Association between intraoperative nociception and surgical invasiveness in patients undergoing non-cardiac surgery under general anesthesia: a retrospective cohort study.

There are several indexes of intraoperative nociception during surgery under general anesthesia. Although a higher degree of surgical invasiveness increases intraoperative nociception, an association between the index of intraoperative nociception and severity of surgical invasiveness has not been reported. We hypothesized that there is associations between averaged values of nociceptive response (NR) throughout surgery (mean NR), as the index of intraoperative nociception, and surgical severity codes in the Surgical outcome risk tool (SORT) or procedure risk codes in the Surgical mortality probability model (S-MPM). The primary outcome was the association between mean NR and severity scores of surgical procedure. Hence, a single institutional retrospective cohort study was performed in consecutive patients undergoing non-cardiac surgery under general anesthesia from June 2018 to May 2019. There were significant increases in the three categories of procedure risk in the S-MPM corresponding to the increase in mean NR values in 5090 patients. In the SORT, the highest intensity in the four categories of surgical severity also significantly correlated with the increase in mean NR values. Increasing intensity of intraoperative nociception is likely associated with higher severity codes of surgical invasiveness in prediction models for postoperative morbidity and mortality.

Association between intraoperative nociception and postoperative complications in patients undergoing laparoscopic gastrointestinal surgery.

A higher degree of surgical invasiveness, which increases intraoperative nociception, might induce postoperative complications. Although several nociceptive indices for use during surgery are available in clinical practice, association between intraoperative nociception and postoperative complications has not been reported. An index representing intraoperative nociception, which is the averaged value of Nociceptive Response throughout the surgery (mean NR) was applied to examine the association in the present study. The retrospective study evaluated consecutive adult patients undergoing laparoscopic gastrointestinal surgery, American Society of Anesthesiologists-physical status (ASA-PS) I or II, whose preoperative C-reactive protein level was < 0.3 mg dL-1. We first used ordinal logistic analysis to examine the association between preoperative and intraoperative risk factors and complications graded by the Clavien-Dindo classification. Next, we performed propensity score matched analysis to evaluate the effects of mean NR throughout surgery on postoperative complications. Ordinal logistic analysis (n = 158) revealed that duration of surgery (P < 0.001), mean NR during surgery (P = 0.002), and ASA-PS (P = 0.016) were risk factors for postoperative complications. Then all patients were divided into two propensity score matched groups, based on a mean NR of < 0.85 and ≥ 0.85, with matching for age, ASA-PS, body mass index and duration of surgery. The severity of postoperative complications was significantly higher in the high NR group than in the low NR group (P = 0.005). In conclusion, there was likely an association between intraoperative nociception and postoperative complications in patients without serious preoperative conditions and comorbidities.

Effects of Thoracic Paravertebral Block on Nociceptive Levels After Skin Incision During Video-Assisted Thoracoscopic Surgery.

BACKGROUND Regional anesthesia provides excellent analgesic effects after surgery. However, the effects of regional anesthesia on nociceptive levels during surgery under general anesthesia have not been quantitatively evaluated. To reveal the effects of thoracic paravertebral block (PVB) on nociceptive levels after skin incision during general anesthesia, we performed a retrospective cohort study in patients without serious preoperative conditions or comorbidities undergoing elective video-assisted thoracoscopic surgery (VATS). Nociceptive levels during general anesthesia were calculated using our previously determined Nociceptive Response (NR) equation, which utilizes common hemodynamic parameters. MATERIAL AND METHODS Data on 77 adult patients who underwent VATS from May 2018 to August 2018 were retrospectively obtained from our institutional database. We then performed propensity score matching between patients who received thoracic PVB (PVB group: n=29) and those who did not (Control group: n=48). The averaged values of systolic blood pressure (SBP), heart rate (HR), perfusion index (PI), bispectral index (BIS), and NR from 10 to 5 minutes before skin incision (T0), 5 to 10 minutes (T1), 10 to 15 minutes (T2), 15 to 20 minutes (T3), and 20 to 25 minutes after skin incision (T4), were calculated. RESULTS Twenty-four propensity score-matched patients in each group were analyzed. Mean NR values at T1 and T2 in the PVB group were significantly lower than those in the Control group. SBP, HR, PI, and BIS, however, showed no significant differences between the 2 groups, except for SBP at T2. CONCLUSIONS Thoracic PVB prevented an increase in NR values, which quantitatively represent nociceptive levels under general anesthesia, in patients undergoing VATS.

