernous sinus were treated using gamma-knife radiosurgery. Tumors with further anterior extension involving the intradural carotid artery or the optic nerve required combination with the orbitozygomatic approach. One of the medial limitations was the posterior clinoid process. To remove tumors attached here, the lateral cavernous wall needed to be removed. To expose the other medial limitation, the so called "central clival depression", another combination approach with either the posterior petrosal, lateral suboccipital, or transcondylar approach was required. The anterior petrosal approach is useful for petroclival meningioma when this approach is combined with other approaches according to the tumor extension.

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We evaluated the results of Gamma Knife radiosurgery for petroclival meningioma in 50 patients (11 males and 39 females. The mean of the patients' age was 55.5 (range : 15 to 79) years old. Stereotactic radiosurgery was performed as a primary treatment in 29 patients. Twenty-one patients had undergone one to five prior resections. Tumors were located at the clivus in 2 patients. In the other 48 cases, tumors were located around the petrous apex or spread over the petro-cliva1 region. Seventeen of the 48 tumors extended into the cavernous sinus. The mean tumor volume was 14.9 (range : 0.7 to 75) ml. The mean maximum dose was 27.2 (range : 18 to 35.7) Gy and the mean tumor margin dose was 13.6 (range : 8.1 to 25) Gy. In a median follow-up period of 36 (range : 6 to 112) months, 20 tumors (40%) decreased in size and 27 tumors (54%) remained unchanged. Only 3 tumors (6%) had radiographic evidence of progression in the treated part of the tumor. Surgical resection was performed in 3 patients after radiosurgery. In 1 patient, a second radio-surgery and then surgical resection was done. A second radiosurgery was also performed in 4 other patients. In 2 of these 4 patients, the second radiosurgery was done for tumor relapse outside the treatment field. The overall tumor control rate was 94%. Cranial nerve deficits without the evidence of tumor growth developed in only 3 patients (6%). Stereotactic radiosurgery was safe and effective in the management of patients with petroclival meningiomas, despite of the proximity of the tumors to critica neural and vascular structures.

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