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Mistry AM, Saver J, Mack W, Kamel H, Elm J, Beall J. Subarachnoid Hemorrhage Trials: Cutting, Sliding, or Keeping mRS Scores and WFNS Grades. Stroke 2024; 55:779-784. [PMID: 38235584 DOI: 10.1161/strokeaha.123.044790] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2024]
Abstract
Rigorous evidence generation with randomized controlled trials has lagged for aneurysmal subarachnoid hemorrhage (SAH) compared with other forms of acute stroke. Besides its lower incidence compared with other stroke subtypes, the presentation and outcome of patients with SAH also differ. This must be considered and adjusted for in designing pivotal randomized controlled trials of patients with SAH. Here, we show the effect of the unique expected distribution of the SAH severity at presentation (World Federation of Neurological Surgeons grade) on the outcome most used in pivotal stroke randomized controlled trials (modified Rankin Scale) and, consequently, on the sample size. Furthermore, we discuss the advantages and disadvantages of different options to analyze the outcome and control the expected distribution of the World Federation of Neurological Surgeons grades in addition to showing their effects on the sample size. Finally, we offer methods that investigators can adapt to more precisely understand the effect of common modified Rankin Scale analysis methods and trial eligibility pertaining to the World Federation of Neurological Surgeons grade in designing their large-scale SAH randomized controlled trials.
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Affiliation(s)
| | - Jeffrey Saver
- Department of Neurology and Comprehensive Stroke Center, David Geffen School of Medicine, University of California, Los Angeles (J.S.)
| | - William Mack
- Department of Neurosurgery, Keck School of Medicine, University of Southern California, Los Angeles (W.M.)
| | - Hooman Kamel
- Department of Neurology, Clinical and Translational Neuroscience Unit, Feil Family Brain and Mind Research Institute, Weill Cornell Medicine, New York, NY (H.K.)
| | - Jordan Elm
- Department of Public Health Sciences, Medical University of South Carolina, Charleston (J.E., J.B.)
| | - Jonathan Beall
- Department of Public Health Sciences, Medical University of South Carolina, Charleston (J.E., J.B.)
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2
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Autio AH, Paavola J, Tervonen J, Lång M, Elomaa AP, Huuskonen TJ, Huttunen J, Kärkkäinen V, von Und Zu Fraunberg M, Lindgren AE, Koivisto T, Kurola J, Jääskeläinen JE, Kämäräinen OP. Acute evacuation of 54 intracerebral hematomas (aICH) during the microsurgical clipping of a ruptured middle cerebral artery bifurcation aneurysm-illustration of the individual clinical courses and outcomes with a serial brain CT/MRI panel until 12 months. Acta Neurochir (Wien) 2024; 166:17. [PMID: 38231317 PMCID: PMC10794262 DOI: 10.1007/s00701-024-05902-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2023] [Accepted: 12/11/2023] [Indexed: 01/18/2024]
Abstract
PURPOSE In aneurysmal intracerebral hemorrhage (aICH), our review showed the lack of the patient's individual (i) timeline panels and (ii) serial brain CT/MRI slice panels through the aICH evacuation and neurointensive care until the final brain tissue outcome. METHODS Our retrospective cohort consists of 54 consecutive aICH patients from a defined population who acutely underwent the clipping of a middle cerebral artery bifurcation saccular aneurysm (Mbif sIA) with the aICH evacuation at Kuopio University Hospital (KUH) from 2010 to 2019. We constructed the patient's individual timeline panels since the emergency call and serial brain CT/MRI slice panels through the aICH evacuation and neurointensive care until the final brain tissue outcome. The patients were indicated by numbers (1.-54.) in the pseudonymized panels, tables, results, and discussion. RESULTS The aICH volumes on KUH admission (median 46 cm3) plotted against the time from the emergency call to the evacuation (median 8 hours) associated significantly with the rebleeds (n=25) and the deaths (n=12). The serial CT/MRI slice panels illustrated the aICHs, intraventricular hemorrhages (aIVHs), residuals after the aICH evacuations, perihematomal edema (PHE), delayed cerebral injury (DCI), and in the 42 survivors, the clinical outcome (mRS) and the brain tissue outcome. CONCLUSIONS Regarding aICH evacuations, serial brain CT/MRI panels present more information than words, figures, and graphs. Re-bleeds associated with larger aICH volumes and worse outcomes. Swift logistics until the sIA occlusion with aICH evacuation is required, also in duty hours and weekends. Intraoperative CT is needed to illustrate the degree of aICH evacuation. PHE may evoke uncontrollable intracranial pressure (ICP) in spite of the acute aICH volume reduction.
