Dr. Pletser’s experience includes 30 years of working with the European Space Agency as a Senior Physicist/Engineer and coordinating their parabolic flight campaigns, and he is the Guinness World Record holder for the most number of aircraft flown (12) in parabolas, personally logging more than 7,300 parabolas.
\\n\\n
Seeing the 5,000th book published makes us at the same time proud, happy, humble, and grateful. This is a great opportunity to stop and celebrate what we have done so far, but is also an opportunity to engage even more, grow, and succeed. It wouldn't be possible to get here without the synergy of team members’ hard work and authors and editors who devote time and their expertise into Open Access book publishing with us.
\\n\\n
Over these years, we have gone from pioneering the scientific Open Access book publishing field to being the world’s largest Open Access book publisher. Nonetheless, our vision has remained the same: to meet the challenges of making relevant knowledge available to the worldwide community under the Open Access model.
\\n\\n
We are excited about the present, and we look forward to sharing many more successes in the future.
\\n\\n
Thank you all for being part of the journey. 5,000 times thank you!
\\n\\n
Now with 5,000 titles available Open Access, which one will you read next?
Preparation of Space Experiments edited by international leading expert Dr. Vladimir Pletser, Director of Space Training Operations at Blue Abyss is the 5,000th Open Access book published by IntechOpen and our milestone publication!
\n\n
"This book presents some of the current trends in space microgravity research. The eleven chapters introduce various facets of space research in physical sciences, human physiology and technology developed using the microgravity environment not only to improve our fundamental understanding in these domains but also to adapt this new knowledge for application on earth." says the editor. Listen what else Dr. Pletser has to say...
\n\n\n\n
Dr. Pletser’s experience includes 30 years of working with the European Space Agency as a Senior Physicist/Engineer and coordinating their parabolic flight campaigns, and he is the Guinness World Record holder for the most number of aircraft flown (12) in parabolas, personally logging more than 7,300 parabolas.
\n\n
Seeing the 5,000th book published makes us at the same time proud, happy, humble, and grateful. This is a great opportunity to stop and celebrate what we have done so far, but is also an opportunity to engage even more, grow, and succeed. It wouldn't be possible to get here without the synergy of team members’ hard work and authors and editors who devote time and their expertise into Open Access book publishing with us.
\n\n
Over these years, we have gone from pioneering the scientific Open Access book publishing field to being the world’s largest Open Access book publisher. Nonetheless, our vision has remained the same: to meet the challenges of making relevant knowledge available to the worldwide community under the Open Access model.
\n\n
We are excited about the present, and we look forward to sharing many more successes in the future.
\n\n
Thank you all for being part of the journey. 5,000 times thank you!
\n\n
Now with 5,000 titles available Open Access, which one will you read next?
\n'}],latestNews:[{slug:"stanford-university-identifies-top-2-scientists-over-1-000-are-intechopen-authors-and-editors-20210122",title:"Stanford University Identifies Top 2% Scientists, Over 1,000 are IntechOpen Authors and Editors"},{slug:"intechopen-authors-included-in-the-highly-cited-researchers-list-for-2020-20210121",title:"IntechOpen Authors Included in the Highly Cited Researchers List for 2020"},{slug:"intechopen-maintains-position-as-the-world-s-largest-oa-book-publisher-20201218",title:"IntechOpen Maintains Position as the World’s Largest OA Book Publisher"},{slug:"all-intechopen-books-available-on-perlego-20201215",title:"All IntechOpen Books Available on Perlego"},{slug:"oiv-awards-recognizes-intechopen-s-editors-20201127",title:"OIV Awards Recognizes IntechOpen's Editors"},{slug:"intechopen-joins-crossref-s-initiative-for-open-abstracts-i4oa-to-boost-the-discovery-of-research-20201005",title:"IntechOpen joins Crossref's Initiative for Open Abstracts (I4OA) to Boost the Discovery of Research"},{slug:"intechopen-hits-milestone-5-000-open-access-books-published-20200908",title:"IntechOpen hits milestone: 5,000 Open Access books published!"},{slug:"intechopen-books-hosted-on-the-mathworks-book-program-20200819",title:"IntechOpen Books Hosted on the MathWorks Book Program"}]},book:{item:{type:"book",id:"640",leadTitle:null,fullTitle:"Modern Arthroscopy",title:"Modern Arthroscopy",subtitle:null,reviewType:"peer-reviewed",abstract:"Modern Arthroscopy will assist practitioners to stay current in the rapidly changing field of arthroscopic surgery. 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\n
1. Introduction
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This chapter aims to provide a conceptual framework of conflicts and social capital (SC) in organizations. These two variables are multifaceted theoretical concepts; conflicts and their positive and negative consequences have been studied intensively, while conflicts are usually categorized as negative behavior and as one of the “dark side” constructs such as aggression, incivility, deviance and bullying [1], but most of the conflict researchers also mention their positive consequences such as promoting subjects and finding solutions [2]. De Dreu and Gelfand [1] divided conflict management in organizations into three levels such as the individual level, the group level, and the organizational level. They claimed that each level of conflict can result in either harming or improving the quality of performance and satisfaction in organizations. The outcome (positive or negative) depends on the context of the conflict. The argument of this chapter is that an important contextual variable is SC. In this chapter, the author introduces the effect of social capital (SC) in various organizational levels and discusses its possible influence on organizational conflicts.
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SC has many definitions and segmentations; it is considered a “positive psychology” variable [3] because it refers to the benefits derived from social interactions [4, 5]. The interface between organizational conflicts and SC is interesting because of their contrasting nature. Moreover, SC can lead to conflicts, and conflicts can lead to SC in every organizational level.
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In order to make the discussion about conflicts simpler and clearer, the author prefers to use the segmentation of “A-type” and “C-type” conflicts, according to Amason et al. [6] and tries to examine their compound relationship with different levels of SC in organizations, that is, personal, intraorganizational, and external SC.
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2. Conflicts in organizations
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The debate whether the organizational conflict is positive or negative is an old one, scholars agree that conflicts are a natural part of the organizational life, and that the context and the management of the conflict will determine whether the conflict will be beneficial or harmful.
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In their classical paper, Amason et al. [6] distinguished between two types of conflicts among teams in organizations: “C-type” and “A-type.”
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“C-type conflict” is a cognitive conflict that reflects disagreements among members of a team. This kind of conflict focuses on substantive, issue-related differences of opinion. The researchers claim that “C-type” conflict leads to better decisions and increased commitment, cohesiveness, empathy, and understanding among the team members.
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“A-type conflict” is an affective conflict that contains disagreements over personalized, individually oriented matters that are largely detrimental to team performance. The roots of this type of conflict are very often tacit; therefore, it is difficult to manage or to solve it. According to Amason et al. [6], this type of conflict often provokes animosity among team members and may lead to poor decision quality, reduced progress and decreased commitment, cohesiveness, and empathy among the team members.
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Amason et al.’s [6] conflict type resembles Jehn’s [2] conflict dimensions: relationship conflict and task conflict. Relationship conflicts are disagreements regarding personal issues that are not related to the group’s task such as personality clashes and annoying behavior of other group members. Task conflicts are disagreements among group members about opinions, ideas, and suggestions regarding the group’s task [16]. The sum of these two dimensions is an indicator of overall conflict. Considering the similarity of Amason et al.’s [6] types and Jehn’s [7, 8] dimensions, the relationship conflict can be defined as an “A-type” conflict, and the task conflict can be defined as a “C-type” conflict.
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Avgar [9, 10] claimed that task conflict, that is, “C-type” conflict, amplifies the social capital in organizations, and relationship conflict, that is, “A-type” conflict reduces it. However, this statement is general because SC is a complex concept, and there are three levels of SC in organizations, and each level can influence conflicts and be affected by conflicts differently. The next section introduces the concept of SC and its levels in organizations.
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3. Social capital (SC)
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Social capital (SC) is a comprehensive concept, which refers to the benefits derived from interactions between people. The concept of SC became widespread following Jane Jacobs’ study in 1961. In her book: “The Death and Life of Great American Cities,” Jacobs [10] argued that interpersonal relations that are based on trust, cooperation, common goals, and common activities can lead to better quality of life in urban neighborhoods, and eventually will raise the property values.
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Leaning toward this observation, Coleman [11] looked at the concept of “SC” as a bridge between sociology [12, 13] and economics [14], that is, social connections that lead to a measurable intangible asset.
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There are many definitions of SC, Putnam [4], for example, claimed that SC refers to features of social organization such as trust, norms, and networks. SC is a relational resource [11], and its function appears to be related to enabling some societal good within the boundary of a specific social level. Because SC is a broad concept, researchers tried to make it more accurate and refine it by distinguishing between its different levels [15].
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Halpern [16] distinguished between three levels of SC in the upbringing and educational research: SC at the microlevel—the family level, SC at the macrolevel—state level, and a level that is in-between—the community level. Similar to Halpern’s [16] typology, the SC in organizations is also divided into three levels such as personal SC, intraorganizational SC, and the macro level—external SC [15].
