gms | German Medical Science

63rd Annual Meeting of the German Society of Neurosurgery (DGNC)
Joint Meeting with the Japanese Neurosurgical Society (JNS)

German Society of Neurosurgery (DGNC)

13 - 16 June 2012, Leipzig

Subarachnoid hemorrhage WFNS grade V: is maximal treatment worthwhile?

Meeting Abstract

  • M. Wostrack - Neurochirurgische Klinik, Klinikum rechts der Isar, Technische Universität München
  • N. Sandow - Neurochirurgische Klinik, Charité - Universitätsmedizin Berlin
  • P. Bijlenga - Department of Neurosurgery, University of Geneva Medical Center, Geneva, Switzerland
  • V. Kehl - Institut für Medizinische Statistik und Epidemiologie, Technische Universität München
  • M. Stoffel - Neurochirurgische Klinik, Klinikum rechts der Isar, Technische Universität München
  • B. Meyer - Neurochirurgische Klinik, Klinikum rechts der Isar, Technische Universität München

Deutsche Gesellschaft für Neurochirurgie. Japanische Gesellschaft für Neurochirurgie. 63. Jahrestagung der Deutschen Gesellschaft für Neurochirurgie (DGNC), Joint Meeting mit der Japanischen Gesellschaft für Neurochirurgie (JNS). Leipzig, 13.-16.06.2012. Düsseldorf: German Medical Science GMS Publishing House; 2012. DocFR.08.08

DOI: 10.3205/12dgnc233, URN: urn:nbn:de:0183-12dgnc2332

Published: June 4, 2012

© 2012 Wostrack et al.
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Outline

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Objective: Aneurysmal subarachnoid hemorrhage (SAH) WFNS grade V is commonly known to be associated with high mortality and a very poor prognosis for the survivors. Therefore, maximal invasive therapy is frequently delayed till any spontaneous improvement with or without an external ventricular drainage (EVD) occurs. The aim of the study was to verify possible predictive factors and the probability of favourable outcome in maximally treated patients.

Methods: 100 consecutive patients with WFNS°V SAH were admitted between 03/2006 and 12/2010. 25 patients died before aggressive therapy could proceed. 75 Patients (male n = 19, female n = 56, median age 54 y.o.), who received maximal treatment and aneurysm occlusion were retrospectively evaluated. The outcome was assessed at discharge and in follow-up with the Glasgow Outcome Scale (GOS). Favourable outcome was defined as GOS 4 or 5. The follow-up is available for 75% (n = 38) of survivors with a median interval of 22 months.

Results: Despite treatment, mortality was high with 32% (n = 24). At discharge, the rate of vegetative and severely disabled patients was 31% (n = 23) and 24% (n = 18), respectively. Favourable outcome at discharge was observed in only 13% (n = 10) of cases, whereas in follow-up it rose to 27% (n = 20). The following potentially predictive factors were analyzed: gender, age, initial Glasgow Coma Scale, initial pupillary status, Fisher Grade, the presence and size of an intracerebral hematoma (ICH), the presence of an intraventricular hematoma (IVH), midline shift on the initial CT scan, treatment modality (endovascular vs. surgery), aneurysm size and location, additional treatment options: angioplasty, decompressive hemicraniectomy, and surgical ICH evacuation. Multivariate linear regression model identified only the IVH being significantly predictive (p = 0,01) for poor outcome.

Conclusions: Despite maximal treatment, initial mortality and severe disability remain high. Nevertheless, favourable outcome was achieved in 27% of aggressively treated patients (20% of all cases). It is reasonable to delay aggressive treatment in patients with WFNS°5 SAH and intraventricular hematoma until spontaneous improvement due to a very poor prognosis. In other patients favourable outcome seems to be unpredictable by means of conventional prognostic factors. In these patients maximal therapy should proceed without delay.