Scoring Model to Predict Functional Outcome in Poor-Grade Aneurysmal Subarachnoid Hemorrhage

Development and Validation of Machine Learning Models for Outcome Prediction in Patients with Poor-Grade Aneurysmal Subarachnoid Hemorrhage Following Endovascular Treatment

Background

Endovascular treatment (EVT) has been recommended as a superior modality for the treatment of intracranial aneurysm. However, there still exists a worse percentage of poor functional outcome in patients with poor-grade aneurysmal subarachnoid hemorrhage (aSAH) undergoing EVT. Therefore, it is urgently needed to investigate the risk factors and develop a critical decision model in the subtype of such patients.

Methods

We extracted the target variables from an ongoing registry cohort study, PROSAH-MPC, which was conducted in multiple centers in China. We randomly assigned these patients to training and validation cohorts with a ratio of 7:3. Univariate and multivariate logistic regressions were performed to find the potential factors, and then nine machine learning models and a stack ensemble model were developed with optimized variables. The performance of these models was evaluated through several indicators, including area under the receiver operating characteristic curve (AUC-ROC). We further use Shapley Additive Explanations (SHAP) methods for the distribution of feature visualization based on the optimal models.

Results

A total of 226 eligible patients with poor-grade aSAH undergoing EVT were enrolled, while 89 (39.4%) has a poor 12-month outcome. Age (Adjusted OR [aOR], 1.08; 95% CI: 1.03-1.13; p = 0.002), subarachnoid hemorrhage volume (aOR, 1.02; 95% CI: 1.00-1.05; p = 0.033), World Federation of Neurosurgical Societies grade (WFNS) (aOR, 2.03; 95% CI: 1.05-3.93; p = 0.035), and Hunt-Hess grade (aOR, 2.36; 95% CI: 1.13-4.93; p = 0.022) were identified as the independent risk factors of the poor outcome. Then, the prediction models developed have revealed that LightGBM algorithm has a superior performance with an AUC-ROC value of 0.842 in the validation cohort, while the SHAP results showed that age is the most important risk factor affecting functional outcomes.

Conclusion

The LightGBM model holds immense potential in facilitating risk stratification for poor-grade aSAH patients undergoing endovascular treatment who are at risk of adverse outcomes, thereby enhancing clinical decision-making processes.

Trial Registration

PROSAH-MPC. NCT05738083. Registered 16 November 2022 - Retrospectively registered, https://clinicaltrials.gov/study/NCT05738083.

Comparison of prediction for short-term and long-term outcomes in patients with aneurysmal subarachnoid hemorrhage: a systematic review and meta-analysis

Despite extensive research on prediction models for outcomes in aneurysmal subarachnoid hemorrhage (aSAH) patients, the distinction between models for short- and long-term outcomes remains insufficiently explored. This study aims to compare these models, identify the risk factors of poor outcomes, summarize the predictors of outcomes, and assess the performance of the prediction models for short- and long-term outcomes in aSAH patients. PubMed, Web of Science, the Cochrane Library, and Embase were searched to identify studies investigating risk factors for developed and/or validated prediction models for short-term (< 12 months) and long-term (≥ 12 months) outcomes in aSAH patients. The main outcome was neurological function, defined as poor if the Glasgow Outcome Scale (GOS) score was ≤ 3, or if the modified Rankin Scale (mRS) score was ≥ 3. Fifty-six studies reporting 61 models with 36,879 aSAH patients were included. A total of 93 predictors were examined and categorized into six domains including demographic factors, scoring systems, clinical factors, aneurysm characteristics, laboratory examinations, and imaging features. Among these, laboratory examinations were included in 57.45% (27/47) of models predicting short-term outcomes, while only 14.29% (2/14) of long-term prediction models incorporated them. An mFisher score of 3-4 [OR = 1.95, 95%CI (1.43, 2.64), P < 0.01] and the presence of multiple aneurysms [OR = 1.56, 95% CI (1.25, 1.94), P < 0.01] were identified as risk factors for poor short-term outcomes, however, this association was weakened in predicting poor long-term outcomes. All studies were found to have a high risk of bias, primarily due to inappropriate data sources and inadequate reporting of the analysis domain. This review suggested that aSAH patients with poor clinical scores and hypertension are at a higher risk of poor outcomes. The majority of the included prediction models perform well, but generally lack reporting in the analysis domain, which may hinder their clinical applicability.

Risk Score for Early Prediction of In-Hospital Mortality After Aneurysmal Subarachnoid Hemorrhage: Pooled Analysis With Score Construction and Validation

OBJECTIVE

Aneurysmal subarachnoid hemorrhage (aSAH) has a high complications burden, with in-hospital mortality as the most devastating outcome. We aimed to develop and validate a risk score for early prediction of in-hospital mortality after aSAH.

METHODS

Data from 2 university hospitals were pooled (n = 1070), with cohorts for score construction (n = 886) and external validation (n = 184). Several parameters assessable at admission were collected. Independent predictors of in-hospital mortality were used as mortality score components. Diagnostic accuracy of the novel score was compared to the Hunt and Hess Age, Intraventricular Hemorrhage, Rebleed and World Federation of Neurosurgical Societies (WFNS) scores.

RESULTS

Overall rate of in-hospital mortality was 19% and 14.7% in construction and validation cohorts, respectively. The novel risk score (aSAH mortality score: 0-12 points) included patients' age (≤55 years: 0 points, 56-70 years: 1 point, >70 years: 2 points), aneurysm rebleeding (2 points), WFNS grade (grade I-II: 0 points, grade III-IV: 2 points, grade V: 5 points), and Hijdra sum score (≤10: 0 points, 11-20: 1 point, 21-30: 2 points, >30: 3 points). In-hospital mortality rates ranged 0.6% (0 points) to 100% (12 points) in the construction cohort, and 0% (0 points) to 60% (10 points) in the validation cohort. In the receiver operating characteristic analysis, the aneurysmal subarachnoid hemorrhage mortality score (area under the curve [AUC]: 0.829 and 0.824 in the construction and validation cohorts, respectively) was superior to the Hunt and Hess Age, Intraventricular Hemorrhage, Rebleed (AUC: 0.811 and 0.813) and WFNS scores (AUC: 0.768 and 0.795).

CONCLUSIONS

Risk of in-hospital mortality after aSAH can be predicted with high accuracy using baseline characteristics. The novel risk score showed best diagnostic performance in the construction and validation cohorts and can aid in early prognostication and treatment decisions.