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3.1. Personal SC
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The first level of SC refers to the individual’s profit from his/her positioning in social networks [17] inside and outside of the organization. Stofer et al. [18] defined personal SC as the set of resources that individuals bring to the performance of their tasks through their own personal relations.
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Personal SC is measured by parameters such as the number of social relationships the individual maintains in the organization and their hierarchical level, the number of social events to which he/she is invited, the degree to which he/she attends these events, and the individual’s involvement in various activities in the organization, est. [19, 20].
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The concept of personal SC leans on Granovetter’s network theory [21]. The main difference between the position of an actor in the network and personal SC is the emphasis on the outcomes—the “capital,” which the individual wins due to his/her position in the social network.
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Shipley and Berry [22] proved that individuals who have high levels of personal SC receive more social benefits than the individuals who have low levels of personal SC. Some of these benefits in organizations are as follows: the status of the individual in the organization [23] receiving information and knowledge, amassing personal power, finding jobs and promotion—both within and between organizations [20, 24], and even earning higher salary [25].
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3.2. Intraorganizational SC
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The middle level intraorganizational SC [26] is derived from interactions within the groups, between them, and up to interactions in the whole organization [27, 28]; therefore, it can be conceptualized as a public good rather than a private good [29]. It entails the premise of mutual objectives [27], trust [30] reciprocity [31], respect and appreciation [32], sharing of information and knowledge [33], and common norms [34].
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The benefits of intraorganizational SC are better cooperation inside the organization, better employee performance [35, 36], and even better health, physical [37, 38] and mental [39] for members of units and organizations with high intraorganizational SC.
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3.3. External SC
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The upper level of SC is created by the connections of leaders [40] and agents from the organizations with external interfaces such as competitors, investors, external directors, customers, and suppliers.
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The benefits from external SC are access to key external providers of resources [41], reputation [42], investments [43], productivity [44], and so on.
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Zhao and Roper [45] claimed that external SC is a type of personal SC. This is partly true, but the use of the SC must be taken into consideration. If an organizational position holder uses the SC for his/her own benefit, it is clearly personal SC, but if the use is for the organizations’ good, this is an external SC. This distinction may seem a bit simplistic because the SC types are interdependent, but usually, use of SC by a representative of the organization [46] for the good of the organization will be categorized as external SC.
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4. SC and conflicts
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According to many definitions (such as 1), SC is a unifying factor, and it aids in bridging conflicts. Varshney [47] supported this by claiming that SC is a peace-building mechanism. Argyle and Furnham [48] suggested that conflict may be more accepted in strong relationships. On the other hand, conflicts are not pleasant and may lead to negative consequences, and to drastic changes in social relations between people, and therefore can undermine existing SC [49].
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However, as Aghajanian [50] explained, all forms of social capital cannot be incorporated under one heading, rather there need to be a separation and narrowing down the measurements to achieve meaningful results. For example, individuals experience conflict differently than groups, and thus, their levels of social capital are likely to change differently. Therefore, we need to inspect the different relationship between every level of SC and conflicts in organizations.
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4.1. Personal SC and conflicts
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A person with a lot of personal SC is probably a person with many friends, and indeed, in organizations, it is possible that a high portion of personal SC results due to expert positioning outside or inside the organizations or formal power (such as managerial or high rank positioning), but the social component is very important in amassing personal SC. Usually, a person with many friends has the practical knowledge of how not to get involved in harmful conflicts [51]. Moreover, personal SC may contribute to avoiding conflicts generally. For example, Guo et al. [52] found that the more friends Chinese older adults in the United States have, the less conflicts they have with their spouse and family. On the other hand, affective conflicts (“A-type”) are usually personal and based on hurt feelings; therefore, they are being created in the personal SC level. Ibarra et al. [53] thought that this dilemma could be answered only by relating the different SC levels at the same time, they created a 2 × 2 matrix in which they presented the possibilities of the interactions between high and low personal SC and high and low intraorganizational SC. If a person has high personal SC and high intraorganizational SC, then this person’s situation is ideal and most of his/her conflicts are “C-type” conflicts. If, however, the person has a low personal SC and low intraorganizational SC, then he/she does not connect with others and has bad relationships with them. If he/she has conflicts, they are “A-type” conflicts because his/her communication with others is bad. If this person has low personal SC and high intraorganizational SC, a rare situation that can be found in totalitarian institutions such as a monastery, then there might be some few “A-type” conflicts, but they would not harm the organization or the groups in it. This perspective was supported by Gilligany et al. [54], who found that people who suffer from conflicts in the personal level tend to have less conflicts in the community level if this community has high SC. The fourth possibility was if this person has high personal SC and low intraorganizational SC, then he/she will have an “A-type” conflicts with people that are not in his/her “in group” or if his/her personal goals contradict the group’s goals [55], Ibarra et al. [53] called this kind of conflict “a tragedy of commons”; they claimed that this situation can be especially harmful to the management of the organizations. In Table 1, all four combinations are presented.
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Personal SC
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Intraorganizational SC
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Low
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High
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High
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Tragedy of commons “A-type” conflicts
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Network congruence “C-type” conflicts
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Low
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Atomized market “A-type” conflicts
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Total institution Very few conflicts
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Table 1.
The interactions of personal and intraorganizational SC with conflict type, adapted from Ibarra et al. [53].
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4.2. Intraorganizational SC and conflicts
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Researchers claim that intraorganizational SC is the most important level for the organizations’ success [56, 36]; therefore, this SC level is very vulnerable for “A-type” conflicts, whereas “C-type” conflicts will strengthen this level because good and valuable interactions are essential for success.
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There are two main perspectives about good relationships inside groups, focusing on informal relationships [57]. One perspective is that high intraorganizational SC can lead to “free riding” by part of the group members that often creates dissatisfaction and a feeling of being exploited among the other part of the members. A similar opinion is expressed by Willem and Scarbrough [58] who claimed that intraorganizational SC can be instrumental if it reflects power relations and opportunism, and therefore, can lead to “A-type” conflicts. The other perspective claims that the better the informal relationship, the more the trust and transparency are, and therefore, the common type of conflicts in the group will be “C-type” conflict. In this context, gossip is an important means of communication, if the intraorganizational SC is high, it can be used for receiving information and raising disputes on the surface and then lead to “C-type” conflict, but if the intraorganizational SC is instrumental of low, then gossip can be evil and harming and can lead to “A-type” conflicts.
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Most of the researchers believe that the second perspective (i.e., that intraorganizational SC is only positive) reflects the reality better [59]; therefore, they believe that high intraorganizational SC leads to “C-type” conflicts. These two perspectives also reflect the tension between the personal and intraorganizational levels of SC. If the person is loyal mostly to himself/herself or to a small group, then the conflicts that will be created are “A-type,” and if he/she is more loyal to the group, then the odds for “C-type” conflicts are higher.
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Additionally, this level raises the dilemma of conflicts between groups, that is, each group can have a high level of intraorganizational SC, but the groups do not interact well and there are “A-type” conflicts between them or “A-type” conflicts between the subunit and the whole organization [60]. Because of loyalty to the subgroup, its goals can contradict the organization’s goals. Therefore, even if there is a “C-type” conflict inside the group, an “A-type” conflict can develop among different groups.
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4.3. External SC and conflicts
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The interfaces of the organizational agents with entities outside of the organization range from connections with stakeholders to connections with rivals (and it is only natural to have conflicts with them). Nevertheless, conflicts can occur with all the external connections of the organizations. Conflicts with competitors have a survival value [61], and therefore, “C-type” conflicts are essential for developing new ideas and finding creative solutions. A person with high external SC should leverage his/her connections for creating “C-type” conflicts with stakeholders and competitors. Nevertheless, “A-type” conflicts with important interfaces are common [62] because of negative feelings that develop toward outside entities as a result of conflicting interests. Consequently, the external SC should be separated from personal SC because this level of SC is subjective and emotional, and resentment and anger can develop faster at the personal level. Developing skills of separating personal conflicts from external conflicts are essential for the organizational survival.
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5. Conclusion: conflicts and three levels of SC in organizations
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As emerges from the review of each of the different SC levels, the development of “C-type” conflicts depends on the interaction between the different SC levels. Ibarra et al.’s [53] SC model leads to the understanding that aptness between personal and intraorganizational SC will form “C-type” conflicts in the team and group levels, and a good match between personal SC and external SC will support “C-type” conflicts in the organizational level.
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The distinction between the different levels is not always clear. For example, there is a lot of writing about conflicts in organizations’ mergers. Allegedly, mergers are in the external level, but once the merger has taken place, the two sides are supposed to create mutual intraorganizational SC, and even if each of the merging sides has a high intraorganizational SC, it is very hard to build a common intraorganizational SC without having “A-type” conflicts. Nevertheless, even if the personal or external SC is low, high intraorganizational SC will usually lead to “C-type” conflicts. Because employees cherish this kind of SC, it is pleasant and causes good atmosphere [15].
