Comparison of operative and endovascular treatment of anterior circulation aneurysms in patients in poor grades.

We assessed the outcome of surgical and endovascular treatment in patients in poor (Hunt & Hess IV or V) grade following subarachnoid haemorrhage due to anterior circulation aneurysm (ACA). There were 41 patients, treated surgically (20), by the endovascular route (20) or both (1). The aneurysms were clipped in 20 patients, wrapped in one; 19 were treated with Guglielmi detachable coils (GDC), one by parent vessel occlusion using detachable balloons. One GDC treatment was interrupted and the aneurysm was surgically clipped instead. We treated five patients surgically to evacuate accompanying intracerebral clots. We treated 14 (66%) patients by the endovascular route and 15 (71%) surgically within 72 h of the haemorrhage. The frequency of delayed ischaemic neurological deficit and/or cerebral infarct due to vasospasm did not differ significantly between the endovascular and surgical groups. We had one surgical and three endovascular procedure-related complications with clinical manifestations. Outcome was evaluated after 6 months. After GDC treatment, angiographic follow-up was carried out between 8 and 26 months (mean 17 months). Good outcomes were achieved in six (29%) of the surgically treated patients (40% of the survivors) and six (30%) of the endovascular treatment patients (60% of the survivors). Outcome was similar after surgical and endovascular approaches. The decision as to which treatment to chosen is influenced mainly by clinical factors such as cerebral haematoma or age.