Machine learning for predicting poor outcomes in aneurysmal subarachnoid hemorrhage: A systematic review and meta-analysis involving 8445 participants

Early prediction of poor outcomes in patients impacted with aneurysmal subarachnoid hemorrhage (aSAH) is crucial for timely intervention and effective management. This systematic review and meta-analysis aimed to evaluate the performance of machine learning (ML) algorithms in predicting poor outcomes in patients with aSAH, assessing their sensitivity, specificity, and other algorithm metrics. A comprehensive search of PubMed, Scopus, Embase, Web of science and Cochrane library conducted to identify eligible studies. We extracted data on sensitivity, specificity, accuracy, precision, F1score and area under the curve (AUC) from the included studies. Out of 2238 studies screened, 12 met our eligibility criteria involving ML approaches in patients with confirmed aSAH. ML algorithms, particularly XGBoost and CatBoost, offer promising performance for predicting poor outcomes in aSAH patients. Meta-analysis was performed on 12 studies resulted in a pooled sensitivity of 0.88 [95 % CI: 0.76-0.94], specificity of 0.78 [95 % CI 0.66-0.86], positive DLR of 3.91 [95 % CI: 2.42-6.30], negative DLR of 0.16 [95 % CI: 0.07-0.34], diagnostic odds ratio of 24.9 [95 % CI: 7.97-77.82], the diagnostic score of 3.21[95 % CI: 2.08-4.35], and the area AUC was 0.82, indicating substantial diagnostic performance. However, conventional LR showed slightly superior predictive function compared to ML algorithms. These findings underscore the potential of ML algorithms to significantly advance the predictability of poor outcomes in patients with aSAH, suggesting that ML can play a critical role in enhancing clinical decision-making.

A nomogram for predicting prognostic risk factors in individuals with poor grade aneurysmal subarachnoid hemorrhage: a retrospective study

Poor-grade aneurysmal subarachnoid hemorrhage (PGASAH) is associated with high mortality and morbidity despite advanced treatments. Accurate prediction of prognosis remains a clinical challenge. This study aimed to identify independent risk factors and develop a predictive nomogram for unfavorable outcomes in PGASAH patients. This retrospective study included 348 PGASAH patients treated between 2003 and 2016. Univariate and multivariate logistic regression analyses were performed to evaluate the association of premorbid conditions, admission aSAH clinical parameters, admission laboratory parameters, and clinical complications with unfavorable outcomes, defined as mRS > 2 at 6 months. Independent predictors were identified, and a nomogram was constructed to assess predictive accuracy and clinical utility. The median age of PGASAH patients was 55.1 years, 64.9% were females. Independent predictors of unfavorable outcomes (mRS > 2) at 6 months included age > 55 years (aOR = 2.44), cardiac valve disease (aOR = 6.50), dilated pupils at admission (aOR = 2.64), early infarction (aOR = 5.56), and delayed cerebral ischemia (aOR = 5.09). The nomogram demonstrated good predictive performance with an AUC of 0.807. Decision curve analysis affirmed its clinical applicability. The intuitive nomogram helps physicians predict PGASAH prognosis at discharge, improving long-term management, optimizing resource allocation, and enhancing patient and family awareness and psychological preparedness. External validation is required for broader clinical use.

Intraoperative Hypotension and Postoperative Newly Developed Cerebral Infarction in Patients With Aneurysmal Subarachnoid Hemorrhage: A Retrospective Cohort Study

AIMS

To investigate the association between intraoperative hypotension and newly developed cerebral infarction in patients with aneurysmal subarachnoid hemorrhage (aSAH) undergoing aneurysm clipping or coiling.

METHODS

The patients who had emergent clipping/coiling procedures for aSAH under general anesthesia were included. The major exposure was mean arterial pressure (MAP) below different absolute or relative thresholds characterized by area under curve (AUC), duration, and time-weighted average (TWA) value. The outcome was newly developed cerebral infarction. The associations between MAP and newly developed cerebral infarction were adjusted by other risk factors. Odds ratio and 95% confidence interval were used to present the statistical difference.

RESULTS

A total of 1205 patients were included in the analysis. Of these, 260 patients (21.6%) developed new cerebral infarctions assessed by computed tomography. Patients with newly developed cerebral infarction had higher incidence of modified Fisher Scale (mFS) score 3 to 4 (80.0 vs. 69.1%, p < 0.01) and longer duration of anesthesia (4.3 vs. 3.9 h, p < 0.01). In the multivariate model, the AUC-MAP (adjusted odds ratio: 1.00, 95% CI: 1.000 to 1.000, p = 0.02) and the TWA-MAP (adjusted odds ratio: 1.01, 95% CI: 1.001 to 1.024, p = 0.04) of 20% decrease from baseline were closely associated with the newly developed cerebral infarction.

CONCLUSIONS

Mean arterial pressure decreased 20% from baseline value were independently associated with postoperative newly developed cerebral infarction in patients with aSAH.

Association of serum glucose/potassium index levels with poor long-term prognosis in patients with Aneurysmal Subarachnoid Hemorrhage

INTRODUCTION

The glucose/potassium index (GPI) has been reported as a predictor biomarker of in-hospital complications in patients with aneurysmal subarachnoid hemorrhage (aSAH).

OBJECTIVES

To determine the association between GPI and functional outcome at 3-6 months after discharge in patients diagnosed with aSAH in a Peruvian referral hospital during 2018-2021.

MATERIALS AND METHODS

We conducted a retrospective cohort observational study with a secondary database in patients with aSAH during 2018-2021 in a Peruvian referral hospital. We evaluated the relationship between GPI values and motor functionality from 3 m to 6 months post-discharge, using a Poisson family generalized linear model with Log link function and robust variance according to categorization of good and poor outcome. We considered a value of p<0.05 as statistically significant. We used restricted cubic splines with five nodes to evaluate the linear correlation between the 2 main variables.

RESULTS

212 patients were included in the analysis. 21.1 % and 19.3 % had poor outcome at 3 and 6 months after discharge, respectively. Multivariate analysis showed that GPI was not associated with poor outcome at 3 (RR=0.999; 95 %CI=0.979-1.018) or 6 months after discharge (RR=0.979; 95 %CI=0.979-1.020). On the other hand, Splines plots showed no correlation between GPI and modified Rankin.

CONCLUSIONS

Despite the usefulness of GPI to prognosticate in-hospital complications, its association with functional outcome is inconclusive.

Comparison of scales for the evaluation of aneurysmal subarachnoid haemorrhage: a retrospective cohort study

BACKGROUND/OBJECTIVES

Aneurysmal subarachnoid haemorrhage (aSAH) is a life-threatening event with major complications. Delayed cerebral infarct (DCI) occurs most frequently 7 days after aSAH and can last for a prolonged period. To determine the most predictive radiological scales in grading subarachnoid or ventricular haemorrhage or both for functional outcome at 3 months in a large aSAH population, we conducted a single-centre retrospective study.

METHODS

A 3-year single-centre retrospective cohort study of 230 patients hospitalised for aSAH was analysed. Initial computed tomography (CT) scans in patients hospitalised for aSAH were blindly assessed using eight grading systems: the Fisher grade, modified Fisher grade, Barrow Neurological Institute scale, Hijdra scale, Intraventricular Haemorrhage (IVH) score, Graeb score and LeRoux score.

RESULTS

Of 200 patients with aSAH who survived to day 7 and were included for DCI analysis, 39% of cases were complicated with DCI. The Hijdra scale was the best predictor for DCI, with a receiver operating characteristic area under the curve (ROCAUC) of 0.80 (95% confidence interval (CI), 0.74-0.85). The IVH score was the most effective grading system for predicting acute hydrocephalus, with a ROCAUC of 0.85 (95% CI, 0.79-0.89). In multivariate analysis, the Hijdra scale was the best predictor of the occurrence of DCI (hazard ratio, 1.18; 95% CI, 1.10-1.25).