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Of course, there are many more parameters influencing conflicts in organizations such as personality, personal situation [63, 64], gender [62], organizational culture and organizational climate, market situation, nationality [65], and so on. Nevertheless, SC is a very important variable in maintaining “C-type” conflicts in organizations. A dispute can easily deteriorate into an “A-type” conflict, but a solid personal, external, and especially, intraorganizational SC will aid in preventing “A-type” conflicts, and if they nevertheless appear, it will be easier to solve them.
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Future research can establish and expand these understandings and connect the two variables (SC and conflicts) to organizational performance. The study of “A-type” conflict is challenging because of its tacit nature, as well as the study of the hidden parts of organizations [66]. Consequently, an investigation in qualitative tools such as observations in organizations and employees’ interviews is required in addition to a quantitative study about the connections of the variables to the performance. Therefore, a dual methodology of using qualitative and quantitative research tools [67] is needed. Another implication that should be sharpened is the organizational need for matching the SC levels to avoid “A-type” conflicts. The intraorganizational level can be controlled by the organization, but it is much more complicated to control the personal SC level. Empowerment of the mid-level managers’ role will allow them to better match the SC levels. For example, if a middle manager identifies an employee whose personal SC does not match their intraorganizational SC, the manager can act accordingly (e.g., support the employee and help expand his/her social network) in order to avoid future “A-type” conflicts.
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\n\n',keywords:"social capital, organizational conflicts, gossip, A-type conflict, C-type conflict",chapterPDFUrl:"https://cdn.intechopen.com/pdfs/58964.pdf",chapterXML:"https://mts.intechopen.com/source/xml/58964.xml",downloadPdfUrl:"/chapter/pdf-download/58964",previewPdfUrl:"/chapter/pdf-preview/58964",totalDownloads:438,totalViews:124,totalCrossrefCites:0,totalDimensionsCites:0,hasAltmetrics:0,dateSubmitted:"May 23rd 2017",dateReviewed:"December 21st 2017",datePrePublished:"February 17th 2018",datePublished:"August 1st 2018",dateFinished:null,readingETA:"0",abstract:"Social capital (SC) is a comprehensive concept, which refers to benefits derived from social interaction. In organizations, SC can be divided into 3 levels: personal SC, which refers to the benefits the individual receives from personal social connections, inside and outside the organization; intraorganizational SC, which refers to the benefits derived from good relationships within organizational units, and the organization as a whole; and external SC, which refers to the profits derived from interfaces of role holders, such as the CEO, with stakeholders. Organizational SC and conflicts in an organization are ostensibly very different in nature, whereas SC is an intangible that fits the positive psychology domain; conflicts are usually unwanted occurrences in organizations. Scholars noted that conflicts affect employee’s SC and usually reduce it, but the opposite was hardly investigated. This chapter examines how and why the conversion of social relationships into capital can result in conflicts at all organizational SC levels. To do this, the interface between the levels of SC in organizations and types of conflicts was examined. In conclusion, developing “C-type” conflicts, which are desirable conflicts, and avoiding “A-type” conflicts, which are destructive conflicts, depend on a good match between the different organizational SC levels.",reviewType:"peer-reviewed",bibtexUrl:"/chapter/bibtex/58964",risUrl:"/chapter/ris/58964",book:{slug:"organizational-conflict"},signatures:"Batia Ben-Hador",authors:[{id:"211812",title:"Ph.D.",name:"Batia",middleName:null,surname:"Ben-Hador",fullName:"Batia Ben-Hador",slug:"batia-ben-hador",email:"batiabh@ariel.ac.il",position:null,institution:{name:"Ariel University",institutionURL:null,country:{name:"Israel"}}}],sections:[{id:"sec_1",title:"1. Introduction",level:"1"},{id:"sec_2",title:"2. Conflicts in organizations",level:"1"},{id:"sec_3",title:"3. Social capital (SC)",level:"1"},{id:"sec_3_2",title:"3.1. Personal SC",level:"2"},{id:"sec_4_2",title:"3.2. Intraorganizational SC",level:"2"},{id:"sec_5_2",title:"3.3. External SC",level:"2"},{id:"sec_7",title:"4. SC and conflicts",level:"1"},{id:"sec_7_2",title:"4.1. Personal SC and conflicts",level:"2"},{id:"sec_8_2",title:"4.2. Intraorganizational SC and conflicts",level:"2"},{id:"sec_9_2",title:"4.3. External SC and conflicts",level:"2"},{id:"sec_11",title:"5. Conclusion: conflicts and three levels of SC in organizations",level:"1"}],chapterReferences:[{id:"B1",body:'De Dreu CKW, Gelfand MJ, editors. The Psychology of Conflict and Conflict Management in Organizations [Internet]. Mahwah: Taylor and Francis; 2007. pp. 3-54\n'},{id:"B2",body:'Jehn KA. A multimethod examination of the benefits and detriments of intragroup conflict. Administrative Science Quarterly. 1995;40(2):256-282. DOI: 10.2307/2393638\n'},{id:"B3",body:'Sheldon KM, King L. Why positive psychology is necessary. American Psychologist. 2001;56(3):216-217. DOI: 10.1037/0003-066X.56.3.216\n'},{id:"B4",body:'Putnam RD. 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Journal of Small Business Management. 2006;44(2):207-220. DOI: 10.1111/j.1540-627X.2006.00164.x\n'},{id:"B57",body:'Kratzer J, Roger Th AJL, Jo ML, Van E. Informal contacts and performance in innovation teams. International Journal of Manpower. 2005;26(6):513-528, 604-605. DOI: 10.1108/01437720510625430\n'},{id:"B58",body:'Willem A, Scarbrough H. Social capital and political bias in knowledge sharing: An exploratory study. Human Relations. 2006;59(10):1343-1370. DOI: 10.1177/0018726706071527\n'},{id:"B59",body:'Tsai W. Social structure of “coopetition” within a multiunit organization: Coordination, competition, and intra organizational knowledge sharing. Organization Science. 2002 Mar;13(2):179-190. DOI: 10.1287/orsc.13.2.179.536\n'},{id:"B60",body:'Barnett WP, McKendrick DG. Why are some organizations more competitive than others? Evidence from a changing global market. Administrative Science Quarterly. 2004;49(4):535-571. DOI: 10.2307/4131490\n'},{id:"B61",body:'Chang K, Chen H. Effects of a rival\'s perceived motives on constructive competition within organizations: A competitive dynamics perspective. Asian Journal of Social Psychology. 2012;15(3):167-177. DOI: 10.1111/j.1467-839X.2012.01368.x\n'},{id:"B62",body:'Demir M, Urberg KA. Friendship and adjustment among adolescents. Journal of Experimental Child Psychology. 2004;88(1):68-82. DOI: 10.1016/j.jecp.2004.02.006\n'},{id:"B63",body:'Ciabattari T. Single mothers, social capital, and work-family conflict. Journal of Family Issues. 2007;28(1):34-60. DOI: 10.1177/0192513X06292809\n'},{id:"B64",body:'Avgar A, Kyung Lee E, Chung W. Conflict in context. International Journal of Conflict Management. 2014;25(3):276-303. DOI: 10.1108/IJCMA-03-2012-0030\n'},{id:"B65",body:'Nibler R, Harris KL. The effects of culture and cohesiveness on intragroup conflict and effectiveness. Journal of Social Psycholog. 2003;143(5):613-631. DOI: 10.1080/00224540309598467\n'},{id:"B66",body:'Ben-Hador B. Executives as tacit performance evaluation: A multiple case study. The Journal of Management Development. 2016;35(1):75-88. DOI: 10.1108/JMD-08-2014-0091\n'},{id:"B67",body:'Eckhaus E, Ben-Hador B. Gossip and gender differences: A content analysis approach. Journal of Gender Studies. 2017:1-12. DOI: 10.1080/09589236.2017.1411789\n'}],footnotes:[],contributors:[{corresp:"yes",contributorFullName:"Batia Ben-Hador",address:"batiabh@ariel.ac.il",affiliation:'
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Serfontein",authors:[{id:"196203",title:"Prof.",name:"Erika",middleName:null,surname:"Serfontein",fullName:"Erika Serfontein",slug:"erika-serfontein"}]},{id:"56529",title:"Well-being and Quality of Working Life of University Professors in Brazil",slug:"well-being-and-quality-of-working-life-of-university-professors-in-brazil",signatures:"Alessandro Vinicius de Paula and Ana Alice Vilas Boas",authors:[{id:"175373",title:"Dr.",name:"Ana Alice",middleName:null,surname:"Vilas Boas",fullName:"Ana Alice Vilas Boas",slug:"ana-alice-vilas-boas"},{id:"196534",title:"Dr.",name:"Alessandro Vinicius",middleName:null,surname:"De Paula",fullName:"Alessandro Vinicius De Paula",slug:"alessandro-vinicius-de-paula"}]},{id:"54223",title:"Work-Related Well-Being: From Qualitative Job Insecurity to Cognitive Reappraisal",slug:"work-related-well-being-from-qualitative-job-insecurity-to-cognitive-reappraisal",signatures:"Delia Vîrgă",authors:[{id:"196953",title:"Ph.D.",name:"Delia",middleName:null,surname:"Virga",fullName:"Delia Virga",slug:"delia-virga"}]},{id:"55004",title:"Psychological Well-Being of Individuals as Employees and a Paradigm in the Future Economy and Society",slug:"psychological-well-being-of-individuals-as-employees-and-a-paradigm-in-the-future-economy-and-societ",signatures:"Simona Šarotar Žižek and Matjaž Mulej",authors:[{id:"192730",title:"Associate Prof.",name:"Simona",middleName:null,surname:"Šarotar Žižek",fullName:"Simona Šarotar Žižek",slug:"simona-sarotar-zizek"},{id:"197979",title:"Dr.",name:"Matjaž",middleName:null,surname:"Mulej",fullName:"Matjaž Mulej",slug:"matjaz-mulej"}]},{id:"54549",title:"Physical and Psychical Well-Being and Stress: The Perspectives of Leaders and Employees",slug:"physical-and-psychical-well-being-and-stress-the-perspectives-of-leaders-and-employees",signatures:"Simona