Actualization of treatment options in poor-grade subarachnoid hemorrhage patients

Since Botterell in 1956 and later Hunt and Hess in 1968 presented a scheme for preoperative grading of subarachnoid hemorrhage (SAH) patients, it became clear that a poor preoperative clinical condition is related to increased mortality and morbidity. The criteria used to decide which poor-grade patients with SAH are irreparably brain-damaged and which autoregulation disorders are irreversible are not clear. Predicting outcome, based only on clinical and diagnostic data found at the time of the admission, may have resulted in withholding treatment from several of the patients who subsequently experienced favorable outcomes. The mortality rate among nonoperatively treated patients with Grade IV and V SAH has been reported to be 90% to 98%. Delayed surgery, in the 1970's to middle 80's, was reported to reduce mortality without increasing the number of survivors in poor condition. These results increased confidence in surgical treatment and many centers changed management practices and introduced selective early surgery. At this time, as well as in the following years, early surgery with selective management criteria reduced mortality considerably, from about 19% to 33%. The present article analyzes four recently published studies on the actual possibilities and limitations in the treatment of these patients.