The prognosis for the severe stage of a ruptured cerebral aneurysm is generally poor. We have had 35 cases of good recovery out of 175 patients with severe ruptured cerebral aneurysms (Hunt-Kosnik Grade IV and V). We analyzed and compared the CT findings, rebleeding, change of consciousness level, surgical procedure, symptomatic vasospasm and Glasgow outcome scale for the 175 cases.
In the most severe cases, where the patients died due to severe brain edema whether or not they were treated surgically, the CT findings demonstrated 1) small ventricle, 2) massive ventricle hemorrhage, 3) severe midline shift due to acute subdural hematoma or acute brain swelling in addition to a bilateral thick clot on the basal cistern.
Cases with an uphill consciousness level within six hours after admission showed promise of very good recovery, due to early surgical operation for ruptured cerebral aneurysms.
There are two big factors which contribute to a poor prognosis after severe subarachnoid hemorrhage. One of them is rebleeding and the other is the appearance of symptomatic vasospasm. So, from the viewpoint of preventing rebleeding, using venous infusion of diltiazem (Ca⁺⁺ antagonist) for control of blood pressure (systolic pressure 120 130mmHg, diastolic pressure 70 90mmHg) and delaying angiography at least six hours after the last attack of ruptured aneurysms is important. We haven't experienced a case of rebleeding after using this treatment.
For prevention of symptomatic vasospasm, we have administrated the intracisternal nicardipine treatment (4mg 2×1/10 days) after early surgery. There was no significant change of occurrence rate of symptomatic vasospasm between a nicardipine treated group and a non-nicardipine-treated group. However, the symptoms were almost transient(80%) in the nicardipine-treated group. Those of the non-nicardipine-treated group were only 10%.
In conclusion, we have adopted the following therapy for severe subarachnoid hemorrhage: 1) in-jected a venous infusion of diltiazem for the control of blood pressure and delayed angiography more than six hours after the last attack, 2) intracisternal administration of nicardipine for preven-tion of symptomatic vasospasm, 3) dopamine and fluoro-carbon if symptomatic vasospasm occurred, 4) barbiturate coma therapy in cases whose consciousness level showed a downhill course due to brain edema, 5) hyperbaric therapy for permanent symptomatic spasm.

View full abstract

Among supratentorial ruptured aneurysms which were operated on at the acute stage, there were 26 cases preoperatively classified as Hunt & Kosnik Grade IV, and we made a retrospective analysis of the prognostic factors from a comparative study of nine cases showing favorable postoperative outcomes (excellent, E; good, G; Fair, F) and 17 cases showing poor postoperative outcomes (poor, P; dead, D).
The average age was 51.3 for the favorable group and 59.2 for the poor group. Eleven percent of the former group had a past history of hypertension, while 53% of the latter group had such a history, which is statistically significant.
On the preoperative angiograms, middle cerebral artery aneurysms of less than 10mm in size were predominant in the E and G groups, comprising a total of seven cases. Vasospasm was recognized in only one case. Anterior communicating artery aneurysms were predominant in P and D groups, half of which were larger than 10mm in size (47.1%); and vasospasm was recognized in six cases out of 17.
According to the preoperative CT findings defined by Fisher's classification, cases of Group III and IV were significantly more in the P and D groups than in the E and G groups.
During the period from the initial onset of symptoms to the stage of Grade IV, six out of seven cases in the E and G groups reruptured, while the incidence of rerupture was significantly low in the P and D groups, suggesting that the incidence of rerupture was not necessarily an index of poor prognosis.
Seven cases out of nine in the favorable group and seven out of 17 in the P and D groups were operated on within six hours from the stage of Grade IV, showing that operation conducted within six hours was likely to result in a rather fair prognosis.
As for systemic complications as well as postoperative symptomatic vasospasm, the incidence of the former was significantly high and that of the latter tended to be high in the P and D groups.