Šarotar Žižek and Vesna Čančer",authors:[{id:"192730",title:"Associate Prof.",name:"Simona",middleName:null,surname:"Šarotar Žižek",fullName:"Simona Šarotar Žižek",slug:"simona-sarotar-zizek"},{id:"197783",title:"Dr.",name:"Vesna",middleName:null,surname:"Čančer",fullName:"Vesna Čančer",slug:"vesna-cancer"}]},{id:"54386",title:"Human Work and its Discontents",slug:"human-work-and-its-discontents",signatures:"Anderson de Souza Sant'Anna, Zélia Miranda Kilimnik and Daniela\nMartins Diniz",authors:[{id:"197768",title:"Prof.",name:"Daniela",middleName:null,surname:"Diniz",fullName:"Daniela Diniz",slug:"daniela-diniz"},{id:"197896",title:"Dr.",name:"Anderson",middleName:"S.",surname:"Sant\\'Anna",fullName:"Anderson Sant\\'Anna",slug:"anderson-sant'anna"},{id:"197897",title:"Prof.",name:"Zélia",middleName:null,surname:"Kilimnik",fullName:"Zélia Kilimnik",slug:"zelia-kilimnik"}]},{id:"54833",title:"Professional Pride and Dignity? A Classic Grounded Theory Study among Social Workers",slug:"professional-pride-and-dignity-a-classic-grounded-theory-study-among-social-workers",signatures:"Heidi Branta, Tina Jacobson and Aida Alvinius",authors:[{id:"145558",title:"Associate Prof.",name:"Aida",middleName:null,surname:"Alvinius",fullName:"Aida Alvinius",slug:"aida-alvinius"},{id:"199969",title:"BSc.",name:"Heidi",middleName:null,surname:"Branta",fullName:"Heidi Branta",slug:"heidi-branta"},{id:"199970",title:"BSc.",name:"Tina",middleName:null,surname:"Jacobson",fullName:"Tina Jacobson",slug:"tina-jacobson"}]}]}]},onlineFirst:{chapter:{type:"chapter",id:"69829",title:"Poor-Grade Aneurysmal Subarachnoid Hemorrhage: Diagnosis, Therapeutical Management, and Prognosis",doi:"10.5772/intechopen.89993",slug:"poor-grade-aneurysmal-subarachnoid-hemorrhage-diagnosis-therapeutical-management-and-prognosis",body:'\n
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1. Introduction
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Aneurysmal subarachnoid hemorrhage (aSAH) is a devastating neurological condition and is associated with high morbidity and mortality. Poor-grade aSAH accounts for approximately 30% of all aSAH, and it is a severe subtype of aSAH. These patients more often present with acute hydrocephalus, severe intraventricular hemorrhage, microcirculatory disturbances, and even multi-organ failure after ictus [1, 2] . Traditionally, these patients are managed conservatively, and only those who show clinical improvement were selected for aggressive treatment [1, 3, 4]. However, aneurysm rebleeding occurs in patients with poor-grade aSAH, and about 50% of rebleeding is at the early stage after the hemorrhage [5]. Nowadays endovascular coiling, surgical clipping, and intensive neurocritical care have improved outcomes in patients with poor-grade aSAH [6, 7, 8, 9, 10, 11]. However, more than 60% of patients have unfavorable outcomes with severe disability [12]. The treatment decision-making is still challenging. There are limited data on high-level clinical trials focusing on the treatment of poor-grade aSAH. Therefore, we review the current therapeutical management and prognosis of poor-grade aSAH.
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2. Diagnosis
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Several grading systems, including Glasgow coma score (GCS), WFNS grade (World Federation of Neurological Societies), Hunt & Hess scale, or modified Hunt & Hess scale, have been used for initial clinical assessment of aSAH. Patients with poor-grade aSAH often present with stupor or coma because of the primary brain injury. WFNS grade has better inter- and intraobserver reliability than Hunt & Hess scale and makes it more appropriate [13]. Poor-grade aSAH is defined as WFNS grade IV or V (a GCS score of 7–12 for grade IV and 3–6 for grade V) [14]. It is important to detect ruptured aneurysms in the setting of poor-grade aSAH. These patients are often unstable and require sedation or anesthesia during examination.
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Traditionally, digital subtraction angiography (DSA) is the gold standard technique for detecting ruptured aneurysms [15, 16, 17, 18, 19]. CT angiography (CTA) is less invasive and less time-consuming in providing information on ruptured intracranial aneurysms as a primary examination tool for aSAH. Current studies have reported the sensitivity and specificity of CTA for detecting intracranial aneurysms [20]. Matsumoto et al. [21] reported that 27 patients underwent successful surgical clipping based on CTA alone. Our previous study reported that more than a third of patients underwent successful surgical treatment on the basis of CTA alone [22]. All ruptured aneurysms were detected and clipped. Complications and clinical outcomes did not significantly differ between CTA alone and DSA group. Therefore, CTA can provide fast and accurate diagnostic and anatomic information on ruptured aneurysms and it can be safely and effectively used in most patients with poor-grade aSAH requiring surgical treatment. Patients with smaller ruptured aneurysms or multiple aneurysms may be considered for additional DSA examination.
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3. Aneurysm rebleeding and predictor of the rebleeding
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Rebleeding more often occurs in patients with poor-grade aSAH [23, 24, 25, 26, 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, 29, 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.
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Many neurosurgeons use preoperative ventricular drainage in all patients with poor-grade aSAH to maintain adequate cerebral perfusion [15, 24, 31, 32, 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 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.
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4. Therapeutical management
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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 should be performed if the patients require respiratory support.
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4.1 Timing of treatment
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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, 16, 17, 33, 37, 38, 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].
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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, 47, 48]. However, there is no evidence to support ultra-early treatment of poor-grade 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 procedure [51].
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A current meta-analysis and systemic review of poor-grade aSAH evaluated outcomes by timing of treatment modality and found that patients receiving ultra-early treatment (within 48 h of aSAH) had the highest rates of good neurological outcome (61% compared to 40% for early and 47% for delayed) [12]. Park et al. [47] reported that ultra-early surgery did not significantly decrease the incidence of rebleeding of poor-grade aSAH and also that it was not associated with outcomes [18, 47, 48]. Ultra-early aneurysm treatment of poor-grade aSAH still remains controversial.
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4.2 Surgical treatment
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Surgical treatment includes external ventricular drainage for hydrocephalus or intraventricular hemorrhage, surgical clipping of ruptured aneurysms, and decompressive craniectomy. Surgical selections are based on aneurysm morphology, patient’s neurological condition, and treatment relative risk following multidisciplinary consultation. Patients with associated large intracerebral hemorrhage (more than 30 ml) are more often considered for surgical clipping. After surgery, patients are transferred to the intensive care unit, and they are treated with standard management for vasospasm. Illustrative case receiving surgical clipping is shown in Figure 1.
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Figure 1.
A 45-year-old male presented with unconsciousness for 2 h and had a Glasgow coma score of 6 and World Federation of Neurosurgical Surgeon grade of V at admission. He was treated with emergency surgical clipping of ruptured aneurysm and hematoma evacuation. He recovered well and had a modified Rankin scale of 1 at 12 months of follow-up. (A) Emergency CT scan shows a large frontotemporal parietal lobe hematoma and midline shift to left side. (B) CT angiography shows a right middle cerebral artery bifurcation aneurysm. (C) CT shows a slight edema of surgical field after 10 days of surgery.
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The international subarachnoid aneurysm trial (ISAT) demonstrated that for aSAH amenable to both treatments, patients treated with endovascular coiling had better outcomes than patients treated with surgical clipping [52]. Although endovascular treatment has been used as an available alternative to surgery for aSAH, surgical treatment is still an important treatment modality for poor-grade aSAH. In the contemporary multicenter cohorts of poor-grade aSAH, patients receiving clipping more often had a lower GCS score, a WFNS grade of V, a higher Fisher grade and modified Fisher grade, and a ruptured anterior circulation aneurysm than those receiving coiling [53]. Patients with WFNS grade V after emergency resuscitation, a better Fisher grade, brain herniation, the presence of ICH, or the absence of IVH more often underwent early surgical clipping [43]. Patients with brain herniation more commonly are treated with surgery. There are no significant differences in rebleeding, cerebral infarction, symptomatic vasospasm, seizure, pneumonia between coiling and clipping groups. There is also no significant difference in outcomes at 6 and 12 months between the two treatments [53].