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Affiliation(s)
- Anniina H Autio
- Neurosurgery, NeuroCenter, Kuopio University Hospital, PL 100, 70029, Kuopio, Finland.
- Institute of Clinical Medicine, School of Medicine, Faculty of Health Sciences, University of Eastern Finland, Kuopio, Finland.
| | - Juho Paavola
- Neurosurgery, NeuroCenter, Kuopio University Hospital, PL 100, 70029, Kuopio, Finland
- Institute of Clinical Medicine, School of Medicine, Faculty of Health Sciences, University of Eastern Finland, Kuopio, Finland
| | - Joona Tervonen
- Neurosurgery, NeuroCenter, Kuopio University Hospital, PL 100, 70029, Kuopio, Finland
- Institute of Clinical Medicine, School of Medicine, Faculty of Health Sciences, University of Eastern Finland, Kuopio, Finland
| | - Maarit Lång
- Institute of Clinical Medicine, School of Medicine, Faculty of Health Sciences, University of Eastern Finland, Kuopio, Finland
- Neurointensive Care Unit, Kuopio University Hospital, Kuopio, Finland
| | - Antti-Pekka Elomaa
- Neurosurgery, NeuroCenter, Kuopio University Hospital, PL 100, 70029, Kuopio, Finland
- Institute of Clinical Medicine, School of Medicine, Faculty of Health Sciences, University of Eastern Finland, Kuopio, Finland
| | - Terhi J Huuskonen
- Neurosurgery, NeuroCenter, Kuopio University Hospital, PL 100, 70029, Kuopio, Finland
- Institute of Clinical Medicine, School of Medicine, Faculty of Health Sciences, University of Eastern Finland, Kuopio, Finland
| | - Jukka Huttunen
- Neurosurgery, NeuroCenter, Kuopio University Hospital, PL 100, 70029, Kuopio, Finland
- Institute of Clinical Medicine, School of Medicine, Faculty of Health Sciences, University of Eastern Finland, Kuopio, Finland
| | - Virve Kärkkäinen
- Neurosurgery, NeuroCenter, Kuopio University Hospital, PL 100, 70029, Kuopio, Finland
| | - Mikael von Und Zu Fraunberg
- Neurosurgery, NeuroCenter, Kuopio University Hospital, PL 100, 70029, Kuopio, Finland
- Institute of Clinical Medicine, School of Medicine, Faculty of Health Sciences, University of Eastern Finland, Kuopio, Finland
- Department of Neurosurgery, Oulu University Hospital, Oulu, Finland
- Research Unit of Clinical Medicine, University of Oulu, Oulu, Finland
| | - Antti E Lindgren
- Neurosurgery, NeuroCenter, Kuopio University Hospital, PL 100, 70029, Kuopio, Finland
- Institute of Clinical Medicine, School of Medicine, Faculty of Health Sciences, University of Eastern Finland, Kuopio, Finland
- Clinical Radiology, Kuopio University Hospital, Kuopio, Finland
| | - Timo Koivisto
- Neurosurgery, NeuroCenter, Kuopio University Hospital, PL 100, 70029, Kuopio, Finland
- Institute of Clinical Medicine, School of Medicine, Faculty of Health Sciences, University of Eastern Finland, Kuopio, Finland
| | - Jouni Kurola
- Institute of Clinical Medicine, School of Medicine, Faculty of Health Sciences, University of Eastern Finland, Kuopio, Finland
- Center for Prehospital Emergency Care, Kuopio University Hospital, Kuopio, Finland
| | - Juha E Jääskeläinen
- Neurosurgery, NeuroCenter, Kuopio University Hospital, PL 100, 70029, Kuopio, Finland
- Institute of Clinical Medicine, School of Medicine, Faculty of Health Sciences, University of Eastern Finland, Kuopio, Finland
| | - Olli-Pekka Kämäräinen
- Neurosurgery, NeuroCenter, Kuopio University Hospital, PL 100, 70029, Kuopio, Finland
- Institute of Clinical Medicine, School of Medicine, Faculty of Health Sciences, University of Eastern Finland, Kuopio, Finland
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Umekawa M, Yoshikawa G. Impact of ventriculo-cisternal irrigation on prevention of delayed cerebral infarction in aneurysmal subarachnoid hemorrhage: a single-center retrospective study and literature review. Neurosurg Rev 2023; 47:6. [PMID: 38062206 PMCID: PMC10703947 DOI: 10.1007/s10143-023-02241-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2023] [Revised: 11/17/2023] [Accepted: 12/04/2023] [Indexed: 12/18/2023]
Abstract
