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Hosogai M, Ikawa F, Hidaka T, Matsuda S, Ozono I, Inamasu J, Kobata H, Murayama Y, Sato A, Kato Y, Sano H, Yamaguchi S, Horie N. Changes in Short-Term Outcomes After Discharge in Patients with Aneurysmal Subarachnoid Hemorrhage: A Multicenter, Prospective, Observational Study. World Neurosurg 2022; 164:e1214-e1225. [PMID: 35688375 DOI: 10.1016/j.wneu.2022.05.140] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2022] [Accepted: 05/31/2022] [Indexed: 10/18/2022]
Abstract
OBJECTIVE The objective of the study was to clarify the prevalence of and factors associated with changes in patients' outcomes between discharge and 3 months after the onset of aneurysmal subarachnoid hemorrhage (aSAH). Additionally, the World Federation of Neurosurgical Societies (WFNS) and modified WFNS (mWFNS) scales were compared. METHODS The data of curatively treated patients with aSAH, collected prospectively in the mWFNS scale study between January 2010 and December 2012, were analyzed retrospectively. The improvement or decline in the modified Rankin Scale (mRS) scores between discharge and 3 months after onset was determined. A multivariable logistic regression analysis was performed to identify factors, such as age and WFNS and mWFNS grades, associated with changes in the outcome. RESULTS The mRS scores improved in 28.3% and declined in 2.5% of the patients. WFNS and mWFNS grades Ⅱ-V on admission were significantly associated with improved mRS scores at 3 months after onset. Older age (age: 65-74 years vs. age <65 years, odds ratio: 6.59, 95% confidence interval: 1.28-34.01; age ≥75 years vs. age <65 years, odds ratio: 17.67, 95% confidence interval: 2.11-148.26) and WFNS grade III were significantly associated with a decline in mRS scores at 3 months after onset. CONCLUSIONS The optimal timing for postdischarge assessment of outcomes may be at 3 months after onset, especially in older patients with aSAH. The mWFNS scale is presumed to more accurately assess the outcomes of patients with aSAH than the WFNS scale, as demonstrated in this study.
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Affiliation(s)
- Masahiro Hosogai
- Department of Neurosurgery, Shimane Prefectural Central Hospital, Izumo, Shimane, Japan; Department of Neurosurgery, Graduate School of Biomedical and Health Sciences, Hiroshima University, Hiroshima, Japan
| | - Fusao Ikawa
- Department of Neurosurgery, Shimane Prefectural Central Hospital, Izumo, Shimane, Japan; Department of Neurosurgery, Graduate School of Biomedical and Health Sciences, Hiroshima University, Hiroshima, Japan.
| | - Toshikazu Hidaka
- Department of Neurosurgery, Shimane Prefectural Central Hospital, Izumo, Shimane, Japan
| | - Shingo Matsuda
- Department of Neurosurgery, Shimane Prefectural Central Hospital, Izumo, Shimane, Japan
| | - Iori Ozono
- Department of Neurosurgery, Shimane Prefectural Central Hospital, Izumo, Shimane, Japan
| | - Joji Inamasu
- Department of Neurosurgery, Saiseikai Utsunomiya hospital, Utsunomiya, Tochigi, Japan
| | - Hitoshi Kobata
- Department of Neurosurgery, Osaka Mishima Emergency Critical Care Center, Osaka, Japan
| | - Yuichi Murayama
- Department of Neurosurgery, The Jikei University School of Medicine, Tokyo, Japan
| | - Akira Sato
- Department of Rehabiltation, Gotanda Rehabilitation Hospital, Tokyo, Japan
| | - Yoko Kato
- Department of Neurosurgery, Fujita Health University Bantane Hospital, Nagoya, Japan
| | - Hirotoshi Sano
- Department of Neurosurgery, Shinkawabashi Hospital, Kawasaki, Japan
| | | | - Nobutaka Horie
- Department of Neurosurgery, Graduate School of Biomedical and Health Sciences, Hiroshima University, Hiroshima, Japan
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Wilson DA, Nakaji P, Albuquerque FC, McDougall CG, Zabramski JM, Spetzler RF. Time course of recovery following poor-grade SAH: the incidence of delayed improvement and implications for SAH outcome study design. J Neurosurg 2013; 119:606-12. [PMID: 23724983 DOI: 10.3171/2013.4.jns121287] [Citation(s) in RCA: 45] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
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.