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Decompressive craniectomy has been reported in the treatment for severe traumatic brain injury, massive ischemic stroke, and aSAH [54, 55, 56, 57, 58, 59, 60]. This procedure can reduce increased intracranial pressure and improve cerebral perfusion and outcomes in selected patients with ruptured aneurysms with associated intracerebral hemorrhage [61]. However, there are no studies focusing on the safety and efficacy of decompressive craniectomy for poor-grade aSAH compared with conventional craniotomy. Our previous study has shown that primary decompressive craniectomy does not increase postoperative complications and can be performed safely in poor-grade sSAH. More than one-half of patients benefit from primary decompressive craniectomy.
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4.3 Endovascular treatment
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Since the ISAT study, endovascular treatment is more commonly used than clipping for ruptured aneurysm. Aneurysms can be coiled though the minimally invasive endovascular approach to reduce the rate of rebleeding and avoid brain swelling and high intracranial pressure. Endovascular treatment is performed in continuity with the initial angiography and requires less treatment time. The current results at the 3- and 6-year follow-up in the ruptured aneurysm treatment study showed that there was no significant difference in outcome between the two treatments for ruptured aneurysms [62, 63]. A current systematic review of surgical and endovascular treatment of poor-grade aSAH has also shown that the proportion of patients with endovascular coiling increased from 10.0 to 62.0% between 1990 and 2000 and 2010 and 2014 [12]. Therefore, endovascular coiling is a feasible and reasonable option for poor-grade aSAH. Illustrative case receiving coiling is shown in Figure 2.
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Figure 2.
A 53-year-old male presented with unconsciousness for 1 h and had a Glasgow coma score of 5 and World Federation of Neurosurgical Surgeon grade of V at admission. He was treated with emergency coiling of ruptured aneurysm and external ventricle drainage. He had a modified Rankin scale of 3 at 12 months of follow-up. (A) Emergency CT scan shows severe subarachnoid hemorrhage and frontal lobe hematoma. (B) Preoperative angiography shows a very small anterior communicating artery aneurysm. (C) Immediate angiography shows complete occlusion of aneurysms using coils.
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Mocco et al. [31] reported that 35 (35.7%) of 98 patients received coiling, and there was also similar outcome between coiling and clipping for poor-grade aSAH. In our prospective and multicenter registry of 262 patients with poor-grade ruptured aneurysm, 133 (50.8%) patients received endovascular coiling within 21 days after poor-grade aSAH [53]. An unadjusted analysis showed that the rate of outcome (mRS 0–2 or mRS 0–3) at discharge at 6 and 12 months in the coiled patients was higher than that in the clipped patients probably because of selection bias. In our exploratory analysis, there was no significant difference in clinical outcomes between the two groups. Patients receiving coiling had a higher risk of radiological hydrocephalus than clipped patients, and there was a trend toward clinical hydrocephalus after coiling. However, Zaidi et al. [64] found that there was no difference in hydrocephalus among patients treated by coiling or clipping.
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With advances of endovascular technology, stent-assisted coiling has been used in the treatment of ruptured aneurysms. There is a main concern about the safety of stent-assisted coiling for poor-grade ruptured aneurysms. A review reported clinical outcomes in the stent-assisted coiling were worse than those in the coiling alone of acutely ruptured aneurysms [65]. Several studies showed that hemorrhagic complications often occurred in patients with acutely ruptured aneurysms after stent-assisted coiling and external ventricular drainage probably because of dual-antiplatelet therapy [66, 67, 68]. Using a multicenter poor-grade aneurysm study, we compared perioperative complications, and clinical outcomes between the stent-assisted coiling and the coiling-alone groups [69]. Twenty-three (17.6%) patients were treated with stent-assisted coiling compared with 108 (82.4%) patients treated with coiling alone. There were no statistically significant differences in intraprocedural rupture, procedure-related ischemic complication, ventricle drainage-related hemorrhagic complication, and symptomatic vasospasm between the stent-assisted coiling group and the coiling-alone group. However, there was a trend toward rebleeding after stent-assisted coiling. The hemorrhagic complication should be considered before the treatment decision-making. Therefore, treatment of wide-necked ruptured aneurysms remains challenging and we still require improvement of endovascular treatment of wide-neck ruptured aneurysms. A clinical trial focused on poor-grade ruptured aneurysms may be necessary to assess the efficacy of the treatment.
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5. Outcomes and prognosis
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The clinical outcomes of patients with aneurysm rebleeding remain very poor probably because of a severe secondary brain injury caused by a large cerebral hematoma or severe intraventricular hemorrhage. The rebleeding is independently associated with poor outcome (odds ratio [OR] 36.37, p < 0.001) and associated with mortality (OR 25.03, p < 0.001) at 12 months [5]. Tanno et al. [70] reported that 152 (84%) of 181 patients presented with semicoma to coma after rebleeding. Of the 30 patients with rebleeding in our previous study, 22 (73.3%) patients died at discharge. At 12 months, 2 (6.7%) patients had a modified Rankin Score (mRS) of 1, 1 (3.3%) had a mRS of 4, and 26 (86.7%) died [5]. A higher modified Fisher grade before rebleeding, larger aneurysms, and a lower GCS score after rebleeding were independently associated with increased mortality. A lower WFNS grade treated with aggressive treatment is more likely to have a good outcome [71].
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Aggressive treatment and successful aneurysm repair can reduce the rebleeding and improve clinical outcomes in selected patients. In a current review of poor-grade aSAH, the rate of good outcome increased from 37.0 to 44.0% over the years. Good outcome was 38% (95% CI = 33–43%) in the endovascular group and 39% (95% CI = 34–44%) in the surgical group at the over 6 months of follow-up [12]. In our multicenter poor-grade aneurysm study [53], 52 (19.8%) patients had a mRS score of 0 or 1, 98 (29.8%) had a mRS score of 0–2, 112 (32.4%) had a mRS score of 0–3, and 51 (19.5%) had died at discharge. Ninety-five (36.3%) patients had a mRS score of 0 or 1, 115 (43.9%) had a mRS of 0–2, 126 (48.1%) had a mRS of 0–3, and 103 (39.3%) had died at 12 months. The outcome is improved after endovascular coiling or clipping over time of the follow-up [53]. In a prospective database of poor-grade aSAH patients, 40% of the 98 patients had a favorable outcome at 12 months [31]. In the 136 patients receiving endovascular coiling, 59 (43.3%) patients had a mRS of 0 or 1, and 64 (47.0%) had a poor outcome (mRS4-6) [72].
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About one-half of patients achieve a good outcome after the treatment, therefore predicting outcome after poor-grade aSAH is essential to support early treatment [73]. A few prognostic prediction models have been reported [3, 31, 74]. However, these studies are from a single center or have a limited sample size. Older age, lower GCS score, absence of pupil reactivity, higher modified Fisher grade, and conservative treatment are associated with poor outcome in most studies [3, 31, 74, 75]. These predictors of poor outcome are summarized in Table 1. We developed an integer-based outcome risk score (WAP) to predict the long-term outcomes [76]. The WAP score consists of three variables: WFNS grade, Age (three categories), and Pupillary reactivity. The sum of the weighted scores was used to assess the overall score and was ranged from 0 to 4. The predicted risk of poor outcome ranged from 25.5% for a WAP score of 0 to 96.2% for a score of 4. The risk score is easily measured and may complement treatment decision-making [76].
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Authors
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Study design
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Mean time of follow-up
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Treatments
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Predictors of poor outcome
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\n\n\n
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Le Roux et al.
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Retrospective
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6 months
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Clipping
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Hunt & Hess Grade V, blood glucose, fibrin degradation products, severity of ventricular hemorrhage, low density on CT, no clinical improvement
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Huang et al.
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Retrospective
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6 months
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Clipping
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Hunt-Hess grade, aneurysm size, rehemorrhage before surgery, acute hydrocephalus
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Mocco et al.
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Prospective
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12 months
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Clipping and coiling
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Older than 65 years, hyperglycernia preoperative Hunt & Hess Grade V, and aneurysm size of at least 13 mm
Older age, lower Glasgow coma scale score (GCS), the absence of pupillary reactivity, higher modified Fisher grade, and conservative treatment
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Table 1.
Summary of predictors of poor outcome at the long-term follow-up.
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6. Conclusions
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Poor-grade aSAH is a severe subtype of subarachnoid hemorrhage caused by ruptured aneurysms. Timing of treatment for the aSAH has shifted from delayed to early surgery, and there will be a trend toward ultra-early treatment for poor-grade aSAH. However, there is no consensus regarding the optimal timing of treatment for poor-grade aSAH. Although endovascular treatment has been used as an available alternative to surgical clipping for aSAH, surgical treatment is still an important treatment modality for poor-grade aSAH. Despite advancements in aneurysm treatment, the morbidity and mortality of poor-grade aSAH remain high. Many retrospective studies have reported the predictors of outcomes, but there is not appropriate prediction model for poor-grade aSAH. The treatment decision-making is still challenging. Further prospective cohort study or clinical trials focused on poor-grade aSAH are required to help guide treatment decisions for this devastating condition.
