Introduction: Patients who present with poor neurological grade after subarachnoid hemorrhage (SAH) often have poor outcomes. In this subgroup, patients with hematoma in the sylvian fissure (intrasylvian hematoma: ISH) associated with middle cerebral artery (MCA) aneurysms may have better outcomes responding to intensive treatment. This study was conducted to reveal clinical distinct features of ISH, and to clarify whether ISH contributes to good functional recovery from poor grade SAH under contemporary surgical and neurocritical management.
Methods: The medical records of 97 consecutive patients with poor initial neurological grade (WFNS grade IV- V) were analyzed to identify characteristics, clinical courses, and complications of SAH with ISH (n=14). During this period, ultra-early intervention of the aneurysm and aggressive prevention of vasospasm by cisternal irrigation with milrinone were attempted. External decompression was added when brain swelling was present. Recovery from poor neurological status was then assessed, correlated with chronological change of radiological findings and focal neurological deficit.
Results: Presence of ISH was significantly associated with intraoperative decision of external decompression and cerebral edema on the next day of the treatment. Cerebral edema decreased and focal neurological deficit improved over time in the ISH group. Accordingly, ISH was correlated with good hospital discharge outcome of poor grade SAH (adjusted OR 5.50 [95% CI 1.28-23.3], p = 0.02).
Conclusions: ISH predicted good functional recovery from poor grade SAH under the strategy combining ultra-early surgery, external decompression, and cisternal irrigation with milrinone. Aggressive treatment is recommended to retrieve potential recovery of this subgroup.
Patient Care: Our research may improve prognosis of a subpopulation of poor-grade aneurysmal SAH
Learning Objectives: By the conclusion of this session, participants should be able to identify an effective treatment for poor grade SAH with intrasylvian hematoma.