title: Perfusion computed tomographic imaging and surgical selection with patients after poor-grade aneurysmal subarachnoid hemorrhage.
abstract: BACKGROUND
  Patients with ruptured aneurysms who present in coma have already experienced significant brain injury, require intensive resuscitation, have aneurysms that are difficult to treat, and generally fare poorly despite aggressive intervention.
  
  
  OBJECTIVE
  To determine whether surgical outcomes in comatose patients with ruptured aneurysms in a modern series might be better than previously reported because of changing surgical indications and multidisciplinary management, and to determine whether perfusion computed tomography (PCT) imaging might help select patients for surgery.
  
  
  METHODS
  A consecutive series of 78 patients with poor-grade aneurysms treated surgically was reviewed. Management consisted of resuscitation, early surgery, intracranial pressure control, comprehensive intensive care, and endovascular therapy for vasospasm. Cerebral blood flow (CBF), volume (CBV), and mean transit time (MTT) were measured on admission PCT studies and correlated with outcomes.
  
  
  RESULTS
  Among 58 grade IV patients (74%) and 20 grade V patients (26%), 44 patients (56%) had favorable outcomes (Glasgow Outcome Scale 5 and 4), and 34 patients (44%) had unfavorable outcomes. Favorable outcomes among grade IV patients were observed in 71%, whereas mortality among grade V patients was 60%. Sixteen patients (89%) with normal cerebral perfusion had favorable outcomes and all 13 patients with hemispheric or global hypoperfusion had unfavorable outcomes.
  
  
  CONCLUSIONS
  PCT provides physiological data that are immediately applicable and can guide decisions to aggressively manage comatose patients with ruptured aneurysms. Grade IV patients with normal or focally abnormal perfusion are good candidates for treatment, whereas grade V patients with hemispheric or global hypoperfusion are poor candidates. Surgery effectively excludes aneurysms with complex anatomy and relieves increased intracranial pressure with hematoma evacuation, lobectomy, and/or hemicraniectomy. Modern neurosurgical, endovascular, and neurointensive critical care produces favorable outcomes in a substantial percentage of carefully selected patients.
authors.affiliation: Department of Neurological Surgery, University of California, San Francisco, San Francisco, California, USA.
authors.forename: Abel Po-Hao
authors.initials: AP
authors.lastname: Huang
authors.forename: Sandeep
authors.initials: S
authors.lastname: Arora
authors.forename: Max
authors.initials: M
authors.lastname: Wintermark
authors.forename: Nerrissa
authors.initials: N
authors.lastname: Ko
authors.forename: Yong-Kwang
authors.initials: YK
authors.lastname: Tu
authors.forename: Michael T
authors.initials: MT
authors.lastname: Lawton
mesh_terms: D000328:Adult; D017542:Aneurysm, Ruptured / Q000150:complications; D005260:Female; D023261:Glasgow Outcome Scale; D006801:Humans; D007427:Intracranial Pressure / Q000502:physiology; D008297:Male; D008875:Middle Aged; D019635:Neurosurgical Procedures / Q000379:methods*; D055420:Perfusion Imaging / Q000379:methods*; D013345:Subarachnoid Hemorrhage / Q000175:diagnosis* / Q000209:etiology / Q000601:surgery*; D017585:Ultrasonography, Doppler, Transcranial / Q000379:methods; D055815:Young Adult