Poor-grade aneurysmal subarachnoid hemorrhage: outcome after treatment with urgent surgery

Neurosurgery. 2003 Dec;53(6):1275-80; discussion 1280-2. doi: 10.1227/01.neu.0000093199.74960.ff.


Objective: We sought to determine whether the rebleeding rate in poor-grade patients justified a period of supportive observation before selective treatment and whether unselected ultraearly surgery would lead to acceptable results.

Methods: A prospectively audited, nonselected series of 177 consecutive poor-grade (i.e., World Federation of Neurological Surgeons Grades IV and V) patients with aneurysmal subarachnoid hemorrhage managed during a 9-year period was analyzed. A management policy of aggressive ultraearly surgery (not selected by age or by grade) was followed. Coiling was not available. Outcomes were assessed at 3 months.

Results: Despite the aggressive management policy, surgery could be performed in only 132 poor-grade patients (75%). Twenty percent of all patients were 70 years of age or older (15% of the surgical cases). All surgery was performed within 12 hours of subarachnoid hemorrhage (majority <6 h). Preoperative rebleeding occurred within the first 12 hours (>85% within 6 h) in 20% of the patients, which is four times the rate found in good-grade patients managed according to the same policy. Outcome assessment performed at 3 months in the 132 poor-grade surgical patients revealed that 40% were independent, 15% were dependent, and 45% had died. There was no significant difference in outcomes for young and old (70+ yr) poor-grade surgical patients (P > 0.05).

Conclusion: The high ultraearly rebleeding rate indicates a need to urgently secure the ruptured aneurysm by performing surgery or coiling, and this indication is more pronounced for poor-grade patients than for good-grade patients. The outcome results of ultraearly surgery indicate that a nonselective policy does not lead to a large number of dependent survivors, even among elderly poor-grade patients.

MeSH terms

  • Adult
  • Aged
  • Aged, 80 and over
  • Emergencies
  • Glasgow Outcome Scale
  • Humans
  • Medical Audit
  • Middle Aged
  • Neurosurgical Procedures / adverse effects*
  • Outcome and Process Assessment, Health Care*
  • Patient Selection*
  • Postoperative Hemorrhage / etiology*
  • Prospective Studies
  • Recurrence
  • Severity of Illness Index
  • Subarachnoid Hemorrhage / surgery*
  • Time Factors