Our Treatment Strategy for Poor-grade Subarachnoid Hemorrhage Patients with Hunt & Kosnik Grade IV, V

The outcome of poor-grade [Hunt & Kosnik (H & K) grade IV, V]subarachnoid hemorrhage (SAH) patients is still unsatisfactory. However, there are some patients who can be saved with aggressive treatment. In our clinic, we have operated on those poor-grade patients who did not show total cerebral ischemia, and who had spontaneous breathing. In our 723 operated (clipping) cases, there were 105 (14.5%) H & K grade IV patients and 30 (4.1%) H & K grade V patients. The GOS of these operated patients was as follows : In grade IV, good recovery (GR) 13%, moderate disability (MD) 13%, severe disability (SD) 20%, persistent vegetative state (V) 10%, death (D) 44% and in grade V, GR 7%, MD 3%, SD 10%, V 23%, D 57%, respectively. The most frequent cause of death among the operated cases was pneumonia, at 63% and 59%, respectively. On the other hand, the mortality rate for non-operated patients was as high as 96% in grade IV, and 98% in grade V. Although the patients' profiles are different in these two groups (operated vs. non-operated), the outcome of the operated group seems better than that of the other, when we consider the high mortality of the non-operated group. With the developments of 3D-CT angiography (3D=CTA), or the technique of inducing mild hypothermia (32-33 degree C), we can accomplish a direct operation for more patients these days than before. We should never give up on positive surgical treatment for those patients. We should establish criteria to select patients for aggressive treatment and do direct clipping for them with the help of induced mild hypothermia. The patients who are indicated for the surgery, are those who do not show total cerebral ischemia (that is, who are not under a long period of hypoxemia or general hypotension), and those who breathe spontaneously, indicating no complete brain herniation yet. Aged patients should never be omitted from those positive surgical treatments based solely on that lone criterior. Those poor-grade patients must be examined promptly and adequately, and be operated on by skilled neurosurgeons, although less invasively. Intraoperative intensive monitoring of the patients' general condition is also important, and postoperative intensive and adequate management, especially of the water balance and early mobilization of the patients, is mandatory. The operative results can also be improved if cisternal irrigation with urokinase is applied to prevent the development of vasospasm. All of these efforts mentioned can achieve better postoperative outcomes for poor-grade SAH patients.