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Acknowledgments
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This work was supported by Shanghai Municipal Education Commission—Gaofeng Clinical Medicine Grant Support (20171914), Shanghai Municipal Commission of Health and Family Planning (201740080), Shanghai Science and Technology Project (18411962700), and the Clinical Research Plan of SHDC (16CR3031A, 16CR2045B), the Shanghai Jiaotong University Medical Engineering and translational Cross-cutting Research Foundation (YG2017MS45, ZH2018ZDA07), Shanghai Jiaotong University School of Medicine Research Project (DLY201821).
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\n',keywords:"intracranial aneurysms, subarachnoid hemorrhage, poor-grade, treatment, prognosis",chapterPDFUrl:"https://cdn.intechopen.com/pdfs/69829.pdf",chapterXML:"https://mts.intechopen.com/source/xml/69829.xml",downloadPdfUrl:"/chapter/pdf-download/69829",previewPdfUrl:"/chapter/pdf-preview/69829",totalDownloads:217,totalViews:0,totalCrossrefCites:0,dateSubmitted:"January 30th 2019",dateReviewed:"October 1st 2019",datePrePublished:"October 30th 2019",datePublished:"May 13th 2020",dateFinished:null,readingETA:"0",abstract:"Aneurysmal subarachnoid hemorrhage (aSAH) is a devastating neurological condition and these patients often have unfavorable outcomes at the long-term follow-up. Poor-grade aSAH is a severe subtype of aSAH and is defined as World Federation of Neurosurgical Surgeon (WFNS) grade IV or V. All patients should be treated by a multidisciplinary team that consists of vascular neurosurgeons, interventional neuroradiologists, neurologists, and anesthetists. Aneurysm rebleeding occurs in the poor-grade aSAH within the first 72 h after ictus. Timing of treatment for aSAH has shifted from delayed to early treatment of ruptured aneurysms, and there will be a trend toward early or ultra-early treatment for poor-grade aSAH. However, there is no consensus regarding the optimal timing of treatment for poor-grade aSAH. Endovascular coiling has provided a viable alternative to surgical clipping. An increasing number of patients have received endovascular treatment. There are limited data on high-level clinical trials focused on the treatment of poor-grade aSAH. An accurate prediction model remains challenging. Predicting long-term outcome is essential to support treatment decision-making. We reviewed the current therapeutical management and prognosis of poor-grade aSAH.",reviewType:"peer-reviewed",bibtexUrl:"/chapter/bibtex/69829",risUrl:"/chapter/ris/69829",signatures:"Bing Zhao, Haixia Xing, Shenghao Ding, Yaohua Pan and Jieqing Wan",book:{id:"9364",title:"New Insight into Cerebrovascular Diseases",subtitle:"An Updated Comprehensive Review",fullTitle:"New Insight into Cerebrovascular Diseases - An Updated Comprehensive Review",slug:"new-insight-into-cerebrovascular-diseases-an-updated-comprehensive-review",publishedDate:"May 13th 2020",bookSignature:"Patricia Bozzetto Ambrosi, Rufai Ahmad, Auwal Abdullahi and Amit Agrawal",coverURL:"https://cdn.intechopen.com/books/images_new/9364.jpg",licenceType:"CC BY 3.0",editedByType:"Edited by",editors:[{id:"221787",title:"Dr.",name:"Patricia",middleName:null,surname:"Bozzetto Ambrosi",slug:"patricia-bozzetto-ambrosi",fullName:"Patricia Bozzetto Ambrosi"}],productType:{id:"1",title:"Edited Volume",chapterContentType:"chapter",authoredCaption:"Edited by"}},authors:[{id:"293852",title:"M.D.",name:"Bing",middleName:null,surname:"Zhao",fullName:"Bing Zhao",slug:"bing-zhao",email:"drzhaobing@yahoo.com",position:null,institution:null},{id:"304033",title:"Dr.",name:"Haixia",middleName:null,surname:"Xing",fullName:"Haixia Xing",slug:"haixia-xing",email:"xhxmed@163.com",position:null,institution:null},{id:"304034",title:"Dr.",name:"Shenghao",middleName:null,surname:"Ding",fullName:"Shenghao Ding",slug:"shenghao-ding",email:"ding_sheng_hao@126.com",position:null,institution:null},{id:"304035",title:"Dr.",name:"Yaohua",middleName:null,surname:"Pan",fullName:"Yaohua Pan",slug:"yaohua-pan",email:"1542612058@qq.com",position:null,institution:null},{id:"304036",title:"Dr.",name:"Jieqing",middleName:null,surname:"Wan",fullName:"Jieqing Wan",slug:"jieqing-wan",email:"jieqingwan@126.com",position:null,institution:null}],sections:[{id:"sec_1",title:"1. Introduction",level:"1"},{id:"sec_2",title:"2. Diagnosis",level:"1"},{id:"sec_3",title:"3. Aneurysm rebleeding and predictor of the rebleeding",level:"1"},{id:"sec_4",title:"4. Therapeutical management",level:"1"},{id:"sec_4_2",title:"4.1 Timing of treatment",level:"2"},{id:"sec_5_2",title:"4.2 Surgical treatment",level:"2"},{id:"sec_6_2",title:"4.3 Endovascular treatment",level:"2"},{id:"sec_8",title:"5. Outcomes and prognosis",level:"1"},{id:"sec_9",title:"6. Conclusions",level:"1"},{id:"sec_10",title:"Acknowledgments",level:"1"}],chapterReferences:[{id:"B1",body:'\nHutchinson PJ, Power DM, Tripathi P, Kirkpatrick PJ. Outcome from poor grade aneurysmal subarachnoid haemorrhage-which poor grade subarachnoid haemorrhage patients benefit from aneurysm clipping? British Journal of Neurosurgery. 2000;14:105-109\n'},{id:"B2",body:'\nWartenberg KE, Sheth SJ, Michael Schmidt J, Frontera JA, Rincon F, Ostapkovich N, et al. Acute ischemic injury on diffusion-weighted magnetic resonance imaging after poor grade subarachnoid hemorrhage. Neurocritical Care. 2011;14:407-415\n'},{id:"B3",body:'\nLe Roux PD, Elliott JP, Newell DW, Grady MS, Winn HR. Predicting outcome in poor-grade patients with subarachnoid hemorrhage: A retrospective review of 159 aggressively managed cases. Journal of Neurosurgery. 1996;85:39-49\n'},{id:"B4",body:'\nMitra D, Gregson B, Jayakrishnan V, Gholkar A, Vincent A, White P, et al. Treatment of poor-grade subarachnoid hemorrhage trial. AJNR. American Journal of Neuroradiology. 2015;36:116-120\n'},{id:"B5",body:'\nZhao B, Fan Y, Xiong Y, Yin R, Zheng K, Li Z, et al. Aneurysm rebleeding after poor-grade aneurysmal subarachnoid hemorrhage: Predictors and impact on clinical outcomes. Journal of the Neurological Sciences. 2016;371:62-66\n'},{id:"B6",body:'\nTaylor CJ, Robertson F, Brealey D, O\'Shea F, Stephen T, Brew S, et al. Outcome in poor grade subarachnoid hemorrhage patients treated with acute endovascular coiling of aneurysms and aggressive intensive care. Neurocritical Care. 2011;14:341-347\n'},{id:"B7",body:'\nDiaz RJ, Wong JH. Clinical outcomes after endovascular coiling in high-grade aneurysmal hemorrhage. Canadian Journal of Neurological Sciences. 2011;38:30-35\n'},{id:"B8",body:'\nPereira AR, Sanchez-Pena P, Biondi A, Sourour N, Boch AL, Colonne C, et al. Predictors of 1-year outcome after coiling for poor-grade subarachnoid aneurysmal hemorrhage. Neurocritical Care. 2007;7:18-26\n'},{id:"B9",body:'\nBracard S, Lebedinsky A, Anxionnat R, Neto JM, Audibert G, Long Y, et al. Endovascular treatment of Hunt and Hess grade IV and V aneurysm. AJNR - American Journal of Neuroradiology. 2002;23:953-957\n'},{id:"B10",body:'\nSuzuki S, Jahan R, Duckwiler GR, Frazee J, Martin N, Vinuela F. 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Cerebrovascular Diseases. 2010;30:105-113\n'},{id:"B14",body:'\nReport of world federation of neurological surgeons committee on a universal subarachnoid hemorrhage grading scale. Journal of Neurosurgery. 