Treatment Policy for Patients with Hunt-Hess Grade IV and V SAH

Oh, Chang Wan; Han, Dae Hee

Abstract

To settle the controversy over the optimum management strategy for patients with poor-grade(Hunt-Hess grade IV and V) aneurysmal subarachnoid hemorrhage, the medical records of 50 patients admitted in poor Hunt-Hess grade have been examined retrospectively with literature review. Twelve patients underwent early surgery for aneurysmal neck clipping, and for the other patients, initial conservative management was done followed by delayed operation for 19 patients who showed stabilization or improvement of neurologic status. All patients were managed by active treatment(hypertensive, hypervolemic and hemodilutional therapy) after aneurysmal neck clipping. Initial findings such as better neurological condition(Hunt-Hess grade IV) and presence of intracerebral hemorrhage were indicators of good prognosis. Patients with intraventricular hemorrhage and uncontrollably increased intracranial pressure(>40 cm H20 after extraventricular drainage) resulted in severe morbidity or mortality. Regarding the timing of surgery, early intervention led to a better outcome with less morbidity(8% vs. 26%) compared with delaying operation, because of the lower incidence of rebleeding, reduced vasospasm and more effective management of delayed ischemia after surgery. The incidence of intraoperative premature rupture and mortality were not significantly influenced by the timing of surgery. It is concluded that, for poor-grade aneurysm patients without a definite evidence of irreversibility such as brainstem failure signs or uncontrollably increased intracranial pressure, early surgery followed by aggressive treatment to prevent cerebral vasospasm is the treatment of choice.