Risk stratification of delayed causative aneurysm detection and long-term outcome in angiographically negative spontaneous subarachnoid haemorrhage

Prognostic Factors and Imaging Strategies in Unknown Subarachnoid Hemorrhage: A Retrospective Study

Background Subarachnoid hemorrhage (SAH) without an identifiable vascular lesion on initial angiography, commonly referred to as unknown or angiogram-negative SAH, remains diagnostically and prognostically challenging. Although perimesencephalic patterns tend to be benign, diffuse hemorrhages are associated with worse outcomes. The role of repeat vascular imaging in improving diagnosis and predicting prognosis remains unclear. Objective This study aimed to identify clinical and radiological factors associated with outcomes in patients with unknown SAH and evaluate the diagnostic and prognostic value of repeat angiography. Methods We retrospectively analyzed 26 patients with spontaneous, non-traumatic SAH and negative findings on initial digital subtraction angiography (DSA). Clinical status, hemorrhage patterns, and imaging data were recorded. Outcomes were assessed at discharge using the modified Rankin Scale (mRS). Repeat angiographic modalities and timing were analyzed in relation to prognosis. Results Patients with focal hemorrhage patterns, higher Glasgow Coma Scale (GCS) scores at admission, and absence of hydrocephalus had significantly better outcomes. Repeat DSA was more frequently performed in the good outcome group, although no new vascular lesions were identified.  Conclusion Unknown SAH is generally associated with favorable outcomes, but vigilance is warranted in diffuse SAH cases. Repeat DSA may not always reveal new lesions, but it plays a valuable role in guiding clinical confidence and management decisions. Tailored imaging strategies based on clinical and radiological risk factors are recommended.

Advanced lung cancer inflammation index is associated with mortality in critically ill patients with non-traumatic cerebral hemorrhage

Existing prognostic tools for non-traumatic intracerebral hemorrhage (NCH) mainly focus on neurological injury severity but overlook systemic factors that cause secondary deterioration. This study aimed to evaluate the Advanced Lung Cancer Inflammation Index (ALI), a biomarker combining nutritional parameters (BMI, albumin) and inflammatory parameters (neutrophil-to-lymphocyte ratio, NLR), as a new prognostic indicator for NCH. It aimed to fill the gap in quantifying the synergy between inflammation and malnutrition in neurocritical care.In this retrospective cohort study, 1502 critically ill NCH patients from the MIMIC-IV database were analyzed. ALI was calculated as (BMI × Albumin)/NLR, and patients were divided into groups based on the quartiles of the log-transformed ALI. The outcomes measured were in-hospital, 90-day, and 1-year mortality. Multivariable logistic regression, ROC curve analysis, restricted cubic spline models, and subgroup analyses were used to assess the prognostic value of ALI.The results showed that lower ALI values could independently predict mortality at all time points. After comprehensive adjustment, a 1-unit increase in the log-transformed ALI was associated with a 26% reduction in in-hospital mortality (OR = 0.74, 95% CI: 0.64-0.86, P < 0.001). The fourth quartile (with the highest ALI) had 56% lower mortality compared to the first quartile (OR = 0.44, P = 0.001). ALI had a strong ability to distinguish in-hospital all-cause mortality (AUC = 0.853, 95% CI: 0.826-0.880, P < 0.001). A threshold effect was found (log-transformed ALI = 4.0), below which ALI was inversely related to mortality (P < 0.001), and above which the relationship leveled off. Subgroup analyses confirmed the consistency of these findings across different age groups, comorbidities, and organ dysfunctions (P for interaction > 0.05). In conclusion, ALI is a reliable prognosticator for NCH, reflecting the interaction between systemic inflammation and malnutrition. Its simplicity and potential for threshold-based stratification may help in personalized interventions. Further prospective validation of ALI-guided protocols is needed.

Predicting postacute phase anaemia after aneurysmal subarachnoid haemorrhage: nomogram development and validation

BACKGROUND

Anaemia is a severe and common complication in patients with aneurysmal subarachnoid haemorrhage (aSAH). Early intervention for at-risk patients before anaemia occurs is indicated as potentially beneficial, but no validated method synthesises patients' complicated clinical features into an instrument. The purpose of the current study was to develop and externally validate a nomogram that predicted postacute phase anaemia after aSAH.

METHODS

We developed a novel nomogram for aSAH patients to predict postacute phase anaemia (3 days after occurrence of aSAH, prior to discharge) on the basis of demographic information, imaging, type of treatment, aneurysm features, blood tests and clinical characteristics. We designed the model from a development cohort and tested the nomogram in external and prospective validation cohorts. We included 456 aSAH patients from The First Affiliated Hospital for the development, 220 from Sanmen People's Hospital for external validation and a prospective validation cohort that included 13 patients from Hangzhou Red Cross Hospital. We assessed the performance of the nomogram via concordance statistics and evaluated the calibration of predicted anaemia outcome with observed anaemia occurrence.

RESULTS

Variables included in the nomogram were age, treatment method (open surgery or endovascular therapy), baseline haemoglobin level, fasting blood glucose level, systemic inflammatory response syndrome score on admission, Glasgow Coma Scale score, aneurysm size, prothrombin time and heart rate. In the validation cohort, the model for prediction of postacute phase anaemia had a c-statistic of 0.910, with satisfactory calibration (judged by eye) for the predicted and reported anaemia outcome. Among forward-looking forecasts, our predictive model achieved an 84% success rate, which showed that it has some clinical practicability.

CONCLUSIONS

The developed and validated nomogram can be used to calculate individualised anaemia risk and has the potential to serve as a practical tool for clinicians in devising improved treatment strategies for aSAH.