Departments of Neuroanesthesia and Neurocritical Care, Neuroradiology and Neurosurgery, National Hospital for Neurology and Neurosurgery, Queen Square, London WC1N 3BG, UK.
Neurocrit Care. 2011 Jun;14(3):341-7. doi: 10.1007/s12028-010-9377-7.
Patients with poor grade (World Federation of Neurosurgeons (WFNS) Grades 4 and 5) subarachnoid hemorrhage (SAH) were historically considered to have a poor neurological outcome and therefore not traditionally offered aggressive treatment. In recent years there has been increasing evidence that early aggressive treatment of this patient group can result in a good outcome. Aim of this study is to identify the outcome of patients with WFNS Grade-4 and -5 SAH treated acutely with endovascular detachable coil embolization (DCE) and aggressive neurocritical care within our institution.
We retrospectively reviewed the records of patients with SAH WFNS Grades 4 and 5 treated with DCE within 7 days of admission between 1st January 2004 and 1st January 2008. Data collected included age, sex, grade SAH, position/number of Aneurysms, coiling complications, time spent on the neurosurgical critical care unit (NCCU), and 6-month outcome assessed by Glasgow outcome scale (GOS). GOS was dichotomized into good outcome (good recovery/moderate disability) and poor outcome (severe disability, vegetative, dead).
A total of 193 acute SAH patients were admitted and treated within this time period, of these, 47 patients were classified as poor grade and included: 70% were female and 30% were male. The mean age was 56 years (33-88 years range). A total of 56 aneurysms were noted at angiography, 52 aneurysms were coiled. Complications of SAH Vasospasm was noted in 18 patients (38%), cerebral infarction in 13 patients (28%), seizures in 7 patients (15%), hydrocephalus in 25 patients (53%). Complications of DCE occurred in 2 patients (4% of total) these were an aneurysmal rupture and a peri-procedure thrombosis. Incomplete coiling occurred in another 5 patients (10.6% of total) due to technical difficulties. The median length of stay on the NCCU was 12 days (1-52 days range). Of the 47 poor grade patients coiled, 25 (53%) had a good outcome (good recovery/moderate disability) and 22 (47%) had a poor outcome (severe disability, vegetative, dead) by the time of the 6-month follow-up.
Potentially, more than half the patients with WFNS Grade-4 and -5 SAH who are treated aggressively with coil embolization in association with supportive neurocritical care can achieve a good quality neurological outcome. However, it should be anticipated that these patients will spend a significant period of time in neurocritical care.
既往认为 WFNS 分级 4 和 5 级蛛网膜下腔出血（SAH）的患者神经功能预后不良，因此传统上不给予积极治疗。近年来，越来越多的证据表明，对这组患者进行早期积极治疗可以获得良好的结局。本研究旨在确定在我院接受血管内可解脱弹簧圈栓塞（DCE）和强化神经重症监护治疗的 WFNS 分级 4 和 5 级 SAH 患者的结局。
我们回顾性分析了 2004 年 1 月 1 日至 2008 年 1 月 1 日期间发病 7 天内接受 DCE 治疗的 WFNS 分级 4 和 5 级 SAH 患者的记录。收集的数据包括年龄、性别、SAH 分级、动脉瘤位置/数量、弹簧圈治疗并发症、在神经重症监护病房（NCCU）的时间以及 6 个月时采用格拉斯哥结局量表（GOS）评估的结局。GOS 分为良好结局（良好恢复/中度残疾）和不良结局（重度残疾、植物状态、死亡）。
在此期间共收治了 193 例急性 SAH 患者，其中 47 例为 WFNS 分级差的患者：70%为女性，30%为男性。平均年龄为 56 岁（33-88 岁）。血管造影共发现 56 个动脉瘤，其中 52 个被弹簧圈栓塞。SAH 的并发症包括血管痉挛 18 例（38%）、脑梗死 13 例（28%）、癫痫发作 7 例（15%）、脑积水 25 例（53%）。DCE 相关并发症 2 例（占总数的 4%），为动脉瘤破裂和术中血栓形成。另有 5 例（占总数的 10.6%）因技术困难导致不完全栓塞。NCCU 的中位住院时间为 12 天（1-52 天）。在接受 DCE 治疗的 47 例 WFNS 分级差的患者中，25 例（53%）在 6 个月随访时获得了良好结局（良好恢复/中度残疾），22 例（47%）结局不良（重度残疾、植物状态、死亡）。
在 WFNS 分级 4 和 5 级 SAH 患者中，采用弹簧圈栓塞并辅以支持性神经重症监护治疗，有半数以上的患者可能获得良好的神经功能结局。然而，应该预计这些患者将在神经重症监护病房度过相当长的一段时间。
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