CONCLUSIONS

Although these results have yet to be prospectively confirmed, our findings suggest that the Hijdra scale may be a good predictor of DCI and could be useful in daily clinical practice.

CLINICAL RELEVANCE STATEMENT

Better assessment of subarachnoid haemorrhage patients would allow for better prognostication and management of expectations, as well as referral for appropriate services and helping to appropriate use limited critical care resources.

KEY POINTS

Aneurysmal subarachnoid haemorrhage is a life-threatening event that causes severe disability and leads to major complications such as delayed cerebral infarction. Accurate assessment of the amount of blood in the subarachnoid spaces on computed tomography with the Hijdra scale can better predict the risk of delayed cerebral infarct. The Hijdra scale could be a good triage tool for subarachnoid haemorrhage patients.

Identifying Patients at Increased Risk for Poor Outcomes Among Poor-Grade Aneurysmal Subarachnoid Hemorrhage Patients: The IPOGRO Risk Model

BACKGROUND

A subarachnoid hemorrhage due to an aneurysmal rupture (aSAH) is a serious condition with severe neurological consequences. The World Federation of Neurosurgical Societies (WFNS) classification is a reliable predictor of death and long-term disability in patients with aSAH. Poor-grade neurological conditions on admission in aSAH (PG-aSAH) are often linked to high mortality rates and unfavorable outcomes. However, more than one-third of patients with PG-aSAH may recover and have good functional outcomes if aggressive treatment is provided. We developed a risk model called Identifying POor GRade Outcomes (IPOGRO) to predict 6-month mRS outcomes in PG-aSAH patients as a secondary analysis of a previously published study.

METHODS

All consecutive patients in poor-grade neurological conditions (WFNS IV-V) admitted to our institute from 2010 to 2020 due to aSAH were considered. Clinical and neuroradiological parameters were employed in the univariable analysis to evaluate the relationship with a 6-month modified Rankin Scale (mRS). Then, a multivariable multinomial regression model was performed to predict 6-month outcomes.

RESULTS

149 patients with PG-aSAH were included. Most patients were surgically treated, with only 33.6% being endovascularly treated. The 6-month mRS score was significantly associated with clinical parameters on admission, such as lowered Glasgow Coma Scale (GCS), leukocytosis, hyperglycemia, raised Systolic Blood Pressure (SBP), greater Simplified Acute Physiology Score (SAPS II score), increased initial serum Lactic Acid (LA) levels, and the need for Norepinephrine (NE) administration. Neuroradiological parameters on the initial CT scan showed a significant association with a worsening 6-month mRS. The IPOGRO risk model analysis showed an association between a WFNS V on admission and a poor outcome (mRS 4-5), while raised SBP was associated with mortality.

CONCLUSIONS

Our IPOGRO risk model indicates that PG-aSAH patients with higher SBP at admission had an increased risk of death at 6-month follow-up, whereas patients with WFNS grade V at admission had an increased risk of poor outcome but not mortality.

Effect of External Ventricular Drainage on Shunt-Dependent Hydrocephalus and Prognosis After Microsurgical Clipping in Patients with Poor-Grade Aneurysmal Subarachnoid Hemorrhage

OBJECTIVE

In poor-grade aneurysm subarachnoid hemorrhage (PaSAH), the use of external ventricular drainage (EVD) may be closely related to the occurrence of shunt-dependent hydrocephalus (SDHC). The purpose of this study was to investigate the effect of EVD on SDHC and prognosis after microsurgically clipping patients with PaSAH.

METHODS

The clinical data of 99 patients with PaSAH admitted to the 904th Hospital of People's Liberation Army from October 2011 to December 2020 were analyzed retrospectively. Univariate and multivariate logistic regression analyses were used to clarify the relationship between EVD implantation and its drainage volume and SDHC after PaSAH. Receiver operating characteristic curves were plotted to compare the prognostic efficiency of different drainage volumes on SDHC. Modified Poisson regression analysis was used to determine the effect of SDHC on prognosis after PaSAH.

RESULTS

EVD implantation increased the risk of SDHC (odds ratio = 6.715, 95% confidence interval 1.120-40.248, P = 0.037). The increased drainage volume on day 1, mean daily drainage volume within 2 days, and average within 3 days increased the risk of SDHC. EVD drainage volume on the first postoperative day has a good predictive ability for SDHC after PaSAH, with an area under the curve of 0.829 (95% confidence interval 0.731-0.928); the optimal cut-off value was 208 ml, with a sensitivity of 79.4%, a specificity of 81.6%, and a Youden index of 0.61. The occurrence of SDHC after aneurysm clipping significantly increases the risk of poor prognosis of PaSAH.

CONCLUSIONS

EVD implantation is an independent risk factor for SDHC after PaSAH, and a large drainage volume in the first 3 days after EVD implantation is an independent risk factor for SDHC after PaSAH. The drainage volume on the first day after surgery is the best predictor of SDHC after PaSAH. SDHC after PaSAH is the strongest independent risk factor for poor prognosis and prolongs hospital stay.

Innovative prognostication: a novel nomogram for post-interventional aneurysmal subarachnoid hemorrhage patients

Background and purpose

Spontaneous aneurysmal subarachnoid hemorrhage (aSAH) is a common acute cerebrovascular disease characterized by severe illness, high mortality, and potential cognitive and motor impairments. We carried out a retrospective study at Fujian Provincial Hospital to establish and validate a model for forecasting functional outcomes at 6 months in aSAH patients who underwent interventional embolization.

Methods

386 aSAH patients who underwent interventional embolization between May 2012 and April 2022 were included in the study. We established a logistic regression model based on independent risk factors associated with 6-month adverse outcomes (modified Rankin Scale Score ≥ 3, mRS). We evaluated the model's performance based on its discrimination, calibration, clinical applicability, and generalization ability. Finally, the study-derived prediction model was also compared with other aSAH prognostic scales and the model's itself constituent variables to assess their respective predictive efficacy.

Results

The predictors considered in our study were age, the World Federation of Neurosurgical Societies (WFNS) grade of IV-V, mFisher score of 3-4, secondary cerebral infarction, and first leukocyte counts on admission. Our model demonstrated excellent discrimination in both the modeling and validation cohorts, with an area under the curve of 0.914 (p < 0.001, 95%CI = 0.873-0.956) and 0.947 (p < 0.001, 95%CI = 0.907-0.987), respectively. Additionally, the model also exhibited good calibration (Hosmer-Lemeshow goodness-of-fit test: X2 = 9.176, p = 0.328). The clinical decision curve analysis and clinical impact curve showed favorable clinical applicability. In comparison to other prediction models and variables, our model displayed superior predictive performance.

Conclusion

The new prediction nomogram has the capability to forecast the unfavorable outcomes at 6 months after intervention in patients with aSAH.

