Outcome after Hunt and Hess Grade V subarachnoid hemorrhage: a comparison of pre-coiling era (1980-1995) versus post-ISAT era (2005-2014).

Konczalla, Juergen; Seifert, Volker; Beck, Jürgen; Güresir, Erdem; Vatter, Hartmut; Raabe, Andreas; Marquardt, Gerhard (2018). Outcome after Hunt and Hess Grade V subarachnoid hemorrhage: a comparison of pre-coiling era (1980-1995) versus post-ISAT era (2005-2014). Journal of neurosurgery, 128(1), pp. 100-110. American Association of Neurological Surgeons 10.3171/2016.8.JNS161075

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OBJECTIVE Outcome analysis of comatose patients (Hunt and Hess Grade V) after subarachnoid hemorrhage (SAH) is still lacking. The aims of this study were to analyze the outcome of Hunt and Hess Grade V SAH and to compare outcomes in the current period with those of the pre-International Subarachnoid Aneurysm Trial (ISAT) era as well as with published data from trials of decompressive craniectomy (DC) for middle cerebral artery (MCA) infarction. METHODS The authors analyzed cases of Hunt and Hess Grade V SAH from 1980-1995 (referred to in this study as the earlier period) and 2005-2014 (current period) and compared the results for the 2 periods. The outcomes of 257 cases were analyzed and stratified on the basis of modified Rankin Scale (mRS) scores obtained 6 months after SAH. Outcomes were dichotomized as favorable (mRS score of 0-2) or unfavorable (mRS score of 3-6). Data and number needed to treat (NNT) were also compared with the results of decompressive craniectomy (DC) trials for middle cerebral artery (MCA) infarctions. RESULTS Early aneurysm treatment within 72 hours occurred significantly more often in the current period (in 67% of cases vs 22% in earlier period). In the earlier period, patients had a significantly higher 30-day mortality rate (83% vs 39% in the current period) and 6-month mortality rate (94% vs 49%), and no patient (0%) had a favorable outcome, compared with 23% overall in the current period (p < 0.01, OR 32), or 29.5% of patients whose aneurysms were treated (p < 0.01, OR 219). Cerebral infarctions occurred in up to 65% of the treated patients in the current period. Comparison with data from DC MCA trials showed that the NNTs were significantly lower in the current period with 2 for survival and 3 for mRS score of 0-3 (vs 3 and 7, respectively, for the DC MCA trials). CONCLUSIONS Early and aggressive treatment resulted in a significant improvement in survival rate (NNT = 2) and favorable outcome (NNT = 3 for mRS score of 0-3) for comatose patients with Hunt and Hess Grade V SAH compared with the earlier period. Independent predictors for favorable outcome were younger age and bilateral intact corneal reflexes. Despite a high rate of cerebral infarction (65%) in the current period, 29.5% of the patients who received treatment for their aneurysms during the current era (2005-2014) had a favorable outcome. However, careful individual decision making is essential in these cases.

Item Type:

Journal Article (Original Article)


04 Faculty of Medicine > Department of Head Organs and Neurology (DKNS) > Clinic of Neurosurgery

UniBE Contributor:

Beck, Jürgen and Raabe, Andreas


600 Technology > 610 Medicine & health




American Association of Neurological Surgeons




Nicole Söll

Date Deposited:

06 Apr 2018 10:41

Last Modified:

23 Oct 2019 14:10

Publisher DOI:


PubMed ID:


Uncontrolled Keywords:

ARR = absolute risk reduction CVS = cerebral vasospasm DC = decompressive craniectomy DCI = delayed cerebral ischemia EVD = external ventricular drain GCS = Glasgow Coma Scale Hunt and Hess Grade V ICH = intracerebral hematoma ICU = intensive care unit ISAT = International Subarachnoid Aneurysm Trial MCA = middle cerebral artery NNT = number needed to treat PERRLA = pupils equal, round, and reactive to light and accommodation SAH = subarachnoid hemorrhage WFNS = World Federation of Neurosurgical Societies clinical outcome coma mRS = modified Rankin Scale prognostic factors severe SAH stroke trials subarachnoid hemorrhage vascular disorders





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