View full abstract

Two hundred thirty-one cases of severe subarachnoid hemorrhage of Hunt and Hess Grade IV and V were reported. Out of those 140 cases were treated surgically, of which 106 cases were operated on in the early stage within 24 hours.
Operative indication and timing of operation were evaluated using our original SAH Grading Scale, CT findings, operative and microscopic findings.
Patients of Grade IV who were given early operation had better outcome than those in whom the operation was delayed. In Grade V cases only early operative cases recovered to a useful life.
It is concluded that indications for early operation of severe cases are as follows: comatous state continuing more than three hours: more than 10 points on the SAH grading scale; and packed sub-arachnoid hemorrhage without hydrocephalus are not indication of operation. The limitation of ear-ly operation are SAH grading score below seven, and no herniation sign on CT.
As for microscopic findings in severe subarachnoid hemorrhage cases, not only the normal struc-ture of subarachnoid space is destroyed by thick hematoma, but ischemic changes are recognized on the brain surface.

View full abstract

Of 178 patients with verified subarachnoid hemorrhage (SAH) seen at Tokyo Metropolitan Fuchu Hospital from 1984 to 1987, 144 cases were admitted within three days after the last bleeding. Patients were graded on arrival on the Hunt scale, and their condition at discharge was evaluated on the Glasgow Outcome Scale (GOS). Except for vertebro-basilar aneurysms we have operated as earlier as possible especially on patients whose admission grade was poor. As a result, of 32 Grade 4 patients, all but two were operated on and their mortality rate was 49%. But of 15 patients whose admission grade was 5, eight cases of complicating intracerebral hematoma were operated on and only one patient survived. Seven other patients, who were not operated on, died.
To determine which patients might expect a fair outcome, computed tomographic (CT) findings are of great prognostic value. In this paper, we proposed a certain type of CT finding and discussed its correlation with the clinical courses.

View full abstract

In a consecutive series of 163 patients, who were operated on for ruptured anterior circulation aneurysm within three days after a subarachnoid hemorrhage, 93 patients (57%) were classified as Hunt and Kosnik Grade III and IV (defined as severe cases), and 70 as Grade I and II (mild cases). Mean age, site of ruptured aneurysm and serial changes in mean blood pressure showed no significant difference between the two groups.
Postoperative electrolytes balance was examined on the 7th day after surgery. Both hyponatremia and hypernatremia were significantly frequent (p<0.025, p<0.001, respectively) in severe cases.
Septicemia, with or without disseminated intravascular coagulopathy, was the main postoperative complication in both groups. Over all, 26% of severe cases had systemic complications, whereas only 13% of mild cases had. This difference was statistically significant (p<0.05). The outcome was considerably unfavorable in the patients with systemic complications.
Delayed ischemic neurological deterioration with irreversible deficits occurred in 30% of severe cases, but in only nine percent of mild cases (p<0.005).
In CT findings, the amount of subarachnoid clot was classified into four groups, described by Fisher, et al. Group 3 (clot or thick layer), which was considered to be most responsible for symptomatic vasospasm, was frequently visualized with significant difference in severe cases (p<0.05; preoperatively, p<0.005; postoperatively). Hydrocephalus with shunt dependency occurred in 44% of severe cases but in only 13% of mild cases (p<0.005).
In the serial measurement of mean hemispheric blood flow, reduced flow was continuously revealed in severe cases, as compared with mild cases. The difference was statistically significant on both the 14th day after surgery, and in the long-term follow-up (p<0.05). The ultimate outcome at six months was quite poor in severe cases. Only 56% had good outcome (good recovery and moderate disability) and 24% died, whereas 90% had good outcome and nine percent died in mild cases. These results suggest that postoperative systemic complications are of some prognostic value in predicting outcome, and it is stressed that systemic intensive care is also indispensable in the management of ruptured intracranial aneurysms.

