Management of poor grade patients after subarachnoid haemorrhage: the importance of neuroradiological findings on clinical outcome.

The prognosis for patients in poor neurological grade (WFNS grades IV and V) after subarachnoid haemorrhage (SAH) is grave. Previous reports of such patients have analysed outcome without defining either the cause or the course of the depressed level of consciousness. We report a retrospective study of the outcome of 62 consecutive patients in poor grade after SAH analysed with respect to their clinical course and the predominant computed tomographic feature. Neuroradiological findings were (1) intracranial haematoma, (2) hydrocephalus with or without intraventricular haemorrhage (IVH) and (3) SAH alone. Sixteen patients (25.8%) had a Glasgow Coma Score (GCS) < or = 12 on admission to hospital and subsequently deteriorated. The predominant computed tomographic feature of these patients was hydrocephalus/IVH. Twelve patients (19.4%) had a GCS < or = 12 on admission and subsequently improved without intervention; all had SAH on computed tomography (CT) on admission. Thirty-four patients (54.8%) had a GCS < or = 12 on admission and did not improve or improved only after emergency surgical intervention. Haematoma (44%) and hydrocephalus/IVH (47%) were the predominant CT features in this group. The overall mortality in the 62 patients was 44%. Fifty-two per cent of patients achieved a good outcome or were moderately disabled. Patients harbouring an intracerebral haematoma had a significantly poorer prognosis when compared with the other groups. Patients in poor neurological grade after SAH are a heterogenous group both clinically and neuroradiologically. Management approaches must consider the cause of clinical deterioration and the related CT findings.