Accuracy of Neurovascular Fellows' Prognostication of Outcome After Subarachnoid Hemorrhage

Navi, Babak B.; Kamel, Hooman; McCulloch, Charles E.; Nakagawa, Kazuma; Naravetla, Bharath; Moheet, Asma M.; Wong, Christine; Hemphill, J. Claude; Smith, Wade S.

doi:10.1161/strokeaha.111.639161

Cited by 33 publications

(16 citation statements)

References 26 publications

Supporting

Mentioning

Contrasting

Order By: Relevance

“…4 Since this paper was accepted, Navi et al have reported outcome over time in 52 patients with nontraumatic SAH whose hemorrhage was Hunt and Hess Grade I-IV. 8 The findings corroborate those reported by Wilson and colleagues. In the Navi et al study, about 80% of patients improved one or more points on the mRS between discharge and 6 months, and 50% of Hunt and Hess Grade IV or V patients had mRS scores of 0-2 by 6 months compared to 0% at discharge.…”

supporting

confidence: 91%

Editorial: Subarachnoid hemorrhage and outcome

Macdonald¹

2013

JNS

View full text Add to dashboard Cite

Wilson and coauthors address an issue of fundamental importance to clinical trial design as well as other topics such as what we tell our patients about how long it will take them to get better after brain injury (in the present case, subarachnoid hemorrhage [SAH]).11 Who could summarize the complexities of time better that William Shakespeare, perhaps the best writer ever, when he began Macbeth's famous soliloquy at the beginning of Scene 5, Act 5: "To-morrow, and to-morrow, and to-morrow, / Creeps in this petty pace from day to day." We wait and wait for days and days to estimate the extent to which our patients will recover, but at what cost?-the cost of time, of rehabilitation and of psychological stress, and of development of new treatments?Wilson et al. reviewed the data from 88 patients who had Hunt and Hess Grade IV or V SAH and who underwent assessment with the modified Rankin Scale (mRS) at discharge and then 6, 12, and 36 months after the hemorrhage.11 The mean mRS score was 4.3 ± 1.3 at discharge, 3.3 ± 2.1 at 6 months, 3.3 ± 2.2 at 12 months, and 3.2 ± 2.3 at 36 months. Thus, overall, other than the difference between discharge and 6-month scores, there were fairly minor changes in the overall mean mRS scores. If we exclude the 9 patients who died before discharge, the mean discharge mRS score would be 4.1 ± 1.2, so there is still substantial improvement from discharge to 6 months. Even more convincing, when examined on an individual patient basis, 61% of patients had improved mRS scores between discharge and 6 months, and about 1 in 5 patients had improved scores between 6-12 months and 12-36 months. The rough percentage improvement would be 91% at 6 and 91% at 12 months, assuming 3 years is 100% improvement.The most important factors associated with improvement over time were Hunt and Hess Grade IV (as opposed to Grade V), no large (> 4 cm) or eloquent cerebral infarction, and age greater than 65 years. These factors were identified in a univariate analysis, so whether they each add independent information in a multivariate analysis is not known. Another key finding was that those who improved in the first 6 months were not necessarily those who improved after 6 months.There are few other data like these in the literature. Greebe et al. 3 have shown the trajectory of recovery in patients discharged to a nursing home after SAH is qualitatively similar to that of the current data, and another group has shown progressive cognitive improvement in predominately good-grade patients over the 1st year after SAH.4 Since this paper was accepted, Navi et al. have reported outcome over time in 52 patients with nontraumatic SAH whose hemorrhage was Hunt and Hess Grade I-IV. 8 The findings corroborate those reported by Wilson and colleagues. In the Navi et al. study, about 80% of patients improved one or more points on the mRS between discharge and 6 months, and 50% of Hunt and Hess Grade IV or V patients had mRS scores of 0-2 by 6 months compared to 0% at discharge. The factors that showed trends toward predic...

show abstract

supporting

confidence: 91%

Editorial: Subarachnoid hemorrhage and outcome

Macdonald¹

2013

JNS

View full text Add to dashboard Cite

show abstract

“…Despite their importance, prognostic studies of subjective clinician judgments for critical care neurology have been few. 24,25 One recent study in ischemic stroke compared prognostic accuracy of physician judgment to a widely available outcome prediction tool and concluded that the formal tool was superior. 26 However, physicians were given hypothetical case vignettes to prognosticate.…”

Section: Participantsmentioning

confidence: 99%

Clinician judgment vs formal scales for predicting intracerebral hemorrhage outcomes