OBJECTIVE The aim of this study was to evaluate the effectiveness of ventriculo-cisternal irrigation (VCI) in preventing vasospasms and delayed cerebral infarction (DCI) by washing out subarachnoid clots earlier after aneurysm surgery. METHODS We retrospectively identified 340 subarachnoid hemorrhage (SAH) patients with ruptured intracranial aneurysms treated with postoperative VCI at our institution between December 2010 and January 2020. As VCI therapy, a ventricular drain/cisternal drain was placed during aneurysm surgery, and lactated Ringer's solution was used for irrigation until day 4 of SAH, followed by intracranial pressure control at 5-10 cmH2O until day 14. RESULTS The median age was 65 years (interquartile range 52-75), with 236 female patients (69%). The World Federation of Neurosurgical Societies grade distribution was as follows: grade I or II, 175 patients (51%); grade III or IV, 84 (25%); and grade V, 81 (24%). With VCI management in all patients, total vasospasm occurred in 162 patients (48%), although the DCI incidence was low (23 patients [6.8%]). Major drainage-related complications were observed in five patients (1.5%). Early surgery, performed on SAH day 0 or 1, was identified as a preventive factor against DCI occurrence (odds ratio (OR) 0.21, 95% confidence interval (CI) 0.07-0.67; P = 0.008), while additional surgery (4.76, 1.62-13.98; P = 0.005) and dyslipidemia (3.27, 1.24-8.63; P = 0.017) were associated with DCI occurrence. CONCLUSION Managing vasospasms with VCI after SAH is considered a safe and effective method to prevent DCI. Early surgery after SAH may be associated with a decreased risk of DCI with VCI therapy.
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Affiliation(s)
- Motoyuki Umekawa
- Department of Neurosurgery, Showa General Hospital, Tokyo, 187-8510, Japan.
- Department of Neurosurgery, The University of Tokyo Hospital, Tokyo, Japan.
| | - Gakushi Yoshikawa
- Department of Neurosurgery, Showa General Hospital, Tokyo, 187-8510, Japan
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Henry J, Dablouk MO, Kapoor D, Koustais S, Corr P, Nolan D, Coffey D, Thornton J, O'Hare A, Power S, Rawluk D, Javadpour M. Outcomes following poor-grade aneurysmal subarachnoid haemorrhage: a prospective observational study. Acta Neurochir (Wien) 2023; 165:3651-3664. [PMID: 37968366 DOI: 10.1007/s00701-023-05884-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2023] [Accepted: 10/18/2023] [Indexed: 11/17/2023]
Abstract
BACKGROUND Up to 35% of aneurysmal subarachnoid haemorrhage (aSAH) cases may present as poor grade, defined as World Federation of Neurosurgical Societies (WFNS) grades IV and V. In this study, we evaluate functional outcomes and prognostic factors. METHODS This prospective study included all patients referred to a national, centralized neurosurgical service with a diagnosis of poor-grade aSAH between 01/01/2016 and 31/12/2019. Multivariable logistic regression models were used to estimate probability of poor functional outcomes, defined as a Glasgow Outcome Scale (GOS) of 1-3 at 3 months. RESULTS Two hundred fifty-seven patients were referred, of whom 116/257 (45.1%) underwent treatment of an aneurysm, with 97/116 (84%) treated within 48 h of referral. Median age was 62 years (IQR 51-69) with a female predominance (167/257, 65%). Untreated patients tended to be older; 123/141 (87%) had WFNS V, 60/141 (45%) unreactive pupils and 21/141 (16%) circulatory arrest. Of all referred patients, poor outcome occurred in 169/230 (73.5%). Unreactive pupils or circulatory arrest conferred a universally poor prognosis, with mortality in 55/56 (98%) and 19/19 (100%), respectively. The risk of a poor outcome was 14.1% (95% CI 4.5-23.6) higher in WFNS V compared with WFNS IV. Age was important in patients without circulatory arrest or unreactive pupils, with risk of a poor outcome increasing by 1.8% per year (95% CI 1-2.7). In patients undergoing aneurysm securement, 48/101 (47.5%) had a poor outcome, with age, rebleeding, vasospasm and cerebrospinal fluid (CSF) diversion being important prognosticators. The addition of serum markers did not add significant discrimination beyond the clinical presentation. CONCLUSIONS The overall outcomes of WFNS IV and V aSAH remain poor, mainly due to the devastating effects of the original haemorrhage. However, in patients selected for aneurysm securement, good outcomes can be achieved in more than half of patients. Age, pre-intervention rebleeding, vasospasm, and CSF diversion are important prognostic factors.
