KISEP KOR J CEREBROVASCULAR DISEASE March 2000 Vo. 2, No 1, page 24-9 자발성지주막하출혈환자의수술전등급 황성남 Preoperative Grading Systems of Spontaneous Subarachnoid Hemorrhage Sung-Nam Hwang, MD Department of Neurosurgery, College of Medicine, Chung-Ang University, Seoul, Korea ABSTRACT Since the first grading system of the subarachnoid hemorrhage was introduced by Botterell in 1956, various grading systems have been presented-mostly based on Botterell s or Glasgow Coma Scale-and studied for their universal validity. At the beginning, management plan for the patients solely depended on the grade of the applied grading system but after introduction of CT and microscope into the diagnosis and surgery for the aneurysmal subarachnoid hemorrhage and better understanding and management of vasospasm, the role of grading system has been changed to emphasize more on the predictability of the postsurgical outcome. The author reviewed the most popular and widely used grading systems to figure out their significance in predicting outcome and clinical applicability. Kor J Cerebrovascular Disease 2:24-9, 2000 KEY WORDSSpontaneous subarachnoid hemorrhage Cerebral aneurysm Grading system Classification. 서 론 지주막하출혈환자의등급변천 24
Table 1. Botterell s original grading system Grade 1conscious patient with or without signs of blood in subarachnoid space Grade 2drowsy patient without significant neurological deficit Grade 3drowsy patient with neurological deficit probable intracerebral clot Grade 4patient with major neurological deficit, deteriorating because of large intracerebral clots, or older patients with less severe neurological deficit but preexisting degenerative cerebrovascular disease Grade 5moribund or nearly moribund patient with failing vital centers and extensor rigidity Table 2. Nishioka s grading system Grade symptom freecompletely recovered from the effects of the last hemorrhage Grade minimally illcomlaining of headache but alert and responsiveno major neurological deficit Grade moderately illa lethargic with headache, neck stiffness but without hemspheric neurologic deficitb alert, recovered from the general effects of subarachnoid hemorrhage but having a hemisheric neurologic deficit Grade seriously illa severely obtunded without major neurologic deficitb lethargic or poorly responsive with hemispheric deficithemiparesis, dysphasia, mental confusion Grade moribunddecerebrate or unresponsive to all stimuli Table 3. Hunt and Hess classification Grade asymptomatic, or minimal headache and slight nuchal rigidity Grade moderate to severe headache, nuchal rigidity, no neurological deficit other than cranial nerve palsy Grade drowsiness, confusion, or mind focal deficit Grade stupor, moderate to severe hemiparesis, possibly early decerebrate rigidity and vegetative disturbances Grade deep coma, decerebrate rigidity, moribund appearance Table 4. Hunt and Kosnik classification Grade 0unruptured aneurysm Grade asymptomatic, or minimal headache and slight nuchal rigidity Grade ano acute meningeal or brain reaction, but with fixed neurological deficit Grade moderate to severe headache, nuchal rigidity, no neurological deficit other than cranial nerve palsy Grade drowsiness, confusion, or mild focal deficit Grade stupor, moderate to severe hemiparesis, possibly early decerebrate rigidity and vegetative disturbances Grade deep coma, decerebrate rigidity, moribund appearance Table 5. Botterell s modified grading system Grade 1minimal bleed alert, no neurological deficit Grade 2mild bleed alert, minimal neurological deficit as a third nerve palsy, stiff neck Grade 3moderate bleed drowsy or confused, stiff neck, with or without neurological deficit Grade 4moderate or severe bleed semi-coma, with or without neurological deficit Grade 5severe bleed coma and decerebrate movement Kor J Cerebrovascular Disease 2:24-9, 2000 25
Table 6. Yaargil s classification Grade 0aunruptured aneurysm, no neurological deficit Grade 0bunruptured, with neurological deficiti 3rd. nerve palsy or progressive hemisyndrome especially in the case of giant aneurysm Grade aasymptomatic following SAH Grade balert and oriented, no meningism, but with focal pronounced neurological deficit hemiparesis, paraparesis, aphasia, sensory deficits, visual field losses Grade aalert, but with headache and meningism Grade bsame, with focal neurological deficit Grade alethargic, confused, disoriented, combative Grade bsame with focal neurological deficit Grade semicomatose, responding to pain but not to voice pupils are reactive to light but patient may show extensor posturing Grade comatose, pupils are not reactive to light, extensor posturing or no reaction to pain, failing vital signs 26 Kor J Cerebrovascular Disease 2:24-9, 2000