Causal Effect Estimation on Imaging and Clinical Data for Treatment Decision Support of Aneurysmal Subarachnoid Hemorrhage

Aneurysmal subarachnoid hemorrhage is a medical emergency of brain that has high mortality and poor prognosis. Causal effect estimation of treatment strategies on patient outcomes is crucial for aneurysmal subarachnoid hemorrhage treatment decision-making. However, most existing studies on treatment decision-making support of this disease are unable to simultaneously compare the potential outcomes of different treatments for a patient. Furthermore, these studies fail to harmoniously integrate the imaging data with non-imaging clinical data, both of which are useful in clinical scenarios. In this paper, we estimate the causal effect of various treatments on patients with aneurysmal subarachnoid hemorrhage by integrating plain CT with non-imaging clinical data, which is represented using structured tabular data. Specifically, we first propose a novel scheme that uses multi-modality confounders distillation architecture to predict the treatment outcome and treatment assignment simultaneously. With these distilled confounder features, we design an imaging and non-imaging interaction representation learning strategy to use the complementary information extracted from different modalities to balance the feature distribution of different treatment groups. We have conducted extensive experiments using a clinical dataset of 656 subarachnoid hemorrhage cases, which was collected from the Hospital Authority Data Collaboration Laboratory in Hong Kong. Our method shows consistent improvements on the evaluation metrics of treatment effect estimation, achieving state-of-the-art results over strong competitors. Code is released at https://github.com/med-air/TOP-aSAH.

The factors associated with the modified Fisher grade in patients with aneurysmal subarachnoid hemorrhage

Background

Aneurysmal subarachnoid hemorrhage (aSAH) is a life-threatening medical condition with a high fatality and morbidity rate. There was a substantial link between the modified Fisher grade of aSAH and the neurological function deficit. This study aimed to analyze the factors associated with the modified Fisher grade of aSAH using a machine learning approach.

Methods

A multi-center observational study was conducted. The patients with aSAH were recruited from five tertiary hospitals in China. The volume of hemorrhage in aSAH was measured using the modified Fisher grade scale. The risk factors responsible for the modified Fisher grade of aSAH were analyzed, which include sociodemographic factors, clinical factors, blood index, and ruptured aneurysm characteristics. We built several tree-based machine learning models (XGBoost, CatBoost, LightGBM) for prediction and used grid search to optimize model parameters. To comprehensively evaluate the model, we used Accuracy, Precision, Area Under the Receiver Operating Characteristic Curve (AUROC), Area Under the Precision-Recall Curve (AUPRC), and Brier as evaluation indicators to assess the model performance and select the best model.

Results

A total of 888 patients with aSAH were recruited, of whom 305 with modified Fisher grade of 3 and 4. The results show that the XGBoost model has the highest AUROC of 0.772, and the indicators are better than CatBoost and LightGBM. The feature importance graph shows that the top feature variables include platelet, thrombin time, fibrinogen, preadmission systolic blood pressure, activated partial thromboplastin time, and the time interval between the onset of aSAH and the first-time CT examination.

Conclusion

The factors responsible for the modified Fisher grade of aSAH were identified, which offered valuable insights for future research and clinical intervention. These risk factors should be controlled in the treatment of unruptured aneurysms, and appropriate treatment can be given if necessary to reduce the risk of severe hemorrhage after aneurysm rupture.

Clinical Factors Associated with SFTS Diagnosis and Severity in Cats

Severe fever with thrombocytopenia syndrome (SFTS) is a potentially fatal tick-borne zoonosis caused by SFTS virus (SFTSV). In addition to tick bites, animal-to-human transmission of SFTSV has been reported, but little is known about feline SFTSV infection. In this study, we analyzed data on 187 cats with suspected SFTS to identify biomarkers for SFTS diagnosis and clinical outcome. Body weight, red and white blood cell and platelet counts, and serum aspartate aminotransferase and total bilirubin levels were useful for SFTS diagnosis, whereas alanine aminotransferase, aspartate aminotransferase and serum SFTSV RNA levels were associated with clinical outcome. We developed a scoring model to predict SFTSV infection. In addition, we performed a phylogenetic analysis to reveal the relationship between disease severity and viral strain. This study provides comprehensive information on feline SFTS and could contribute to the protection of cat owners, community members, and veterinarians from the risk of cat-transmitted SFTSV infection.

Factors Affecting Outcomes of Poor-Grade Subarachnoid Hemorrhage

OBJECTIVE

Poor-grade subarachnoid hemorrhage (SAH) accounts for 20% of all SAH and is associated with poor outcomes. The first step in improving outcomes is to analyze the factors that contribute to poor outcomes.

METHODS

This was a multicenter, retrospective, observational, cohort study. Data fields included demographic, clinical, radiological, and outcome data for all spontaneous patients with SAH treated at 4 hospitals in Aomori Prefecture in Japan. Patients with modified Rankin Scale score 0-2 at discharge were defined as the good outcome group, and those with modified Rankin Scale score 3-6 were defined as the poor outcome group, and comparisons were made between the 2 groups.

RESULTS

There were 329 eligible patients with poor-grade SAH, 41 with good outcome group, and 288 with poor outcome group. On multivariate analysis of the outcome, conservative treatment (P < 0.001), Fisher group 4 (P < 0.007), age ≥65 years (P = 0.011), and Hunt and Kosnik grade V on admission (P = 0.021) were significant factors contributing to a poor outcome.

CONCLUSIONS

Nonelderly patients who are not in grade V and Fisher group 4 should undergo aneurysm treatment as soon as possible because they are more likely to have a good outcome, whereas elderly patients in grade V and Fisher group 4 are unlikely to benefit from aneurysm treatment at present. The development of a treatment for early brain injury may be important to improve the outcomes of patients with poor-grade SAH.

Explainable machine learning in outcome prediction of high-grade aneurysmal subarachnoid hemorrhage

OBJECTIVE

Accurate prognostic prediction in patients with high-grade aneruysmal subarachnoid hemorrhage (aSAH) is essential for personalized treatment. In this study, we developed an interpretable prognostic machine learning model for high-grade aSAH patients using SHapley Additive exPlanations (SHAP).

METHODS

A prospective registry cohort of high-grade aSAH patients was collected in one single-center hospital. The endpoint in our study is a 12-month follow-up outcome. The dataset was divided into training and validation sets in a 7:3 ratio. Machine learning algorithms, including Logistic regression model (LR), support vector machine (SVM), random forest (RF), and extreme gradient boosting (XGBoost), were employed to develop a prognostic prediction model for high-grade aSAH. The optimal model was selected for SHAP analysis.

RESULTS

Among the 421 patients, 204 (48.5%) exhibited poor prognosis. The RF model demonstrated superior performance compared to LR (AUC = 0.850, 95% CI: 0.783-0.918), SVM (AUC = 0.862, 95% CI: 0.799-0.926), and XGBoost (AUC = 0.850, 95% CI: 0.783-0.917) with an AUC of 0.867 (95% CI: 0.806-0 .929). Primary prognostic features identified through SHAP analysis included higher World Federation of Neurosurgical Societies (WFNS) grade, higher modified Fisher score (mFS) and advanced age, were found to be associated with 12-month unfavorable outcome, while the treatment of coiling embolization for aSAH drove the prediction towards favorable prognosis. Additionally, the SHAP force plot visualized individual prognosis predictions.