View full abstract

Out of 380 patients who underwent CT scanning on the day of aneurysmal rupture, 67 were classified as Hunt and Kosnik grade IV-V several hours after the initial SAH when neurological status was most stable.
Precise information was available from the initial ictus in these 67 patients, about the episodes suggestive of rebleeding i. e., sudden deterioration of consciousness level with or without headache, nausea, and vomiting. The most frequent factors causative of the poor grade in these patients were series-forming multiple bleeds in a short period immediately after the first ictus. These too early rebleeding episodes appeared hardly preventable even by ultra-early surgery. The most important regimen seemed to be mild induced hypotention and deep sedation upon transfer, and preoperative examinations.
As for CT evaluation the maximus two sites of cisternal high density area were chosen and summed up by CT number; this is designated as the SAH score. Neither intracerebral hematoma (ICH) nor intraventricular hemorrhage (IVH) was included in the CT number sum up for this SAH score. Almost all these 67 patients demonstrated ICH and/or IVH in addition to SAH of varied SAH scores. The prognosis in these patients were generally poor, and only three patients had good outcome after early operation. Although the concomitant ICHs or IVHs were large, it is noteworthy that SAH scores were relatively low in these patients with good outcome.
The surgical indication for poor grade patients with ruptured aneurysm is quite limited. However, a small number of patients, who have large ICH and/or IVH not associated with massive SAH, may be possible candidates for ultra-early aneurysmal surgery with hematoma removal.

View full abstract

We have discussed treatment for ruptured intracranial aneurysms and analysed the results of current neurosurgical treatment of serious patients. 790 cases of ruptured intracranial aneurysms were admitted within three days of their last attack during the period from 1978 to 1987. We defined as serious all patients who, on the modified Hunt & Kosnik grading, were Grade III, IVA(stuporous or severely drowsy), IVB and V(semicomatous or comatous) at the time of admission. There were 397 such cases, or 50.3% of the total. Angiographically, aneurysm, were found arising from the anterior communicating artery in 84 patients, the anterior cerebral artery in 21, the internal carotid artery in 55, the middle cerebral artery in 65 and the vertebro-basilar system in 18. They were managed according to established principles of treatment. Radical operations for cerebral aneurysms were done as early as possible after admission on patients who were Grade III and IVA. On patients who were Grade IVB and V on admission, administration of Sendai cocktail and continuous ventricular drainage were done to decrease intracranial pressure at first. And only patients whose preoperative grading were more than IVA received radical surgery. On 243 out of 397 serious cases(61.2%) aneurysmal clipping was carried out. Of 243 operative cases, 158 cases(65.0%) had an emergency operation within 48 hours after the initial or recurrent bleeding episode. 35 cases(14.4%) were operated upon within the first week, 23 cases(9.5%) within the second week, 27 cases(11.1%) at a later date. At the time of operation, 178 patients(73.3%) were in Grade I to III, 55 patients (22.6%) were in Grade IVA and 10(4.1%) were in Grade IVB.
During operation, continuous ventricular drainage was instituted in all patients. In the patients whose CT scan on admission revealed severe diffuse SAH, that is, their Hounsfield number was over 65, bifrontal or bilateral fronto-temporal craniotomy was used regardless of the location of the ruptured aneurysm and an attempt was made to remove the subarachnoid clot as completely as possible, using 50mM NaNO₂ in order to prevent vasospasm.
Overall mortality of serious patients was 164 cases(41.3%) and morbidity 79 cases(19.9%). 131 out of 154 cases(85.%) of conservative treatment died. Operative mortality was 33 cases(13.6%) and morbidity 57 cases(23.4%). Cases of poor clinical outcome(90 cases, 37.0%of total operative cases) related to vasospasm during the hospital course(45 cases, 50.0%), primary brain damage due to aneurysm bleeding(20 cases, 22.2% ), general and CNS complications(21 cases, 23.2%), operative complications(3 cases, 3.3% ) and post-operative rupture of another aneurysm(1 case, 1.2%). Vasospasm was the most important cause of poor outcome. It was also pointed out that preoperative management of the general condition of serious patients played on important role in the outcome of acute surgery.

