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Outcome in Poor Grade Subarachnoid Hemorrhage Patients Treated with Acute Endovascular Coiling of Aneurysms and Aggressive Intensive Care

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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.

Conclusion

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.

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References

  1. Teasdale GM, et al. A universal subarachnoid hemorrhage grading scale. J Neurol Neurosurg Psychiatr. 1988;51:1457.

    Article  PubMed  CAS  Google Scholar 

  2. Adams HP, Kassell NF, Torner JC, Nibbelink DW, Sahs AL. Early management of aneurysmal SAH: a report to the cooperative aneurysm study. J Neurosurg. 1981;54(2):141–5.

    Article  PubMed  Google Scholar 

  3. Testa C, Andreoli A, Arista A, Limoni P, Tognetti F. Overall results in 304 consecutive patients with acute spontaneous subarachnoid hemorrhage. Surg Neurol. 1985;24:377–85.

    Article  PubMed  CAS  Google Scholar 

  4. Hijdra A, van Gijn J, Nagelkerke NJ, Vermeulen M, Van Crevel H. Prediction of delayed cerebral ischemia, rebleeding, and outcome after aneurysmal subarachnoid hemorrhage. Stroke. 1988;19:1250–6.

    PubMed  CAS  Google Scholar 

  5. Freckmann N, Noll M, Winkler D, Nowak G, Rehn H, Neuss M, Herrmann HD. Does the timing of aneurysm surgery neglect the real problems of the subarachnoid hemorrhage? ACTA Neurochir (Wien). 1987;89:91–9.

    Article  CAS  Google Scholar 

  6. Ohno K, Suzuki R, Masaoka H, Monma S, Matsushima Y, Inaba Y. A review of 102 consecutive patients with intracranial aneurysms in a community hospital in Japan. Acta Neurochir (Wien). 1988;94:23–7.

    Article  CAS  Google Scholar 

  7. Bailes JE, Spetzler RF, Hadley MN, Baldwin HZ. Management morbidity and mortality of poor grade aneurysm patients. J Neurosurg. 1990;72:559–66.

    Article  PubMed  CAS  Google Scholar 

  8. Steudel WI, Reif J, Voges M. Modulated surgery in the management of ruptured intracranial aneurysm in poor grade patients. Neurol Res. 1994;16:49–53.

    PubMed  CAS  Google Scholar 

  9. Le Roux PD, Elliot JP, Newell DW, Grady MS, Winn HR. Predicting outcome in poor-grade patients with subarachnoid hemorrhage: a retrospective review of 159 aggressively managed cases. J Neurosurg. 1996;85:39–49.

    Article  PubMed  Google Scholar 

  10. Le Roux PD, Winn HR. Intracranial aneurysms and subarachnoid hemorrhage management of the poor grade patient. Acta Neurochir Suppl. 1999;72:7–26.

    PubMed  Google Scholar 

  11. Weir RU, Marcellus ML, Do HM, Steinberg GK, Marks MP. Aneurismal subarachnoid hemorrhage in patients with Hunt and Hess Grade 4 or 5: treatment using the Guglielmi detachable coil system. Am J Neuroradiol. 2003;24:585–90.

    PubMed  Google Scholar 

  12. Bergui M, Bradac GB. Acute endovascular treatment of ruptured aneurysms in poor grade patients. Neuroradiology. 2004;46:161–4.

    Article  PubMed  CAS  Google Scholar 

  13. Pereira AR, et al. Predictors of 1-year outcome after coiling for poor grade subarachnoid aneurysmal hemorrhage. Neurocrit Care. 2007;7:18–26.

    Article  PubMed  Google Scholar 

  14. Molyneux A, Kerr R, Stratton I, Sandercock P, Clarke M, Shrimpton J, Holman R. International Subarachnoid Aneurysm Trial (ISAT) of neurosurgical clipping versus endovascular coiling in 2143 patients with ruptured intracranial aneurysms: a randomised trial. Lancet. 2002;360(9342):1267–74.

    Article  PubMed  Google Scholar 

  15. Komotar RJ, et al. Resuscitation and critical care of poor grade subarachnoid hemorrhage. Neurosurgery. 2009;64:397–411.