CONCLUSIONS

This study demonstrated the potential of machine learning techniques in prognostic prediction for high-grade aSAH patients. The features identified through SHAP analysis enhance model interpretability and provide guidance for clinical decision-making.

Factors affecting 30-day mortality in poor-grade aneurysmal subarachnoid hemorrhage: a 10-year single-center experience

Background

The management of patients with poor-grade aneurysmal subarachnoid hemorrhage (aSAH) is burdened by an unfavorable prognosis even with aggressive treatment. The aim of the present study is to investigate the risk factors affecting 30-day mortality in poor-grade aSAH patients.

Methods

We performed a retrospective analysis of a prospectively collected database of poor-grade aSAH patients (World Federation of Neurosurgical Societies, WFNS, grades IV and V) treated at our institution from December 2010 to December 2020. For all variables, percentages of frequency distributions were analyzed. Contingency tables (Chi-squared test) were used to assess the association between categorical variables and outcomes in the univariable analysis. Multivariable analysis was performed by using the multiple logistic regression method to estimate the odds ratio (OR) for 30-day mortality.

Results

A total of 149 patients were included of which 32% had WFNS grade 4 and 68% had WFNS grade 5. The overall 1-month mortality rate was 21%. On univariable analysis, five variables were found to be associated with the likelihood of death, including intraventricular hemorrhage (IVH ≥ 50 mL, p = 0.005), the total amount of intraventricular and intraparenchymal hemorrhage (IVH + ICH ≥ 90 mL, p = 0.019), the IVH Ratio (IVH Ratio ≥ 40%, p = 0.003), posterior circulation aneurysms (p = 0.019), presence of spot sign on initial CT scan angiography (p = 0.015).Nonetheless, when the multivariable analysis was performed, only IVH Ratio (p = 0.005; OR 3.97), posterior circulation aneurysms (p = 0.008; OR 4.05) and spot sign (p = 0.022; OR 6.87) turned out to be independent predictors of 30-day mortality.

Conclusion

The risk of mortality in poor-grade aSAH remains considerable despite maximal treatment. Notwithstanding the limitations of a retrospective study, our report highlights some neuroradiological features that in the emergency setting, combined with leading clinical and anamnestic parameters, may support the multidisciplinary team in the difficult decision-making process and communication with family members from the earliest stages of poor-grade aSAH. Further prospective studies are warranted.

Clinical Outcome of Patients with Poor-Grade Aneurysmal Subarachnoid Hemorrhage with Bundled Treatments: A Propensity Score-Matched Analysis

BACKGROUND

Poor-grade aneurysmal subarachnoid hemorrhage (aSAH), defined as Hunt and Hess (HH) grades IV and V, is a challenging disease because of its high mortality and poor functional outcomes. The effectiveness of bundled treatments has been demonstrated in critical diseases. Therefore, poor-grade aSAH bundled treatments have been established. This study aims to evaluate whether bundled treatments can improve long-term outcomes and mortality in patients with poor-grade aSAH.

METHODS

This is a comparative study using historical control from 2008 to 2022. Bundled treatments were introduced in 2017. We compared the rate of favorable outcomes (modified Rankin Scale score 0-2) at 6 months and mortality before and after the introduction of the bundled treatments. To eliminate confounding bias, the propensity score matching method was used.

RESULTS

A total of 90 consecutive patients were evaluated. Forty-three patients received bundled treatments, and 47 patients received conventional care. The proportion of patients with HH grade V was higher in the bundle treatment group (41.9% vs. 27.7%). Conversely, the proportion of patients with fixed pupils on the initial examination was higher in the conventional group (30.2% vs. 38.3%). After 1:1 propensity score matching, 31 pairs were allocated to each group. The proportion of patients with 6-month favorable functional outcomes was significantly higher in the bundled treatments group (46.4% vs. 20.7%, p = 0.04). The 6-month mortality rate was 14.3% in the bundled treatments group and 27.3% in the conventional group (p = 0.01). Bundled treatments (odd ratio 14.6 [95% confidence interval 2.1-100.0], p < 0.01) and the presence of an initial pupil reflex (odd ratio 12.0 [95% confidence interval 1.4-104.6], p = 0.02) were significantly associated with a 6-month favorable functional outcome.

CONCLUSIONS

The bundled treatments improve 6-month functional outcome and mortality in patients with poor-grade aSAH.

Intraoperative blood pressure and cardiac complications after aneurysmal subarachnoid hemorrhage: a retrospective cohort study

BACKGROUND

Previous studies report that intraoperative hypotension worsens outcomes after aneurysmal subarachnoid hemorrhage (aSAH). However, the hypotensive harm threshold for major adverse cardiovascular events (MACE) remains unclear.

METHODS

The authors included aSAH patients who had general anesthesia for aneurysmal clipping/coiling. MACE were defined by a composite of acute myocardial injury, acute myocardial infarction, and other cardiovascular complications identified by electrocardiogram and echocardiography. The authors initially used logistic regression and change-point analysis based on the second derivative to identify mean arterial pressure (MAP) of 75 mmHg as the harm threshold. Thereafter, our major exposure was MAP below 75 mmHg characterized by area, duration, and time-weighted average. The area below 75 mmHg represents the severity and duration of exposure and was defined as the sum of all areas below a specified threshold using the trapezoid rule. Time-weighted average MAP was derived by dividing area below the threshold by the duration of anesthesia. All analyses were adjusted for baseline risk factors including age greater than 70 years, female sex, severity of intracerebral hemorrhage, history of cardiovascular disease, and preoperative elevated myocardial enzymes.

RESULTS

Among 1029 patients enrolled, 254 (25%) developed postoperative MACE. Patients who experienced MACE were slightly older (59±11 vs. 54±11 years), were slightly more often women (69 vs. 58%), and had a higher prevalence of cardiovascular history (65 vs. 47%). Adjusted cardiovascular risk increased nearly linearly over the entire range of observed MAP. However, there was a slight inflexion at MAP of 75 mmHg. MACE was significantly associated with area [adjusted odds ratios (aOR) 1.004 per 10 mmHg.min, 95% CI: 1.001-1.007, P =0.002), duration (aOR 1.031 per 10 min, 95% CI: 1.009-1.054, P =0.006), and time-weighted average (aOR 3.516 per 10 mmHg, 95% CI: 1.818-6.801, P <0.001) of MAP less than 75 mmHg.

CONCLUSIONS

Lower blood pressures were associated with cardiovascular complications over the entire observed range, but worsened when MAP was less than 75 mmHg. Pending trial data to establish causality, it may be prudent to keep MAP above 75 mmHg in patients having surgical aSAH repairs to reduce the risk of MACE.

Length of Survival, Outcome, and Potential Predictors in Poor-Grade Aneurysmal Subarachnoid Hemorrhage Patients Treated with Microsurgical Clipping

BACKGROUND

Poor-grade aneurysmal subarachnoid hemorrhage (aSAH) has been associated with severe morbidity and high mortality. It has been demonstrated that early intervention is of paramount importance. The aim of our study is to evaluate the functional outcome and the overall survival of early microsurgically treated patients.

