Outcome in poor grade subarachnoid hemorrhage patients treated with acute endovascular coiling of aneurysms and aggressive intensive care.
BACKGROUND
Patients with poor grade (World Federation of Neurosurgeons (WFNS) Grades 4 and 5) subarachnoid hemorrhage (SAH) were historically considered to have a poor neurological outcome and therefore not traditionally offered aggressive treatment. In recent years there has been increasing evidence that early aggressive treatment of this patient group can result in a good outcome. Aim of this study is to identify the outcome of patients with WFNS Grade-4 and -5 SAH treated acutely with endovascular detachable coil embolization (DCE) and aggressive neurocritical care within our institution.


METHODS
We retrospectively reviewed the records of patients with SAH WFNS Grades 4 and 5 treated with DCE within 7 days of admission between 1st January 2004 and 1st January 2008. Data collected included age, sex, grade SAH, position/number of Aneurysms, coiling complications, time spent on the neurosurgical critical care unit (NCCU), and 6-month outcome assessed by Glasgow outcome scale (GOS). GOS was dichotomized into good outcome (good recovery/moderate disability) and poor outcome (severe disability, vegetative, dead).


RESULTS
A total of 193 acute SAH patients were admitted and treated within this time period, of these, 47 patients were classified as poor grade and included: 70% were female and 30% were male. The mean age was 56 years (33-88 years range). A total of 56 aneurysms were noted at angiography, 52 aneurysms were coiled. Complications of SAH Vasospasm was noted in 18 patients (38%), cerebral infarction in 13 patients (28%), seizures in 7 patients (15%), hydrocephalus in 25 patients (53%). Complications of DCE occurred in 2 patients (4% of total) these were an aneurysmal rupture and a peri-procedure thrombosis. Incomplete coiling occurred in another 5 patients (10.6% of total) due to technical difficulties. The median length of stay on the NCCU was 12 days (1-52 days range). Of the 47 poor grade patients coiled, 25 (53%) had a good outcome (good recovery/moderate disability) and 22 (47%) had a poor outcome (severe disability, vegetative, dead) by the time of the 6-month follow-up.


CONCLUSIONS
Potentially, more than half the patients with WFNS Grade-4 and -5 SAH who are treated aggressively with coil embolization in association with supportive neurocritical care can achieve a good quality neurological outcome. However, it should be anticipated that these patients will spend a significant period of time in neurocritical care.
Taylor
Christopher J
CJ
Departments of Neuroanesthesia and Neurocritical Care, Neuroradiology and Neurosurgery, National Hospital for Neurology and Neurosurgery, Queen Square, London WC1N 3BG, UK. christophertaylor_1999@yahoo.com
Robertson
Fergus
F
Brealey
David
D
O'shea
Frankie
F
Stephen
Tina
T
Brew
Stefan
S
Grieve
Joan P
JP
Smith
Martin
M
Appleby
Ian
I
D000208:Acute Disease; D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D017542:Aneurysm, Ruptured / Q000145:classification / Q000401:mortality / Q000628:therapy; D003422:Critical Care / Q000379:methods*; D004185:Disability Evaluation; D004621:Embolization, Therapeutic / Q000379:methods*; D005260:Female; D015600:Glasgow Coma Scale; D023261:Glasgow Outcome Scale; D017052:Hospital Mortality; D006801:Humans; D008297:Male; D008875:Middle Aged; D009460:Neurologic Examination; D012189:Retrospective Studies; D013345:Subarachnoid Hemorrhage / Q000145:classification / Q000401:mortality / Q000628:therapy*
Neurocrit Care. 2007;7(1):18-26
17657653
Neurosurgery. 2009 Jan;64(1):86-92; discussion 92-3
19050656
Neuroradiology. 2004 Feb;46(2):161-4
14689126
AJNR Am J Neuroradiol. 2003 Apr;24(4):585-90
12695185
Stroke. 1999 Dec;30(12):2617-22
10582987
J Neurosurg. 1981 Feb;54(2):141-5
7005404
Lancet. 2002 Oct 26;360(9342):1267-74
12414200
Acta Neurochir (Wien). 1987;89(3-4):91-9
3434353
Neurosurgery. 2009 Mar;64(3):397-410; discussion 410-1
19240601
Stroke. 1988 Oct;19(10):1250-6
3176085
Surg Neurol. 1985 Oct;24(4):377-85
4035547
Acta Neurochir Suppl. 1999;72:7-26
10337410
J Neurosurg. 1996 Jul;85(1):39-49
8683281
J Neurosurg. 1990 Apr;72(4):559-66
2319314
Br J Neurosurg. 2000 Apr;14(2):105-9
10889881
Neurol Res. 1994 Feb;16(1):49-53
7913532
J Neurosurg. 1968 Jan;28(1):14-20
5635959
J Neurosurg. 2001 Feb;94(2):238-40
11213960
Lancet. 1975 Mar 1;1(7905):480-4
46957
No Shinkei Geka. 2004 Jun;32(6):579-84
15352627
J Cereb Blood Flow Metab. 2010 Jun;30(6):1110-20
20051974
Curr Opin Anaesthesiol. 2007 Oct;20(5):400-7
17873592
J Neurol Neurosurg Psychiatry. 1988 Nov;51(11):1457
3236024
Neurosurgery. 2002 Mar;50(3):457-64; discussion 464-5
11841712
Acta Neurochir (Wien). 1988;94(1-2):23-7
3177042
Arch Neurol. 1989 Jul;46(7):744-52
2742543
J Neurosurg. 1990 Jul;73(1):18-36
2191090