====== Poor-grade aneurysmal subarachnoid hemorrhage outcome ======

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[[Poor-grade aneurysmal subarachnoid hemorrhage]] (SAH) is associated with poor neurological outcomes and high mortality. A major factor influencing morbidity and mortality is [[brain swelling]] in the acute phase
((Güresir E, Lampmann T, Brandecker S, Czabanka M, Fimmers R, Gempt J, Haas P, Haj A, Jabbarli R, Kalasauskas D, König R, Mielke D, Németh R, Oppong MD, Pala A, Prinz V, Ringel F, Roder C, Rohde V, Schebesch KM, Wagner A, Coch C, Vatter H. PrImary decompressive Craniectomy in AneurySmal Subarachnoid hemOrrhage (PICASSO) trial: study protocol for a randomized controlled trial. Trials. 2022 Dec 20;23(1):1027. doi: 10.1186/s13063-022-06969-4. PMID: 36539817; PMCID: PMC9764529.)).

see [[Poor-grade aneurysmal subarachnoid hemorrhage complications]].

see also [[Aneurysmal subarachnoid hemorrhage outcome]].

===== Nomogram =====

A study provides a reliable and valuable nomogram that can accurately predict the risk of poor prognosis in patients with poor-grade aSAH after microsurgical clipping. This tool is easy to use and can help physicians make appropriate clinical decisions to improve patient prognosis significantly
((Zhou Z, Liu Z, Yang H, Zhang C, Zhang C, Chen J, Wang Y. A nomogram for predicting the risk of poor prognosis in patients with poor-grade aneurysmal subarachnoid hemorrhage following microsurgical clipping. Front Neurol. 2023 Mar 22;14:1146106. doi: 10.3389/fneur.2023.1146106. PMID: 37034089; PMCID: PMC10073426.)).

===== Factors of poor outcome =====

Age, loss of consciousness at onset, systolic blood pressure on admission, Hunt-Hess grade 4-5 on admission, epileptic seizures, modified Fisher grade 3-4, microsurgical clipping, size of the ruptured aneurysm, and cerebrospinal fluid replacement were independent risk factors for aSAH outcomes
((Liu H, Xu Q, Yang H. Clinical Analysis of Poor Outcomes After Surgery for Aneurysmal Subarachnoid Hemorrhage in Guizhou, China. World Neurosurg. 2023 Mar 11:S1878-8750(23)00305-4. doi: 10.1016/j.wneu.2023.03.011. Epub ahead of print. PMID: 36907268.)).

WFNS grade 5, signs of [[brain herniation]], aneurysm size, and space-occupying [[hematoma]]
((Schuss P, Hadjiathanasiou A, Borger V, Wispel C, Vatter H, Güresir E. Poor-Grade Aneurysmal Subarachnoid Hemorrhage: Factors Influencing Functional Outcome--A Single-Center Series. World Neurosurg. 2016 Jan;85:125-9. doi: 10.1016/j.wneu.2015.08.046. Epub 2015 Sep 2. PMID: 26341439.)) 

===== Rebleeding =====

Ultra-early [[vasospasm]] (UEV) and the presence of [[dissecting aneurysm]]s are the strongest [[predictor]]s of aneurysmal [[rebleeding]]. Their presence should be carefully evaluated in the acute management of poor-grade aSAH
((Panni P, Riccio L, Cao R, Pedicelli A, Marchese E, Caricato A, Feletti A, Testa M, Zanatta P, Gitti N, Piva S, Mardighian D, Semeraro V, Nardin G, Lozupone E, Paiano G, Picetti E, Montanaro V, Petranca M, Bortolotti C, Scibilia A, Cirillo L, Lanterna AL, Ambrosi A, Mortini P, Beretta L, Falini A. Clinical Impact and Predictors of Aneurysmal Rebleeding in Poor-Grade Subarachnoid Hemorrhage: Results From the National POGASH Registry. Neurosurgery. 2023 Apr 3. doi: 10.1227/neu.0000000000002467. Epub ahead of print. PMID: 37010298.)).

===== Vasospasm =====

There is a tendency for patients in poor clinical grades to have more vasospasm. The patients with the most vasospasm have significantly higher mortality than those with the least
((Weir B, Grace M, Hansen J, Rothberg C. Time course of vasospasm in man. J Neurosurg. 1978 Feb;48(2):173-8. doi: 10.3171/jns.1978.48.2.0173. PMID: 624965.)).

