Predictors of outcome in World Federation of Neurologic Surgeons grade V aneurysmal subarachnoid hemorrhage patients.

BACKGROUND

Only a small percentage of World Federation of Neurologic Surgeons grade V aneurysmal subarachnoid hemorrhage patients have a favorable outcome. The influence of clinical parameters on outcome was assessed.

METHODS

Retrospective evaluation of consecutive patients admitted from 2000-2007 with grade V subarachnoid hemorrhage at two institutions by evaluating, over time, the motor value of the Glasgow Coma Scale, effects of external ventricular drainage and rebleeding on outcome. Six-month outcome was assessed with the extended Glasgow Outcome Scale; favorable outcome was defined as good recovery or moderately disabled.

FINDINGS

Of 126 patients, 28 had absent brainstem reflexes, without improvement after external ventricular drainage. Rebleeding occurred in 26 patients, resulting in treatment withdrawal in 14. Only one patient had a favorable outcome after rebleeding. Of the 84 remaining patients, 61 improved at day 2 after subarachnoid hemorrhage to Glasgow Coma Scale motor value ≥4; 24 of these (39%) had a favorable outcome. All 23 patients with a Glasgow Coma Scale motor value ≤3 had an unfavorable outcome or died. Patients younger than 65 yrs of age had a better outcome (p < .03). Hydrocephalus was present in 71 of 84 patients. Favorable outcome was similar for patients with a positive external ventricular drainage response (8 of 28) as compared to no response to external ventricular drainage (12 of 43).

INTERPRETATION

The high rebleeding rate and subsequent poor outcome in World Federation of Neurologic Surgeons grade V patients warrants early treatment to secure the ruptured aneurysm. Favorable outcome was seen in 39% of patients with a Glasgow Coma Scale motor value ≥4 at day 2. In this study, patients with Glasgow Coma Scale motor value ≤3 at day 2 all had a very poor prognosis.