Previously Undiagnosed Spinal and Bulbar Muscular Atrophy as a Cause of Airway Obstruction after Robot-Assisted Laparoscopic Prostatectomy.

BACKGROUND: Preoperative vocal cord paralysis is a risk factor for postoperative respiratory distress following extubation after general anesthesia. We present an unusual case where a geriatric patient developed airway obstruction after robot-assisted laparoscopic prostatectomy. CASE PRESENTATION: A 67-year-old male, who had suffered from left vocal cord paralysis of unknown etiology, was scheduled for robot-assisted laparoscopic prostatectomy (RALP). General anesthesia was performed without any problems. The patient, however, developed airway obstruction one hour after extubation and was reintubated following commencement of mechanical ventilation for one day. At the age of 70 years, the patient received an emergency tracheostomy due to bilateral vocal cord paralysis and then was diagnosed with spinal and bulbar muscular atrophy (SBMA). Although no muscle weakness of either upper or lower extremities was observed, rocuronium showed hypersensitivity during total laryngectomy under general anesthesia. CONCLUSIONS: Vocal cord paralysis combined with postoperative laryngeal edema, the cause of which was presumed to be SBMA, likely caused airway obstruction after RALP. As neuromuscular symptoms progress gradually in patients with SBMA, muscle relaxants should be used carefully, even if patients with SBMA present no immobility of their extremities.

Fibrinogen γ-Chain Peptide-Coated Adenosine 5' Diphosphate-Encapsulated Liposomes Rescue Mice From Lethal Blast Lung Injury via Adenosine Signaling.

OBJECTIVES: Fibrinogen γ-chain (dodecapeptide HHLGGAKQAGDV)-coated adenosine 5'-diphosphate-encapsulated liposomes can accumulate via dodecapeptide HHLGGAKQAGDV interactions at bleeding sites where they release adenosine 5'-diphosphate that is rapidly metabolized to adenosine, which has tissue-protective effects. We investigated the efficacy of fibrinogen γ-chain (dodecapeptide HHLGGAKQAGDV)-coated adenosine 5'-diphosphate-encapsulated liposomes to treat blast lung injury, with a focus on adenosine signaling. DESIGN: Controlled animal study. SETTING: University research laboratory. SUBJECTS: Adult male C57BL/6 mice. INTERVENTIONS: Mice were pretreated with fibrinogen γ-chain (dodecapeptide HHLGGAKQAGDV)-coated adenosine 5'-diphosphate-encapsulated liposomes, dodecapeptide HHLGGAKQAGDV-(phosphate-buffered saline)-liposomes, adenosine 5' diphosphateliposomes, or phosphate-buffered saline-liposomes. Five minutes after treatment the mice received a single laser-induced shock wave (1.8 J/cm) that caused lethal blast lung injury, and their survival times and lung injuries were then assessed. We also evaluated the therapeutic effect of posttreatment with fibrinogen γ-chain (dodecapeptide HHLGGAKQAGDV)-coated adenosine 5'-diphosphate-encapsulated liposomes or H12-(phosphate-buffered saline)-liposomes 1 minute after laser-induced shock wave exposure. To examine the effect of adenosine signaling, adenosine A2A receptor (ZM241385) or adenosine A2B receptor (PSB 1115) antagonists were administered to the mice 1 hour before the pretreatment with fibrinogen γ-chain (dodecapeptide HHLGGAKQAGDV)-coated adenosine 5'-diphosphate-encapsulated liposomes that was followed by laser-induced shock wave exposure. MEASUREMENTS AND MAIN RESULTS: Pre- and posttreatment with fibrinogen γ-chain (dodecapeptide HHLGGAKQAGDV)-coated adenosine 5'-diphosphate-encapsulated liposomes significantly increased mouse survival [fibrinogen γ-chain (dodecapeptide HHLGGAKQAGDV)-coated adenosine 5'-diphosphate-encapsulated liposomes: 58% survival vs H12-(phosphate-buffered saline)-liposomes: 8%; p < 0.05 (posttreatment)] and mitigated pulmonary tissue damage/hemorrhage and neutrophil accumulation after laser-induced shock wave exposure. fibrinogen γ-chain (dodecapeptide HHLGGAKQAGDV)-coated adenosine 5'-diphosphate-encapsulated liposomes accumulated at pulmonary vessel injury sites after laser-induced shock wave exposure with both pre- and posttreatment. Furthermore, pretreatment with fibrinogen γ-chain (dodecapeptide HHLGGAKQAGDV)-coated adenosine 5'-diphosphate-encapsulated liposomes reduced albumin and macrophage inflammatory protein-2 levels in bronchoalveolar lavage fluid. Although fibrinogen γ-chain (dodecapeptide HHLGGAKQAGDV)-coated adenosine 5'-diphosphate-encapsulated liposomes pretreatment did not affect blood coagulation activity in the injured mice, its beneficial effect on blast lung injury was significantly abrogated by A2A or A2B adenosine receptor antagonists (A2A antagonist: 17% survival; A2B antagonist: 33% vs dimethyl sulfoxide control: 80%; p < 0.05, respectively). CONCLUSIONS: Fibrinogen γ-chain (dodecapeptide HHLGGAKQA GDV)-coated adenosine 5'-diphosphate-encapsulated liposomes may be effective against blast lung injury by promoting tissue-protective adenosine signaling and could represent a novel controlled-release drug delivery system.

