Misdiagnosis Worsens Prognosis in Subarachnoid Hemorrhage With Good Hunt and Hess Score

Abstract

Background and Purpose— Our aim was to describe variables associated with initial misdiagnosis of subarachnoid hemorrhage (SAH). We also analyzed the relationship of misdiagnosis with poor outcome and complications in good Hunt and Hess (HH) cases. Methods— In a prospective cohort of 401 patients with SAH, misdiagnosis was defined as failure to correctly identify, at first physician contact, a subsequently documented SAH; this meant no urgent radiological study and lumbar puncture was performed. Poor outcome was defined as modified Rankin Scale score 3 to 6 at 3-month follow-up. We recorded age, sex, hypertension, diabetes mellitus, current smoking, previous antithrombotic treatment, initial HH and radiological severity, presence of aneurysm, first therapeutic procedure, hydrocephalus, delayed cerebral ischemia (DCI), rebleeding, and procedure-related complications. Results— Misdiagnosis was confirmed in 104/401 (25.9%) patients, who also had a longer time-to-admission to hospital. Misdiagnosis was associated with less clinical and radiological severity, compared with a correct diagnosis; the 2 groups did not differ in age or cardiovascular risk factor profile. Poor outcome was registered in 167/401 patients (41.6%). Age, misdiagnosis, and greater clinical and radiological initial severity were independent predictors of poor outcome. In the 236 patients (58.8% of cohort) with HH 1–2, misdiagnosis was associated with poor outcome in univariate and multivariate analysis, respectively (odds ratio=3.89; 95% CI, 1.89–8.01). Delayed cerebral ischemia (odds ratio=2.47; 95% CI, 1.2–5.09) and procedure-related complications (odds ratio=2.27; 95% CI, 1.07–4.82) were independently associated with misdiagnosis. Conclusions— Misdiagnosis is an unresolved problem in SAH, and it is a missed opportunity for good outcome in patients with HH 1–2. The poor outcome is partially explained by a higher risk of delayed cerebral ischemia and procedure-related complications in misdiagnosed patients. There is a need to improve the diagnostic strategy in patients reporting only a headache (HH 1–2) after SAH.

Development and Clinical Translation of a Perioperative Nomogram Incorporating Free Fatty Acids to Predict Poor Outcome of Aneurysmal Subarachnoid Hemorrhage Following Endovascular Treatment

“…For endovascular therapy, a grading system named Changhai score worked well on the aSAH clinical outcome prediction (21), of which the 4 pronounced risk factors including age, HH grade, mFS, and aneurysm location were identical to these findings. Although the HH grade and mFS have been widely used to evaluate the severity and outcome of aSAH in clinical practice, these evaluation scales have many limitations which could lead to the initial misdiagnosis due to the subjectivity of the neuro interventionalists or the adjudicated information (27,28). Hence, it may be useful to take other preoperative factors into account for better predictions.…”

The Role of the Blood Neutrophil-to-Lymphocyte Ratio in Aneurysmal Subarachnoid Hemorrhage

“…More than 30% of survivors may develop severe disability and delayed neurological dysfunction due to complications such as delayed cerebral ischemia (DCI) and rebleeding ( 3 ). The progression of aSAH is individualized and rapid, so accurate risk stratification and prognosis prediction is challenging ( 4 ). A growing body of research has found that neuroinflammation and immune disorders after aSAH may play an important role in both early brain injury (EBI) and delayed neurological injury ( 5 ).…”

A clinically applicable deep-learning model for detecting intracranial aneurysm in computed tomography angiography images

“…Although aneurysmal SAH accounts for 5-10% of all strokes in the United States 3 , it may cause significantly high mortality 4 , and the survivors may suffer from long-term neuropsychological effects and decreased quality of life 5 . Early diagnosis of underlying IAs can both influence clinical management and guide prognosis in intracerebral hemorrhage patients 6,7 . For patients with spontaneous SAH, timely and accurate identification of IAs is critical for immediate intervention or surgical management, whereas for patients without IAs, reliable exclusion of IAs is also important for specialized management 8 .…”