J Neurosurg. 2018 Jan;128(1):100-110. doi: 10.3171/2016.8.JNS161075. Epub 2017 Feb 24.
OBJECTIVE Outcome analysis of comatose patients (Hunt and Hess Grade V) after subarachnoid hemorrhage (SAH) is still lacking. The aims of this study were to analyze the outcome of Hunt and Hess Grade V SAH and to compare outcomes in the current period with those of the pre-International Subarachnoid Aneurysm Trial (ISAT) era as well as with published data from trials of decompressive craniectomy (DC) for middle cerebral artery (MCA) infarction. METHODS The authors analyzed cases of Hunt and Hess Grade V SAH from 1980-1995 (referred to in this study as the earlier period) and 2005-2014 (current period) and compared the results for the 2 periods. The outcomes of 257 cases were analyzed and stratified on the basis of modified Rankin Scale (mRS) scores obtained 6 months after SAH. Outcomes were dichotomized as favorable (mRS score of 0-2) or unfavorable (mRS score of 3-6). Data and number needed to treat (NNT) were also compared with the results of decompressive craniectomy (DC) trials for middle cerebral artery (MCA) infarctions. RESULTS Early aneurysm treatment within 72 hours occurred significantly more often in the current period (in 67% of cases vs 22% in earlier period). In the earlier period, patients had a significantly higher 30-day mortality rate (83% vs 39% in the current period) and 6-month mortality rate (94% vs 49%), and no patient (0%) had a favorable outcome, compared with 23% overall in the current period (p < 0.01, OR 32), or 29.5% of patients whose aneurysms were treated (p < 0.01, OR 219). Cerebral infarctions occurred in up to 65% of the treated patients in the current period. Comparison with data from DC MCA trials showed that the NNTs were significantly lower in the current period with 2 for survival and 3 for mRS score of 0-3 (vs 3 and 7, respectively, for the DC MCA trials). CONCLUSIONS Early and aggressive treatment resulted in a significant improvement in survival rate (NNT = 2) and favorable outcome (NNT = 3 for mRS score of 0-3) for comatose patients with Hunt and Hess Grade V SAH compared with the earlier period. Independent predictors for favorable outcome were younger age and bilateral intact corneal reflexes. Despite a high rate of cerebral infarction (65%) in the current period, 29.5% of the patients who received treatment for their aneurysms during the current era (2005-2014) had a favorable outcome. However, careful individual decision making is essential in these cases.
目前仍缺乏蛛网膜下腔出血（SAH）后昏迷患者（Hunt 和 Hess 分级 V）的结果分析。本研究旨在分析 Hunt 和 Hess 分级 V 的 SAH 结果，并比较当前时期与国际蛛网膜下腔动脉瘤试验（ISAT）前时期以及减压性颅骨切除术（DC）治疗大脑中动脉（MCA）梗死试验的结果。
作者分析了 1980-1995 年（在此研究中称为早期）和 2005-2014 年（当前时期）的 Hunt 和 Hess 分级 V 的 SAH 病例，并比较了这两个时期的结果。根据 SAH 后 6 个月获得的改良 Rankin 量表（mRS）评分，对 257 例病例的结果进行分层。结果分为有利（mRS 评分 0-2）或不利（mRS 评分 3-6）。还将数据和需要治疗的人数（NNT）与 MCA 梗死的减压性颅骨切除术（DC）试验结果进行了比较。
当前时期早期的动脉瘤治疗在 72 小时内明显更为常见（占 67%），而早期为 22%。在早期，30 天死亡率（83% vs 当前时期的 39%）和 6 个月死亡率（94% vs 当前时期的 49%）显著更高，并且没有患者（0%）有良好的预后，而当前时期的总体预后为 23%（p < 0.01，OR 32），或动脉瘤治疗的 29.5%的患者（p < 0.01，OR 219）。当前时期多达 65%的治疗患者发生脑梗死。与 DC MCA 试验的数据比较表明，当前时期的 NNT 明显较低，生存率为 2，mRS 评分 0-3 为 3（而 DC MCA 试验分别为 3 和 7）。
与早期相比，昏迷的 Hunt 和 Hess 分级 V 的 SAH 患者的早期和积极治疗显著提高了生存率（NNT = 2）和有利预后（mRS 评分 0-3 的 NNT = 3）。有利预后的独立预测因素是年龄较小和双侧角膜反射完整。尽管当前时期的脑梗死发生率很高（65%），但在当前时期（2005-2014 年）接受动脉瘤治疗的 29.5%的患者有良好的预后。然而，在这些情况下，需要谨慎地做出个体决策。
