**3. Aneurysm rebleeding and predictor of the rebleeding**

Rebleeding more often occurs in patients with poor-grade aSAH [23–27]. Van Donkelaar et al. [28] reported that 41 (11.0%) of 374 patients experienced rebleeding. Of the 297 patients included in our previous study, 30 (10.1%) patients experienced rebleeding; 14 (46.7%) cases occurred within 24 h after ictus, 11 (36.7%) occurred between 1 and 7 days, and 5 (16.6%) occurred after 7 days [5]. High blood pressure, poor-grade clinical condition, modified Fisher grade, posterior circulation aneurysms, larger aneurysms (>10 mm), intracerebral or intraventricular hemorrhage are reported to be important predictors of rebleeding after aSAH [24, 28–30]. Van Donkelaar et al. [28] reported that a higher modified Fisher grade was a strong risk factor associated with a rebleeding probably because the amount of blood was a marker of stability of the ruptured aneurysm wall.

Many neurosurgeons use preoperative ventricular drainage in all patients with poor-grade aSAH to maintain adequate cerebral perfusion [15, 24, 31–33]; however, there is no guideline for the drainage after poor-grade aSAH. Laidlaw and Siu reported that 2 of 133 patients treated with surgery underwent ventricular drainage because of the concern of rebleeding [34]. On the other hand, several studies

**107**

procedure [51].

*Poor-Grade Aneurysmal Subarachnoid Hemorrhage: Diagnosis, Therapeutical Management…*

found no increased risk of rebleeding after the drainage [35, 36]. Our previous study showed that a lower Fisher grade, ruptured anterior cerebral artery aneurysms, and preoperative external ventricular drainage were independently associated with rebleeding after poor-grade aSAH [5]. Therefore, these patients may have increased risk of rebleeding after ventricle drainage without aneurysm repair, and early aneurysm treatment may be considered for patients who required emergency ventricle

Poor-grade aSAH should be treated with a multidisciplinary team that consists of neurologists, neurosurgeons, interventional neuroradiologists, and anesthetists. Emergency treatment should include aggressive resuscitation to keep the basic life support. Central venous catheters are first inserted for fluid and medicine administration and hemodynamic monitoring. Systolic blood pressure should be maintained below 160 mmHg to prevent the rebleeding. Oral or nasotracheal intubation

There is no consensus regarding the optimal timing of treatment for poor-grade aSAH. Traditionally, these patients have been managed medically and only undergo the treatment of the ruptured aneurysm when clinically stabilized and improved. In the past decades, several studies have shown that early surgery (within 72 h of ictus) improved the outcome in selected patients with poor-grade aneurysms [15–17, 33, 37–39]. At more than 6 months of follow-up, 46% of patients had a good outcome after early surgical clipping [40]. Zentner et al. [41] reported that early surgery resulted in a good outcome of 22% of patients with the worst grade. A study of 103 patients with grade V showed a good outcome in 26% of patients at follow-up [42]. Despite the rates of morbidity and death remaining high in patients with WFNS grade V, these findings suggest that early aneurysm repair is feasible and safe for poor-grade aSAH. Early treatment for ruptured aneurysm may help reduce the risk of rebleeding and manage cerebral vasospasm and delayed ischemia. Patients with younger age, WFNS IV after emergency resuscitation, and middle cerebral artery aneurysms are more likely to have a favorable outcome after early surgery [43]. Aneurysm treatment as early as possible is recommended to prevent rebleeding after initial aSAH [44, 45]. Ultra-early treatment (within 24 h) reduces the risk of rebleeding and improves outcomes in most patients with good-grade aSAH [46–48]. However, there is no evidence to support ultra-early treatment of poorgrade aSAH because these patients experience more severe brain swelling than good-grade patients [42, 49]. With development in microsurgical techniques, there has been growing interest in ultra-early treatment of aSAH. A current series of 78 patients with poor-grade treated with surgical treatment showed 44 patients (56%) had a good outcome, including 26% of patients presenting with WFNS grade V, and surgery was performed within 24 h after admission [33]. In a multicenter and contemporary cohort of poor-grade aSAH, 47 (40%) of 118 patients underwent ultra-early surgery, 16 (34%) patients in ultra-early surgery group and 42 (59%) patients in delayed group had a good outcome [50]. Laidlaw et al. [17, 34]reported 40% of patients were independent after 3 months and 45% died. With coiling, there are few technical limitations to ultra-early treatment of aSAH as the limitations related to inflammation and brain swelling do not affect the technical aspects of the

should be performed if the patients require respiratory support.

*DOI: http://dx.doi.org/10.5772/intechopen.89993*

**4. Therapeutical management**

**4.1 Timing of treatment**

drainage.

*Poor-Grade Aneurysmal Subarachnoid Hemorrhage: Diagnosis, Therapeutical Management… DOI: http://dx.doi.org/10.5772/intechopen.89993*

found no increased risk of rebleeding after the drainage [35, 36]. Our previous study showed that a lower Fisher grade, ruptured anterior cerebral artery aneurysms, and preoperative external ventricular drainage were independently associated with rebleeding after poor-grade aSAH [5]. Therefore, these patients may have increased risk of rebleeding after ventricle drainage without aneurysm repair, and early aneurysm treatment may be considered for patients who required emergency ventricle drainage.