Validation of the predictive accuracy of “clinical + morphology nomogram” for the rebleeding risk of ruptured intracranial aneurysms after admission

BackgroundPre-treatment re-bleeding following aneurysmal subarachnoid hemorrhage (aSAH) affects up to 7.2% of patients even with ultra-early treatment within 24 hours. We retrospectively compared the utility of three published re-bleed prediction models and individual predictors between cases who re-bled matched to controls using size and parent vessel location from a cohort of patients treated in an ultra-early, ‘endovascular first’ manner.MethodsOn retrospective analysis of our 9-year cohort of 707 patients suffering 710 episodes of aSAH, there were 53 episodes of pre-treatment re-bleeding (7.5%). Forty-seven cases who had a single culprit aneurysm were matched to 141 controls. Demographic, clinical and radiological data were extracted and predictive scores calculated. Univariate, multivariate, area under the receiver operator characteristic curve (AUROCC) and Kaplan–Meier (KM) survival curve analyses were performed.ResultsThe majority of patients (84%) were treated using endovascular techniques at a median 14.5 hours post-diagnosis. On AUROCC analysis the score of Liuet al.had minimal utility (C-statistic 0.553, 95% confidence interval (CI) 0.463 to 0.643) while the risk score of Opponget al.(C-statistic 0.645 95% CI 0.558 to 0.732) and the ARISE-extended score of van Lieshoutet al.(C-statistic 0.53 95% CI 0.562 to 0.744) had moderate utility. On multivariate modeling, the World Federation of Neurosurgical Societies (WFNS) grade was the most parsimonious predictor of re-bleeding (C-statistic 0.740, 95% CI 0.664 to 0.816).ConclusionsFor aSAH patients treated in an ultra-early timeframe matched on size and parent vessel location, WFNS grade was superior to three published models for re-bleed prediction. Future re-bleed prediction models should incorporate the WFNS grade.

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Pre-treatment re-bleeding following aneurysmal subarachnoid hemorrhage: a systematic review of prediction models

Dissanayake

Phillips

et al. 2023

Preprint

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Pre-treatment rebleeding following aneurysmal subarachnoid hemorrhage (aSAH) increases the risk of a poor outcome. Treatment as early as practicable is recommend to mitigate this risk though the benefit of emergency treatment is debated, emphasising the need for individualised risk prediction. Predictive models have been recently described incorporating established risk factors. Following prospective registration on the International prospective register of systematic reviews (PROSPERO) CRD 42023421235; Ovid Medline (Pubmed), Embase and Googlescholar were searched for English language studies describing clinical prediction models between May 2002 and May 2023 for pre-treatment rebleed prediction following aSAH in adults ³18 years. Of 763 unique records, 17 full texts were scrutinised with 5 publications describing 4 models reviewed. The Critical Appraisal and Data Extraction for Systematic Reviews of Prediction Modelling Studies (CHARMS) checklist and the Prediction model Risk Of Bias ASsessment Tool (PROBAST) were used. Reported performance varied from 0.790 to 0.939. The Intracranial Aneurysm Risk Score demonstrated a high risk of bias and low clinical applicability. The risk score of Oppong et al. was not validated or calibrated and the Clinical + Morphological model of Liu et al. did not have a sufficient event-to-predictor ratio. The ARISE extended model was formulated using patient data from multiple centres and time periods increasing the risk of non-standardised predictor assessment. Furthermore, patient recruitment overlapped the period of the endovascular paradigm shift in aneurysm treatment, limiting the applicability of this model to patients treated according to modern conditions. Thus, no published predictive model could be recommended for clinical use.

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Validation of the predictive accuracy of “clinical + morphology nomogram” for the rebleeding risk of ruptured intracranial aneurysms after admission

Cited by 3 publications

References 34 publications

Pre-treatment re-bleeding following aneurysmal subarachnoid hemorrhage: A systematic review of published prediction models with risk of bias and clinical applicability assessment

Pre-treatment re-bleeding following aneurysmal subarachnoid hemorrhage: A systematic review of published prediction models with risk of bias and clinical applicability assessment

Rebleeding following aneurysmal subarachnoid hemorrhage before ‘endovascular first’ treatment: a retrospective case-control study of published scoring systems

Pre-treatment re-bleeding following aneurysmal subarachnoid hemorrhage: a systematic review of prediction models

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