Time course of recovery following poor-grade SAH: the incidence of delayed improvement and implications for SAH outcome study design

Abstract

Object Data regarding the time course of recovery after poor-grade subarachnoid hemorrhage (SAH) is lacking. Most SAH studies assess outcome at a single time point, often as early as 3 or 6 months following SAH. The authors hypothesized that recovery following poor-grade SAH is a dynamic process and that early outcomes may not always approximate long-term outcomes. To test this hypothesis, they analyzed long-term outcome data from a cohort of patients with poor-grade aneurysmal SAH to determine the incidence and predictors of early and delayed neurological improvement. Methods The authors reviewed outcome data from 88 poor-grade SAH patients enrolled in a prospective SAH treatment trial (the Barrow Ruptured Aneurysm Trial). They assessed modified Rankin Scale (mRS) scores at discharge, 6 months, 12 months, and 36 months after treatment to determine the incidence and predictors of neurological improvement during each interval. Results The mean aggregate mRS scores at 6 months (3.31 ± 2.1), 12 months (3.28 ± 2.2), and 36 months (3.17 ± 2.3) improved significantly compared with the mean score at hospital discharge (4.33 ± 1.3, p < 0.001), but they did not differ significantly among themselves. Between discharge and 6 months, 61% of patients improved on the mRS. The incidence of improvement between 6–12 months and 12–36 months was 18% and 19%, respectively. Hunt and Hess Grade IV versus V (OR 6.20, 95% CI 2.11–18.25, p < 0.001) and the absence of large (> 4 cm) (OR 2.76, 95% CI 1.02–7.55, p = 0.05) or eloquent (OR 5.17, 95% CI 1.89–14.10, p < 0.01) stroke were associated with improvement up to 6 months. Age ≤ 65 years (OR 5.56, 95% CI 1.17–26.42, p = 0.02), Hunt and Hess Grade IV versus V (OR 4.17, 95% CI 1.10–15.85, p = 0.03), and absence of a large (OR 8.97, 95% CI 2.65–30.40, p < 0.001) or eloquent (OR 4.54, 95% CI 1.46–14.08, p = 0.01) stroke were associated with improvement beyond 6 months. Improvement beyond 1 year was most strongly predicted by the absence of a large stroke (OR 7.62, 95% CI 1.55–37.30, p < 0.01). Conclusions A substantial minority of poor-grade SAH patients will experience delayed recovery beyond the point at which most studies assess outcome. Younger patients, those presenting in better clinical condition, and those without CT evidence of large or eloquent stroke demonstrated the highest capacity for delayed recovery.

Endovascular Coiling versus Surgical Clipping for Poor-Grade Ruptured Intracranial Aneurysms: Postoperative Complications and Clinical Outcome in a Multicenter Poor-Grade Aneurysm Study

“…Our results are slightly better than those reported in older studies (good outcome of 38.3%-40.0%) 1,2 and are in agreement with current studies showing a good outcome of approximately 50%. 10,16 These findings might suggest that there is an increase in the proportion of patients experiencing good outcomes in recent years. In addition, our results also support the recent study showing that poor-grade patients have experienced delayed recovery with time.…”

“…In addition, our results also support the recent study showing that poor-grade patients have experienced delayed recovery with time. 16 Cerebral recovery may be attributable to cerebral plasticity.…”

Early Versus Late Assessment of Stroke Outcome

“…As a result, the design of the ongoing Phase III MISTIE III Trial has the primary endpoint at 6 months. Substantial recovery beyond three months has been noted in patients with poor grade subarachnoid hemorrhage [11] and with major upper extremity deficits from ischemic stroke [12]. …”

Editorial: Subarachnoid hemorrhage and outcome

“…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.…”

“…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?…”