Noradrenalin effectively rescues mice from blast lung injury caused by laser-induced shock waves.

BACKGROUND: Blast lung injuries (BLI) caused by blast waves are extremely critical in the prehospital setting, and hypotension is thought to be the main cause of death in such cases. The present study aimed to elucidate the pathophysiology of severe BLI using laser-induced shock wave (LISW) and identify the initial treatment. METHODS: The current investigation comprised two parts. For the validation study, mice were randomly allocated to groups that received a single shot of 1.2, 1.3, or 1.4 J/cm(2) LISW to both lungs. The survival rates, systolic blood pressure (sBP), heart rate (HR), peripheral oxyhemoglobin saturation (SpO2), and shock index were monitored for 60 min, and lung tissues were analyzed histopathologically. The study evaluated the effects of catecholamines as follows. Randomly assigned mice received 1.4 J/cm(2) LISW followed by the immediate intraperitoneal administration of dobutamine, noradrenalin, or normal saline. The primary outcome was the survival rate. Additionally, sBP, HR, SpO2, and the shock index were measured before and 5 and 10 min after LISW, and the cardiac output, left ventricular ejection fraction, and systemic vascular resistance (SVR) were determined before and 1 min after LISW. RESULTS: The triad of BLI (hypotension, bradycardia, and hypoxemia) was evident immediately after LISW. The survival rates worsened with increasing doses of LISW (100 % in 1.2 J/cm(2) vs. 60 % in 1.3 J/cm(2), 10 % in 1.4 J/cm(2)). The histopathological findings were compatible with those of human BLI. The survival rate in LISW high group (1.4 J/cm(2)) was highest in the group that received noradrenalin (100 %), with significantly elevated SVR values (from 565 to 1451 dyn s/min(5)). In contrast, the survival rates in the dobutamine and normal saline groups were 40 and 10 %, respectively, and the SVR values did not change significantly after LISW in either group. CONCLUSIONS: The main cause of death during the initial phase of severe BLI is hypotension due to the absence of peripheral vasoconstriction. Therefore, the immediate administration of noradrenalin may be an effective treatment during the initial phase of severe BLI.

Thoracic shock wave injury causes behavioral abnormalities in mice.

BACKGROUND: Mild traumatic brain injury (mTBI) is caused by complex mechanisms of systemic, local and cerebral responses to blast exposure. However, the molecular mechanisms of cognitive impairment after exposure to blast waves are not clearly known. We tested the hypothesis that thoracic injury induced functional and morphological impairment in the brain, leading to behavioral abnormalities. METHODS: Mice were exposed to laser-induced shock waves (LISWs) impacting the thorax and assessed for behavioral outcome at 7 and 28 days post injury. Hippocampus and lung were collected for histopathological analysis and gene expression profiling after injury. RESULTS: Thoracic injury transiently decreased the heart rate, blood pressure, peripheral oxyhemoglobin saturation and cerebral blood flow immediately after LISW exposure. Although LISWs exposure caused pulmonary contusions, hemorrhage was not apparent in the brain. At 7 and 28 days after, the injured mice exhibited impaired short-term memory and depression-like behavior compared with controls. Histological assessments showed an increase in neuronal cell death after shock wave exposure, especially in the CA3 region of the hippocampus. Moreover, shock wave exposure altered the expression of functionally relevant genes in the hippocampus at 1 h and 1 day post injury. CONCLUSIONS: Our findings indicate that the LISW-induced thoracic injury with no direct impact on the brain affected the hippocampal gene expression and led to morphological alterations, resulting in behavioral abnormalities. Therefore, body protection may be extremely important in the effective prevention against blast-induced alterations in brain function.

