くも膜下出血の現状 当院における重症くも膜下出血の治療方針―４年間における成績―

Abstract

Indication of early treatment remains controversial for patients with poor-grade (WFNS grade IV and V) subarachnoid hemorrhage (SAH). Since 2006, we have tried endovascular treatment mainly using the Guglielmi detachable coil (GDC) as one treatment option for these patients. In this study, we compared clinical outcome and complications in patients treated in 2004–2005 with those treated in 2006–2007, and evaluated the changes in treatment strategy. Between 2004 and 2007, we treated 81 patients with poor-grade SAH, and 61 underwent early aggressive treatment in our hospital. For 29 cases (10 males, 19 females, mean age 64.6 years) in 2004–2005 (Group 1), treatment options were early craniotomy (clipping) except for 1 case of intentionally delayed surgery, while for 32 cases (8 males, 24 females, mean age 66.2 years) in 2006–2007 (Group 2), endovascular coil embolization (mainly using GDC) at the acute stage was added to treatment options for cases of high age and/or poor general condition. We compared these 2 groups in terms of percentage of treatment option, clinical course and outcome, assessed with Glasgow Outcome Scale score (GOS) at discharge. The percentage of patients treated by coil embolization increased from 0% in Group 1 to 20% in Group 2 for Grade IV and 6.7% to 50% for Grade V. The outcomes of patients in Grade IV were better in Group 2 than in Group 1. That is, for Grade IV cases, the percentage of good recovery (GR) significantly increased from 15.4% in Group 1 to 42.9% in Group 2. For Grade V cases, good outcome—GR and moderately disabled (MD)—increased from 13.3% in Group 1 to 26.3% in Group 2, otherwise dead also increased from 13.3% in Group 1 to 31.6% in Group 2 due to uncontrolled general complications. For Grade V cases, more than 50% patients in Group 2 were MD or severely disabled, or in a vegetative state. The incidence of symptomatic vasospasm and hydrocephalus did not differ between Group 1 and Group 2. The introduction of coil embolization extended the indication of early treatment for poor-grade SAH patients and improved the outcome of those patients. On the contrary, over-indication of coil embolization revealed poor outcome of poor-grade SAH patients. It is necessary for surgical indication in poor-grade SAH to objectively evaluate grade and familial and social aspects.