Results of Proactive Surgical Clipping in Poor-Grade Aneurysmal Subarachnoid Hemorrhage: Pattern of Recovery and Predictors of Outcome.

Background: The outcome associated with the treatment of poor-grade aneurysmal subarachnoid hemorrhage is rather discouraging. Even then, some patients may survive; however, the long-term outcomes and the patterns of recovery of these survivors have not received much attention in the literature.

Methods: A total of 85 patients (mean age 53.3 years, male/female = 34:51, 98 aneurysms) with post resuscitation Hunt and Hess grades 4 and 5 subarachnoid hemorrhage were studied. Modified Rankin Scale score was used to determine the functional outcome. Different factors were analyzed with uni- and multivariate models for their effect on the functional outcomes after surgery.

Results: A total of 23 patients died in the 30-day perioperative period, whereas 8 patients died at follow-up (n = 31, 36.5%). Nearly 35% and 51% of the survivors obtained favorable short- and long-term functional outcomes, respectively. The presence of a space-occupying hematoma (P = 0.014) and the functional status at discharge significantly affected the long-term functionality (P = 0.004) in our patients. The functional improvement was steady with time (the probability of good outcome at about 2 months of discharge was around 65%, about 55% at 1 year, and 40% at 2 years and then achieved a plateau). Marked improvement occurred in 11% survivors even after 18 months.

Conclusions: If operated at the earliest opportunity after admission, meaningful survival may be provided to a significant number of patients with poor-grade subarachnoid hemorrhage. The recovery process in the survivors is a dynamic process and considering the late improvements in some, it is advisable be follow them beyond the conventional end points.