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Affiliation(s)
- David A Wilson
- Division of Neurological Surgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona 85013, USA
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Ransom ER, Mocco J, Komotar RJ, Sahni D, Chang J, Hahn DK, Kim GH, Schmidt JM, Sciacca RR, Mayer SA, Connolly ES. External ventricular drainage response in poor grade aneurysmal subarachnoid hemorrhage: effect on preoperative grading and prognosis. Neurocrit Care 2007; 6:174-80. [PMID: 17572860 DOI: 10.1007/s12028-007-0019-7] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
INTRODUCTION The importance of preoperative response to external ventricular drainage (EVD) for treatment of acute hydrocephalus (HCP) following poor grade (Hunt & Hess grade IV or V) aneurysmal subarachnoid hemorrhage (aSAH) has not been clearly defined. The effect of EVD response on preoperative grade and prognosis is described. METHODS Fifty-nine poor grade patients had an EVD placed preoperatively and underwent definitive aneurysm treatment between September 1996 and March 2002. Patients improving > or = one Hunt and Hess grade were considered responders. Case-control comparisons were completed for each responder, based on clinical grade; the pre-EVD grade and the post-EVD (response) grade were used to generate two independent control cohorts. Logistic regression was used to evaluate the relationship of 12-month modified Rankin disability score (mRS) to clinical grade. RESULTS Nineteen (32%) responders were identified, and were less likely Grade V (p < 0.05), and more often had smaller (<13 mm, p < 0.01) and posterior circulation (p < 0.03) aneurysms. The frequency of favorable outcome (mRS < or= 3) was greater in responders than non-responders (68% vs. 28%, p < 0.001). Responders had a similar incidence of favorable outcome as response-grade controls (74%), and a higher incidence of favorable outcome than pre-EVD controls (47%). Regression analysis identified the post-EVD grade, but not the pre-EVD grade, as significantly predictive of long-term outcome (p < 0.04). CONCLUSION Long-term outcomes in poor grade patients who improve after EVD placement are similar to patients with lower grade hemorrhages. When an EVD is placed preoperatively in a poor grade aSAH patient, the neurological status after EVD determines the clinical grade.
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Affiliation(s)
- Evan R Ransom
- Department of Neurological Surgery, Columbia University, College of Physicians & Surgeons, Neurological Institute of New York, 710 W 168th Street, Room 431, New York, NY 10032, USA
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Mocco J, Ransom ER, Komotar RJ, Schmidt JM, Sciacca RR, Mayer SA, Connolly ES. Preoperative prediction of long-term outcome in poor-grade aneurysmal subarachnoid hemorrhage. Neurosurgery 2006; 59:529-38; discussion 529-38. [PMID: 16955034 DOI: 10.1227/01.neu.0000228680.22550.a2] [Citation(s) in RCA: 129] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023] Open
Abstract
OBJECTIVE To evaluate which presentation indices, demographics, and clinical information predict 12-month outcome in poor-grade aneurysmal subarachnoid hemorrhage (SAH), and to provide a preoperative index of prognosis. METHODS Data were obtained on all patients with poor-grade (Hunt and Hess Grades IV and V) aneurysmal SAH from a prospectively maintained SAH database and health outcomes project. Demographics, medical history, presenting clinical condition, and health outcomes were analyzed. Survival analysis was performed and Kaplan-Meier curves were generated. Multivariable logistic regression analysis was used to identify significant predictors of poor outcome at 12 months after hemorrhage, as measured by the modified Rankin disability scale. RESULTS Survival curves for open surgery and endovascular treatment did not differ significantly. Overall, 40% of the 98 definitively treated patients had a favorable outcome at 12 months. Multivariable analysis identified patient age older than 65 years (P < 0.001), hyperglycemia (P < 0.03), worst preoperative Hunt and Hess Grade V (P < 0.0001), and aneurysm size of at least 13 mm (P < 0.002) as significant predictors of poor outcome. These variables were weighted and used to compute a poor-grade aneurysmal SAH Prognosis Score (hereafter, Prognosis Score) for each patient. A Prognosis Score of 0 was associated with a 90% favorable outcome; Prognosis Score of 1 with 83%; Prognosis Score of 2 with 43%; Prognosis Score of 3 with 8%; Prognosis Score of 4 with 7%; and a Prognosis Score of 5 with 0%. CONCLUSION Outcome in poor-grade aneurysmal SAH is strongly predicted by patient age, worst preoperative Hunt and Hess clinical grade, and aneurysm size. Hyperglycemia on admission after poor-grade aneurysmal SAH increases the likelihood of poor outcome, and is a potentially modifiable risk factor. The Prognosis Score is a useful tool for preoperatively assessing the likelihood of a favorable outcome for poor-grade aneurysmal SAH patients.
