Management of The Poor Grade Aneurysm Patient

Shin, Yong Sam; Lee, Kyu Chang

Abstract

Patients who suffer a severe aneurysmal subarachnoid hemorrhage(SAH) and who have arrived in the emergency room with devastated neurological or medical condition by this event are categorized as poor grade(Grade IV or V) aneurysm patients. As the poor grade patients are more prone to develop rebleeding, acute hydrocephalus, intracerebral and intraventricular hematoma, and delayed ischemic neurological deficits, the management of these patients remains challenging and controversial. However, it is now becoming evident that a significant number of the poor grade patients can be salvaged with an aggressive management from the moment of patient's arrival to the hospital. Initial management for the poor grade patients should be directed to the life threatening conditions such as cardiopulmonary depression, seizure, acute intracranial hypertension and rebleeding. The authors suggest that: 1) the Grade IV patients should be treated aggressively with direct clipping for patients with non-complex aneurysms, acute hydrocephalus, or significant amount of intracerebral hematoma; 2) The Grade V patients who show neurological improvement with supportive care could be the patients for an aggressive management; 3) Intra-aneurysmal treatment with Guglielmi Detachable Coil would be an alternative therapeutic option in the poor grade patients with advanced age, poor general physical condition, or complex aneurysm such as aneurysm of the posterior circulation or paraclinoid segment of the internal carotid artery.