Triaging boosts outcomes for half of poor grade aneurysms.
A significant proportion of patients with poor grade aneurysms that are triaged properly and aggressively treated can survive without disastrous sequelae, said Joseph Zabramski, M.D., of the Barrow Neurological Institute in Phoenix.
"This is certainly not a group of patients who should be ignored," he said.
Less than 15% of Hunt and Hess grade IV and V aneurysm patients recovered in the early 1980s, when it was customary medical practice to delay surgery for weeks. Studies of current practices that focus on early aggressive treatment have reported good outcomes in 30%-40% of these same patients.
"It's a neurosurgical myth that poor grade aneurysm patients do not benefit from acute intervention," Dr. Zabramski said during a scientific session at the joint annual meeting of the American Association of Neurological Surgeons and the American Society of Interventional and Therapeutic Neuroradiology.
It's also a myth that clinical grade upon admission accurately predicts a patient's prognosis. Grade IV patients are stuporous with moderate to severe hemiparesis, and grade V patients are often in deep coma and appear moribund.
Undertaking a CT head scan and angiography "adds just a few minutes, and in many cases it provides all the information you need about management of the patient," Dr. Zabramski said.
An external ventriculostomy drain is placed in essentially all poor grade patients without causing significant vital brain destruction.
Surgical intervention is contraindicated in patients with an absence of brain stem reflexes, significant vital brain destruction, uncontrolled intracranial pressure, liver failure, and no or poor flow on CT angiography.
These patients are contraindicated for surgical intervention and should receive palliative care only, Dr. Zabramski said.
All other patients should be managed with a combined surgical and endovascular approach such as a craniotomy with clipping of an aneurysm and evacuation of a hematoma performed at the same time or endovascular coiling.
Dr. Zabramski and colleagues followed this protocol in a prospective study of 54 grade IV and V patients seen over 30 months. There were 35 patients who qualified for surgical treatment consisting of early surgery, prophylactic hypervolemia, and aggressive treatment of vasospasm, and 19 patients who received palliative care only.
Mortality was 100% in the nonsurgical group and the mean survival time was 32 hours.
At 3 months, 19 patients in the surgical group (54%) had a good outcome based on the Modified Rankin scale, 4 (11.4%) had a fair outcome, 4 (11.4%) had a poor outcome, and 8 (23%) died.
Rapid triage and aggressive surgery improved outcomes significantly, compared with the era of delayed surgery, when only about 10% of patients survived without serious sequelae, 20% had a poor outcome, and 60% died, Dr. Zabramski said.
Generally, infection is a serious complication associated with the placement of ventriculostomy catheters, complicating about 9% of such procedures. However, the infection rate in the study was less than 2%. Study protocol was to draw and culture cerebrospinal fluid (CSF) at the time the catheter was placed and every 3 days thereafter, and to use antimicrobial-impregnated catheters.
Infection rates declined from 9% to 1.3% in a study of the Cook Spectrum Glide minocycline/rifampin impregnated catheter, said Dr. Zabramski, who participated in the study. The catheter was approved in August 2004. and follow-up data showed similar reductions in a clinical setting. The catheters are more expensive, at about $150 versus $50 for a traditional catheter, but pay for themselves by preventing costly infections.
"It's important to find out early on if you have an infection," Dr. Zabramski said. "Especially in grade IV and V patients it's hard to tell why they're deteriorating, and certainly CSF is one issue."
BY PATRICE WENDLING
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|Publication:||Internal Medicine News|
|Date:||Mar 15, 2005|
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