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Affiliation(s)
- J Mocco
- Department of Neurological Surgery, Columbia University, New York, New York 10032, USA
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ter Laan M, Mooij JJA. Improvement after treatment of hydrocephalus in aneurysmal subarachnoid haemorrhage: implications for grading and prognosis. Acta Neurochir (Wien) 2006; 148:325-8; discussion 328. [PMID: 16328775 DOI: 10.1007/s00701-005-0661-9] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2004] [Accepted: 09/22/2005] [Indexed: 10/25/2022]
Abstract
Two patients with aneurysmal subarachnoid haemorrhage and hydrocephalus are presented. On admission they scored E1M4V1 and E1M3Vtube on the Glasgow Coma Scale. The first patient recovered to E3M5Vtube after treatment of hydrocpehalus by extraventricular drainage. The second recovered to E2M5Vtube and later E4M6V4 after treatment of hydrocephalus with lumbar drainage. Based on the literature it is argued that these cases are no exception as to the improvement after treatment of hydrocephalus. The prognosis of patients with hydrocephalus after a subarachnoid haemorrhage, improves in parallel with the Glasgow Coma Scale after treatment of hydrocephalus. Therefore decision making on whether or not to treat a patient with a subarachnoid haemorrhage should be postponed until after treatment of hydrocephalus, if present.
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Affiliation(s)
- M ter Laan
- Department of Neurosurgery, University Medical Centre Groningen, University of Groningen, The Netherlands
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Ter Minassian A, Proust F, Berré J, Hans P, Bonafé A, Puybasset L, Audibert G, de Kersaint-Gilly A, Beydon L, Bruder N, Boulard G, Ravussin P, Dufour H, Lejeune JP, Gabrillargues J. [Severity criteria for subarachnoid haemorrhage: intracranial hypertension, hydrocephalus]. ANNALES FRANCAISES D'ANESTHESIE ET DE REANIMATION 2005; 24:723-8. [PMID: 15922542 DOI: 10.1016/j.annfar.2005.03.021] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/02/2023]
Affiliation(s)
- A Ter Minassian
- Département d'anesthésie-réanimation chirurgicale I, CHU, 4, rue Larrey, 49033 Angers cedex 1, France.
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Ross J, O'Sullivan MG, Grant IS, Sellar R, Whittle IR. Impact of early endovascular aneurysmal occlusion on outcome of patients in poor grade after subarachnoid haemorrhage: a prospective, consecutive study. J Clin Neurosci 2002; 9:648-52. [PMID: 12604276 DOI: 10.1054/jocn.2002.1100] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Patients in poor grade (WFNS IV and V) after aneurysmal subarachnoid hemorrhage (SAH) often have a bad outcome. To evaluate early GDC embolisation on such patients a prospective observational study, with comparison to a historical cohort was performed. From January 1996 to December 1998 113 patients were admitted to the Department of Clinical Neurosciences in poor grade after SAH (45 WFNS IV and 68 WFNS V). Eighty-one patients were managed actively with endovascular occlusion of the aneurysm (n = 42) where possible and delayed clipping (n = 16) where not. On an intention to treat basis, 46% had a favourable outcome (Glasgow Outcome Score IV or V) and 48% had died by 3 months. Compared to an historical cohort managed in the same unit between 1992 and 1995 (n = 62, 52% favourable outcome) these results suggest that early GDC aneurysmal occlusion has had a minimal impact on overall outcome.
