Timing of clinical grade assessment and poor outcome in patients with aneurysmal subarachnoid hemorrhage

Giraldo, Elias A.; Mandrekar, Jay; Rubin, Mark N.; Dupont, Stefan A.; Zhang, Yi; Lanzino, Giuseppe; Wijdicks, Eelco F. M.; Rabinstein, Alejandro A.

doi:10.3171/2012.3.jns11706

Cited by 46 publications

(35 citation statements)

References 8 publications

(7 reference statements)

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“…8,14 This notion is corroborated by our data. Up to now, hydrocephalus has been thought to be the main confounder interfering with grading in patients with SAH.…”

Section: Seizures and Timing Of Grading In Patients With Sahsupporting

confidence: 82%

“…7 Neurological resuscitation included intubation and mechanical ventilation for airway protection or, if respiratory distress developed, placement of arterial and venous lines, a CSF diversion via an external ventricular drain (EVD) or lumbar drain in case of hydrocephalus, and initiation of antiepileptic drugs (AEDs) after reported seizure, with administration of parenteral fluids to maintain euvolemia and initiation of nimodipine on admission. 8 In cases in which the patient's Glasgow Coma Scale (GCS) score could not be assessed due to continued sedation, the last GCS score before intubation was used. Patients were dichotomized into good-grade (WFNS I-III) and poor-grade (WFNS IV-V) groups.…”

Section: Methodsmentioning

confidence: 99%

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Impact of early-onset seizures on grading and outcome in patients with subarachnoid hemorrhage

Fung¹,

Balmer²,

Murek³

et al. 2015

JNS

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O n presentation at a neurosurgical-neurovascular center, patients suffering from aneurysmal subarachnoid hemorrhage (SAH) may exhibit a reduced level of consciousness due to initial bleeding, rebleeding, hydrocephalus, sedation, or seizure 1,9,15,20,22 as well as other conditions. Subarachnoid hemorrhage causes seizures in up to 26% of patients, which occur most commonly within the first 24 hours. 3,9,20,23 Most seizures occur before hospital presentation. 20 The severity of SAH, as graded on scales like the World Federation of Neurosurgical Societies (WFNS) scale, as well as intracerebral hemorrhage (ICH), localization of the aneurysm, and the amount of subarachnoid blood are important risk factors for the development of early seizures. obJect After subarachnoid hemorrhage (SAH), seizure occurs in up to 26% of patients. The impact of seizure on outcome has been studied, yet its impact on grading is unknown. The authors evaluated the impact of early-onset seizures (EOS) on grading of spontaneous SAH and on outcome. methods This retrospective analysis included consecutive patients with SAH who were treated at the NeuroCenter, Inselspital, University Hospital Bern, Switzerland, between January 2005 and December 2010. Demographic data, clinical data, and reports of EOS were recorded. The EOS were defined as seizures occurring within 24 hours after ictus. Patients were graded according to the World Federation of Neurosurgical Societies (WFNS) scale pre- and postresuscitation and dichotomized into good (WFNS I-III) and poor (WFNS IV-V) grades. Outcome was assessed at 6 months by using the modified Rankin Scale (mRS); an mRS score of 0-3 was considered a good outcome and an mRS score of 4-6 was considered a poor outcome. results Forty-one of 425 patients with SAH had EOS. Twenty-seven of those 41 patients (65.9%) had a poor WFNS grade. Twenty-eight (68.3%) achieved a good outcome, 11 (26.8%) had a poor outcome, and 2 (4.9%) were lost to followup. Early-onset seizures were proven in 9 of 16 electroencephalograms. The EOS were associated with poor WFNS grade (OR 2.81, 97.5% CI 1.14-7.46; p = 0.03) and good outcome (OR 4.01, 97.5% CI 1.63-10.53; p = 0.03). Increasing age, hydrocephalus, intracerebral hemorrhage, and intraventricular hemorrhage were associated with poor WFNS grade, whereas only age, intracerebral hemorrhage (p < 0.001), and poor WFNS grade (p < 0.001) were associated with poor outcome. coNclusioNs Patients with EOS were classified significantly more often in a poor grade initially, but then they significantly more often achieved a good outcome. The authors conclude that EOS can negatively influence grading. This might influence decision making for the care of patients with SAH, so grading of patients with EOS should be interpreted with caution.

