くも膜下出血の急性期治療 重症くも膜下出血手術治療予後における手術時期と年齢について

Abstract

To determine the indication for surgical management in poor-grade aneurysm patients, we analyzed 1095 patients with World Federation of Neurological Societies (WFNS) Grade IV/V aneurysm admitted within 48 hours after subarachnoid hemorrhage (SAH) between Jan. 1989 and Dec. 2000, retrospectively. Nineteen patients who were operated on between Day 4 and Day 9 and 16 patients who underwent coil embolization were excluded from this study. There were 397 patients aged <60 years, 327 patients aged 60-69 years, and 336 patients aged ≥70 years. Surgical treatment was done between Day 0 and Day 3 in 678 patients (early surgery (ES)), Day 10 or beyond in 164 patients (late surgery (LS)); 218 patients did not undergo surgical management. The latter 2 groups of patients were designated non-early surgery (non-ES). The outcome was evaluated with GOS at 3 months after SAH. Rebleeding developed in 56 patients within 24 hours of admission and in 47 patients 24 hours after admission. It was difficult to assign patients with rebleeding within 24 hours to ES or non-ES. These patients were, therefore, excluded from ES and non-ES and designated early management group (EMG) and non-early management group (non-EMG), respectively. In the analysis of Grade IV, 47.9% of ES and 50% of LS in the <60 years age group showed Good Recovery (GR). In contrast, the proportions of GR were 49.5% in EMG and 35.2% in non-EMG (P=0.0345). Among the 60-69 years age group, the rates of GR were 26.9% and 35.3% in ES and LS, respectively; and 28.0% and 24.0% in EMG and non-EMG, respectively. Among the ≥70 years age group, the incidence of GR was 10.1% and 14.6% in ES and LS, respectively; and 10.6% and 8.4% in EMG and on-EMG, respectively. Regarding the Grade V, among the <60 years age group, only 10.6% of ES resulted in GR. Although the incidence of GR was not statistically different between ES and LS, 25.0% of LS showed GR. The incidence of GR was 9.8% and 10.9% in EMG and non-EMG, respectively. Among the 60-69 years age group, the proportions of GR were 12.2% and 17.6% in ES and LS, respectively; 11.8% and 6.0% in EMG and non-EMG, respectively. Among the ≥70 years age group, only 1.3% of ES and 1.3% of EMG showed GR. No patients showed GR in LS or non-EMG. The outcome of LS was possibly better than that of ES because some patients who did not recover well in the late stage had less chance to undergo surgery. In contrast, EMG might show better results than non-EMG because patients in non-EMG often presented in poor general condition, contraindicating surgery. Considering these 2 possibilities, we conclude that early surgery benefits patients aged <60 years with Grade IV. Late surgery following good response from conservative therapy is suggested in patients with Grade IV and aged <70years and the≥70years age group of Grade IV.