Cost-effective outcome for treating poor-grade SAH.

Abstract

To the Editor Recently, Wilby et al published the results of a study on the costs and outcome of treating poor-grade subarachnoid hemorrhage (SAH) patients.1 Poor-grade SAH was defined as World Federation of Neurological Surgeons (WFNS) grades 4 and 5. The authors showed that aggressive management of these patients is clinically justified since a significant subset of patients can achieve favorable outcomes (defined as Glasgow Outcome Scale (GOS) scores 4 [moderate disability] and 5 [good]). Thus, although expensive with major demands on critical care resources, the treatment of these patients was found to be cost-effective overall. We fully agree with the conclusion of the authors, but we would like to make some comments on the management protocol used in this study. After diagnosis of poor-grade SAH, patients in this study were sedated, ventilated, and transferred from the referring hospital to the referral neurosurgical unit. Fluid and electrolyte resuscitation was carried out, hydrocephalus was treated if necessary, but diagnostic angiography and treatment of the culprit aneurysm was postponed. After 24 hours sedation was reversed and a new neurological assessment was performed. Only patients with a Glasgow Motor Score (GMS) of at least 4 were selected for angiography. This means that almost half of the patients (47%) were managed conservatively, all of whom eventually died, and that probably most patients who actually proceeded to diagnosis and treatment of the aneurysm were in WFNS grade 4. We recently presented the results of a prospective study of the endovascular treatment of 11 patients with SAH WFNS grade 5 admitted during a 12-month period.2 …