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Affiliation(s)
- J Ross
- Department of Clinical Neurosciences, Western General Hospital, Edinburgh, UK
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Chiang VLS, Claus EB, Awad IA. Toward More Rational Prediction of Outcome in Patients with High-grade Subarachnoid Hemorrhage. Neurosurgery 2000. [DOI: 10.1093/neurosurgery/46.1.28] [Citation(s) in RCA: 52] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Affiliation(s)
- Veronica L. S. Chiang
- Department of Neurosurgery, Yale University School of Medicine, New Haven, Connecticut
| | - Elizabeth B. Claus
- Department of Neurosurgery, Yale University School of Medicine, New Haven, Connecticut
| | - Issam A. Awad
- Department of Neurosurgery, Yale University School of Medicine, New Haven, Connecticut
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Hellawell DJ, Taylor R, Pentland B. Persisting symptoms and carers' views of outcome after subarachnoid haemorrhage. Clin Rehabil 1999; 13:333-40. [PMID: 10460121 DOI: 10.1191/026921599669500092] [Citation(s) in RCA: 31] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
OBJECTIVE To report the outcome of aneurysmal subarachnoid haemorrhage (SAH) in terms of subjective symptoms and carers' perspective over a period of two years. DESIGN Forty-four consecutive patients admitted to a Regional Neurosurgical Unit and who survived aneurysmal SAH were invited for outpatient assessment at 6, 12 and 24 months post haemorrhage. MEASURES The Glasgow Outcome Scale (GOS) was used to measure global outcome; the Hospital Anxiety and Depression Scale (HAD) to screen for affective symptoms; the Head Injury Symptom Checklist (HISC) to detect symptoms commonly reported after head trauma; and information was collected from a close friend or relative of the patient using the Relative's Questionnaire (RQ). RESULTS GOS outcome was significantly related to the severity of the original haemorrhage, as classified by the World Federation of Neurological Surgeons (WFNS) Grading Scale, on admission to hospital. However, even in cases where patients had made a good recovery according to the GOS, a variety of problems were frequently reported by patients and relatives, and many of these persisted for the duration of the study. The three most common and persistent symptoms were tiredness (63%, 59% and 59% at 6, 12 and 24 months respectively), memory disturbance (50%, 52% and 56%) and passivity (61%, 47% and 46%). In contrast, the prevalence of disturbed mood, as reported using the HAD, was similar to that of the general population. CONCLUSIONS Studies of outcome following SAH should address these subtle disturbances, and information pertaining to potential long-term problems should be provided to patients and relevant others.
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Affiliation(s)
- D J Hellawell
- Rehabilitation Studies Unit, The University of Edinburgh, Scotland
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Le Roux PD, Winn HR. Intracranial aneurysms and subarachnoid hemorrhage management of the poor grade patient. ACTA NEUROCHIRURGICA. SUPPLEMENT 1999; 72:7-26. [PMID: 10337410 DOI: 10.1007/978-3-7091-6377-1_2] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/12/2023]
Abstract
Between 20 and 30% of patients who suffer cerebral aneurysm rupture are in poor clinical grade when first evaluated. Management of these patients is controversial and challenging but can be successful with an aggressive proactive approach that begins with in the field resuscitation and continues through rehabilitation. In this article we review the epidemiology, pathology and pathophysiology, clinical features, evaluation, surgical and endovascular management, critical care, cost, and outcome prediction of patients in poor clinical grade after subarachnoid hemorrhage.
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Affiliation(s)
- P D Le Roux
- Department of Neurosurgery, New York University, New York, USA
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