View full 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.

View full abstract

In this paper, authors reported and discussed the acute management of severe subarachnoid hemorrhage due to cerebral aneurysm rupture. There were 45 cases in Hunt & Hess Grade IV or V with no assessment as to any systemic complications, among 137 cases with ruptured cerebral aneurysms during the period from April, 1984 to September, 1987 in Showa General Hospital.
Out of 18 cases in Grade IV, 12 were graded IV on arrival and six were regarded as Grade IV following aneurysm re-rupture after emergent procedures. Seventeen cases were operated on, mostly within 48 hours and barbiturate therapy was performed in 12 cases before and/or after the operation (aneurysm neck clipping) during 10 days on average. One conservatively treated patient died and among 17 surgically treated cases the outcome was as follows; good, six; poor, four; death, seven.
Out of 27 cases in Grade V, 15 were in Grade V at admission and 12 fell into Grade V following a second or third rupture after admission. Aneurysm neck clipping was performed in 14 cases within 24 hours, among whom 12 cases were under barbiturate therapy for seven days on an average and the outcome consisted of: good, four cases; poor, six cases; and death four cases. All of the 13 cases with no radical operations died.
Barditurate therapy for the patients with severe subarachnoid hemorrhage is expected to protect the brain from ischemic damage due to vasospasm and to lower the increased intracranial pressure. These beneficial effects might be connected to or explain the relatively good results in this report.
The palliative therapy without acute aneurysm neck clipping may sometimes be profitable while awaiting neurological improvements but often runs the risk of preoperative aneurysm re-rupture. The acute management of early operation and intensive care, including barbiturate therapy for Grade IV or V patients, did not necessarily result in poor outcomes and therefore can be more significant than the strategy of so-called conservative management or intentionally delayed operation.

View full abstract

We reviewed the clinical features and surgical outcome of 95 severe SAH.
1. Hypertension was an important risk factor causing severe SAH.
2. Rerupture more often occurred during 12 hours after the first attack of SAH, and resulted in severe neurological deterioration.
3. The locations of aneurysms with severe SAH were 40% in the MC, 34% in the Acom and 15% in the ICPC. Mass lesions such as ICH and IVH totaled 91% in the MC, 68% in the Acorn and 58% in the ICPC. Thirty nine percent of severe SAH were treated operatively (neck clipping and removal of ICH) and the outcome was poor (8% useful life and 76% poor or dead).
The most favored candidates for surgery were young patients having MC aneurysms with hematoma, little cisternal clotting, and at a stage of incomplete tentorial herniation.

View full abstract

The result of surgical treatment in cases classified as Hunt and Kosnik Grade IV and V was analysed and the surgical indication for these cases was discussed in this paper.
The clinical material for this study consisted of 58 cases of Grade IV and 12 cases of Grade V.
Locations of the ruptured cerebral aneurysms were as follow: Grade IV, 24 in the internal carotid artery, 12 in the middle cerebral artery, 12 in the anterior communicating artery, four in the anterior cerebral artery, and six in the vertebro-basilar artery. For Grade V there were six in the internal carotid artery, five in the middle cerebral artery, and one in the anterior communicating artery.
The operation was performed within 72 hours after the bleeding in 41 cases, between four and 14 days in five cases, over 15 days in 12 cases in Grade IV, and within 24 hours in all 12 cases of Grade V.
Overall mortality and morbidity were eight cases (31%) and 19 cases (33%) in Grade IV, and 10 cases (83%) and two cases (17%) in Grade V. Good clinical outcome was noted in 21 cases (36%) of Grade IV but was not found in any cases of Grade V.
In cases of Grade IV, the rate of clinically good outcome was significantly higher in cases operated on within 72 hours after bleeding (19 out of 41 cases: 46%) than in cases operated on more than four days after bleeding (2 out of 17 cases: 12%).
Clinical outcome was not significantly influenced by the location of the ruptured cerebral aneurysm, patient's age at time of operation, use of temporary clip, presence of intraoperative bleeding from the aneurysm, CT findings, use of continuous cisternal drainage or external decompression.
Causes of poor clinical outcome were primary brain damage in 23 cases (62%), vasospasm in 12 cases (32%) and other causes in two cases (6%) out of 37 poor cases of Grade IV, and primary brain damage in nine cases (75%) and primary brain damage plus vasospasm in three cases (25%) out of 12 cases of Grade V.
From these results, we can conclude that surgery should be carried out within 72 hours after bleeding in cases of Grade IV, irrespective of the location of the ruptured aneurysm, patient's age and CT findings, if the patients had been able to function in normal daily living without severe systemic diseases before the bleeding.
Furthermore, these results indicate that basically, surgery should not be recommended in cases of Grade V.

