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Management of poor‐grade subarachnoid haemorrhage: a self‐fulfilling prophecy of good outcome?

Hoogmoed et al. [1] should be congratulated on an interesting piece of work looking at outcome in patients with poor-grade aneurysmal subarachnoid haemorrhage (aSAH). Management of aSAH has changed significantly over the past 20 years from a conservative approach and delayed aneurysmal treatment (clipping), thought to be beyond the traditional vasospasm period, to a more aggressive approach with early aneurysmal treatment (commonly with endovascular coiling). The management of patients with poor World Federation of Neurological Surgeons grade, however, has not evolved in the same way and there is still a widespread reluctance to offer invasive therapy or even transfer to a dedicated neuroscience centre due to the perceived poor outcome. This cohort of patients with aSAH are poorly represented in the large randomized trials recruiting aSAH (only 5% of patients recruited into The International Subarachnoid Aneurysm Trial were poor grade [2]). Studies that have looked at poor-grade aSAH have tended to be retrospective and subject to bias. Patients who show some neurological improvement after a few days may have their treatment plans revised but the hypothesis put forward by the authors of a ‘self-fulfilling prophecy of poor outcome’ may hold true. The true criteria defining poor-grade aSAH, decisions regarding treatment and timing of treatment are difficult to interpret from the literature. Is there a subgroup of these patients who would benefit from aggressive treatment and, if so, are there factors that can be used to identify this cohort? For example, post hoc analysis of the subgroup of patients with poor-grade aSAH in the Barrow Ruptured Aneurysm Trial would suggest that younger patients and those without evidence of stroke can achieve best outcome with treatment [3]. Other parameters include aneurysm size and hyperglycaemia on admission [4]. The difficulties relate to the inconsistency seen in the literature in even basic parameters such as the classification system used to define the grade of the aSAH (Hunt and Hess versus World Federation of Neurological Surgeons) and combining (often inappropriately) grades 4 and 5 in analyses [5]. Timing of treatment is another inconsistency. The size of the subgroup that may benefit from aggressive treatment may be as high as 24% [6,7]. The geographical neurosurgical set-up in The Netherlands has allowed a comparison of units with two different approaches to patients with poor-grade aSAH. A good outcome (as defined by a Glasgow Outcome Scale of 1–3) was noted in 22% of patients treated aggressively with early aneurysm treatment and external ventricular drainage, compared with only 11% in those treated in a conservative fashion. Interestingly, whereas early aneurysm treatment was strongly associated with a good outcome, there were no significant differences in rebleed rates. This demonstrates the benefits of early occlusion beyond a straightforward reduction in rebleed rates. An occluded aneurysm allows aggressive prophylactic and treatment hyperdynamic therapy that would otherwise be judiciously administered when faced with a delayed ischaemic neurological deficit and an unsecured aneurysm. With an unsecured aneurysm, management tends to become less clearly defined. As such, this study not only compared units that delivered different interventions, but also compared the different mindsets of those units. Aggressive early treatment of all patients will not only pick up and treat the smaller unknown subgroup of patients who would benefit from treatment, but will also increase the exposure of the treating unit to the condition and increase volumes of treatment episodes. This, in my mind, becomes a self-fulfilling prophecy of changing the expected outcome. Further work is required to help identify the various clinical, radiological and anatomical factors that have a significant impact on the overall outcome of these patients. Only then can we accurately apply a tailor-made approach to each individual patient with poor-grade aSAH. I don’t think we are there yet though.