Poor-grade Aneurysmal Subarachnoid Hemorrhage: Outcome after Treatment with Urgent Surgery

John D. Laidlaw, Kevin H. Siu, H. Hunt Batjer, Daniel L. Barrow, Robert A. Solomon, Edward W. Mee, Charles Y. Liu, Steven L. Giannotta

Research output: Contribution to journalArticlepeer-review

99 Scopus citations


OBJECTIVE: We sought to determine whether the rebleeding rate in poor-grade patients justified a period of supportive observation before selective treatment and whether unselected ultraearly surgery would lead to acceptable results. METHODS: A prospectively audited, nonselected series of 177 consecutive poor-grade (i.e., World Federation of Neurological Surgeons Grades IV and V) patients with aneurysmal subarachnoid hemorrhage managed during a 9-year period was analyzed. A management policy of aggressive ultraearly surgery (not selected by age or by grade) was followed. Coiling was not available. Outcomes were assessed at 3 months. RESULTS: Despite the aggressive management policy, surgery could be performed in only 132 poor-grade patients (75%). Twenty percent of all patients were 70 years of age or older (15% of the surgical cases). All surgery was performed within 12 hours of subarachnoid hemorrhage (majority <6 h). Preoperative rebleeding occurred within the first 12 hours (>85% within 6 h) in 20% of the patients, which is four times the rate found in good-grade patients managed according to the same policy. Outcome assessment performed at 3 months in the 132 poor-grade surgical patients revealed that 40% were independent, 15% were dependent, and 45% had died. There was no significant difference in outcomes for young and old (70+ yr) poor-grade surgical patients (P > 0.05). CONCLUSION: The high ultraearly rebleeding rate indicates a need to urgently secure the ruptured aneurysm by performing surgery or coiling, and this indication is more pronounced for poor-grade patients than for good-grade patients. The outcome results of ultraearly surgery indicate that a nonselective policy does not lead to a large number of dependent survivors, even among elderly poor-grade patients.

Original languageEnglish (US)
Pages (from-to)1275-1282
Number of pages8
Issue number6
StatePublished - Dec 2003


  • Aneurysm surgery
  • Cerebral aneurysm
  • Poor grade
  • Rebleeding
  • Subarachnoid hemorrhage

ASJC Scopus subject areas

  • Surgery
  • Clinical Neurology


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