MATERIAL AND METHODS

Poor-grade aSAH patients admitted at our institution over fifteen years (January 2008 - December 2022) were included in our retrospective study. All participants underwent brain Computed Tomography Angiography (CTA). Fisher scale was used to assess the severity of hemorrhage. All our study participants underwent microsurgical clipping, and their functional outcome was assessed with the Glasgow Outcome Scale (GOS). We used logistic regression analysis to identify any parameters associated with a favorable outcome at 12 months. Cox proportional hazard analysis was also performed, identifying factors affecting the length of survival.

RESULTS

Our study included 39 patients with a mean age of 54 years. Thirty of our participants (76.9%) were Hunt and Hess grade V, while the vast majority (94.9%) were Fisher grade 4. The observed six-month mortality rate was 48.6%. The mean follow-up time was 18.6 months. The functional outcome at six months was favorable in 6 patients (16.2%), increased to 23.5% at 12 months. Our data analysis showed that the age, as well as the employment of temporary clipping during surgery, affected the overall outcome.

CONCLUSION

Management of poor-grade aSAH patients has been dramatically changed. Microsurgical clipping provides promising results in carefully selected younger patients.

Prognostic value of scales for aneurysmal subarachnoid hemorrhage: Report of a reference center in Peru

INTRODUCTION

Multiple scales have been designed to stratify the severity and predict the prognosis in the initial evaluation of patients with aneurysmal subarachnoid hemorrhage (aSAH). Our study aimed to validate the most commonly used prognostic scales for aSAH in our population: Hunt-Hess, modified Hunt-Hess, World Federation of Neurosurgical Societies (WFNS), Prognosis on Admission of Aneurysmal Subarachnoid Hemorrhage (PAASH), and Barrow Aneurysm Institute (BAI) scales.

METHODS

This study includes all aSAH cases treated at our institution between June 2019 and December 2020. We developed a retrospective cohort by reviewing medical records and radiologic images performed during hospitalization. The outcome was evaluated using the modified Rankin scale (mRS). It was defined as a poor outcome (mRS 4-5) and mortality (mRS 6). The ROC curves and the area under the curve (AUC) of each of the prognostic scales were calculated to evaluate their prognostic prediction capacity.

RESULTS

A total of 142 patients were diagnosed with aSAH. A poor outcome occurred in 52.1% of the patients, whereas mortality was 27.5%. The AUC of the scales studied was similar and no significant difference was found between them for predicting a poor outcome (P = .709) or mortality (P = .715).

CONCLUSION

We determined that the prognostic scales for aSAH had a similar predictive value for poor clinical outcomes and mortality in our institution, with no significant difference. Thus, we recommend the most simple and well-known scale used institutionally.

Preoperative scale proposal based on clinical outcome for elderly patients with ruptured intracranial aneurysms undergoing microsurgery

INTRODUCTION

Life expectancy in individuals has increased in recent years. There is no consensus in the literature on the best treatment for a ruptured aneurysm in the elderly (> 60 years), but some places only have microsurgery as a therapeutic strategy. This work aims to develop a prognostic scale for ruptured intracranial aneurysms in the elderly.

MATERIAL AND METHODS

Two thousand five hundred thirty patients with subarachnoid hemorrhage were retrospectively evaluated in the last ten years, and 550 of them were elderly. We developed a prognostic scale from the analysis of medical records, clinical and tomographic features that had statistical significance. Glasgow Coma Outcome (GOS) was the outcome of interest and p value < 0,05 was considered statistically significant.

RESULTS

Five hundred fifty patients were evaluated, and the comorbidities that were independent variables for poor prognosis were smoking and arterial hypertension; clinical variables were Hunt-Hess, modified Rankin and Glasgow Coma Scale; tomographic was Fisher scale. Poor outcome was defined as GOS ≤ 3. Poor surgical outcomes were more remarkable in the high-risk factor categories, being 6.41 times higher among individuals who had 3 to 4 risk factors and 8.80 times higher among individuals with 5 to 6 risk factors.

CONCLUSION

In some vascular neurosurgery services worldwide, microsurgery is the only therapeutic option. This scale aimed at the elderly patient individualizes the treatment and can predict the clinical outcome in ruptured intracranial aneurysms.

Predictive nomogram models for unfavorable prognosis after aneurysmal subarachnoid hemorrhage: Analysis from a prospective, observational cohort in China

AIM

The aim of the study was to identify predictors for 3-month poor functional outcome or death after aSAH and develop precise and easy-to-use nomogram models.

METHODS

The study was performed at the department of neurology emergency in Beijing Tiantan Hospital. A total of 310 aSAH patients were enrolled between October 2020 and September 2021 as a derivation cohort, while a total of 208 patients were admitted from October 2021 to March 2022 as an external validation cohort. Clinical outcomes included poor functional outcome defined as modified Rankin Scale score (mRS) of 4-6 or all-cause death at 3 months. Least absolute shrinkage and selection operator (LASSO) analysis, as well as multivariable regression analysis, were applied to select independent variables associated with poor functional outcome or death and then to construct two nomogram models. Model performance were evaluated through discrimination, calibration, and clinical usefulness in both derivation cohort and external validation cohort.

RESULTS

The nomogram model to predict poor functional outcome included seven predictors: age, heart rate, Hunt-Hess grade on admission, lymphocyte, C-reactive protein (CRP), platelet, and direct bilirubin levels. It demonstrated high discrimination ability (AUC, 0.845; 95% CI: 0.787-0.903), satisfactory calibration curve, and good clinical usefulness. Similarly, the nomogram model combining age, neutrophil, lymphocyte, CRP, aspartate aminotransferase (AST) levels, and treatment methods to predict all-cause death also revealed excellent discrimination ability (AUC, 0.944; 95% CI: 0.910-0.979), satisfactory calibration curve, and clinical effectiveness. Internal validation showed the bias-corrected C-index for poor functional outcome and death was 0.827 and 0.927, respectively. When applied to the external validation dataset, both two nomogram models exhibited high discrimination capacity [poor functional outcome: AUC = 0.795 (0.716-0.873); death: AUC = 0.811 (0.707-0.915)], good calibration ability, and clinical usefulness.

CONCLUSIONS

Nomogram models constructed for predicting 3-month poor functional outcome or death after aSAH are precise and easily applicable, which can help physicians to identify patients at risk, guide decision-making, and provide new directions for future studies to explore the novel treatment targets.

Neurocognitive Sequelae and Rehabilitation after Subarachnoid Hemorrhage: Optimizing Outcomes

Subarachnoid hemorrhage (SAH) is a medical emergency that requires immediate intervention. The etiology varies between cases; however, rupture of an intracranial aneurysm accounts for 80% of medical emergencies. Early intervention and treatment are essential to prevent long-term complications. Over the years, treatment of SAH has drastically improved, which is responsible for the rapid rise in SAH survivors. Post-SAH, a significant number of patients exhibit impairments in memory and executive function and report high rates of depression and anxiety that ultimately affect daily living, return to work, and quality of life. Given the rise in SAH survivors, rehabilitation post-SAH to optimize patient outcomes becomes crucial. The review addresses the current rehabilitative strategies to combat the neurocognitive and behavioral issues that may arise following SAH.