et al. 2016

View full text Add to dashboard Cite

Objective: To compare the performance of formal prognostic instruments vs subjective clinical judgment with regards to predicting functional outcome in patients with spontaneous intracerebral hemorrhage (ICH).Methods: This prospective observational study enrolled 121 ICH patients hospitalized at 5 US tertiary care centers. Within 24 hours of each patient's admission to the hospital, one physician and one nurse on each patient's clinical team were each asked to predict the patient's modified Rankin Scale (mRS) score at 3 months and to indicate whether he or she would recommend comfort measures. The admission ICH score and FUNC score, 2 prognostic scales selected for their common use in neurologic practice, were calculated for each patient. Spearman rank correlation coefficients (r) with respect to patients' actual 3-month mRS for the physician and nursing predictions were compared against the same correlation coefficients for the ICH score and FUNC score. Results:The absolute value of the correlation coefficient for physician predictions with respect to actual outcome (0.75) was higher than that of either the ICH score (0.62, p 5 0.057) or the FUNC score (0.56, p 5 0.01). The nursing predictions of outcome (r 5 0.72) also trended towards an accuracy advantage over the ICH score (p 5 0.09) and FUNC score (p 5 0.03). In an analysis that excluded patients for whom comfort care was recommended, the 65 available attending physician predictions retained greater accuracy (r 5 0.73) than either the ICH score (r 5 0.50, p 5 0.02) or the FUNC score (r 5 0.42, p 5 0.004). Conclusions:Early subjective clinical judgment of physicians correlates more closely with 3-month outcome after ICH than prognostic scales. Neurology ® 2016;86:126-133 GLOSSARY ERICH 5 Ethnic/Racial Variations of Intracerebral Hemorrhage; GCS 5 Glasgow Coma Scale; ICH 5 intracerebral hemorrhage; mRS 5 modified Rankin Scale; NICU 5 neuroscience intensive care unit.Spontaneous intracerebral hemorrhage (ICH) is a devastating stroke subtype, with high rates of mortality and long-term disability.

show abstract

“…17 An observational study including neurovascular fellows assessed outcomes in 66 patients with subarachnoid hemorrhage. 18 Final outcomes were determined by phone interview and dichotomized into good (mRS 0-2) and poor (mRS 3-6). Estimates were only provided by a single fellow during intensive care unit rotation.…”

Section: Factors Independently Associated With Accurate Estimationsmentioning

confidence: 99%

“…Overall, clinician accuracy ranged from 78% to 88% with no significant dayto-day variation. 18 Of note, fellows were able to use variables known to predict outcomes including scales such as the Hunt-Hess scale, Fisher score, Glasgow Coma Scale on admission, and need for mechanical ventilation. Similar results in clinician predictions were observed in the SUPPORT study using the APACHE score in critically ill patients.…”

Section: Factors Independently Associated With Accurate Estimationsmentioning

confidence: 99%

JURaSSiC

et al. 2013

View full text Add to dashboard Cite

Objective: We compared the accuracy of clinicians and a risk score (iScore) to predict observed outcomes following an acute ischemic stroke. Methods:The JURaSSiC (Clinician JUdgment vs Risk Score to predict Stroke outComes) study assigned 111 clinicians with expertise in acute stroke care to predict the probability of outcomes of 5 ischemic stroke case scenarios. Cases (n 5 1,415) were selected as being representative of the 10 most common clinical presentations from a pool of more than 12,000 stroke patients admitted to 12 stroke centers. The primary outcome was prediction of death or disability (modified Rankin Scale [mRS] $3) at discharge within the 95% confidence interval (CI) of observed outcomes. Secondary outcomes included 30-day mortality and death or institutionalization at discharge.Results: Clinicians made 1,661 predictions with overall accuracy of 16.9% for death or disability at discharge, 46.9% for 30-day mortality, and 33.1% for death or institutionalization at discharge. In contrast, 90% of the iScore-based estimates were within the 95% CI of observed outcomes. Nearly half (n 5 53 of 111; 48%) of participants were unable to accurately predict the probability of the primary outcome in any of the 5 rated cases. Less than 1% (n 5 1) provided accurate predictions in 4 of the 5 cases and none accurately predicted all 5 case outcomes. In multivariable analyses, the presence of patient characteristics associated with poor outcomes (mRS $3 or death) in previous studies (older age, high NIH Stroke Scale score, and nonlacunar subtype) were associated with more accurate clinician predictions of death at 30 days (odds ratio [OR] 2.40, 95% CI 1.57-3.67) and with a trend for more accurate predictions of death or disability at discharge (OR 1.85, 95% CI 0.99-3.46). Conclusions:Clinicians with expertise in stroke performed poorly compared to a validated tool in predicting the outcomes of patients with an acute ischemic stroke. Use of the risk stroke outcome tool may be superior for decision-making following an acute ischemic stroke. Stroke is a leading cause of adult disability and can be devastating for patients and their families. Approximately two-thirds of stroke survivors have long-term functional deficits that can diminish their quality of life.1,2 Patients and families naturally have questions about prognosis after an acute ischemic stroke. Advanced age, stroke severity, and a cardioembolic mechanism are the most common factors associated with death and disability after ischemic stroke.3-6 The process underlying clinicians' prognostication is complex and difficult, especially when considering the diversity of stroke syndromes and the multiple factors influencing outcomes.7 Clinicians involved in the acute management of patients with ischemic stroke provide outcome predictions based on their assessment of From the Stroke Outcomes

show abstract

Accuracy of Neurovascular Fellows' Prognostication of Outcome After Subarachnoid Hemorrhage

Abstract: Neurologists were generally but not perfectly accurate in their prognostications of functional outcomes. The accuracy of prognoses did not correlate with the hospital day on which they were made but was affected by clinical factors that can cloud the neurological examination.

Cited by 33 publications

References 26 publications

Editorial: Subarachnoid hemorrhage and outcome

Editorial: Subarachnoid hemorrhage and outcome

Clinician judgment vs formal scales for predicting intracerebral hemorrhage outcomes

JURaSSiC

Contact Info

Product

Resources

About