The value of the Charlson Co-morbidity Index in aneurysmal subarachnoid haemorrhage

The value of comorbidities and illness severity scores as prognostic tools for early outcome estimation in patients with aneurysmal subarachnoid hemorrhage

Aneurysmal subarachnoid hemorrhage (aSAH) is a severe cerebrovascular disease not only causing brain injury but also frequently inducing a significant systemic reaction affecting multiple organ systems. In addition to hemorrhage severity, comorbidities and acute extracerebral organ dysfunction may impact the prognosis after aSAH as well. The study objective was to assess the value of illness severity scores for early outcome estimation after aSAH. A retrospective analysis of consecutive aSAH patients treated from 2012 to 2020 was performed. Comorbidities were evaluated applying the Charlson comorbidity index (CCI) and the American Society of Anesthesiologists (ASA) classification. Organ dysfunction was assessed by calculating the simplified acute physiology score (SAPS II) 24 h after admission. Modified Rankin scale (mRS) at 3 months was documented. The outcome discrimination power was evaluated. A total of 315 patients were analyzed. Significant comorbidities (CCI > 3) and physical performance impairment (ASA > 3) were found in 15% and 12% of all patients, respectively. The best outcome discrimination power showed SAPS II (AUC 0.76), whereas ASA (AUC 0.65) and CCI (AUC 0.64) exhibited lower discrimination power. A SAPS II cutoff of 40 could reliably discriminate patients with good (mRS ≤ 3) from those with poor outcome (p < 0.0001). Calculation of SAPS II allowed a comprehensive depiction of acute organ dysfunctions and facilitated a reliable early prognosis estimation in our study. In direct comparison to CCI and ASA, SAPS II demonstrated the highest discrimination power and deserves a consideration as a prognostic tool after aSAH.

Short- and long-term mortality of subarachnoid hemorrhage according to hospital volume and severity using a nationwide multicenter registry study

Introduction

Recent improvements in treatment for subarachnoid hemorrhage (SAH) have decreased the mortality rates; however, the outcomes of SAH management are dependent on many other factors. In this study, we used nationwide, large-scale, observational data to investigate short- and long-term mortality rates after SAH treatment and the influence of patient severity and hospital volume.

Patients and methods

We selected patients with SAH treated with clipping and coiling from the South Korean Acute Stroke Assessment Registry. High- and low-volume hospitals performed ≥20 clipping and coiling procedures and <20 clipping and coiling procedures per year, respectively. Short- and long-term mortality were tracked using data from the Health Insurance Review and Assessment Service.

Results

Among 2,634 patients treated using clipping and coiling, 1,544 (58.6%) and 1,090 (41.4%) were hospitalized in high- and low-volume hospitals, respectively, and 910 (34.5%) and 1,724 (65.5%) were treated with clipping and coiling, respectively. Mortality rates were 13.5, 14.4, 15.2, and 16.1% at 3 months, 1, 2, and 4 years, respectively. High-volume hospitals had a significantly lower 3-month mortality rate. Patients with mild clinical status had a significantly lower 3-month mortality rate in high-volume hospitals than in low-volume hospitals. Patients with severe clinical status had significantly lower 1- and 2-year mortality rates in high-volume hospitals than in low-volume hospitals.

Conclusion

Short- and long-term mortality in patients with SAH differed according to hospital volume. In the modern endovascular era, clipping and coiling can lead to better outcomes in facilities with high stroke-care capabilities.

Regional Variability in the Care and Outcomes of Subarachnoid Hemorrhage Patients in the United States

Background and Objectives

Regional variability in subarachnoid hemorrhage (SAH) care is reported in physician surveys. We aimed to describe variability in SAH care using patient-level data and identify factors impacting hospital outcomes and regional variability in outcomes.

Methods

A retrospective multi-center cross-sectional cohort study of consecutive non-traumatic SAH patients in the Vizient Clinical Data Base, between January 1st, 2009 and December 30th, 2018 was performed. Participating hospitals were divided into US regions: Northeast, Midwest, South, West. Regional demographics, co-morbidities, severity-of-illness, complications, interventions and discharge outcomes were compared. Multivariable logistic regression was performed to identify factors independently associated with primary outcomes: hospital mortality and poor discharge outcome. Poor discharge outcome was defined by the Nationwide Inpatient Sample-SAH Outcome Measure, an externally-validated outcome measure combining death, discharge disposition, tracheostomy and/or gastrostomy. Regional variability in the associations between care and outcomes were assessed by introducing an interaction term for US region into the models.

Results

Of 109,034 patients included, 24.3% were from Northeast, 24.9% Midwest, 34.9% South, 15.9% West. Mean (SD) age was 58.6 (15.6) years and 64,245 (58.9%) were female. In-hospital mortality occurred in 21,991 (20.2%) and 44,159 (40.5%) had poor discharge outcome. There was significant variability in severity-of-illness, co-morbidities, complications and interventions across US regions. Notable findings were higher prevalence of surgical clipping (18.8 vs. 11.6%), delayed cerebral ischemia (4.3 vs. 3.1%), seizures (16.5 vs. 14.8%), infections (18 vs. 14.7%), length of stay (mean [SD] days; 15.7 [19.2] vs. 14.1 [16.7]) and health-care direct costs (mean [SD] USD; 80,379 [98,999]. vs. 58,264 [74,430]) in the West when compared to other regions (all p < 0.0001). Variability in care was also associated with modest variability in hospital mortality and discharge outcome. Aneurysm repair, nimodipine use, later admission-year, endovascular rescue therapies reduced the odds for poor outcome. Age, severity-of-illness, co-morbidities, hospital complications, and vasopressor use increased those odds (c-statistic; mortality: 0.77; discharge outcome: 0.81). Regional interaction effect was significant for admission severity-of-illness, aneurysm-repair and nimodipine-use.

