New in EM 002: What is the outcome for poor grade SAH?

11 Apr

Originally Published on RCEM Learning Podcast April 2017

As part of the RCEM Learning Podcast I record reviews of recent literature with Dave McCreary. We’ve been doing this for about a year now and you can hear them all on the RCEM Learning Podcast each month. I’d like to have them here and searchable on this site too so I’ll be posting the ones I find most relevant here. You can always hear the newest ones by subscribing to the free RCEM Learning Podcast. 


Clinical Question:

  • What is the outcome for poor grade SAH?

Title of Paper:

Journal and Year

  • Journal Neurosurgery, 2017


  • Konzcalla


  • Poor grade SAH can be defined on either H&H or WFNS scoring systems but both imply comatose patients with lots of blood in their brain. Common practice is expectant management rather than aggressive management of the aneurysm.
  • H&H grade V is commonly thought to have a 10% survival rate never mind good functional outcomes.
  • This group have been treating H&H V with early and aggressive aneurysm treatment for 15 years now and this is their outcome data

Patients studied

  • Compared 2 groups
    • Historical data from a chart review (no methods) from H&H V patients in their centre in the 80s when they were conservative
    • Recent data from a prospective database (so much higher quality data) of their current management of SAH
  • Looked to see the difference in survival and mRS 0-2 (2 = Slight disability; unable to carry out all previous activities, but able to look after own affairs without assistance)
  • They also add some comparisons with data from the decompressive craniectomy and malignant MCA literature


  • 50 patients in the early group (8% of all SAH)
    • Intervened on 25% of patients
    • Everyone did badly (mRS 0-2 = 0)
  • 200 in the recent group (17% of all SAH)
    • They intervened on the aneurysm in 75% of patients (over half within 12 hrs, half got clipped, half got coiled)
    • A quarter did well (mRS 0-2 = 23%)
  • They compare with the DC and malignant MCA data and suggest the H&H V guys do better



  • All kinds of issues with the comparisons here (lots of apples and oranges) but the bottom line figure of mRS 0-2 of 23% in H&H V is a take home. Whether or not you can provide this in your centre is a different question but the knee jerk, “extubate and comfort care” is being challenged here
  • The therapeutic nihilism is not just the neurosurgeons and we need to lost the tribalism and note we’re all guilty of this
  • We also need to be cognisant that although as HCPs we’re often very negative about outcomes resulting in disability that does not mean that our patients feel the same way.

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