title: Poor-grade subarachnoid hemorrhage: is surgical clipping worthwhile?
abstract: BACKGROUND
  Management of patients with poor-grade aneurysmal subarachnoid hemorrhage (SAH) is difficult and the protocols followed differ from center to center.
  
  
  METHODS
  In this report, we present our experience with aneurysmal clipping in patients with poor-grade SAH. Patients with poor Hunt and Hess (H and H) grade (Grade IV and Grade V) were offered surgery after stabilization of their hemodynamic and metabolic parameters. The status was recorded as favorable (good recovery, mild to moderate disability but independent), unfavorable (severe disability, vegetative) and dead.
  
  
  RESULTS
  Out of a total of 1196 patients who underwent aneurysmal clipping, 165(13.8%) were in poor grade. Of the 165 patients, 99 (60%) were in H and H Grade IV and 66 (40%) were in Grade V. More than half of the patients (58%) were operated within 24 h of admission. There was an overall mortality of 50.9%. In the long term, of the survivors who were followed up, about 72% achieved a favorable outcome.
  
  
  CONCLUSIONS
  With an aggressive approach aimed at early clipping, the chances of rebleed are reduced and vasospasm can be managed more aggressively. This protocol resulted in survival in a significant proportion of patients who would have otherwise died. In the long-term follow-up, the surviving patients showed significant improvement from the status at discharge.
authors.affiliation: Department of Neurosurgery, Postgraduate Institute of Medical Education and Research, Chandigarh, India. drguptasunil@gmail.com
authors.forename: Sunil K
authors.initials: SK
authors.lastname: Gupta
authors.forename: Rajesh K
authors.initials: RK
authors.lastname: Ghanta
authors.forename: Rajesh
authors.initials: R
authors.lastname: Chhabra
authors.forename: Sandeep
authors.initials: S
authors.lastname: Mohindra
authors.forename: Suresh N
authors.initials: SN
authors.lastname: Mathuriya
authors.forename: Kanchan K
authors.initials: KK
authors.lastname: Mukherjee
authors.forename: Alok U
authors.initials: AU
authors.lastname: Umredkar
authors.forename: Navneet
authors.initials: N
authors.lastname: Singla
mesh_terms: D000293:Adolescent; D000328:Adult; D000368:Aged; D005260:Female; D006801:Humans; D002532:Intracranial Aneurysm / Q000150:complications / Q000601:surgery*; D008297:Male; D008875:Middle Aged; D011379:Prognosis; D013345:Subarachnoid Hemorrhage / Q000209:etiology / Q000601:surgery*; D013525:Surgical Instruments; D016896:Treatment Outcome