Management morbidity and mortality in grade IV and V patients with aneurysmal subarachnoid haemorrhage

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Abstract
In a retrospective study the clinical management of 74 patients with aneurysmal subarachnoid haemorrhage (SAH) admitted in grade IV and V Hunt and Hess was examined. 39 patients (53%) were admitted within 24 hours after SAH, 29 patients (39%) between 24 and 72 hours after SAH, and 6 patients 8%) later than this time interval. The ruptured aneurysms were located at the anterior communicating artery complex in 34 patients (46%), on the middle cerebral artery in 19 patients (26%), on the internal carotid artery in 12 patients (16%) and at the vertebro-basilar artery complex in 9 patients (12%). In 38 patients (51%) no surgical attack on the aneurysm was performed. 19 (50%) of these patients were in grade IV on admission and 19 (50%) in grade V. In 36 patients (49%) the aneurysm was clipped. Of these patients 29 (81%) were in grade IV and 7 (19%) in grade V. Of the 38 patients in whom no aneurysm surgery was done, 37 patients died, representing a mortality rate of 97%, one patient survived in grade III Glasgow Outcome Scale (GOS). Concerning the outcome in those patients with aneurysm clipping, of 19 patients in grade IV operated on early, 10 patients (53%) made a good recovery, 3 (16%) were left severely disabled and 6 patients (31%) remained in a vegetative state or died. Of the 10 patients in grade IV with delayed surgery 4 (40%) were in grade I and II postoperatively, 2 (20%) in grade III, and again 4 (40%) in grade IV and V GOS. None of the 4 patients in Hunt and Hess grade V in whom early surgery was done achieved a good postoperative outcome. 2 patients survived in grade III GOS, and another 2 patients died. Only three patients admitted in grade V survived long enough to be subjected to delayed surgery. Of these patients one survived without deficit, one survived severely disabled and one patient died. From the data presented the following conclusions are drawn: 1. Without surgery the chance of survival in poor-grade aneurysm patients is almost non existent 2. Patients admitted in grade V have a uniformly poor prognosis with a very high mortality whether surgery is done or not, and whether surgery is performed early or late. 3. Patients in grade IV represent a distinct group with a better prognosis than those in grade V, justifying an aggressive surgical management. 4. Early surgery in grade IV patients leads to better results than delayed surgery especially in terms of overall management morbidity and mortality. 5. In order to further improve the results of management of poor-grade aneurysm patients early referral to neurosurgical centres is mandatory.