Do intra operative brain conditions during clipping for ruptured intra cranial aneurysms affect the outcome? Being devil's advocate

Introduction: For a disease like aneurysmal subarachnoid haemorrhage (aSAH) which continues to have high morbidity and mortality, prognostication is imperative. This gives realistic goals to both the health-care worker and the patient. Unfavourable brain conditions during surgery like dural bulge, brain swelling, petechial haemorrhages, need for ventricular tap are conventionally thought to be harbingers of poor outcomes. But is it really so? Methods: Fifty-four consecutively operated patients of aSAH were studied. Clinical grade at admission (H and H, World Federation of Neurosurgical Societies (WFNS)), Dural bulge, brain swelling, petechial haemorrhages, need for ventricular tap, and brain pulsatility were studied for outcome parameters like Glasgow outcome scale (GOS) at 1 and 3 months and development of focal deficits. Results: H and H and WFNS grades had a significant correlation with GOS. We found that the need for augmentation duraplasty had a significant association with the outcome and appearance of focal deficits. However, unfavourable brain conditions like--dural bulge, brain swelling, petechial haemorrhages, need for ventricular tap, absence of brain pulsatility during surgery did not have a significant impact on the outcome. Conclusions: Clinical grading by far remains the best predictor of outcome. Intra-operative brain conditions did not have a bearing on the outcome. The mechanism by which poor grade patients exhibit poor outcomes remains elusive. At least in the present study, it was not by way of manifesting as unfavourable brain conditions. A word of caution--further large studies are required before definite conclusions can be drawn.