Discussion

Multiple hospital-care factors impact SAH outcomes and significant variability in hospital-care and modest variability in discharge-outcomes exists across the US. Variability in SAH-severity, nimodipine-use and aneurysm-repair may drive variability in outcomes.

Survival After Ischemic and Hemorrhagic Stroke: A 4-Year Follow-Up at a Mexican Hospital

BACKGROUND

Overall, 75.2% of deaths from stroke occur in low- and middle-income countries. Mexico is a middle-income country with little information about the prognosis of early and late postischemic and hemorrhagic stroke.

OBJECTIVE

To evaluate the factors associated with post-stroke survival in the Mexican population.

METHODS

Observational study of consecutive stroke cases involving a first-ever hemorrhagic or ischemic stroke, with patients who received care at the National Institute of Neurology and Neurosurgery, in Mexico City, between 2009 and 2012. Patients were followed for up to 4 years after the index event. Exploratory analysis of survival was carried out with Kaplan-Meier and log-rank tests. Factors associated with survival time were determined using Cox models.

RESULTS

A total of 300 out of 544 (55.15%) patients had a hemorrhagic stroke, 135 of 544 (24.82%) patients died during the entire follow-up period, and 56 of 544 (10.29%) died in the first 30 days post-stroke (early mortality). Early mortality after stroke was associated with age ≥ 65 years (Adjusted Hazard Ratio - AHR = 2.07, P = .02) and ≥ 2 in-hospital medical complications (AHR = 46.13, P < .01). Late mortality was associated with age ≥ 65 years (AHR = 3.43, P < .01), ≥2 in-hospital medical complications (AHR = 2.55, P < .01), high comorbidity (AHR = 5.43, P < .01), and recurrence (AHR = 1.90, P = .01).

CONCLUSIONS

Patients with hemorrhagic and ischemic stroke who presented in-hospital medical complications, high comorbidity, and were over 65 years old had higher rates of early and late mortality.

Factors associated with clinical and radiological status on admission in patients with aneurysmal subarachnoid hemorrhage

Grading scales yield objective measure of the severity of aneurysmal subarachnoid hemorrhage and serve as to guide treatment decisions and for prognostication. The purpose of this cohort study was to determine what factors govern a patient's disease-specific admission scores in a representative Central European cohort. The Swiss Study of Subarachnoid Hemorrhage includes anonymized data from all tertiary referral centers serving subarachnoid hemorrhage patients in Switzerland. The 2009-2014 dataset was used to evaluate the impact of patient and aneurysm characteristics on the patients' status at admission using descriptive and multivariate regression analysis. The primary/co-primary endpoints were the GCS and the WFNS grade. The secondary endpoints were the Fisher grade, the presence of a thick cisternal or ventricular clot, the presence of a new focal neurological deficit or cranial nerve palsy, and the patient's intubation status. In our cohort of 1787 consecutive patients, increasing patient age by 10 years and low pre-ictal functional status (mRS 3-5) were inversely correlated with "high" GCS score (GCS ≥ 13) (OR 0.91, 95% CI 0.84-0.97 and OR 0.67, 95% CI 0.31-1.46), "low" WFNS grade (grade VI-V) (OR 1.21, 95% CI 1.04-1.20 and OR 1.47, 95% CI 0.66-3.27), and high Fisher grade (grade III-IV) (OR 1.08, 95% CI 1.00-1.17 and OR 1.54, 95% CI 0.55-4.32). Other independent predictors for the patients' clinical and radiological condition at admission were the ruptured aneurysms' location and its size. In sum, chronological age and pre-ictal functional status, as well as the ruptured aneurysm's location and size, determine the patients' clinical and radiological condition at admission to the tertiary referral hospital.

Health-Related Quality of Life Dynamics 2 Years Following Aneurysmal Subarachnoid Hemorrhage: A Prospective Cohort Study Using EQ-5D

BACKGROUND

Previous studies have shown that aneurysmal subarachnoid hemorrhage (aSAH) affects health-related quality of life (HRQoL) to a large extent. However, longitudinal studies on HRQoL after aSAH are scarce, and there is limited knowledge whether different HRQoL dimension scores change over time, and if so, if the scoring differs from results from the general population.

OBJECTIVE

To evaluate HRQoL dynamics over time, 2 years following aSAH, and compare the results with general population.

METHODS

In a prospective cohort design, 88 consecutive aSAH patients (85% of eligible) were followed up with the generic HRQoL instrument EQ-5D at 3 time points: 6 months, 1 year, and 2 years after the onset. Data were collected in 2006 to 2009, and the results were compared with a general population sample from the Stockholm Public Health Survey 2006, matched by age and sex.

RESULTS

Overall HRQoL in the aSAH sample was stationary over time. Improved function was only found in the usual activities dimension (P = .026). HRQoL was most affected in participants reporting comorbidity. Compared with the general population, women in the aSAH sample reported significantly more problems in 4 out of 5 dimensions (mobility, self-care, usual activities, and anxiety/depression). Men in the aSAH sample reported significantly more problems in the usual activities dimension in comparison to the general population.

CONCLUSION

HRQoL is stationary during the first 2 years following aSAH, and is significantly worse when compared to the general population. Rehabilitation efforts should be initiated shortly after hospitalization.