Management morbidity and mortality of poor-grade aneurysm patients

Abstract

Preliminary experience with the occasional good survival of patients in Hunt and Hess Grade IV or V with aneurysmal subarachnoid hemorrhage (SAH) led to a prospective management protocol employed during a 2 1/2-year period. The protocol utilized computerized tomography (CT) scanning to diagnose SAH and to obtain evidence for irreversible brain destruction, consisting of massive cerebral infarction with midline shift or dominant basal ganglia or brain-stem hematoma. These patients, along with those who exhibited poor or absent intracranial filling on CT or angiography, were excluded from active treatment and given supportive care only. All other patients had immediate ventriculostomy placement and, if intracranial pressure (ICP) was controllable (less than or equal to 30 cm H2O without an intracranial clot or less than or equal to 50 cm H2O in the presence of a clot), went on to have craniotomy for aneurysm clipping. Aggressive postoperative hypertensive, hypervolemic, hemodilutional therapy was subsequently employed. Of 54 patients with poor-grade aneurysms, ventriculostomy was placed in 47 (87.0%) and yielded high ICP's in the overwhelming majority, with the mean ICP being 40.2 cm H2O. Nineteen poor-grade aneurysm patients received no surgical treatment and survived a mean of 31.8 hours with 100% mortality. Thirty-five patients underwent placement of a ventriculostomy, craniotomy for aneurysm clipping and intracranial clot evacuation, and postoperative hypertensive, hypervolemic, hemodilutional therapy. The outcome at 3 months of the 35 patients who were selected for active treatment was good in 19 (54.3%), fair in four (11.4%), poor in four (11.4%), and death in eight (22.9%). It is concluded that poor-grade aneurysm patients usually present with intracranial hypertension, even those without an intracranial clot. Based on radiographic rather than neurological criteria, a portion of these patients can be selected for active and successful treatment. Increased ICP can be present without ventriculomegaly, and immediate ventriculostomy should be performed. As long as ICP is controllable, craniotomy and postoperative intensive care can effect a favorable outcome in a significant percentage of these patients.

Third ventriculostomy through the lamina terminalis for intracranial pressure monitoring after aneurysm surgery: technical note

“…In patients with SAH, ventriculostomy is useful for 1) ICP monitoring; 2) cerebrospinal fluid (CSF) drainage and 3) managing hydrocephalus 2,3,5,[9][10][11] . Although the risk of aneurysmal rebleeding increases 4 , it is outweighed by the benefits 5 .…”

“…Early surgery for treatment of ruptured intracranial aneurysms is well established 1,2 . Intracranial pressure (ICP), monitoring, by means of a ventriculostomy, may improve the outcome as it decreases the incidence of ischaemic complications and hydrocephalus [3][4][5] .…”

Poor-Grade Ruptured Middle Cerebral Artery Aneurysm With Intracerebral Hematoma: Bleeding Characteristics and Management

“…1,3,5,6,17,19,29,34) Patients do not always achieve outcomes consistent with their initial neurological status, and 50-60% of patients affected by rupture of an intracranial aneurysm can become functional survivors. 3,[9][10][11][12]14,18,20,22,25,26) However, insufficient surgical intervention may result in loss of potentially salvageable function or life. 1,3,9,12,15,26,27) Adequate treatment often requires hematoma evacuation and decompressive maneuvers in addition to clipping procedures.…”

“…3,[9][10][11][12]14,18,20,22,25,26) However, insufficient surgical intervention may result in loss of potentially salvageable function or life. 1,3,9,12,15,26,27) Adequate treatment often requires hematoma evacuation and decompressive maneuvers in addition to clipping procedures. 4,7,16,21,23,24,26) However, there are few detailed descriptions of procedures that are appropriate for the management of poor-grade SAH with ruptured MCA aneurysm.…”

Follow-up of Large Aneurysms Treated with Coil Embolization at an Acute Stage in Patients with Poor-Grade Subarachnoid Hemorrhage

“…This study focused on poor-grade SAH patients with large aneurysms. Most neurosurgeons approved the management policy of Bailes et Al in poor-grade patients 1 : when the neurological status has improved and intracranial pressure (ICP) is controlled after ventriculostomy, craniotomy and postoperative care can affect a favorable outcome in a significant percentage of cases. Ventriculostomy, however, sometimes induces re-rupture of the aneurysm 3,6,10 .…”