Outcome from poor grade aneurysmal subarachnoid haemorrhage which poor grade subarachnoid haemorrhage patients benefit from aneurysm clipping?

Patients with poor grade aneurysmal subarachnoid haemorrhage (SAH) are asso ciated with high mortality and morbidity, and hence are often treated conse rvatively. This study has set out to determine the outcome for all poor gra de subarachnoid haemorrhage patients, and attempts to identify a subgroup w ith a more favourable prognosis. During a prospective audit of patients wit h aneurysmal SAH, patients of poor grade [World Federation of Neurological Surgeons (WFNS) IV land not obeying commands) and V] were sedated, paralyse d and ventilated for transfer to the Regional Neurosurgical Unit. Any intra ventricular blood and/or hydrocephalus was treated by external ventricular drainage. Following a 24-h period for active blood gas, fluid and electroly te resuscitation, patients were assessed after reversal of sedation. Select ion for angiography and potential aneurysm surgery was restricted to those who showed a purposeful response to painful stimulation. Patients who could readily obey commands were not considered 'true' poor grade and were exclu ded from analysis. In 102 patients with 'true' poor grade SAH admitted betw een 1991 and 1997, the overall management outcome at 6 months was poor (fav ourable outcome 25%, mortality 67%). Following reversal of sedation, 55 pat ients demonstrated a purposeful response and proceeded to angiography, of w hom 37 underwent clipping and three coiling of aneurysm. The outcome in thi s aneurysm treated subgroup was favourable in 53% (mortality 28%). If patie nts over the age of 65 years are excluded, the management outcome was favou rable in 35% (mortality 58%), with those patients proceeding to clipping or coiling of aneurysms having a favourable outcome in 57% (mortality 27%). P atients over the age of 65 years with poor grade SAH had a favourable outco me in only 6% (mortality 85%). The mortality for poor grade SAH patients re mains high. However, following resuscitation and correction of any acute hy drocephalus, a patient subgroup identified on simple clinical criteria can be identified who can expect a better outcome.