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Affiliation(s)
- Jack Henry
- National Neurosurgical Centre, Beaumont Hospital, Dublin, Ireland.
- Royal College of Surgeons in Ireland, Dublin, Ireland.
| | - Mohammed O Dablouk
- National Neurosurgical Centre, Beaumont Hospital, Dublin, Ireland
- Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Dhruv Kapoor
- National Neurosurgical Centre, Beaumont Hospital, Dublin, Ireland
| | - Stavros Koustais
- National Neurosurgical Centre, Beaumont Hospital, Dublin, Ireland
- Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Paula Corr
- National Neurosurgical Centre, Beaumont Hospital, Dublin, Ireland
| | - Deirdre Nolan
- National Neurosurgical Centre, Beaumont Hospital, Dublin, Ireland
| | - Deirdre Coffey
- National Neurosurgical Centre, Beaumont Hospital, Dublin, Ireland
| | - John Thornton
- Department of Neuroradiology, Beaumont Hospital, Dublin, Ireland
| | - Alan O'Hare
- Department of Neuroradiology, Beaumont Hospital, Dublin, Ireland
| | - Sarah Power
- Department of Neuroradiology, Beaumont Hospital, Dublin, Ireland
| | - Daniel Rawluk
- National Neurosurgical Centre, Beaumont Hospital, Dublin, Ireland
| | - Mohsen Javadpour
- National Neurosurgical Centre, Beaumont Hospital, Dublin, Ireland.
- Royal College of Surgeons in Ireland, Dublin, Ireland.
- Department of Academic Neurology, Trinity College Dublin, Dublin, Ireland.
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Mistry AM, Saver J, Mack W, Kamel H, Elm J, Beall J. Subarachnoid Hemorrhage Trials: Cutting, Sliding, or Keeping mRS Scores and WFNS Grades. MEDRXIV : THE PREPRINT SERVER FOR HEALTH SCIENCES 2023:2023.09.28.23296257. [PMID: 37873354 PMCID: PMC10593043 DOI: 10.1101/2023.09.28.23296257] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/25/2023]
Abstract
Rigorous evidence generation with randomized controlled trials (RCTs) has lagged for aneurysmal subarachnoid hemorrhage (SAH) compared to other forms of acute stroke. Besides its lower incidence compared to other stroke subtypes, the presentation and outcome of SAH patients also differ. This must be considered and adjusted for in designing pivotal RCTs of SAH patients. Here, we show the effect of the unique expected distribution of the SAH severity at presentation (World Federation of Neurological Surgeons, WFNS, grade) on the outcome most used in pivotal stroke RCTs (modified Rankin Scale, mRS) and consequently on the sample size. Further, we discuss the advantages and disadvantages of different options to analyze the outcome and control the expected distribution of WFNS grades in addition to showing their effects on the sample size. Last, we offer methods that investigators can adapt to more precisely understand the effect of common mRS analysis methods and trial eligibility pertaining to the WFNS grade in designing their large-scale SAH RCTs.
