WFNS grade Vの重症くも膜下出血症例の治療成績  [in Japanese] Surgical Treatment Results for Subarachnoid Hemorrhage Patients with WFNS Grade V  [in Japanese]

The surgical management and therapeutic indication for poor-grade patients with subarachnoid hemorrhage (SAH) is controversial. Our hospital has an emergency medical center and admits many poor-grade SAH patients at ultra-early stages. We treated SAH patients with World Federation Neurological Surgeons (WFNS) Grade V who displayed the presence of the light reflex, intra-cerebral hematoma (ICH) or improvement of WFNS grade. We retrospectively evaluated 43 WFNS Grade V patients treated with surgical clipping (SC) or coil embolization (CE) in the period of 1998 to 2008. Forty-two patients (98%) were admitted within 180 minutes after SAH onset. SC was performed in 17 patients (40%), and CE was performed in 26 patients (60%). ICH was observed in 8 patients (18.6%). Rebleeding occurred in 9 patients (20.9%). At the time of surgery, the light reflex was present in 32 patients (74.4%). Grade improvement in the acute stage was observed in 18 patients (41.9%). In 24 patients (55.8%), SC or CE was performed within 24 hours. Symptomatic vasospasm was observed in 5 patients (11.6%), and shunt operation was performed in 14 patients (32.6%). The length of hospitalization ranged from 3 to 233 days (mean: 62.6 days). The overall outcomes assessed at discharge by the Glasgow outcome scale (GOS) were GR in 11 (25.6%), MD in 12 (27.9%), SD in 10 (23.3%), and dead in 10 patients (23.3%). The percentage of GR was 29.4% in the SC group and 23.1% in the CE group. Similarly, MD was 29.4% and 26.9%; SD was 23.5% and 23.1%. But mortality was 17.6% and 26.9%. Favorable outcomes (GR+MD) were observed in 11 patients (61.1%) with grade improvement, in 22 patients (68.8%) with the presence of light reflex and in 6 patients (75%) with ICH. Patients with pre-operative Glasgow coma scale scores of 3, 4 obtained unfavorable outcomes. About half of WFNS Grade V patients obtained unfavorable outcomes, but favorable outcomes can be obtained in patients with grade improvement, the presence of the light reflex or ICH.