Current Management of aneurysm patients in poor neurologic condition:
The Hunt and Hess classification system is commonly used to define the degree of neurologic injury patients incur after a subarachnoid hemorrhage. Grade I patients have minimal headache or slight nuchal rigidity, grade II patients have moderate to severe headache, nuchal rigidity, no neurologic deficit other than cranial nerve palsy, grade III patients are drowsy, confused, or have mild focal neurologic deficits. Patients in grade IV neurologic condition are those who are stuporous with moderate to severe hemiparesis, possibly early decerebrate rigidity, and vegetative disturbances. Grade V patients are those in deep coma with decerebrate rigidity or a moribund appearance. Patients presenting with a grade IV or V hemorrhage have typically been managed conservatively or with comfort measures for the patient only. Mortality rates of 80-90% were the rule with this type of management.
Over the past three years, we have taken a different approach to the management of these poor grade patients. In a good proportion of these patients, a reversible mechanism of neurologic impairment can be identified. Evaluation The CT scan in poor grade patients may define potentially reversible causes of coma. Patients with intraparenchymal hemorrhage (without vital brain destruction) associated with an aneurysm represent one situation where removal of the blood clot may result in neurologic improvement. Similarly, intraventricular hemorrhage or hydrocephalus associated with subarachnoid hemorrhage may be conditions where insertion of a ventricular drainage system will alleviate elevate intracranial pressure (ICP). Given these potentially reversible conditions, rapid evaluation and treatment of patients in poor neurologic condition after subarachnoid hemorrhage should proceed.
Patients presenting in poor neurologic condition undergo a head CT. If there is vital brain destruction with no hope for improvement, comfort measures only are instituted. If the head CT shows diffuse subarachnoid hemorrhage, hydrocephalus, or an intraparenchymal hemorrhage which could be removed surgically with some hope of neurologic improvement, a ventriculostomy is inserted. Once the ventricular drain is in place, the intracranial pressure can be monitored. If the ICP remains controllable (less than 20 mm Hg), and if there is improved neurologic condition with adequate brainstem function, we proceed with cerebral angiography to define the source of the hemorrhage. If the intracranial pressure remains uncontrolled or the patient makes no neurologic improvement with poor brainstem function, then no further aggressive therapy is recommended to the patient’s family. In cases where cerebral angiography is performed, the aneurysm location and size is evaluated. A decision is then made on the best treatment for the aneurysm, whether that be with direct surgery and clipping of the lesion with possible removal of intraparenchymal blood clot or possibly an endovascular approach to obliterate the aneurysm. This decision is often made through discussions between the neurosurgeon, the interventional neuroradiologist, and a neurologist. As well, discussions with the family are important at this interval to try to help family members understand the potential outcomes for a poor grade aneurysm patient.
Post-treatment care Following treatment of the aneurysm, the ventricular drain is maintained and maximal medical therapy is instituted for potential vasospasm. This involves elevated blood pressure with intravenous pressor agents, hypervolemia with central venous pressure monitoring, and hemodilution with hematocrit maintained between 30 – 32%. By using transcranial doppler monitoring in conjunction with neurologic examination, the severity of vasospasm and efficacy of treatment can be followed. Results Using the management plan outlined, we have treated 32 patients in poor neurologic condition. In 12 patients managed without treatment of the aneurysm, 2 survived. In these patients, angiogram failed to reveal an intracranial aneurysm. In the 10 other patients, uncontrolled intracranial pressure or failure to improve neurologically after placement of ventriculostomy led us to conclude that neurologic improvement was unlikely. Of 18 grade IV and V patients managed with surgery, 8 (45%) had excellent or good outcome, 2 (11%) had a fair outcome, 2 (11%) had a poor outcome, and 6 (33%) died. Although we have been able to improve the outcome of patients in poor neurologic condition after subarachnoid hemorrhage, it should be noted that of 32 patients treated, 16 were patients whose poor neurologic condition was due to a second hemorrhage from their aneurysm. This emphasizes the importance of early diagnosis and treatment of patients presenting with subarachnoid hemorrhage. It is through this type of recognition that overall improved management of aneurysm patients can be expected to occur.
- Patients presenting in poor neurologic condition after subarachnoid hemorrhage may have a reversible etiology of their impairment.
- Prompt evaluation and treatment is crucial to the overall goal of reducing the morbidity and mortality of patients in poor neurologic condition.
Christopher S. Ogilvy, M.D.
Ojemann RG, Ogilvy CS, Heros RC, Crowell RM, eds. Surgical Management of Cerebrovascular Disease.
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