title: Outcome in poor grade subarachnoid hemorrhage patients treated with acute endovascular coiling of aneurysms and aggressive intensive care.
abstract: 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.
authors.affiliation: 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
authors.forename: Christopher J
authors.initials: CJ
authors.lastname: Taylor
authors.forename: Fergus
authors.initials: F
authors.lastname: Robertson
authors.forename: David
authors.initials: D
authors.lastname: Brealey
authors.forename: Frankie
authors.initials: F
authors.lastname: O'shea
authors.forename: Tina
authors.initials: T
authors.lastname: Stephen
authors.forename: Stefan
authors.initials: S
authors.lastname: Brew
authors.forename: Joan P
authors.initials: JP
authors.lastname: Grieve
authors.forename: Martin
authors.initials: M
authors.lastname: Smith
authors.forename: Ian
authors.initials: I
authors.lastname: Appleby
mesh_terms: 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*
references.citation: Neurocrit Care. 2007;7(1):18-26
references.pmid: 17657653
references.citation: Neurosurgery. 2009 Jan;64(1):86-92; discussion 92-3
references.pmid: 19050656
references.citation: Neuroradiology. 2004 Feb;46(2):161-4
references.pmid: 14689126
references.citation: AJNR Am J Neuroradiol. 2003 Apr;24(4):585-90
references.pmid: 12695185
references.citation: Stroke. 1999 Dec;30(12):2617-22
references.pmid: 10582987
references.citation: J Neurosurg. 1981 Feb;54(2):141-5
references.pmid: 7005404
references.citation: Lancet. 2002 Oct 26;360(9342):1267-74
references.pmid: 12414200
references.citation: Acta Neurochir (Wien). 1987;89(3-4):91-9
references.pmid: 3434353
references.citation: Neurosurgery. 2009 Mar;64(3):397-410; discussion 410-1
references.pmid: 19240601
references.citation: Stroke. 1988 Oct;19(10):1250-6
references.pmid: 3176085
references.citation: Surg Neurol. 1985 Oct;24(4):377-85
references.pmid: 4035547
references.citation: Acta Neurochir Suppl. 1999;72:7-26
references.pmid: 10337410
references.citation: J Neurosurg. 1996 Jul;85(1):39-49
references.pmid: 8683281
references.citation: J Neurosurg. 1990 Apr;72(4):559-66
references.pmid: 2319314
references.citation: Br J Neurosurg. 2000 Apr;14(2):105-9
references.pmid: 10889881
references.citation: Neurol Res. 1994 Feb;16(1):49-53
references.pmid: 7913532
references.citation: J Neurosurg. 1968 Jan;28(1):14-20
references.pmid: 5635959
references.citation: J Neurosurg. 2001 Feb;94(2):238-40
references.pmid: 11213960
references.citation: Lancet. 1975 Mar 1;1(7905):480-4
references.pmid: 46957
references.citation: No Shinkei Geka. 2004 Jun;32(6):579-84
references.pmid: 15352627
references.citation: J Cereb Blood Flow Metab. 2010 Jun;30(6):1110-20
references.pmid: 20051974
references.citation: Curr Opin Anaesthesiol. 2007 Oct;20(5):400-7
references.pmid: 17873592
references.citation: J Neurol Neurosurg Psychiatry. 1988 Nov;51(11):1457
references.pmid: 3236024
references.citation: Neurosurgery. 2002 Mar;50(3):457-64; discussion 464-5
references.pmid: 11841712
references.citation: Acta Neurochir (Wien). 1988;94(1-2):23-7
references.pmid: 3177042
references.citation: Arch Neurol. 1989 Jul;46(7):744-52
references.pmid: 2742543
references.citation: J Neurosurg. 1990 Jul;73(1):18-36
references.pmid: 2191090