title: Aneurysmal subarachnoid hemorrhage in patients with Hunt and Hess grade 4 or 5: treatment using the Guglielmi detachable coil system.
abstract: OBJECTIVE
  Patients in poor clinical condition (Hunt and Hess grade 4 or 5) after subarachnoid hemorrhage (SAH) have historically fared poorly and many often were excluded from aggressive treatment. Early aggressive surgical treatment of SAH can produce good-quality survival for a higher percentage of patients than previously reported. We assessed the outcome of patients with Hunt and Hess grade 4 or 5 who were treated with Guglielmi detachable coil (GDC) embolization.
  
  
  METHODS
  We retrospectively evaluated the records of 27 consecutive grade 4 and 5 patients with 29 aneurysms treated within 72 hours of SAH by using GDCs. Percentage aneurysm occlusion after embolization, perioperative complications, and symptoms of vasospasm were evaluated. Outcome was assessed with the Glasgow Outcome Scale.
  
  
  RESULTS
  Sixteen patients (59%) were grade 4, and 11 (41%) were grade 5. Eighteen (67%) had one aneurysm, six (22%) had two aneurysms, and three (11%) had three aneurysms. Twenty-nine aneurysms were treated. Fourteen (48%) were completely occluded, and four (14%) were nearly completely occluded (>/=95% occlusion) at embolization. Eleven aneurysms (38%) had partial coiling (<95% occlusion). In the 27 patients, one technical (4%) and one clinical (4%) complication occurred at embolization. No rehemorrhage occurred in any patients (follow-up, 6-44 months; mean, 23 months). Twenty-five (92%) had vasospasm, and seven required endovascular treatment because of worsening clinical status. Sixteen patients (59%) died within 30 days of SAH. Eight patients (30%) had a good clinical outcome at a mean follow-up of 23 months.
  
  
  CONCLUSIONS
  Patients with Hunt and Hess grade 4 or 5 after SAH can undergo successful coil embolization of the aneurysms despite their poor medical condition and a high frequency of vasospasm at the time of treatment. Morbidity and mortality rates with this disease are still high. These findings compare favorably with those published in surgical series for aggressively treated patients with Hunt and Hess grade 4 or 5.
authors.affiliation: Department of Radiology, Stanford University Medical Center, CA 94305-5105, USA.
authors.forename: Raymond U
authors.initials: RU
authors.lastname: Weir
authors.forename: Mary L
authors.initials: ML
authors.lastname: Marcellus
authors.forename: Huy M
authors.initials: HM
authors.lastname: Do
authors.forename: Gary K
authors.initials: GK
authors.lastname: Steinberg
authors.forename: Michael P
authors.initials: MP
authors.lastname: Marks
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D017542:Aneurysm, Ruptured / Q000145:classification / Q000000981:diagnostic imaging / Q000401:mortality / Q000628:therapy*; D000800:Angioplasty, Balloon; D002533:Cerebral Angiography; D004621:Embolization, Therapeutic / Q000295:instrumentation*; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D002532:Intracranial Aneurysm / Q000145:classification / Q000000981:diagnostic imaging / Q000401:mortality / Q000628:therapy*; D008297:Male; D008875:Middle Aged; D011379:Prognosis; D019736:Prostheses and Implants; D012008:Recurrence; D019233:Retreatment; D012189:Retrospective Studies; D013345:Subarachnoid Hemorrhage / Q000145:classification / Q000000981:diagnostic imaging / Q000401:mortality / Q000628:therapy*; D015996:Survival Rate; D014057:Tomography, X-Ray Computed; D016896:Treatment Outcome; D020301:Vasospasm, Intracranial / Q000000981:diagnostic imaging / Q000401:mortality / Q000628:therapy