Comparison of the level of intraoperative nociception between laparoscopic and open hepatic resection.

BACKGROUND/AIMS: Sufficient suppression of perioperative nociception is important for ensuring favorable postoperative outcomes. Although the level of nociception during laparoscopic surgery is generally lower than during laparotomy, there is insufficient evidence to support this for hepatic resection. METHODOLOGY: To develop a method to retrospectively evaluate the intraoperative nociceptive level, we collected data of intraoperative averaged values of heart rate, perfusion index, systolic blood pressure during three surgeries with different levels of intraoperative nociception. After we validated the utility of discriminant analysis using these variables for the retrospective evaluation of nociception during surgery, we performed this analysis in patients who underwent either laparoscopic or open hepatic resection. RESULTS: Although there was a significant difference in discriminant score between the open and the laparoscopic hepatic resection groups before propensity score matching, discriminant score showed no significant difference between two groups after matching. CONCLUSIONS: The level of nociception during laparoscopic hepatic resection is likely similar to that during open hepatic resection. An assertive anti-nociceptive strategy might be required for laparoscopic procedures under general anesthesia, as with open procedures.

Subacute subdural hematoma.

Subacute subdural hematoma (SASDH) is a rare entity. We retrospectively reviewed 8 patients with SASDH. Four patients were male and 4 were female, with an age range of 45-87 years (mean, 67.8 years). The minimal level of deterioration ranged from 8 to 14 (mean, 10.5). The deterioration of neurological symptoms was confirmed 4-20 days after injury (mean, 12.9). The hematoma volume was increased in 6 patients. Seven patients underwent surgeries (burr-hole irrigation in 6, craniotomy in 1). The Glasgow Outcome Scale indicated a good recovery in 4 patients and moderate disability in 4 patients. Increased cerebral blood flow was observed just below the SDH in 1 patient. We consider that the hypoperfused tissue in the acute phase might become hyperperfused during the subacute phase owing to impaired autoregulation, and the hyperperfusion may be responsible for the development of the SASDH, leading to deterioration. Further investigations in a larger series are needed to elucidate the mechanism underlying the development of SASDH.

Clinical characteristics and surgical outcomes of patients with aneurysmal subarachnoid hemorrhage and acute subdural hematoma undergoing decompressive craniectomy.

OBJECTIVE: This report presents 12 consecutively managed patients with aneurysmal subarachnoid hemorrhage (SAH) associated with acute subdural hematoma (ASDH) who underwent decompressive craniectomy (DC) with special attention to their clinical characteristics and surgical outcomes. METHODS: We retrospectively reviewed medical charts, radiologic findings, surgical notes, and video records. RESULTS: Among these 12 patients (mean age 59.1 years, 4 men, 8 women), the Hunt and Kosnik clinical grade was grade V in 7 patients (58.3%), grade IV in 2 patients (16.7%), grade III in 2 patients (16.7%), and grade II in 1 patient (8.3%). The aneurysms were located on the internal carotid artery in four patients, the middle cerebral artery in six patients, and the anterior communicating artery in two patients. Computed tomography findings on admission revealed ASDH in all patients. In addition, SAH was seen in 11 patients. An intracerebral hematoma was found in eight patients, intraventricular hemorrhaging occurred in four, and an acute hydrocephalus was seen in one patient. All patients underwent a microsurgical clipping procedure and an additional DC. Symptomatic vasospasm was confirmed in six (50%), and eight patients with chronic hydrocephalus received a ventriculoperitoneal shunt (67%). The Glasgow Outcome Scale at discharge showed good recovery in five patients (41.7%), severe disability in four (33.3%), vegetative state in two (16.7%), and death in one patient (8.3%). A favorable outcome was achieved in five patients (41.7%). CONCLUSIONS: We suggest that the DC was effective for reducing morbidity and mortality in poor grade patients with SAH presenting with ASDH.