View full abstract

One hundred fourteen serious cases of ruptured intracranial aneurysms were studied clinically with special reference to prognosis and surgical indication. In this series, 57 cases underwent radical surgery in the acute stage and 57 cases were treated conservatively (including cases only treated with continuous ventricular drainage). The criterion for these serious cases was designated as semicoma or coma state just before operation in the radically treated group, and at admission in the conservative group. CT findings were divided into the following four types based on the cause of the severe disturbance of consciousness: 1) subarachnoid hemorrhage (SAH) type having only severe subarachnoid clot, 2) intraventricular hemorrhage (IVH) type having packed intraventricular hematoma, 3) intracerebral hematoma (ICH) type which showed massive ICH, and 4) subdural hematoma (SDH) type which showed massive SDH.
All patients in the conservatively treated group died except for one vegetative case. On the other hand, the outcome in 57 surgically treated cases was as follows: four (7.0%) fully recovered; 10 (17.5%) were capable of self management; 22 (38.6%) were partially of fully dependent, and 21 (36.8%) died. In the radically treated cases, we investigated preoperative factors that might predict clinical outcome, such as neurological grade, brain stem response, CT findings, response after injection of 20% Mannitol (300-900ml), and time from the last bleeding episode to the operation. It was recognized that there is no relationship between the neurological grade just before radical operation and the outcome in these serious cases. Results were good in patients in each of the following sub-groups: 1) Neurological symptom improved after rapid administration of 20% Mannitol even though the patient was still comatose. 2) Cases in which brain stem responses such as the ciliospinal reflex and oculocephalic reflex were preserved. 3) Surgery could be performed within six hours of the last bleeding episode.
If surgery is performed when any of the above conditions prevail, we feel that completely successful early surgery can be expected. It is important to emphasize, in addition, that our experience shows that a great deal of unfavorable outcome can be eliminated by the evacuation of clots at the time of clipping of the neck of the ruptured aneurysms. Thus, evacuation of the following four types of clots should be included in the surgical procedure: ICH, SDH, IVH and SAH.

