ＳＡＨ重症例 重症くも膜下出血に対する超早期治療

Abstract

Indications for treatment for poor-grade patients with subarachnoid hemorrhage (SAH) are still controversial. As an emergency center, our hospital admits many poor-grade patients with SAH at ultra-early stage. We have difficulty with the rationale of allowing these patients to have unsecured aneurysms during the peak rebleeding period to see which ones are likely to spontaneously improve. In this study, we report the results of ultra-early treatment for poor-grade patients with SAH. Between August 2003 and March 2005, our hospital admitted 73 patients with SAH. Fifty-two of them (71%) who had WFNS Grade IV (14) and V (38) were analyzed in this study. Patients were not selected based on age (mean age 63.1 years ranging from 27-91). After stable vital parameters were established, the patients underwent radiological examination and surgical treatment for aneurysms in the anterior circulation or endovascular treatment for aneurysms in the posterior circulation as soon as possible. Outcomes were assessed at 3 months after SAH onset. Forty-six (88%) of 52 poor-grade patients were admitted within 90 minutes after SAH onset. Despite the aggressive management policy, definitive treatment could be given in only 32 patients (62%). The treatment was initiated within 9 hours after SAH onset in 26 patients (81%). Clipping was performed in 19 patients and endovascular coil embolization in 13. Overall mortality was 52%, and overall good outcomes (good recovery+moderate disability) were obtained in 25%. All 17 patients resuscitated after cardiopulmonary arrest (CPA) had Grade V and died with or without treatment. On the other hand, good outcomes were obtained in 37% and mortality was 29% in 35 patients without CPA. However, 4 of the 35 (11%) died because of ultra-early rebleeding. In patients with Grade IV, mortality was 7% and good outcomes were obtained in 50%. In patients with Grade V, mortality was 68% and good outcomes were obtained in 16%. The outcomes of ultra-early treatment in poor-grade patients with SAH suggest that a non-selective policy of treatment as early as possible provides acceptable results, especially in Grade IV. However, definitive treatment should not be performed for patients with CPA because there is no chance to save them.