Surgical outcome following a decompressive craniectomy for acute epidural hematoma patients presenting with associated massive brain swelling.

Acute epidural hematomas (AEDH) are generally managed with rapid surgical hematoma evacuation and bleeding control. However, the surgical outcome of patients with serious brain edema is poor. This study reviewed the clinical outcome for AEDH patients and evaluated the efficacy of the DC, especially in patients with associated massive brain swelling. Eighty consecutive patients surgically treated with AEDH were retrospectively assessed. The patients were divided into two groups: (a) hematoma evacuation (HE: 46 cases) and (b) HE+ an external decompression (ED: 34 cases). The medical charts, operative findings, radiological findings, and operative notes were reviewed. In the poor outcome group, there were 18 patients (72%), with a GCS score of less than 8 (severe injury), and 22 patients (88%) who showed pupil abnormalities. Many more patients showed a midline shift, basal cistern effacement, and brain contusion in comparison to the favorable outcome group. In the favorable outcome group, almost all of the patients (98%) showed less than 12 mm of a midline shift. The influential factors may be age, GCS, pupil abnormalities, size, midline shift, basal cistern effacement, coincidence of contusion and swelling. We conclude that an A DC may be effective to manage the AEDH patients with cerebral contusion or massive brain swelling.

Significance of monitoring the initial intracranial pressure on hematoma irrigation with trephination therapy for acute subdural hematomas in critical conditions.

Acute subdural hematoma (ASDH) patients presenting in a severe condition tend to have poor outcomes due to the significant brain edema required to maintain the ICP at less than 20-25 mmHg. This study compared the surgical outcomes of 16 critically ill patients with ASDH who underwent hematoma irrigation with trephination therapy (HITT) based on their initial ICP values. The initial mean GCS score upon admission was four. A unilateral dilated pupil was seen in one and bilateral dilated pupils were seen in seven patients. The co-existence of a brain contusion was seen in seven patients, brain swelling was noted in six patients, and both basal cistern effacement and a midline shift greater than 5 mm were observed in all patients. The mean initial ICP value was 45 mmHg (range: 3 to 85 mmHg). Ten patients (62.5%) underwent a rapid external decompression to evacuate the hematoma. By using the Glasgow Outcome Scale upon discharge a score of good recovery (GR) was assigned to two (12.5 %), moderate disability (MD) to four (25.0 %), vegetative state (VS) to two (12.5 %), and death (D) to eight (50.0 %) patients. All six patients who showed an initial ICP greater than 60 mmHg died despite intensive care. Eight patients who showed an initial ICP less than 40 mmHg had a favorable outcome, but two patients deteriorated due to a traumatic cerebrovascular disorder. It seems that the initial ICP monitoring with HITT for ASDH patients in critical condition may be an important factor for predicting both surgical outcome and clinical course.

Prognosis for severe traumatic brain injury patients treated with bilateral decompressive craniectomy.

PURPOSE: Decompressive craniectomy for traumatic brain injury patients has been shown to reduce intracranial hypertension, while it often results in increased brain edema and/or contralateral space-occupied hematoma. The purpose of this study was to determine the prognosis of bilateral decompressive craniectomy in severe head injury patients with the development of either bilateral or contralateral lesions after ipsilateral decompressive craniectomy. METHODS: Twelve patients underwent bilateral decompressive craniectomy among 217 individuals who had been treated with decompressive craniectomy with dural expansion from September 1995 to August 2006. The following patient data were retrospectively collected: age, neurological status at admission, time between injury and surgical decompression, time between first and second decompression, laboratory and physiological data collected in the intensive care unit, and outcome according to the Glasgow Outcome Scale. RESULTS: Patient outcomes fell into the following categories: good recovery (three patients); mild disability (one patient); severe disability (two patients); persistent vegetative state (one patient); and death (five patients). Patients with good outcomes were younger and had better pupil reactions and neurological statuses on admission. Other factors existing prior to the operation did not directly correlate with outcome. At 24 h post-surgery, the average intercranial pressure (ICP), cerebral perfusion pressure (CPP), glucose level, and lactate level in patients with poor outcomes differed significantly from those of patients with a good prognosis. CONCLUSION: Head injury patients with either bilateral or contralateral lesions have poor prognosis. However, bilateral decompressive craniectomy may be a favorable treatment in certain younger patients with reactive pupils, whose ICP and CPP values are stabilized 24 h post-surgery.

