PATIENTS IN POOR NEUROLOGICAL CONDITION AFTER SUBARACHNOID HEMORRHAGE- EARLY MANAGEMENT AND LONG-TERM OUTCOME

We report management and outcome data on 118 patients that presented t o our emergency room over a 4 year interval (1990-1994) in poor neurol ogical condition after subarachnoid hemorrhage. All patients were trea ted following a strict protocol. After initial evaluation, patients un derwent a head computerized tomography (CT) scan to try to understand the mechanism of coma. If CT did not show destruction of vital brain a reas, a ventriculostomy was inserted and ICP measured. If ICP was less than 20 mm Hg, or if standard treatment of increased ICP was able to lower the ICP to a value less than 20 mmHg, patients were evaluated wi th cerebral angiogram to determine the location of the ruptured aneury sm. The lesion was then treated by craniotomy for aneurysm clipping or endovascular obliteration. Postoperative monitoring for vasospasm wit h clinical exam and transcranial doppler studies was performed routine ly. Ii vasospasm developed, this was managed aggressively with hyperte nsive, hypervolemic and hemodilutional therapy and, at times, endovasc ular treatment with angioplasty or papaverine. Outcome was measured at 1 year or more after treatment. Among patients who mel criteria for a neurysm treatment, 47% had excellent or good neurologic outcome. There was a 30% mortality rate in these patients. In patients with high ICP , poor brainstem function or destruction of vital brain areas on CT, c omfort measures only were offered and almost all died. It is concluded that an approach of early aneurysm obliteration and aggressive medica l and endovascular management of vasospasm is warranted in patients in poor neurological conditions after subarachnoid hemorrhage.