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Affiliation(s)
| | - Jeffrey Saver
- Department of Neurology and Comprehensive Stroke Center, David Geffen School of Medicine, University of California, Los Angeles, CA
| | - William Mack
- Department of Neurosurgery, Keck School of Medicine, University of Southern California, Los Angeles, CA
| | - Hooman Kamel
- Clinical and Translational Neuroscience Unit, Feil Family Brain and Mind Research Institute and Department of Neurology, Weill Cornell Medicine, New York, NY
| | - Jordan Elm
- Department of Public Health Sciences, Medical University of South Carolina, Charleston, SC
| | - Jonathan Beall
- Department of Public Health Sciences, Medical University of South Carolina, Charleston, SC
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6
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Kobata H, Ikawa F, Sato A, Kato Y, Sano H. Significance of Pupillary Findings in Decision Making and Outcomes of World Federation of Neurological Societies Grade V Subarachnoid Hemorrhage. Neurosurgery 2023; 93:309-319. [PMID: 36825904 DOI: 10.1227/neu.0000000000002410] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2022] [Accepted: 12/15/2022] [Indexed: 02/25/2023] Open
Abstract
BACKGROUND There is considerable debate regarding the definition of grade V subarachnoid hemorrhage (SAH). Recently, the Glasgow Coma Scale-Pupil (GCS-P) score was advocated for assessing traumatic brain injury. OBJECTIVE To study the significance of pupillary findings and GCS-P in the management and outcomes of the World Federation of Neurological Societies (WFNS) grade V SAH. METHODS We analyzed data obtained from a Japanese nationwide prospective registration study on the modified WFNS SAH grading system. Bilateral pupillary dilatation without reactivity was defined as pupil score 2, unilateral pupil dilation without reactivity as score 1, and no pupil dilatation with reactivity as score 0. The GCS-P score was calculated by subtracting the pupil score from the total GCS score. The characteristics and pupillary findings were examined in patients with each GCS score in WFNS grade V. RESULTS Among 1638 patients, 472 (men/women = 161/311, age 67.0 ± 14.0 years) had a GCS score of ≤6 after initial resuscitation on arrival. Overall, lower GCS scores were associated with poorer neurological outcomes and higher mortality. Aneurysms were treated in 20.5%, 53.9%, and 67.5% of patients with pupil scores of 2, 1, and 0, respectively. Favorable outcomes (modified Rankin Scale 0-2) at 3 months occurred in 4.5%, 10.8%, and 21.4% in patients with pupil scores 2, 1, and 0, respectively ( P < .0001), and in 0%, 0%, 13.6%, 28.6%, 16.7%, and 18.8% of patients with GCS-P scores 1 to 6 ( P < .0001), respectively. CONCLUSION Our study confirmed the significance of pupillary findings in decision making and outcomes of WFNS grade V SAH.
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Affiliation(s)
- Hitoshi Kobata
- Department of Neurosurgery, Osaka Mishima Emergency Critical Care Center, Takatsuki, Japan
- Department of Neurosurgery, Osaka Medical and Pharmaceutical University, Takatsuki, Japan
| | - Fusao Ikawa
- Department of Neurosurgery, Shimane Prefectural Central Hospital, Izumo, Japan
| | - Akira Sato
- Gotanda Rehabilitation Hospital, Tokyo, Japan
| | - Yoko Kato
- Department of Neurosurgery, Banbuntane Hotokukai Hospital, Nagoya, Aichi, Japan
| | - Hirotoshi Sano
- Department of Neurosurgery, Shinkawabashi Hospital, Kawasaki, Japan
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Goldberg J, Z'Graggen WJ, Hlavica M, Branca M, Marbacher S, D'Alonzo D, Fandino J, Stienen MN, Neidert MC, Burkhardt JK, Regli L, Seule M, Roethlisberger M, Guzman R, Zumofen DW, Maduri R, Daniel RT, El Rahal A, Corniola MV, Bijlenga P, Schaller K, Rölz R, Scheiwe C, Shah M, Heiland DH, Schnell O, Beck J, Raabe A, Fung C. Quality of Life After Poor-Grade Aneurysmal Subarachnoid Hemorrhage. Neurosurgery 2023; 92:1052-1057. [PMID: 36700700 DOI: 10.1227/neu.0000000000002332] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2022] [Accepted: 10/31/2022] [Indexed: 01/27/2023] Open
Abstract
