Poor-grade aneurysmal subarachnoid hemorrhage: outcome after treatment with urgent surgery.
OBJECTIVE
We sought to determine whether the rebleeding rate in poor-grade patients justified a period of supportive observation before selective treatment and whether unselected ultraearly surgery would lead to acceptable results.


METHODS
A prospectively audited, nonselected series of 177 consecutive poor-grade (i.e., World Federation of Neurological Surgeons Grades IV and V) patients with aneurysmal subarachnoid hemorrhage managed during a 9-year period was analyzed. A management policy of aggressive ultraearly surgery (not selected by age or by grade) was followed. Coiling was not available. Outcomes were assessed at 3 months.


RESULTS
Despite the aggressive management policy, surgery could be performed in only 132 poor-grade patients (75%). Twenty percent of all patients were 70 years of age or older (15% of the surgical cases). All surgery was performed within 12 hours of subarachnoid hemorrhage (majority <6 h). Preoperative rebleeding occurred within the first 12 hours (>85% within 6 h) in 20% of the patients, which is four times the rate found in good-grade patients managed according to the same policy. Outcome assessment performed at 3 months in the 132 poor-grade surgical patients revealed that 40% were independent, 15% were dependent, and 45% had died. There was no significant difference in outcomes for young and old (70+ yr) poor-grade surgical patients (P > 0.05).


CONCLUSIONS
The high ultraearly rebleeding rate indicates a need to urgently secure the ruptured aneurysm by performing surgery or coiling, and this indication is more pronounced for poor-grade patients than for good-grade patients. The outcome results of ultraearly surgery indicate that a nonselective policy does not lead to a large number of dependent survivors, even among elderly poor-grade patients.
Laidlaw
John D
JD
Department of Neurosurgery, The Royal Melbourne Hospital, Parkville, Victoria, Australia. john.laidlaw@mh.org.au
Siu
Kevin H
KH
D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D004630:Emergencies; D023261:Glasgow Outcome Scale; D006801:Humans; D008485:Medical Audit; D008875:Middle Aged; D019635:Neurosurgical Procedures / Q000009:adverse effects*; D010043:Outcome and Process Assessment, Health Care; D018579:Patient Selection; D019106:Postoperative Hemorrhage / Q000209:etiology*; D011446:Prospective Studies; D012008:Recurrence; D012720:Severity of Illness Index; D013345:Subarachnoid Hemorrhage / Q000601:surgery*; D013997:Time Factors