1988;68:985-986. DOI:10.3171/jns.1988.68.6.0985. PMID: 3131498\n'},{id:"B15",body:'\nBailes JE, Spetzler RF, Hadley MN, Baldwin HZ. Management morbidity and mortality of poor-grade aneurysm patients. Journal of Neurosurgery. 1990;72:559-566\n'},{id:"B16",body:'\nOda S, Shimoda M, Sato O. Early aneurysm surgery and dehydration therapy in patients with severe subarachnoid haemorrhage without ich. Acta Neurochirurgica. 1996;138:1050-1056\n'},{id:"B17",body:'\nLaidlaw JD, Siu KH. Ultra-early surgery for aneurysmal subarachnoid hemorrhage: Outcomes for a consecutive series of 391 patients not selected by grade or age. Journal of Neurosurgery. 2002;97:250-258. Discussion 247-259\n'},{id:"B18",body:'\nSandstrom N, Yan B, Dowling R, Laidlaw J, Mitchell P. Comparison of microsurgery and endovascular treatment on clinical outcome following poor-grade subarachnoid hemorrhage. Journal of Clinical Neuroscience. 2013;20:1213-1218\n'},{id:"B19",body:'\nGupta SK, Ghanta RK, Chhabra R, Mohindra S, Mathuriya SN, Mukherjee KK, et al. Poor-grade subarachnoid hemorrhage: Is surgical clipping worthwhile? Neurology India. 2011;59:212-217\n'},{id:"B20",body:'\nWesterlaan HE, Van Dijk JM, Jansen-van der Weide MC, de Groot JC, Groen RJ, Mooij JJ, et al. Intracranial aneurysms in patients with subarachnoid hemorrhage: Ct angiography as a primary examination tool for diagnosis--systematic review and meta-analysis. Radiology. 2011;258:134-145\n'},{id:"B21",body:'\nMatsumoto M, Sato M, Nakano M, Endo Y, Watanabe Y, Sasaki T, et al. Three-dimensional computerized tomography angiography-guided surgery of acutely ruptured cerebral aneurysms. Journal of Neurosurgery. 2001;94:718-727\n'},{id:"B22",body:'\nZhao B, Lin F, Wu J, Zheng K, Tan X, Cao Y, et al. A multicenter analysis of computed tomography angiography alone versus digital subtraction angiography for the surgical treatment of poor-grade aneurysmal subarachnoid hemorrhage. World Neurosurgery. 2016;91:106-111\n'},{id:"B23",body:'\nInagawa T, Kamiya K, Ogasawara H, Yano T. Rebleeding of ruptured intracranial aneurysms in the acute stage. Surgical Neurology. 1987;28:93-99\n'},{id:"B24",body:'\nNaidech AM, Janjua N, Kreiter KT, Ostapkovich ND, Fitzsimmons BF, Parra A, et al. Predictors and impact of aneurysm rebleeding after subarachnoid hemorrhage. Archives of Neurology. 2005;62:410-416\n'},{id:"B25",body:'\nRosenorn J, Eskesen V, Schmidt K, Ronde F. The risk of rebleeding from ruptured intracranial aneurysms. Journal of Neurosurgery. 1987;67:329-332\n'},{id:"B26",body:'\nDavies BM, Chung KH, Dulhanty L, Galea J, Patel HC. Pre-protection re-haemorrhage following aneurysmal subarachnoid haemorrhage: Where are we now? Clinical Neurology and Neurosurgery. 2015;135:22-26\n'},{id:"B27",body:'\nStarke RM, Connolly ES Jr. Rebleeding after aneurysmal subarachnoid hemorrhage. Neurocritical Care. 2011;15:241-246\n'},{id:"B28",body:'\nvan Donkelaar CE, Bakker NA, Veeger NJ, Uyttenboogaart M, Metzemaekers JD, Luijckx GJ, et al. Predictive factors for rebleeding after aneurysmal subarachnoid hemorrhage: Rebleeding aneurysmal subarachnoid hemorrhage study. Stroke; a Journal of Cerebral Circulation. 2015;46:2100-2106\n'},{id:"B29",body:'\nTang C, Zhang TS, Zhou LF. Risk factors for rebleeding of aneurysmal subarachnoid hemorrhage: A meta-analysis. PLoS One. 2014;9:e99536\n'},{id:"B30",body:'\nBoogaarts HD, van Lieshout JH, van Amerongen MJ, de Vries J, Verbeek AL, Grotenhuis JA, et al. Aneurysm diameter as a risk factor for pretreatment rebleeding: A meta-analysis. Journal of Neurosurgery. 2015;122:921-928\n'},{id:"B31",body:'\nMocco J, Ransom ER, Komotar RJ, Schmidt JM, Sciacca RR, Mayer SA, et al. Preoperative prediction of long-term outcome in poor-grade aneurysmal subarachnoid hemorrhage. Neurosurgery. 2006;59:529-538. Discussion 529-538\n'},{id:"B32",body:'\nRansom ER, Mocco J, Komotar RJ, Sahni D, Chang J, Hahn DK, et al. External ventricular drainage response in poor grade aneurysmal subarachnoid hemorrhage: Effect on preoperative grading and prognosis. Neurocritical Care. 2007;6:174-180\n'},{id:"B33",body:'\nHuang AP, Arora S, Wintermark M, Ko N, Tu YK, Lawton MT. Perfusion computed tomographic imaging and surgical selection with patients after poor-grade aneurysmal subarachnoid hemorrhage. Neurosurgery. 2010;67:964-974. Discussion 975\n'},{id:"B34",body:'\nLaidlaw JD, Siu KH. Poor-grade aneurysmal subarachnoid hemorrhage: Outcome after treatment with urgent surgery. Neurosurgery. 2003;53:1275-1280. discussion 1280-1272\n'},{id:"B35",body:'\nMcIver JI, Friedman JA, Wijdicks EF, Piepgras DG, Pichelmann MA, Toussaint LG 3rd, et al. Preoperative ventriculostomy and rebleeding after aneurysmal subarachnoid hemorrhage. Journal of Neurosurgery. 2002;97:1042-1044\n'},{id:"B36",body:'\nHellingman CA, van den Bergh WM, Beijer IS, van Dijk GW, Algra A, van Gijn J, et al. Risk of rebleeding after treatment of acute hydrocephalus in patients with aneurysmal subarachnoid hemorrhage. Stroke; a Journal of Cerebral Circulation. 2007;38:96-99\n'},{id:"B37",body:'\nNowak G, Schwachenwald R, Arnold H. Early management in poor grade aneurysm patients. Acta Neurochirurgica. 1994;126:33-37\n'},{id:"B38",body:'\nVersari PP, Talamonti G, D\'Aliberti G, Villa F, Solaini C, Collice M. Surgical treatment of poor-grade aneurysm patients. Journal of Neurosurgical Sciences. 1998;42:43-46\n'},{id:"B39",body:'\nChiang VL, Claus EB, Awad IA. Toward more rational prediction of outcome in patients with high-grade subarachnoid hemorrhage. Neurosurgery. 2000;46:28-35. discussion 35-26\n'},{id:"B40",body:'\nZhao B, Cao Y, Tan X, Zhao Y, Wu J, Zhong M, et al. Complications and outcomes after early surgical treatment for poor-grade ruptured intracranial aneurysms: A multicenter retrospective cohort. International Journal of Surgery. 2015;23:57-61\n'},{id:"B41",body:'\nZentner J, Hoffmann C, Schramm J. Results of early surgery in poor-grade aneurysm patients. Journal of Neurosurgical Sciences. 1996;40:183-188\n'},{id:"B42",body:'\nWostrack M, Sandow N, Vajkoczy P, Schatlo B, Bijlenga P, Schaller K, et al. Subarachnoid haemorrhage WFNS grade V: Is maximal treatment worthwhile? Acta Neurochirurgica. 2013;155:579-586\n'},{id:"B43",body:'\nZhao B, Tan X, Zhao Y, Cao Y, Wu J, Zhong M, et al. Variation in patient characteristics and outcomes between early and delayed surgery in poor-grade aneurysmal subarachnoid hemorrhage. Neurosurgery. 2016;78:224-231\n'},{id:"B44",body:'\nConnolly ES Jr, Rabinstein AA, Carhuapoma JR, Derdeyn CP, Dion J, Higashida RT, et al. Guidelines for the management of aneurysmal subarachnoid hemorrhage: A guideline for healthcare professionals from the American heart association/American stroke association. Stroke; a Journal of Cerebral Circulation. 2012;43:1711-1737\n'},{id:"B45",body:'\nSteiner T, Juvela S, Unterberg A, Jung C, Forsting M, Rinkel G. European stroke organization guidelines for the management of intracranial aneurysms and subarachnoid haemorrhage. Cerebrovascular Diseases. 2013;35:93-112\n'},{id:"B46",body:'\nPhillips TJ, Dowling RJ, Yan B, Laidlaw JD, Mitchell PJ. Does treatment of ruptured intracranial aneurysms within 24 hours improve clinical outcome? Stroke; a Journal of Cerebral Circulation. 2011;42:1936-1945\n'},{id:"B47",body:'\nPark J, Woo H, Kang DH, Kim YS, Kim MY, Shin IH, et al. Formal protocol for emergency treatment of ruptured intracranial aneurysms to reduce in-hospital rebleeding and improve clinical outcomes. Journal of Neurosurgery. 