Risk factors and short-term outcome in patients with angiographically negative subarachnoid hemorrhage

Increasing Frailty Predicts Worse Outcomes and Increased Complications After Angiogram-Negative Subarachnoid Hemorrhages

BACKGROUND

The effect of frailty on outcomes after angiogram-negative subarachnoid hemorrhages (ANSAH) is currently unknown. We investigated frailty's effects on ANSAH outcomes, including mortality and in-hospital complications.

METHODS

Patients from 2014 to 2018 with non-traumatic subarachnoid hemorrhage and cerebral angiograms with an unidentifiable hemorrhage source were retrospectively reviewed. The cohort was divided into non-frail (modified frailty index [mFI] = 0) and frail (mFI ≥1) groups based on pre-hemorrhage characteristics. Primary outcomes were mortality rate and discharge location. Multivariate logistic regression analyses determined predictors of ANSAH severity and primary endpoints. Receiver operating characteristic curves were used to discriminate risks for primary endpoints comparing mFI, Hunt and Hess and Fisher scores, and age.

RESULTS

We included 75 patients with a mean age of 55.4 ± 1.5 years, comprising 42 (56%) women, and 41 (54.7%) with perimesencephalic bleeds. A total of 32 of 75 (42.7%) patients were classified as frail. Frail individuals were 6.2 times less likely to be discharged home (odds ratio [OR] = 0.16; 95% confidence interval [CI]: 0.05-0.5; P = 0.001) and all mortalities occurred in frail patients (12.5% [n = 4 of 32]; P = 0.030). The only independent predictor of mortality was higher mFI (OR = 5.4; 95% CI: 1.5-19.1; P = 0.009), and lower mFI best predicted discharge home (OR = 0.39; 95% CI: 0.17-0.88; P = 0.023). Receiver operating characteristic analysis showed that mFI best predicted both mortality (area under the curve = 0.9718; P = 0.002) and discharge home (area under the curve = 0.7998; P < 0.001).

CONCLUSIONS

Frail ANSAH patients have poorer outcomes and increased mortality compared with non-frail patients. Although prospective study is needed, this information significantly impacts our understanding of ANSAH outcomes and frailty should be used for prognostication as it was a better predictor than Hunt and Hess or Fisher scores.

Subarachnoid haemorrhage with negative initial neurovascular imaging: a systematic review and meta-analysis

Background

In patients with spontaneous subarachnoid haemorrhage (SAH), a vascular cause for the bleed is not always found on initial investigations. This study aimed to systematically evaluate the delayed investigation strategies and clinical outcomes in these cases, often described as “non-aneurysmal” SAH (naSAH).

Methods

A systematic review was performed in concordance with the PRISMA checklist. Pooled proportions of primary outcome measures were estimated using a random-effects model.

Results

Fifty-eight studies were included (4473 patients). The cohort was split into perimesencephalic naSAH (PnaSAH) (49.9%), non-PnaSAH (44.7%) and radiologically negative SAH identified on lumbar puncture (5.4%). The commonest initial vascular imaging modality was digital subtraction angiography. A vascular abnormality was identified during delayed investigation in 3.9% [95% CI 1.9–6.6]. There was no uniform strategy for the timing or modality of delayed investigations. The pooled proportion of a favourable modified Rankin scale outcome (0–2) at 3–6 months following diagnosis was 92.0% [95% CI 86.0–96.5]. Complications included re-bleeding (3.1% [95% CI 1.5–5.2]), hydrocephalus (16.0% [95% CI 11.2–21.4]), vasospasm (9.6% [95% CI 6.5–13.3]) and seizure (3.5% [95% CI 1.7–5.8]). Stratified by bleeding pattern, we demonstrate a higher rate of delayed diagnoses (13.6% [95% CI 7.4–21.3]), lower proportion of favourable functional outcome (87.2% [95% CI 80.1–92.9]) and higher risk of complications for non-PnaSAH patients.

Conclusion

This study highlights the heterogeneity in delayed investigations and outcomes for patients with naSAH, which may be influenced by the initial pattern of bleeding. Further multi-centre prospective studies are required to clarify optimal tailored management strategies for this heterogeneous group of patients.

Electronic supplementary material

The online version of this article (10.1007/s00701-019-04025-w) contains supplementary material, which is available to authorized users.

Determining rural risk for aneurysmal subarachnoid hemorrhages: A structural equation modeling approach

An aneurysmal subarachnoid hemorrhage (aSAH) carries a high disability burden. The true impact of rurality as a predictor of outcome severity is unknown. Our aim is to clarify the relationship between the proposed explanations of regional and rural health disparities linked to severity of outcome following an aSAH. An initial literature search identified limited data directly linking geographical location, rurality, rural vulnerability, and aSAH. A further search noting parallels with ischemic stroke and acute myocardial infarct literature presented a number of diverse and interrelated predictors. This a priori knowledge informed the development of a conceptual framework that proposes the relationship between rurality and severity of outcome following an aSAH utilizing structural equation modeling. The presented conceptual framework explores a number of system, environmental, and modifiable risk factors. Socioeconomic characteristics, modifiable risk factors, and timely treatment that were identified as predictors of severity of outcome following an aSAH and within each of these defined predictors a number of contributing specific individual predictors are proposed. There are considerable gaps in the current knowledge pertaining to the impact of rurality on the severity of outcome following an aSAH. Absent from the literature is any investigation of the cumulative impact and multiplicity of risk factors associated with rurality. The proposed conceptual framework hypothesizes a number of relationships between both individual level and system level predictors, acknowledging that intervening predictors may mediate the effect of one variable on another.

The role of antiplatelet medications in angiogram-negative subarachnoid hemorrhage

BACKGROUND

The use of antiplatelet medications has greatly expanded and this has been associated with an increased rate of complications after aneurysmal subarachnoid hemorrhage (SAH). The influence of antiplatelet medications on outcomes after non-aneurysmal SAH is unknown.

OBJECTIVE

To analyze the frequency and impact on outcome of antiplatelet medication use among patients with angiogram-negative SAH.

METHODS

An analysis of patients within the Columbia University SAH Outcomes Project database was performed. All patients who underwent catheter cerebral angiography after presenting with nontraumatic SAH between 1996 and 2013 were included. Outcomes were assessed by using the modified Rankin Scale.

RESULTS

A total of 1351 patients underwent catheter angiography for evaluation of SAH. Of these, 173 (13%) were designated angiogram-negative. The fraction of patients presenting with angiogram-negative SAH as well as the frequency of antiplatelet use among these patients significantly increased during the study period. Antiplatelet use was more commonly associated with angiogram-negative SAH than with angiogram-positive SAH (27% vs 14%, P = .001). At 14 days after presentation, poor outcome was significantly more frequent among patients who took antiplatelet agents than among those who did not (38% vs 20%, P = .017). This effect was also seen after multivariate analysis (odds ratio, 2.58; P = .034), although no difference was observed by 12 months (P > .05).

CONCLUSION

Antiplatelet medication use is associated with poor early, but not late, outcomes after angiogram-negative SAH. Corresponding increased rates of antiplatelet medication use and angiogram-negative SAH may be related. Additional studies are needed to confirm this association.