===== Hunt and Hess Score =====

There was a better outcome in patients with an HH score of 4 compared to an HH score of 5 and both groups benefited from surgical treatment, which resulted in a positive outcome in almost 50% of surgically treated patients
((Ahmetspahić A, Janković D, Burazerovic E, Rovčanin B, Šahbaz A, Hasanagić E, Džurlić A, Granov N, Feletti A. Clinical Characteristics of Poor-Grade Aneurysmal Subarachnoid Hemorrhage Treatment. Asian J Neurosurg. 2023 Mar 27;18(1):132-138. doi: 10.1055/s-0043-1764118. PMID: 37056885; PMCID: PMC10089758.)).

===== Ventilation =====

Patients with poor-grade subarachnoid hemorrhage (SAH) admitted to the [[intensive care unit]] (ICU) often require prolonged invasive [[mechanical ventilation]] due to prolonged time to obtain neurological [[recovery]]. [[Impairment]] of [[consciousness]] and [[airway]] protective mechanisms usually require [[tracheostomy]] during the ICU stay to facilitate [[weaning]] from [[sedation]], promote neurological [[assessment]], and reduce mechanical ventilation (MV) duration and associated complications
((Bini G, Russo E, Antonini MV, Pirini E, Brunelli V, Zumbo F, Pronti G, Rasi A, Agnoletti V. Impact of early percutaneous dilatative tracheostomy in patients with subarachnoid hemorrhage on main cerebral, hemodynamic, and respiratory variables: A prospective observational study. Front Neurol. 2023 Mar 27;14:1105568. doi: 10.3389/fneur.2023.1105568. PMID: 37051061; PMCID: PMC10083491.)).

===== Temperature =====

A lower mean temperature was univariately associated with a worse primary brain injury, with higher Fisher grade and higher MD glycerol concentration, as well as a worse neurological recovery at 1 year. There was otherwise no association between temperature and cerebral physiological variables in the early phase. There was a transition toward an increased burden of hyperthermia (temperature > 38 °C) in the vasospasm phase. This was associated with concurrent infections but not with neurological or radiological injury severity at admission. The elevated temperature was associated with higher MD pyruvate concentration, a lower rate of an MD pattern indicative of ischemia, and a higher rate of poor neurological recovery at 1 year. There was otherwise no association between temperature and cerebral physiological variables in the vasospasm phase. The associations between temperature and clinical outcome did not hold true in multiple logistic regression analyses.

Spontaneously low temperature in the early phase reflected a worse primary [[brain injury]] and indicated a worse outcome prognosis. [[Hyperthermia]] was common in the [[vasospasm]] phase and was more related to [[infection]]s than primary injury severity but also with a more favorable energy metabolic pattern with better substrate supply, possibly related to [[hyperemia]]
((Svedung Wettervik T, Hånell A, Ronne-Engström E, Lewén A, Enblad P. Temperature Changes in Poor-Grade Aneurysmal Subarachnoid Hemorrhage: Relation to Injury Pattern, Intracranial Pressure Dynamics, Cerebral Energy Metabolism, and Clinical Outcome. Neurocrit Care. 2023 Mar 15. doi: 10.1007/s12028-023-01699-0. Epub ahead of print. PMID: 36922474.)).

===== Gastrointestinal bleeding =====

Gastrointestinal bleeding was most frequently seen in those cases operated on between the third and seventh days after the last subarachnoid hemorrhage (8.9%) and was more common in cases with a relatively poor preoperative grade. The development of such [[bleeding]] in cases with a good preoperative grade was due to problems with the surgical operation in most cases, although the influence of vasospasm must not be ignored. The development of bleeding in cases with a poor preoperative grade is thought to be due primarily to vasospasm and transitory brain damage to the hypothalamus and the orbital portion of the anterior lobe due to a hematoma caused by aneurysm rupture. 
First, the location of gastrointestinal bleeding should be determined endoscopically and, if hemostasis is not achieved by coagulation, then the desirability of surgery should be considered early. Abdominal surgery may be performed
((Tanaka S, Mori T, Ohara H, Takaku A, Suzuki J. Gastrointestinal bleeding in cases of ruptured cerebral aneurysms. Acta Neurochir (Wien). 1979;48(3-4):223-30. doi: 10.1007/BF02056970. PMID: 314727.)).