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“…8,14 This notion is corroborated by our data. Up to now, hydrocephalus has been thought to be the main confounder interfering with grading in patients with SAH.…”

Section: Seizures and Timing Of Grading In Patients With Sahsupporting

confidence: 82%

Section: Methodsmentioning

confidence: 99%

Impact of early-onset seizures on grading and outcome in patients with subarachnoid hemorrhage

Fung¹,

Balmer²,

Murek³

et al. 2015

JNS

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“…4 Although a good clinical grade was definitely the strongest factor associated with greater chances of excellent outcome in our cohort, we also found that nearly onethird of patients who presented with poor clinical grade were able to reach an excellent recovery. These numbers are higher than those reported in a previous study, which found that 16% of poor-grade patients who underwent aneurysm treatment had an MRS score of 0-1 at 1 year.…”

Section: Discussionmentioning

confidence: 65%

Predictors of excellent functional outcome in aneurysmal subarachnoid hemorrhage

Pegoli¹,

Mandrekar²,

Rabinstein

et al. 2015

JNS

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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.

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“…8,35,36,42 Some researchers have also argued about the optimal time point for assessing neurological status for purposes of prognostication, with different time points proposed in the literature, including clinical assessment soon after injury, 4 and after neurological resuscitation. 12 Third, because the study is not population based, there is the potential that we systematically underestimated the magnitude of prognostic associations, as patients who died prior to hospital admission were not accounted for. Furthermore, the data were weighted toward trial patients.…”

Section: Discussionmentioning

confidence: 99%

Prognostic value of premorbid hypertension and neurological status in aneurysmal subarachnoid hemorrhage: pooled analyses of individual patient data in the SAHIT repository

Jaja

Lingsma

Schweizer

et al. 2015

JNS

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obJect The literature has conflicting reports about the prognostic value of premorbid hypertension and neurological status in aneurysmal subarachnoid hemorrhage (SAH). The aim of this study was to investigate the prognostic value of premorbid hypertension and neurological status in the SAH International Trialists repository. methods Patient-level meta-analyses were conducted to investigate univariate associations between premorbid hypertension (6 studies; n = 7249), admission neurological status measured on the World Federation of Neurosurgical Societies (WFNS) scale (10 studies; n = 10,869), and 3-month Glasgow Outcome Scale (GOS) score. Multivariable analyses were performed to sequentially adjust for the effects of age, CT clot burden, aneurysm location, aneurysm size, and modality of aneurysm repair. Prognostic associations were estimated across the ordered categories of the GOS using proportional odds models. Nagelkerke's R 2 statistic was used to quantify the added prognostic value of hypertension and neurological status beyond those of the adjustment factors. results Premorbid hypertension was independently associated with poor outcome, with an unadjusted pooled odds ratio (OR) of 1.73 (95% confidence interval [CI] 1.50-2.00) and an adjusted OR of 1.38 (95% CI 1.25-1.53). Patients with a premorbid history of hypertension had higher rates of cardiovascular and renal comorbidities, poorer neurological status (p ≤ 0.001), and higher odds of neurological complications including cerebral infarctions, hydrocephalus, rebleeding, and delayed ischemic neurological deficits. Worsening neurological status was strongly independently associated with poor outcome, including WFNS Grades II (OR 1.85, 95% CI 1.68-2.03), III (OR 3.85,, IV (OR 5.58, and V (OR 14.18,. Neurological status had substantial added predictive value greater than the combined value of other prognostic factors (R 2 increase > 10%), while the added predictive value of hypertension was marginal (R 2 increase < 0.5%). coNclusioNs This study confirmed the strong prognostic effect of neurological status as measured on the WFNS scale and the independent but weak prognostic effect of premorbid hypertension. The effect of premorbid hypertension could involve multifactorial mechanisms, including an increase in the severity of initial bleeding, the rate of comorbid events, and neurological complications.

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Timing of clinical grade assessment and poor outcome in patients with aneurysmal subarachnoid hemorrhage

Abstract: Timing of WFNS grade assessment affects its prognostic value. Outcome after aneurysmal SAH is best predicted by assessing WFNS grade after neurological resuscitation.

Cited by 46 publications

References 8 publications

Impact of early-onset seizures on grading and outcome in patients with subarachnoid hemorrhage

Impact of early-onset seizures on grading and outcome in patients with subarachnoid hemorrhage

Predictors of excellent functional outcome in aneurysmal subarachnoid hemorrhage

Prognostic value of premorbid hypertension and neurological status in aneurysmal subarachnoid hemorrhage: pooled analyses of individual patient data in the SAHIT repository

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