Management of poor-grade patients with aneurysmal subarachnoid hemorrhage in the acute stage: Importance of close monitoring for neurological grade changes.

BACKGROUND: The optimal management of poor-grade patients with aneurysmal subarachnoid hemorrhage (SAH) remains controversial. We evaluated therapeutic outcomes to identify appropriate treatments for SAH patients admitted with a poor grade.
METHODS: We retrospectively studied 136 patients admitted within 6 hours after SAH onset with a poor Hunt & Kosnik Grade (IV and V).
RESULTS: Of 136 poor-grade patients, 20 with massive intracerebral or subdural hematoma underwent urgent hematoma evacuation and aneurysmal neck clipping. Seven of these achieved a favorable outcome (good recovery or moderate disability). Another 7 patients with prominent hydrocephalus or massive intraventricular hematoma underwent urgent continuous ventricular drainage. Of these, 4 manifested spontaneous grade improvement and underwent neck clipping; the other 3 died resulting from rebleeding. The remaining 109 patients whose poor grade was primarily because of SAH were observed without immediate surgery. In 43 patients of 109, the grade improved within 24 hours after hospitalization and within 38 hours in the other 4 patients. Aneurysmal neck clipping was performed in these 47 patients and a favorable outcome was achieved in 25 patients. The remaining 62 patients did not improve and the outcome was unfavorable.
CONCLUSIONS: Poor-grade SAH patients should be treated according to the pathogenesis underlying their poor grade. Close monitoring for a grade change over the first 24 hours after hospitalization is mandatory in patients whose poor grade is primarily because of the SAH and helps to determine the appropriateness of surgery.