A 90-Day Prognostic Model Based on the Early Brain Injury Indicators after Aneurysmal Subarachnoid Hemorrhage: the TAPS Score

This study aimed to establish a new scoring model based on the early brain injury (EBI) indicators to predict the 90-day functional outcomes in patients with aneurysmal subarachnoid hemorrhage (aSAH). We retrospectively enrolled 825 patients and prospectively enrolled 108 patients with aSAH who underwent surgical clipping or endovascular coiling (derivation cohort = 640; validation cohort = 185; prospective cohort = 108) in our institute. We established a logistic regression model based on independent risk factors associated with 90-day unfavorable outcomes. The discrimination of the prognostic model was assessed by the area under the curve in a receiver operating characteristic curve analysis. The Hosmer-Lemeshow goodness-of-fit test and a calibration plot were used to evaluate the calibration of the prediction model. The developed scoring model named "TAPS" (total score, 0-7 points) included the following admission variables: age > 55 years old, WFNS grade of 4-5, mFS grade of 3-4, Graeb score of 5-12, white blood cell count > 11.28 × 109/L, and surgical clipping. The model showed good discrimination with the area under the curve in the derivation, validation, and prospective cohorts which were 0.816 (p < 0.001, 95%CI = 0.77-0.86), 0.810 (p < 0.001, 95%CI = 0.73-0.90), and 0.803 (p < 0.001, 95%CI = 0.70-0.91), respectively. The model also demonstrated good calibration (Hosmer-Lemeshow goodness-of-fit test: X2 = 1.75, df = 8, p = 0.988). Compared with other predictive models, TAPS is an easy handle tool for predicting the 90-day unfavorable outcomes of aSAH patients, which can help clinicians better understand the concept of EBI and quickly identify those patients at risk of poor prognosis, providing more positive treatment strategies. Trial registration: NCT04785976. Registered 5 March 2021-retrospectively registered, http://www.clinicaltrials.gov .

A nomogram for predicting the risk of poor prognosis in patients with poor-grade aneurysmal subarachnoid hemorrhage following microsurgical clipping

Objective

Aneurysmal subarachnoid hemorrhage (aSAH) is a common and potentially fatal cerebrovascular disease. Poor-grade aSAH (Hunt-Hess grades IV and V) accounts for 20-30% of patients with aSAH, with most patients having a poor prognosis. This study aimed to develop a stable nomogram model for predicting adverse outcomes at 6 months in patients with aSAH, and thus, aid in improving the prognosis.

Method

The clinical data and imaging findings of 150 patients with poor-grade aSAH treated with microsurgical clipping of intracranial aneurysms on admission from December 2015 to October 2021 were retrospectively analyzed. Least absolute shrinkage and selection operator (LASSO), logistic regression analyses, and a nomogram were used to develop the prognostic models. Receiver operating characteristic (ROC) curves and Hosmer-Lemeshow tests were used to assess discrimination and calibration. The bootstrap method (1,000 repetitions) was used for internal validation. Decision curve analysis (DCA) was performed to evaluate the clinical validity of the nomogram model.

Result

LASSO regression analysis showed that age, Hunt-Hess grade, Glasgow Coma Scale (GCS), aneurysm size, and refractory hyperpyrexia were potential predictors for poor-grade aSAH. Logistic regression analyses revealed that age (OR: 1.107, 95% CI: 1.056-1.116, P < 0.001), Hunt-Hess grade (OR: 8.832, 95% CI: 2.312-33.736, P = 0.001), aneurysm size (OR: 6.871, 95% CI: 1.907-24.754, P = 0.003) and refractory fever (OR: 3.610, 95% CI: 1.301-10.018, P < 0.001) were independent predictors of poor outcome. The area under the ROC curve (AUC) was 0.909. The calibration curve and Hosmer-Lemeshow tests showed that the nomogram had good calibration ability. Furthermore, the DCA curve showed better clinical utilization of the nomogram.

Conclusion

This study provides a reliable and valuable nomogram that can accurately predict the risk of poor prognosis in patients with poor-grade aSAH after microsurgical clipping. This tool is easy to use and can help physicians make appropriate clinical decisions to significantly improve patient prognosis.

A novel nomogram model for clinical outcomes of severe subarachnoid hemorrhage patients

Background

Systemic responses, especially inflammatory responses, after aneurysmal subarachnoid hemorrhage (SAH) are closely related to clinical outcomes. Our study aimed to explore the correlation between the systemic responses in the acute stage and the mid-term outcomes of severe SAH patients (Hunt-Hess grade III-V).

Materials and methods

Severe SAH patients admitted to Jinling Hospital from January 2015 to December 2019 were retrospectively analyzed in the study. The univariate and multivariate logistic regression analyses were used to explore the risk factors of 6-month clinical outcomes in severe SAH patients. A predictive model was established based on those risk factors and was visualized by a nomogram. Then, the predictive nomogram model was validated in another severe SAH patient cohort from January 2020 to January 2022.

Results

A total of 194 patients were enrolled in this study. 123 (63.4%, 123 of 194) patients achieved good clinical outcomes at the 6-month follow-up. Univariate and multivariate logistic regression analysis revealed that age, Hunt-Hess grade, neutrophil-to-lymphocyte ratio (NLR), and complications not related to operations were independent risk factors for unfavorable outcomes at 6-month follow-up. The areas under the curve (AUC) analysis showed that the predictive model based on the above four variables was significantly better than the Hunt-Hess grade (0.812 vs. 0.685, P = 0.013). In the validation cohort with 44 severe SAH patients from three different clinical centers, the AUC of the prognostic nomogram model was 0.893.

Conclusion

The predictive nomogram model could be a reliable predictive tool for the outcome of severe SAH patients. Systemic inflammatory responses after SAH and complications not related to operations, especially hydrocephalus, delayed cerebral ischemia, and pneumonia, might be the important risk factors that lead to poor outcomes in severe SAH patients.

Serum concentrations of NLRP3 in relation to functional outcome and delayed cerebral ischemia after aneurysmal subarachnoid hemorrhage

BACKGROUND

Nucleotide-binding oligomerization domain-like receptor family pyrin domain-containing 3 (NLRP3) participates in neuroinflammation. We endeavored to determine the role of serum NLRP3 as a biomarker of neuroinflammation, severity, delayed cerebral ischemia (DCI) and functional outcome following aneurysmal subarachnoid hemorrhage (aSAH).

METHODS

In this prospective and observational study, a total of 118 aSAH patients and 118 healthy volunteers were enrolled. Serum NLRP3 concentrations, blood glucose concentrations, serum C-reactive protein concentrations, and blood leucocyte counts were quantified. A poor outcome was defined as extended Glasgow outcome scale scores of 1-4 at post-injury 90 days.

RESULTS

As compared to controls, significantly increased serum NLRP3 concentrations after aSAH were intimately correlated with the Glasgow coma scale scores, World Federation of Neurological Surgeons scale scores, Hunt-Hess scores, modified Fisher scores, extended Glasgow outcome scale scores, blood glucose concentrations, serum C-reactive protein concentrations and blood leucocyte counts. Serum NLRP3 emerged as an independent predictor for DCI and poor 90-day outcome. Using receiver operating characteristic curve, serum NLRP3 concentrations were significantly predictive of DCI and poor 90-day outcome. Its prognostic predictive ability was comparable to those of the Glasgow coma scale scores, World Federation of Neurological Surgeons scale scores, Hunt-Hess scores and modified Fisher scores.

