by Christopher S. Ogilvy,
Aneurysm & AVM Center
Management of aneurysm patients in poor
neurologic condition: Some patients
| Post treatment care | Management plan
| Results | Key points | Other
sources of information
Hunt and Hess classification system is commonly used to define the degree of neurologic
injury patients incur after a subarachnoid hemorrhage. Grade I patients have minimal
headache or slight nuchal rigidity; grade II patients have moderate to severe
headache, nuchal rigidity, no neurologic deficit other than cranial nerve palsy;
grade III patients are drowsy, confused, or have mild focal neurologic deficits.
Patients in grade IV neurologic condition are those who are stuporous with moderate
to severe hemiparesis, possibly early decerebrate rigidity, and vegetative disturbances.
Grade V patients are those in deep coma with decerebrate rigidity or a moribund
appearance. Patients presenting with a grade IV or V hemorrhage have typically
been managed conservatively or with comfort measures for the patient only. Mortality
rates of 80-90% were the rule with this type of management.
Over the past three years, we have taken a different approach to the management
of these poor grade patients. In a good proportion of these patients, a reversible
mechanism of neurologic impairment can be identified. Evaluation
The CT scan in poor grade patients may define potentially reversible causes of
coma. Patients with intraparenchymal hemorrhage (without vital brain destruction)
associated with an aneurysm represent one situation where removal of the blood
clot may result in neurologic improvement. Similarly, intraventricular hemorrhage
or hydrocephalus associated with subarachnoid hemorrhage may be conditions where
insertion of a ventricular drainage system will alleviate elevate intracranial
pressure (ICP). Given these potentially reversible conditions, rapid evaluation
and treatment of patients in poor neurologic condition after subarachnoid hemorrhage
should proceed. Management
plan The overall management strategy of
poor grade aneurysm patients is shown on the flow diagram. Patients presenting
in poor neurologic condition undergo a head CT. If there is vital brain destruction
with no hope for improvement, comfort measures only are instituted. If the head
CT shows diffuse subarachnoid hemorrhage, hydrocephalus, or an intraparenchymal
hemorrhage which could be removed surgically with some hope of neurologic improvement,
a ventriculostomy is inserted. Once the ventricular drain is in place, the intracranial
pressure can be monitored. If the ICP remains controllable (less than 20 mm Hg),
and if there is improved neurologic condition with adequate brainstem function,
we proceed with cerebral angiography to define the source of the hemorrhage. If
the intracranial pressure remains uncontrolled or the patient makes no neurologic
improvement with poor brainstem function, then no further aggressive therapy is
recommended to the patient's family. In cases
where cerebral angiography is performed, the aneurysm location and size is evaluated.
A decision is then made on the best treatment for the aneurysm, whether that be
with direct surgery and clipping of the lesion with possible removal of intraparenchymal
blood clot or possibly an endovascular approach to obliterate the aneurysm. This
decision is often made through discussions between the neurosurgeon, the interventional
neuroradiologist, and a neurologist. As well, discussions with the family are
important at this interval to try to help family members understand the potential
outcomes for a poor grade aneurysm patient.
care Following treatment of the aneurysm, the
ventricular drain is maintained and maximal medical therapy is instituted for
potential vasospasm. This involves elevated blood pressure with intravenous pressor
agents, hypervolemia with central venous pressure monitoring, and hemodilution
with hematocrit maintained between 30 - 32%. By using transcranial doppler monitoring
in conjunction with neurologic examination, the severity of vasospasm and efficacy
of treatment can be followed. Results
Using the management plan outlined, we have treated 32 patients in poor neurologic
condition. In 12 patients managed without treatment of the aneurysm, 2 survived.
In these patients, angiogram failed to reveal an intracranial aneurysm. In the
10 other patients, uncontrolled intracranial pressure or failure to improve neurologically
after placement of ventriculostomy led us to conclude that neurologic improvement
was unlikely. Of 18 grade IV and V patients managed with surgery, 8 (45%) had
excellent or good outcome, 2 (11%) had a fair outcome, 2 (11%) had a poor outcome,
and 6 (33%) died. Although we have been able
to improve the outcome of patients in poor neurologic condition after subarachnoid
hemorrhage, it should be noted that of 32 patients treated, 16 were patients whose
poor neurologic condition was due to a second hemorrhage from their aneurysm.
This emphasizes the importance of early diagnosis and treatment of patients presenting
with subarachnoid hemorrhage. It is through this type of recognition that overall
improved management of aneurysm patients can be expected to occur. Key
- Patients presenting
in poor neurologic condition after subarachnoid hemorrhage may have a reversible
etiology of their impairment.
- Prompt evaluation
and treatment is crucial to the overall goal of reducing the morbidity and mortality
of patients in poor neurologic condition.
Information sources on poor grade aneurysmal subarachnoid hemorrhage
Ojemann RG, Ogilvy CS, Heros RC, Crowell RM, eds. Surgical Management of Cerebrovascular
Disease, Third edition. Williams & Wilkins, Baltimore, in press.