    Article  PubMed  Google Scholar 

  16. Smith M. Intensive care management of patients with subarachnoid hemorrhage. Curr Opin Anaesthesiol. 2007;20:400–7.

    Article  PubMed  Google Scholar 

  17. Jennett B, Bond M. Assessment of outcome after severe brain damage: a practical scale. Lancet. 1975;1:480–4.

    Article  PubMed  CAS  Google Scholar 

  18. Seule MA, et al. Therapeutic hypothermia in patients with aneurismal subarachnoid hemorrhage, refractory intracranial hypertension, or cerebral vasospasm. Neurosurgery. 2009;64:86–92.

    Article  PubMed  Google Scholar 

  19. Hunt WE, Hess RM. Surgical risk as related to time of intervention in the repair of intracranial aneurysms. J Neurosurg. 1968;28:14–20.

    Article  PubMed  CAS  Google Scholar 

  20. Kremer C, Groden C, Hansen HC, Gryska U, Zeumer H. Outcome after endovascular treatment of Hunt and Hess Grade IV or V aneurysms: comparison of anterior versus posterior circulation. Stroke. 1999;30:2617–22.

    PubMed  CAS  Google Scholar 

  21. Yasunobu G, Sen Y. Differences in outcome in patients with poor grade subarachnoid hemorrhage (WFNS Grade IV and V): according to the perioperative management against vasospasm. Neurol Surg. 2004;32(6):579–84.

    Google Scholar 

  22. Kassell NF, Torner JC, Haley EC Jr, et al. The International Cooperative Study on the Timing of Aneurysm Surgery part 1: overall management results. J Neurosurg. 1990;73:18–36.

    Article  PubMed  CAS  Google Scholar 

  23. Graff-Radford NR, Tomer J, Adams HP, Kassell NF. Factors associated with hydrocephalus after subarachnoid hemorrhage. A report of the cooperative aneurysm study. Arch Neurol. 1989;46(7):744–52.

    PubMed  CAS  Google Scholar 

  24. Sluzewski M, Bosch JA, van Rooij WJ, Nijssen PCG, Wijnalda D. Rupture of intracranial aneurysms during treatment with Guglielmi detachable coils: incidence, outcome, and risk factors. J Neurosurg. 2001;94:238–40.

    Article  PubMed  CAS  Google Scholar 

  25. Hutchinson PJ, et al. Outcome from poor grade aneurysmal subarachnoid haemorrhage—which poor grade subarachnoid haemorrhage patients benefit from aneurysm clipping? Br J Neurosurg. 2000;14(2):105–9.

    Article  PubMed  CAS  Google Scholar 

  26. Van Loon J, Waerzeggers Y, Wilms G, Van Calenbergh F, Goffin J, Plets C. Early endovascular treatment of ruptured cerebral aneurysms in patients in very poor neurological condition. Neurosurgery. 2002;50(3):457–64. discussion 464–5.

    PubMed  Google Scholar 

  27. Sato K, et al. Acute stage diffusion weighted magnetic resonance imaging for predicting outcome of poor grade aneurismal subarachnoid hemorrhage. J Cereb Blood Flow Metab. 2010 Jan 6.

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Authors and Affiliations

  1. Departments of Neuroanesthesia and Neurocritical Care, Neuroradiology and Neurosurgery, National Hospital for Neurology and Neurosurgery, Queen Square, London, WC1N 3BG, UK

    Christopher J. Taylor, Fergus Robertson, David Brealey, Frankie O’shea, Tina Stephen, Stefan Brew, Joan P. Grieve, Martin Smith & Ian Appleby

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  1. Christopher J. Taylor
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  2. Fergus Robertson
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  3. David Brealey
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  4. Frankie O’shea
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  5. Tina Stephen
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  6. Stefan Brew
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  7. Joan P. Grieve
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  8. Martin Smith
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  9. Ian Appleby
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Correspondence to Christopher J. Taylor.

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Taylor, C.J., Robertson, F., Brealey, D. et al. Outcome in Poor Grade Subarachnoid Hemorrhage Patients Treated with Acute Endovascular Coiling of Aneurysms and Aggressive Intensive Care. Neurocrit Care 14, 341–347 (2011). https://doi.org/10.1007/s12028-010-9377-7

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