Treatment strategy for poor-grade subarachnoid hemorrhage cases: Controversies on the decision making and its evidence

Abstract

Treatment strategy tor poor-grade subarachnoid hemorrhage (SAH) cases is reviewed paying attention to the controversies on the decision making and its evidence. Among the consecutive 1,012 cases of SAH experienced at the Kyorin University Hospital, the authors prospectively studied several clinical characteristics and defined the significant factors contributing to a poor outcome, such as bilaterally dilated pupils, apnea, cardiac arrest and abnormal blood pressure (systolic pressure < 100mmHg, > 200mmHg). Theoretically, good candidates for aggressive treatment are those who had reversible primary brain damage, however, any reviewed characteristics failed to show definite evidence of this. The authors currently proposed the treatment strategy for poor-grade SAH is as follows: 1.) in some cases, evaluated as exaggeratory, demonstrated a poor-condition on very early admission or a relatively small amount of SAH on CT, and some of the primary damage contributing to an increased intracranial pressure could be controlled, such as acute hydrocephalus and intracerebral hematoma, 2.) absolute contraindications for treatment are the loss of brainstem function and anoxic and/or ischemic insult to the whole brain, and 3.) evaluation of a patient's condition on their admission followed by deep sedation is reasonable to avoid losing curable candidates who are missed under a wait-and-see policy.