Clinical and radiological findings and surgical management of ruptured aneurysms at the non-branching sites of the internal carotid artery.

Ruptured aneurysms located at the non-branching sites of the internal carotid artery, including blister-like aneurysms, possess unique clinical and technical features. This report presents nine consecutively managed patients with these types of aneurysm, detailing the clinical and radiological characteristics and surgical outcomes. The initial angiography identified aneurysmal lesions in six of the nine patients with two of these patients requiring additional three-dimensional (3D) angiography. In three patients the aneurysm was only diagnosed on second or third angiograms. Six patients had blister-like aneurysms, and two had saccular-shaped aneurysms diagnosed on the basis of intraoperative findings. One patient with a saccular aneurysm died without surgery. Eight patients underwent a microsurgical procedure: clipping in five, clipping on wrapping with suturing in two and trapping in one. Three of these eight patients had an intraoperative rupture. A favorable outcome was obtained in seven patients. Advances in microsurgical techniques to prevent premature rupture and 3D radiological diagnosis with careful pre-operative consideration of the surgical strategies will be required for a further improvement of the clinical outcome.

Clinical features and surgical outcomes of ruptured distal anterior cerebral artery aneurysms in 20 consecutively managed patients.

Optimal surgical management of ruptured aneurysms of the distal anterior cerebral artery continues to provide unique technical challenges. This study presents 20 consecutively managed such patients, with special attention given to the clinical and radiological characteristics, as well as the surgical outcomes. Intracerebral hematoma was seen in 11 of the 20 patients, and intraventricular hemorrhage occurred in 4 (20%). Angiography revealed that 9 (45%) patients had multiple aneurysms. Three patients (15%) had "mirror" distal anterior cerebral arterial aneurysms on the contralateral side. Eleven patients (55%) had aneurysms located at the supracallosal portion of the anterior cerebral artery, while 9 patients (45%) had aneurysms located below the genu of the corpus callosum. The mean aneurysmal diameter was 3.85 mm; 18 aneurysms (90%) were less than 6 mm in diameter. Eighteen patients (90%) underwent a microsurgical procedure; 2 (10%) underwent endovascular coiling due to poor clinical grade. A favorable outcome was achieved in 14 (70%) patients. Advances in microsurgical techniques will be required to further improve clinical outcome.

Surgical outcome following decompressive craniectomy for poor-grade aneurysmal subarachnoid hemorrhage in patients with associated massive intracerebral or Sylvian hematomas.

BACKGROUND: Patients with poor-grade aneurysmal subarachnoid hemorrhage (SAH) presenting with large intracerebral (ICH) or sylvian hematomas (SylH) have poor outcomes due to the mass effect of significant brain stem compression following mass effect. On the other hand, decompressive craniectomy (DC) can reduce morbidity and mortality in critically ill patients with massive ischemic infarction and severe head injury. However, the role of DC in SAH patients is not fully understood. We investigated the outcome of DC in poor-grade SAH presenting with large ICH or SylH. METHODS: 110 consecutive patients with poor-grade SAH (Hunt & Kosnik (H&K) grades IV and V, and Fisher group 4) were admitted to our hospital between April 1, 1993, and July 30, 2004. We treated 57 of those who presented with large ICH or SylH using DC. We retrospectively reviewed medical charts, radiological findings, operative notes, and video records. RESULTS: Among the 57 patients (mean age 57.8, male 29, female 28), 25 were classified as H&K grade IV and 32 as grade V. Ruptured aneurysms were located on the internal carotid artery in 11 and the middle cerebral artery in 46 patients. 50 of the aneurysms were small, 5 were medium, and 2 were large. Rerupture was preoperatively confirmed in 13 (22.8%). Hypothermia was applied to 17 (29.8%). The Glasgow Outcome Scale on discharge showed good recovery, moderate recovery, severe disability, vegetative state, and death in 8 (14.0%), 13 (22.8%), 16 (28.1%), 8 (14.0%), and 12 (21.1%), respectively. The outcomes of grade IV patients were favorable and poor in 14 (56.0%) and 10 (40.0%), respectively, and 1 (4.0%) died. CONCLUSION: Several experimental studies have also indicated that DC significantly improves outcome due to reduced intracranial pressure or increased perfusion pressure. Urgent DC for poor-grade SAH with space-occupying hematoma can lead to survival with good recovery in some patients.