Predictors of excellent functional outcome in aneurysmal subarachnoid hemorrhage

Abstract

A lthough the incidence of aneurysmal subarachnoid hemorrhage (aSAH) has remained stable over time, case fatality rates have decreased by 17% during the last three decades. 11,18 In parallel with refinements in endovascular and surgical treatment and advances in neurocritical care, there has also been an improvement in functional outcome. 2,16,19,23 There are many studies on factors predictive of poor functional and cognitive outcome after aSAH, 5,6,22,25 but much less information on predictors of excellent outcome. In this study, we analyzed predictors of excellent functional outcome in a contemporary series of patients with aSAH. Methods Study PopulationAfter Institutional Review Board approval from the Mayo Clinic, we performed a retrospective chart review of adult patients with aSAH admitted to St. Mary's HospitalMayo Medical Center in Rochester, Minnesota, between February 2001 and June 2013. Subarachnoid hemorrhage (SAH) was confirmed radiologically or by the presence of xanthochromia in the CSF. Only patients with a documented aneurysm on cerebral angiography that was considered to be the cause of the SAH were included.abbreviatioNS aSAH = aneurysmal SAH; DCI = delayed cerebral ischemia; ICH = intracerebral hemorrhage; IVH = intraventricular hemorrhage; mRS = modified Rankin Scale; SAH = subarachnoid hemorrhage; WFNS = World Federation of Neurosurgical Societies. reSultS Three hundred seventy-three patients were identified with posthospital follow-up. Excellent outcome was noted in 236 patients (63.3%), including an mRS score of 0 in 122 (32.7%) and an mRS score of 1 in 114 (30.6%). On univariate analysis, the following factors were associated with an excellent outcome: indicators of less severe bleeding, such as better World Federation of Neurosurgical Societies grade at any of the times of assessment, better modified Fisher grade, and absence of intracerebral hemorrhage (ICH), intraventricular hemorrhage (IVH), and symptomatic hydrocephalus; aneurysm treatment with coil embolization; absence of symptomatic vasospasm, delayed cerebral ischemia, and radiological infarction; absence of in-hospital seizures; lack of need for CSF diversion; fewer hours with fever; less severe anemia; and absence of transfusion. On multivariable analysis, the 4 variables that were most strongly associated with excellent outcome were presence of good clinical grade after neurological resuscitation, absence of ICH on initial CT scan, blood transfusion during the hospitalization, and radiological infarctions on final brain imaging. coNcluSioNS Excellent outcomes (mRS score 0-1) can be achieved in the majority of patients with aSAH. The likelihood of excellent outcome is predicted by good clinical condition after resuscitation, absence of ICH on presentation, no evidence of infarction on brain imaging, and absence of blood transfusion during hospitalization.

Effects of Red Blood Cell Transfusion on Long-Term Disability of Patients with Traumatic Brain Injury

“…Notably, this observed negative influence was more evident at the 12-than 6-month follow-ups, suggesting a long-lasting negative effect of RBCT that increases with time (Table 3; Figs. 2, 3), as previously documented in other clinical scenarios [19,20]. The higher rates of unfavorable outcomes observed in patients with TBI receiving RBCT might have been the result of the interaction of several factors.…”

“…The median [interquartile range] pretransfusion Hb concentration was 82 [60-110] g/L. Transfused patients received a median of 5 [3][4][5][6][7][8] units of packed RBC with a median length of storage of 15 [11][12][13][14][15][16][17][18][19][20] days. Concomitantly with RBCT, 29 (17.6 %) patients received fresh frozen plasma and 27 (16.4 %) received pooled platelets.…”

Effect of treatment modality on in-hospital outcome in patients with subarachnoid hemorrhage: a nationwide study in Japan (J-ASPECT Study)

“…Therefore, international, national, and longitudinal comparisons of outcomes for patients with SAH treated using different therapeutic modalities should be discussed in light of socioeconomic indicators, acute stroke care capabilities at the specific time, 13,14,26,28,31 and patient-level characteristics such as SAH severity. 27 The present study is the first to compare outcomes for SAH patients treated with clipping and coiling via a mixed-model analysis of a large nationwide discharge database (DPC database) after adjustment for patient-level characteristics including age, sex, level of consciousness (JCS score), CCI score, and hospital-level CSC capabilities (CSC score). 14,15 Our results revealed that patients who had undergone coiling exhibited significantly higher in-hospital mortality (12.4% vs 8.7%) and shorter hospital stays (32.0 vs 37.0 days) than those in patients who had undergone clipping.…”

Evolution of diffusion tensor imaging parameters after acute subarachnoid haemorrhage: a prospective cohort study

“…The prognosis after SAH is determined by the initial insult as translated into clinical scales, such as the Hunt and Hess grade, but also by the occurrence of complications like vasospasm and delayed cerebral ischemia (DCI) [1,[3][4][5]. Besides these well-known factors, the occurrence of early brain injury at the time of haemorrhage is emerging as a leading cause of mortality [2].…”