BACKGROUND Poor-grade aneurysmal subarachnoid hemorrhage (aSAH) is associated with high mortality and poor disability outcome. Data on quality of life (QoL) among survivors are scarce because patients with poor-grade aSAH are underrepresented in clinical studies reporting on QoL after aSAH. OBJECTIVE To provide prospective QoL data on survivors of poor-grade aSAH to aid clinical decision making and counseling of relatives. METHODS The herniation World Federation of Neurosurgical Societies scale study was a prospective observational multicenter study in patients with poor-grade (World Federation of Neurosurgical Societies grades 4 & 5) aSAH. We collected data during a structured telephone interview 6 and 12 months after ictus. QoL was measured using the EuroQoL - 5 Dimensions - 3 Levels (EQ-5D-3L) questionnaire, with 0 representing a health state equivalent to death and 1 to perfect health. Disability outcome for favorable and unfavorable outcomes was measured with the modified Rankin Scale. RESULTS Two hundred-fifty patients were enrolled, of whom 237 were included in the analysis after 6 months and 223 after 12 months. After 6 months, 118 (49.8%) patients were alive, and after 12 months, 104 (46.6%) patients were alive. Of those, 95 (80.5%) and 89 (85.6%) reached a favorable outcome with mean EQ-5D-3L index values of 0.85 (±0.18) and 0.86 (±0.18). After 6 and 12 months, 23 (19.5%) and 15 (14.4%) of those alive had an unfavorable outcome with mean EQ-5D-3L index values of 0.27 (±0.25) and 0.19 (±0.14). CONCLUSION Despite high initial mortality, the proportion of poor-grade aSAH survivors with good QoL is reasonably large. Only a minority of survivors reports poor QoL and requires permanent care.
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Affiliation(s)
- Johannes Goldberg
- Department of Neurosurgery, Inselspital, Bern University-Hospital, Bern, Switzerland
| | - Werner J Z'Graggen
- Department of Neurosurgery, Inselspital, Bern University-Hospital, Bern, Switzerland
| | - Martin Hlavica
- Department of Neurosurgery, Inselspital, Bern University-Hospital, Bern, Switzerland.,Department of Neurosurgery, Kantonsspital St. Gallen, St. Gallen, Switzerland
| | | | - Serge Marbacher
- Department of Neurosurgery, Kantonspital Aarau, Aarau, Switzerland
| | - Donato D'Alonzo
- Department of Neurosurgery, Kantonspital Aarau, Aarau, Switzerland
| | - Javier Fandino
- Department of Neurosurgery, Kantonspital Aarau, Aarau, Switzerland
| | - Martin N Stienen
- Department of Neurosurgery, Kantonsspital St. Gallen, St. Gallen, Switzerland.,Department of Neurosurgery, Clinical Neuroscience Center, University-Hospital Zurich and University of Zurich, Zurich, Switzerland
| | - Marian C Neidert
- Department of Neurosurgery, Kantonsspital St. Gallen, St. Gallen, Switzerland.,Department of Neurosurgery, Clinical Neuroscience Center, University-Hospital Zurich and University of Zurich, Zurich, Switzerland
| | - Jan-Karl Burkhardt
- Department of Neurosurgery, Clinical Neuroscience Center, University-Hospital Zurich and University of Zurich, Zurich, Switzerland.,Department of Neurosurgery, Hospital of the University of Pennsylvania, Penn Medicine, Philadelphia, Pennsylvania, USA
| | - Luca Regli
- Department of Neurosurgery, Clinical Neuroscience Center, University-Hospital Zurich and University of Zurich, Zurich, Switzerland
| | - Martin Seule
- Department of Neurosurgery, Kantonsspital St. Gallen, St. Gallen, Switzerland
| | - Michel Roethlisberger
- Department of Neurosurgery, University-Hospital Basel, University of Basel, Basel, Switzerland
| | - Raphael Guzman
- Department of Neurosurgery, University-Hospital Basel, University of Basel, Basel, Switzerland
| | - Daniel Walter Zumofen
- Department of Surgery, Neurology, and Radiology, Maimonides Medical Center, Brooklyn, USA
| | - Rodolfo Maduri
- Swiss Medical Network, Clinique de Genolier, Genolier, Switzerland
| | - Roy Thomas Daniel
- Department of Neurosurgery, University-Hospital Lausanne, Lausanne, Switzerland
| | - Amir El Rahal
- Department of Neurosurgery, University-Hospital Geneva, Geneva, Switzerland.,Department of Neurosurgery, Medical Center, University of Freiburg, Freiburg, Germany
| | - Marco V Corniola
- Department of Neurosurgery, University-Hospital Geneva, Geneva, Switzerland.,Department of Neurosurgery, University-Hospital Rennes, Rennes, France
| | - Philippe Bijlenga
- Department of Neurosurgery, University-Hospital Geneva, Geneva, Switzerland
| | - Karl Schaller
- Department of Neurosurgery, University-Hospital Geneva, Geneva, Switzerland
