OBJECT Current data show a favorable outcome in up to 50% of patients with World Federation of Neurosurgical Societies (WFNS) Grade V subarachnoid hemorrhage (SAH) and a rather poor prediction of worst cases. Thus, the usefulness of the current WFNS grading system for identifying the worst scenarios for clinical studies and for making treatment decisions is limited. One reason for this lack of differentiation is the use of “negative” or “silent” diagnostic signs as part of the WFNS Grade V definition. The authors therefore reevaluated the WFNS scale by using “positive” clinical signs and the logic of the Glasgow Coma Scale as a progressive herniation score. METHODS The authors performed a retrospective analysis of 182 patients with SAH who had poor grades on the WFNS scale. Patients were graded according to the original WFNS scale and additionally according to a modified classification, the WFNS herniation (hWFNS) scale (Grade IV, no clinical signs of herniation; Grade V, clinical signs of herniation). The prediction of poor outcome was compared between these two grading systems. RESULTS The positive predictive values of Grade V for poor outcome were 74.3% (OR 3.79, 95% CI 1.94–7.54) for WFNS Grade V and 85.7% (OR 8.27, 95% CI 3.78–19.47) for hWFNS Grade V. With respect to mortality, the positive predictive values were 68.3% (OR 3.9, 95% CI 2.01–7.69) for WFNS Grade V and 77.9% (OR 6.22, 95% CI 3.07–13.14) for hWFNS Grade V. CONCLUSIONS Limiting WFNS Grade V to the positive clinical signs of the Glasgow Coma Scale such as flexion, extension, and pupillary abnormalities instead of including “no motor response” increases the prediction of mortality and poor outcome in patients with severe SAH.
Zusammenfassung. Mit einfachen Mitteln kann bereits in der Hausarztpraxis entschieden werden, welche Behandlung einer distalen Radiusfraktur angestrebt werden soll. Man soll vor allem keinen Respekt davor haben, sie konservativ zu behandeln. Unsere Empfehlung ist, dass gerade bei Patienten älter als 65 Jahre, die eine nicht bzw. wenig dislozierte oder eine stabil reponierte Fraktur haben, eine Operation oft überflüssig ist. Eine Fraktur, sofern ohne die oben genannte Instabilitätskriterien, soll und darf konservativ in der Hausarztpraxis behandelt werden. Aufgrund meist geringerer funktioneller Ansprüche bei älteren Patienten darf man bei der Beurteilung der Fraktur oft grosszügiger sein in Hinblick auf die anatomischen Verhältnisse sein. Eine solche Fraktur oder Reposition muss nicht in perfekter Stellung ruhiggestellt werden beziehungsweise heilen.
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