Poor grade subarachnoid haemorrhage: Treatment decisions and timing influence outcome. Should we, and when should we treat these patients?

Abstract Background A poor admission status (World Federation of Neurosurgical Science (WFNS) IV-V) after aneurysmal subarachnoid hemorrhage (SAH) is well known as a negative prognostic factor for the future outcome of patients. In this retrospective study, we examine the factors that can be influenced by the treating doctors in this highly affected patient group. Methods Patients with SAH were prospectively entered into a database, and outcome and prognostic factors were reviewed. Outcome was assessed using the modified Rankin Scale (mRS: favorable (mRS 0-2) vs. unfavorable (mRS 3-6)), six months after SAH. Results A total of 1003 patients were selected, of whom 449 (44.8%) patients showed a poor admission status. Multivariate analysis showed the following independent, poor prognostic factors for a later unfavorable outcome: a concomitant intracerebral hemorrhage (ICH), delayed cerebral ischemia (DCI), and an untreated ruptured aneurysm. Additionally, early treatment (within 12 hours of ictus) showed a notable effect on a favorable patient outcome (46%). Overall, 39% of patients with WFNS IV-V showed a favorable outcome. Conclusion Patients with WFNS IV-V often have an unfavorable outcome (61% overall). Significant factors influencing the outcome of patients with WFNS IV-V are, ICH, and DCI. As the non-treatment of aneurysm is the only parameter that can be influenced, SAH patients will benefit from aneurysm treatment and, especially, from treatment in the first 12 hours after ictus. In cases of early treatment, the number of patients with a favorable outcome increases to 46%.