Treatment Policy for Grade IV and V Patients

Abstract

To settle the controversy over optimum management strategy for patients with poor-grade (Hunt and Hess grade IV and V) aneurysmal subarachnoid hemorrhage (SAH), the rnedical records of 50 patients admitted with poor Hunt and Hess grade have been examined retrospectively with literature review, Initial findings such as better neurological condition (Hunt and Hess grade IV) and presence of intracerebral hemorrhage were indicators of good prognosis, Patients with intraventricular hemorrhage and uncontrollably increased intracranial pressure (>40cm H20 after extraventricular drainage) resulted in severe morbidity or mortality, Regarding the timing ofsurgery, early intervention led to a better outcome with less morbidity because of the marked decrease ofthe severity of vasospasrn and the incidence of rebleeding. The'frequency of intraoperative premature rupture and the overall mortality were not significantly influen ¢ ed by the timing of surgery, It is concluded that, fbr patients in poor Hunt and Hess grade without a definite evidence of irreversibility such as brainstern failure signs or uncontrollably increased intracranial pressure, early surgery fbllowed by aggressive treatment to prevent cerebral vasospasm is the treatment of choice.