2015;122:383-391\n'},{id:"B48",body:'\nWong GK, Boet R, Ng SC, Chan M, Gin T, Zee B, et al. Ultra-early (within 24 hours) aneurysm treatment after subarachnoid hemorrhage. World Neurosurgery. 2012;77:311-315\n'},{id:"B49",body:'\nWilson DA, Nakaji P, Albuquerque FC, McDougall CG, Zabramski JM, Spetzler RF. Time course of recovery following poor-grade sah: The incidence of delayed improvement and implications for SAH outcome study design. Journal of Neurosurgery. 2013;119:606-612\n'},{id:"B50",body:'\nZhao B, Zhao Y, Tan X, Cao Y, Wu J, Zhong M, et al. Factors and outcomes associated with ultra-early surgery for poor-grade aneurysmal subarachnoid haemorrhage: A multicentre retrospective analysis. BMJ Open. 2015;e007410:5\n'},{id:"B51",body:'\nLuo YC, Shen CS, Mao JL, Liang CY, Zhang Q , He ZJ. Ultra-early versus delayed coil treatment for ruptured poor-grade aneurysm. Neuroradiology. 2015;57:205-210\n'},{id:"B52",body:'\nMolyneux A, Kerr R, Stratton I, Sandercock P, Clarke M, Shrimpton J, et al. International subarachnoid aneurysm trial (ISAT) of neurosurgical clipping versus endovascular coiling in 2143 patients with ruptured intracranial aneurysms: A randomised trial. Lancet. 2002;360:1267-1274\n'},{id:"B53",body:'\nZhao B, Tan X, Yang H, Li Z, Zheng K, Xiong Y, et al. Endovascular coiling versus surgical clipping for poor-grade ruptured intracranial aneurysms: Postoperative complications and clinical outcome in a multicenter poor-grade aneurysm study. AJNR. American Journal of Neuroradiology. 2016;37:873-878\n'},{id:"B54",body:'\nSmith ER, Carter BS, Ogilvy CS. Proposed use of prophylactic decompressive craniectomy in poor-grade aneurysmal subarachnoid hemorrhage patients presenting with associated large sylvian hematomas. Neurosurgery. 2002;51:117-124. Discussion 124\n'},{id:"B55",body:'\nBuschmann U, Yonekawa Y, Fortunati M, Cesnulis E, Keller E. Decompressive hemicraniectomy in patients with subarachnoid hemorrhage and intractable intracranial hypertension. Acta Neurochirurgica. 2007;149:59-65\n'},{id:"B56",body:'\nSchirmer CM, Hoit DA, Malek AM. Decompressive hemicraniectomy for the treatment of intractable intracranial hypertension after aneurysmal subarachnoid hemorrhage. Stroke. 2007;38:987-992\n'},{id:"B57",body:'\nOtani N, Takasato Y, Masaoka H, Hayakawa T, Yoshino Y, Yatsushige H, et al. Surgical outcome following decompressive craniectomy for poor-grade aneurysmal subarachnoid hemorrhage in patients with associated massive intracerebral or sylvian hematomas. Cerebrovascular Diseases. 2008;26:612-617\n'},{id:"B58",body:'\nUozumi Y, Sakowitz O, Orakcioglu B, Santos E, Kentar M, Haux D, et al. Decompressive craniectomy in patients with aneurysmal subarachnoid hemorrhage: A single-center matched-pair analysis. Cerebrovascular Diseases. 2014;37:109-115\n'},{id:"B59",body:'\nGuresir E, Schuss P, Vatter H, Raabe A, Seifert V, Beck J. Decompressive craniectomy in subarachnoid hemorrhage. Neurosurgical Focus. 2009;26:E4\n'},{id:"B60",body:'\nDorfer C, Frick A, Knosp E, Gruber A. Decompressive hemicraniectomy after aneurysmal subarachnoid hemorrhage. World Neurosurgery. 2010;74:465-471\n'},{id:"B61",body:'\nZhao B, Zhao Y, Tan X, Cao Y, Wu J, Zhong M, et al. Primary decompressive craniectomy for poor-grade middle cerebral artery aneurysms with associated intracerebral hemorrhage. Clinical Neurology and Neurosurgery. 2015;133:1-5\n'},{id:"B62",body:'\nSpetzler RF, McDougall CG, Albuquerque FC, Zabramski JM, Hills NK, Partovi S, et al. The barrow ruptured aneurysm trial: 3-year results. Journal of Neurosurgery. 2013;119:146-157\n'},{id:"B63",body:'\nSpetzler RF, McDougall CG, Zabramski JM, Albuquerque FC, Hills NK, Russin JJ, et al. The barrow ruptured aneurysm trial: 6-year results. Journal of Neurosurgery. 2015:123:609-617\n'},{id:"B64",body:'\nZaidi HA, Montoure A, Elhadi A, Nakaji P, McDougall CG, Albuquerque FC, et al. Long-term functional outcomes and predictors of shunt-dependent hydrocephalus after treatment of ruptured intracranial aneurysms in the brat trial: Revisiting the clip vs coil debate. Neurosurgery. 2015;76:608-613. Discussion 613-604; quiz 614\n'},{id:"B65",body:'\nBodily KD, Cloft HJ, Lanzino G, Fiorella DJ, White PM, Kallmes DF. Stent-assisted coiling in acutely ruptured intracranial aneurysms: A qualitative, systematic review of the literature. AJNR - American Journal of Neuroradiology. 2011;32:1232-1236\n'},{id:"B66",body:'\nChung J, Lim YC, Suh SH, Shim YS, Kim YB, Joo JY, et al. Stent-assisted coil embolization of ruptured wide-necked aneurysms in the acute period: Incidence of and risk factors for periprocedural complications. Journal of Neurosurgery. 2014;121:4-11\n'},{id:"B67",body:'\nAmenta PS, Dalyai RT, Kung D, Toporowski A, Chandela S, Hasan D, et al. Stent-assisted coiling of wide-necked aneurysms in the setting of acute subarachnoid hemorrhage: Experience. Neurosurgery. 2012;70:1415-1429. Discussion 1429\n'},{id:"B68",body:'\nKim DJ, Suh SH, Kim BM, Kim DI, Huh SK, Lee JW. Hemorrhagic complications related to the stent-remodeled coil embolization of intracranial aneurysms. Neurosurgery. 2010;67:73-78. Discussion 78-79\n'},{id:"B69",body:'\nZhao B, Tan X, Yang H, Zheng K, Li Z, Xiong Y, et al. Stent-assisted coiling versus coiling alone of poor-grade ruptured intracranial aneurysms: A multicenter study. Journal of NeuroInterventional Surgery. 2017;9:165-168\n'},{id:"B70",body:'\nTanno Y, Homma M, Oinuma M, Kodama N, Ymamoto T. Rebleeding from ruptured intracranial aneurysms in north eastern province of Japan. A cooperative study. Journal of the Neurological Sciences. 2007;258:11-16\n'},{id:"B71",body:'\nZhao B, Yang H, Zheng K, Li Z, Xiong Y, Tan X, et al. Predictors of good functional outcomes and mortality in patients with severe rebleeding after aneurysmal subarachnoid hemorrhage. Clinical Neurology and Neurosurgery. 2016;144:28-32\n'},{id:"B72",body:'\nZhao B, Yang H, Zheng K, Li Z, Xiong Y, Tan X, et al. Preoperative and postoperative predictors of long-term outcome after endovascular treatment of poor-grade aneurysmal subarachnoid hemorrhage. Journal of Neurosurgery. 2017;126:1764-1771\n'},{id:"B73",body:'\nHoward BM, Barrow DL, et al. Outcomes for patients with poor-grade subarachnoid hemorrhage: To treat or not to treat? World Neurosurgery. 2015\n'},{id:"B74",body:'\nSchuss P, Hadjiathanasiou A, Borger V, Wispel C, Vatter H, Guresir E. Poor-grade aneurysmal subarachnoid hemorrhage: Factors influencing functional outcome-a single-center series. World Neurosurgery. 2016;85:125-129\n'},{id:"B75",body:'\nMack WJ, Hickman ZL, Ducruet AF, Kalyvas JT, Garrett MC, Starke RM, et al. Pupillary reactivity upon hospital admission predicts long-term outcome in poor grade aneurysmal subarachnoid hemorrhage patients. Neurocritical Care. 2008;8:374-379\n'},{id:"B76",body:'\nZheng K, Zhong M, Zhao B, Chen SY, Tan XX, Li ZQ , et al. Poor-grade aneurysmal subarachnoid hemorrhage: Risk factors affecting clinical outcomes in intracranial aneurysm patients in a multi-center study. Frontiers in Neurology. 2019;10:123\n'}],footnotes:[],contributors:[{corresp:null,contributorFullName:"Bing Zhao",address:null,affiliation:'
Department of Neurosurgery, Renji Hospital, Shanghai Jiao Tong University School of Medicine, China
Department of Neurosurgery, Renji Hospital, Shanghai Jiao Tong University School of Medicine, China
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