CONCLUSIONS

Serum NLRP3 may represent an inflammatory biomarker in relation to the severity, DCI and poor functional outcome after aSAH.

Mortality among patients treated for aneurysmal subarachnoid hemorrhage in Eastern Denmark 2017-2019

OBJECTIVE

The aim of the study was to investigate (1) the 30-day, 3-month, and 12-month cumulative mortalities for patients who underwent aneurysm occlusion, and (2) the causes of death, and (3) the potential risk factors for death.

METHODS

All patients who underwent surgical clipping or endovascular treatment of a ruptured aneurysm at Copenhagen University Hospital, during the period of January 1, 2017-December 31, 2019, were included and followed up for 12 months. Data regarding vital status, causes of death, comorbidities, treatment, and clinical presentations on admission was collected. The absolute mortality risk was estimated as a function of time with a 95% confidence interval. The associations between potential risk factors and death were estimated as odds ratios with 95% confidence intervals using logistic regression models.

RESULTS

A total of 317 patients were included. The overall cumulative mortalities after 30 days, 3 months, and 12 months were 10.7%, 12.9%, and 16.1%, respectively. The most common cause of death was severe primary hemorrhage (52.9%), followed by infections (15.7%) and rebleeding (11.8%). WFNS score > 3 and Fisher score > 3 on admission, preprocedural hydrocephalus, and preprocedural rebleeding were found significantly associated with higher risk of death.

CONCLUSIONS

Considerable mortality was seen. Possible preventable causes accounted for approximately 22% of the deaths. The occurrence of both pre- and postprocedural rebleeding's indicates an opportunity of further improvement of the mortality by (1) further reduction of time from aSAH to aneurysm occlusion and (2) continuous efforts in improving methods of aneurysm occlusion.

Ultra-early endovascular treatment improves prognosis in High grade aneurysmal subarachnoid hemorrhage: A single-center retrospective study

Background

The long-term survival prognosis of patients with high-grade (Hunt-Hess grade IV–V or World Federation of Neurosurgical Societies grade IV–V) aneurysmal subarachnoid hemorrhage (aSAH) is generally poor, and the association between endovascular treatment timing and the prognosis of high-grade aSAH has not been explored in depth. This retrospective cohort study aimed to determine whether endovascular treatment within 24 h of high-grade aSAH is associated with a better prognosis.

Methods

We retrospectively analyzed the clinical data of patients with high-grade aSAH who were admitted to our institution between January 2018 and January 2021. The Modified Rankin Scale score was used to assess the 6-month prognosis of patients. Univariate and multivariate logistic regression analyses were used to identify the factors associated with prognosis. The area under the receiver operating characteristic (ROC) curve was used to assess the model's discriminatory ability.

Results

Eighty-six patients were included in the study. In the multivariate analysis, the timing of endovascular treatment (odds ratio = 7.003 [1.800–27.242], P = 0.005) was an independent risk factor for prognosis. The ROC curve showed that the predictive power of the timing of endovascular treatment was 0.744, the best cut-off value was 12.5 h, and the corresponding sensitivity and specificity were 71.4 and 70.5%, respectively. Hydrocephalus (P = 0.005) and pulmonary infection (P = 0.029) were also associated with prognosis. In addition, cerebrospinal fluid drainage immediately after endovascular treatment had a significant effect on reducing hydrocephalus formation.

Conclusions

Endovascular therapy within 24 h is feasible and improves the prognosis of patients with high-grade aSAH.

Admission Homocysteine as a Potential Predictor for Delayed Cerebral Ischemia After Aneurysmal Subarachnoid Hemorrhage

Background

Delayed cerebral ischemia (DCI) is a primary cause of poor prognosis after aneurysmal subarachnoid hemorrhage (aSAH) and needs close medical attention in clinical practice. Homocysteine (Hcy) has been implicated in cerebrovascular diseases. This study aimed to investigate whether serum Hcy could help to predict the occurrence of DCI in aSAH patients, and compare its diagnostic value with traditional methods.

Methods

We enrolled 241 aSAH patients in this study. Serum Hcy levels were collected from each patient. The baseline information was reviewed and analyzed. The binary logistic regression was used to explore the relation of serum Hcy levels with occurrence of DCI, and diagnostic performance of serum Hcy for predicting DCI was evaluated using a receiver operating characteristic (ROC) curve.

Results

The admission serum Hcy levels were found significantly higher in aSAH patients with DCI than those without (P < 0.001). The serum Hcy levels were positively correlated with the World Federation of Neurosurgical Societies (WFNS) scores, modified Fisher scores as well as Hunt and Hess scores at admission. Multivariate analysis revealed that occurrence of DCI was associated with serum Hcy levels (Odds Ratio [OR] = 1.257; 95% Confidence Interval [CI], 1.133–1.396, P < 0.001), modified Fisher scores (OR = 1.871; 95%CI, 1.111–3.150, P = 0.018) and Hunt and Hess scores (OR = 2.581; 95%CI, 1.222–5.452, P = 0.013) after adjusting for the significant variables in univariate analysis. Meanwhile, serum Hcy levels achieved good performance for DCI prediction (area under the curve [AUC], 0.781; 95%CI, 0.723–0.831, P < 0.001).

Conclusion

Serum homocysteine might have the potential to be a useful and cost-effective biomarker for predicting the occurrence of DCI in aSAH patients.

DCI after Aneurysmal Subarachnoid Hemorrhage Is Related to the Expression of MFG-E8

Objective

To explore the predictive value of milk fat globule epidermal growth factor 8 (MFG-E8) in the occurrence of delayed cerebral ischemia (DCI) after an aneurysmal subarachnoid hemorrhage (aSAH).

Methods

We recruited 32 patients with aSAH as the case group and 24 patients with unruptured aneurysms as the control group. Serum MFG-E8 levels were measured by western blot and enzyme-linked immunosorbent assay. We analyzed the relationship between MFG-E8 levels and the risk of DCI.

Results

The levels of serum MFG-E8 in the case group (mean = 11160.9 pg/mL) were significantly higher than those in the control group (mean = 3081.0 pg/mL, p < 0.001). MFG-E8 levels highly correlated with the World Federation of Neurosurgical Societies (WFNS) and modified Fisher scores (r = -0.691 and - 0.767, respectively, p < 0.001). In addition, MFG-E8 levels in patients with DCI (5882.7 ± 3162.4 pg/mL) were notably higher than those in patients without DCI (15818.2 ± 3771.6 pg/mL, p < 0.001). A receiver operating characteristic curve showed that the occurrence of DCI could effectively be predicted by MFG-E8 (area under the curve = 0.976, 95%CI = 0.850-1.000). Kaplan-Meier survival analysis showed a remarkable decrease in the incidence of DCI in case group individuals with high levels of MFG-E8 (≥11160.9 pg/mL, p < 0.001).

Conclusion

MFG-E8 may be a useful predictive marker for DCI after an aSAH and could be a promising surrogate end point.