View full abstract

To prevent the possibility of rerupture and the development of vasospasm in the period before aneurysm surgery, we have adopted a policy of performing acute stage operations within 48 hours of the onset of symptoms. The most important indications for acute stage surgery are the patient's level of consciousness and the changes of consciousness over time. Except for Hunt and Kosnik Grade V cases and those whose level of consciousness is progressively downhill, we believe acute stage operation is indicated in all cases.
In the present study, we reported the surgical results of severe cases of ruptured cerebral aneurysms operated on directly during the last 10 years from 1977 to 1986. Among 871 operative cases, the preoperative clinical grades were Grade 0 in 29 cases, I in 218 cases, I a in 28 cases, II in 375 cases, III in 180 cases and IV in 59 cases. The clinical material for this study consists of a total of. 239 Grade III and IV patients. For analysis of the surgical results, we have classified the first 137 cases (those operated on between 1977 and 1981) as Group 1, and the last 102 cases (those operated on from 1982 to 1986) as Group 2. Of the total of 239 patients, 146 (61.1%) were judged to have recovered well, while 72 (30.1%) were morbid. Twenty-one (8.8%) died. When Group 2 is compared to Group 1, it is seen that the mortality rate in Group 2 was the same as in Group 1 (8.8 compared to 8.7%), but the percentage of patients with good recovery rose to 65.7% in Group 2 as compared to 57.7% in Group 1, indicating a notable improvement in the morbidity rate. This improvement of surgical results is obvious in the acute stage operation cases, especially those operated on within 48 hours from the onset. There were 34 cases (25%) in Group 1, and 57 cases (56%) in Group 2 operated on within 48 hours, and the number of patients experiencing a good outcome rose to 68% in Group 2 as compared to 53% in Group 1.
From this study, it is considered that good therapeutic results can be obtained by means of acute stage surgery, even in severe cases, provided that proper care is taken with regard to indications for surgery, choice of surgical approaches, use of measures to prevent or suppress vasospasm, and control of intracranial pressure.

View full abstract

Among 187 consecutive cases of ruptured intracranial aneurysms admitted to our clinic, twenty-one had rebleeding before or during admission. Six died within a week after the second ictus and one was in a vegetable state. Fourteen cases were operated on radically. Nine cases were operated on within 24 hours and five cases more than 24 hours after the second bleeding. It seemed that operations as early as possible after the rebleeding would have better clinical results. Thus five out of nine cases operated on earlier had good recoveries, while only one recovered well in the five cases of later surgery.

View full abstract

Over a three year period (January 1, 1985-December 31, 1987), 38 patients with ruptured single aneurysms were operated on within three days after the last subarachnoid hemorrhage (SAH). Each patient was treated by cisternal drainage and hemodilution-volume expansion therapy after radical surgery.
Sixteen of the patients underwent radical surgery with simultaneous decompressive craniotomy (Group A) whereas 22 patients were not given decompressive craniotomy (Group B). The mortality rate among cases of preoperative Hunt and Kosnik Grade III-V was 28.6% in Group A and 45.5% in Group B. Compared with the mortality rate for unconscious patients whose preoperative Japan Coma Scale (JCS) scores were between 20 and 200, the patients in Group A had lower mortality (33.3%) than those in Group B (80.0%).
These results suggest that decompressive craniotomy may suppress the increase of intracranial pressure (ICP) due to ischemic brain edema caused by vasospasm. Therefore, decompressive craniotomy may reduce the degree of irreversible brain injury following low perfusion under increased ICP as result of ischemic brain edema.

View full abstract

In this paper, case histories are prasented of 38 patients in Hunt & Kosnik Grades III and V who suffered severe ruptured aneurysms with cerebral herniation and had surgical treatment acompanied with decompressed craniotomy, and of 16 patients with severe ruptured aneurysm who were not operated on. In these surgical cases, 30 primary cases suffered early rerupture and massive ICH or subdural hematoma; and eight secondary cases had herniation after the vasospasm or post-operative hemorrhage. The operative procedures were: 1). aneurysmal clipping. 2). decompressed craniotomy. 3). contineous ventricular drainage or cisternal drainage. 4). tracheotomy in about half the cases. A study of the outcome shows that non-surgically treated severe ruptured aneurysmal cases had 94% mortality. On the other hand, surgical cases with decompressed craniotomy had 47% mortality and about 30% returned to a useful (?) life with or without a helper. Technically, decom-pressed craniotomy should be performed with good timing before irreversible change a large enough craniotomy with a dural opening, and an additional decompression technique.
The main cause of severe cases was re-attack a short time after the first attack (usually within six hours). So we should act as soon and as tenderly as possible and perform acute surgical therapy even with or without decompressed craniotomy, especially in severe cases.

View full abstract