Table 8. GCS grading system Grade GCS Grading System 0 Unruptured anneurysm GCS score of 15 GCS score of 1214 GCS score of 911 GCS score of 68 GCS score of 305 Table 7. WFNS SAH scale WFNS grade GCS score Motor deficit 15 absent 1413 absent 1413 present 12 7 present or absent 6 3 present or absent Table 9. modified GCS based grading system Grade GCS Grading System GCS score of 15 GCS score of 1114 GCS score of 810 GCS score of 47 GCS score of 3 Kor J Cerebrovascular Disease 2:24-9, 2000 27
결론 중심단어 : REFERENCES 1) Adams JP Jr, Kassell NF, Torner JC. Usefulness of computed tomography in predicting outcome after aneurysmal subarachnoid haemorrhage: a preliminary report of the Cooperative Aneurysm Study. Neurology 35:1263-1267, 1985 2) Auer LM, Schneider GH, Auer T. Computerized tomography and prognosis in early aneurysm surgery. J Neurosurg 65:217-221, 1986 3) Botterell EH, Lougheed WM, Morley TP, et al. Hypothermia in the surgical treatment of ruptured intracranial aneurysms. J Neurosurg 15:4-18, 1958 4) Botterell EH, Lougheed WM, Scott JW, et al. Hypothermia, and interruption of carotid, or carotid and vertebral circulation in the surgical management of intracranial aneurysms. J Neurosurg 13: 1-42, 1956 5) Drake CG, Hunt WE, Sano K, et al. Report of World Federation of Neurological Surgeons Committee Universal Subarachnoid Hemorrhage Grading Scale. J Neurosurg 68:985-986, 1988 6) Gerber CJ, Lang DA, Neil-Dwyer G, et al. A simple scoring system for accurate prediction of outcome within four days of subarachnoid hemorrhage. Acta Neurochir (Wien) 122:11-22, 1993 7) Gotoh O, Tamura A, Yasui N, et al. Glasgow Coma Scale in the prediction of outcome after early aneurysm surgery. Neurosurgery 39/1:19-25, 1996 8) Hirai S, Ono J, Yamaura A. Clinical grading and outcome after early surgery in aneurysmal subarachnoid hemorrhage. Neurosurgery 39:441-447, 1996 9) Hunt WE, Hess RM. Surgical risk as related to time of intervention in the repair of intracranial aneurysms. J Neurosurg 28:14-20, 1967 10) Hunt WE, Kosnik EJ. Timing and perioperative care in intracranial aneurysm surgery. Clin Neurosurg 21:79-89, 1974 11) Jagger J, Torner JC, Kassell NF. Neurological assessment of subarachnoid hemorrhage in a large patient series. Surg Neurol 32: 327-333, 1989 12) Kassell NF, Torner JC, Haley EC Jr, et al. The International Cooperative Study on the Timing of Aneurysm Surgery. Part 1-Overall management results. J Neurosurg 73:18-36 13) Lindsay KW, Teasdale GM, Knill-Jones RP, et al. Observer variability in grading patients with subarachnoid hemorrhage. J Neurosurg 56:628-633, 1982 14) Lindsay KW, Teasdale GM, Knill-Jones RP. Observer variability in assessing the clinical features of subarachnoid hemorrhage. J Neurosurg 58:57-62, 1983 15) Lougheed WM, Marshall BM. Management of aneurysms of the anterior circulation by intracranial procedures, in Youmans JR: Neurological Surgery. ed 1, Philadelphia, W.B. Saunders Co., 1973, pp 731-767 16) Nishioka H. Report on the Cooperative Study of Intracranial Aneuryms and Subarachnoid Hemorrhage. Section Ⅶ, Part I. Evaluation of conservative management of ruptured intracranial aneurysms. J Neurosurg 25:574-592, 1966 17) Norln G, Olivecrona H. The treatment of aneurysms of the circle of Willis. J Neurosurg 10:404-415, 1953 18) Oshiro EM, Walter KA, Piantadosi S, et al. A new subarachnoid hemorrhage grading system based on the Glasgow Coma Scale: a comparison with the Hunt and Hess and World Federation of Neurological Surgeons Scales in a clinical series. Neurosurgery 41: 28 Kor J Cerebrovascular Disease 2:24-9, 2000
140-148, 1997 19) Starmark JE, Holmgren E, Stalhammar D. Current reporting of responsiveness in acute cerebral disorders. J Neurosurg 69:692-698, 1988 20) Takagi K, Tamura A, Nakagomi T, et al. How should a subarachnoid hemorrhage grading scale be determined? a combinatorial approach based solely on the Glasgow Coma Scale. J Neurosurg 90:680-687, 1999 21) Teasdale G, Knill-Jones RP, Lindsay KW. Clinical assessment of SAH. J Neurosurg 59:550-551, 1983 (Letter) 22) Yaargil MG. Microneurosurgery, Vol Ⅱ: Clinical Considerations, Surgery of the Intracranial Aneurysms and Results. New York, Stuttgart, George Thiem Verlag, 1984, pp 1-32 Kor J Cerebrovascular Disease 2:24-9, 2000 29