| | - Roland Rölz
- Department of Neurosurgery, Medical Center, University of Freiburg, Freiburg, Germany
| | - Christian Scheiwe
- Department of Neurosurgery, Medical Center, University of Freiburg, Freiburg, Germany
| | - Mukesch Shah
- Department of Neurosurgery, Medical Center, University of Freiburg, Freiburg, Germany
| | - Dieter Henrik Heiland
- Department of Neurosurgery, Medical Center, University of Freiburg, Freiburg, Germany
| | - Oliver Schnell
- Department of Neurosurgery, Medical Center, University of Freiburg, Freiburg, Germany
| | - Jürgen Beck
- Department of Neurosurgery, Medical Center, University of Freiburg, Freiburg, Germany
| | - Andreas Raabe
- Department of Neurosurgery, Inselspital, Bern University-Hospital, Bern, Switzerland
| | - Christian Fung
- Department of Neurosurgery, Medical Center, University of Freiburg, Freiburg, Germany
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8
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de Winkel J, Cras TY, Dammers R, van Doormaal PJ, van der Jagt M, Dippel DWJ, Lingsma HF, Roozenbeek B. Early predictors of functional outcome in poor-grade aneurysmal subarachnoid hemorrhage: a systematic review and meta-analysis. BMC Neurol 2022; 22:239. [PMID: 35773634 PMCID: PMC9245240 DOI: 10.1186/s12883-022-02734-x] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2022] [Accepted: 05/19/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Patients with poor-grade aneurysmal subarachnoid hemorrhage (aSAH) often receive delayed or no aneurysm treatment, although recent studies suggest that functional outcome following early aneurysm treatment has improved. We aimed to systematically review and meta-analyze early predictors of functional outcome in poor-grade aSAH patients. METHODS: We included studies investigating the association of early predictors and functional outcome in adult patients with confirmed poor-grade aSAH, defined as World Federation of Neurological Surgeons (WFNS) grade or Hunt and Hess (H-H) grade IV-V. Studies had to use multivariable regression analysis to estimate independent predictor effects of favorable functional outcome measured with the Glasgow Outcome Scale or modified Rankin Scale. We calculated pooled adjusted odds ratios (aOR) and 95% confidence intervals (CI) with random effects models. RESULTS: We included 27 studies with 3287 patients. The likelihood of favorable outcome increased with WFNS grade or H-H grade IV versus V (aOR 2.9, 95% CI 1.9-4.3), presence of clinical improvement before aneurysm treatment (aOR 3.3, 95% CI 2.0-5.3), and intact pupillary light reflex (aOR 2.9, 95% CI 1.6-5.1), and decreased with older age (aOR 0.7, 95% CI 0.5-1.0, per decade), increasing modified Fisher grade (aOR 0.4, 95% CI 0.3-0.5, per grade), and presence of intracerebral hematoma on admission imaging (aOR 0.4, 95% CI 0.2-0.8). CONCLUSIONS We present a summary of early predictors of functional outcome in poor-grade aSAH patients that can help to discriminate between patients with favorable and with unfavorable prognosis and may aid in selecting patients for early aneurysm treatment.
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Affiliation(s)
- Jordi de Winkel
- Department of Neurology, Erasmus MC University Medical Center Rotterdam, Rotterdam, The Netherlands. .,Department of Public Health, Erasmus MC University Medical Center Rotterdam, Rotterdam, The Netherlands.
| | - Tim Y Cras
- Department of Neurology, Erasmus MC University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Ruben Dammers
- Department of Neurosurgery, Erasmus MC University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Pieter-Jan van Doormaal
- Department of Radiology and Nuclear Medicine, Erasmus MC University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Mathieu van der Jagt
- Department of Intensive Care Adults, Erasmus MC University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Diederik W J Dippel
- Department of Neurology, Erasmus MC University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Hester F Lingsma
- Department of Public Health, Erasmus MC University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Bob Roozenbeek
- Department of Neurology, Erasmus MC University Medical Center Rotterdam, Rotterdam, The Netherlands
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