Aneurysmal Subarachnoid Hemorrhage Grading Scales: Something Old, Something Borrowed, Something New, and Silver Sixpence in Our Shoes!

Prognostic Value of the Neurological Pupil Index in Patients With Acute Subarachnoid Hemorrhage

BACKGROUND

The Neurological Pupil index (NPi) provides a quantitative assessment of pupil reactivity and may have prognostic value in patients with subarachnoid hemorrhage (SAH). We aimed to explore associations between the NPi and clinical outcomes in patients with SAH.

METHODS

A retrospective analysis of 79 consecutive patients with acute SAH. Age, sex, Acute Physiology and Chronic Health Evaluation-II score, and respiratory failure and NPi in each eye were recorded at admission. The primary outcomes included death and poor clinical outcome (defined as inpatient death, care withdrawal, or discharge Glasgow Outcome Score <4). Groups were compared using the Fisher exact test, and predictive models developed with fast-and-frugal trees (FFTs).

RESULTS

A total of 53 patients were included: 21 (40%) had poor clinical outcomes and 2 (4%) died. Univariate analysis found that only APACHE-II score (P < 0.001) and respiratory failure (P = 0.04) were significantly associated with poor clinical outcomes. NPi was lower among patients with poor clinical outcomes (mean 4.3 in the right eye and 4.2 in the left eye) vs those without (mean 4.5 in the right eye and 4.5 in the left eye), but neither was significant. However, the most accurate FFTs for death and poor clinical outcome included NPi after accounting for age in the death FFT and APACHE-II score in the poor outcome FFT (sensitivity [sn] = 100%, specificity [sp] = 94%, and accuracy (ac) = 94% in a model for death; sn = 100%, sp = 50%, and ac = 70%) in a model for poor clinical outcome.

CONCLUSIONS

Our study supports the NPi as a useful prognostic marker for poor outcomes in acute SAH after accounting for age and APACHE-II score.

Ocular Fundus Abnormalities in Acute Subarachnoid Hemorrhage: The FOTO-ICU Study

BACKGROUND

Ocular fundus abnormalities, especially intraocular hemorrhage, may represent a clinically useful prognostic marker in patients with acute subarachnoid hemorrhage (SAH).

OBJECTIVE

To evaluate associations between ocular fundus abnormalities and clinical outcomes in acute SAH.

METHODS

Prospective evaluation of acute SAH patients with ocular fundus photography at bedside. Multivariable logistic models were used to evaluate associations between fundus abnormalities and poor outcome (inpatient death, care withdrawal, or discharge Glasgow Outcome Score <4) and intensive care unit (ICU) and hospital lengths-of-stay, controlling for APACHE II score, respiratory failure at ICU admission, Hunt & Hess score, aneurysmal etiology, age, and sex.

RESULTS

Fundus abnormalities were present in 29/79 patients with acute SAH (35.4%), and 20/79 (25.3%) had intraocular hemorrhage. In univariate analyses, poor outcomes were more likely among patients with fundus abnormalities vs without (15/28 [53.6%] vs 15/51 [29.4%], P = .03); median length of ICU stay was longer in patients with intraocular hemorrhage than without (18 d [interquartile range (IQR) 12-25] vs 11 [IQR 7-17], P = .03). Logistic regression with fundus abnormality as predictor of interest showed that male sex (odds ratio [OR] 5.33 [95% CI 1.09-26.0], P = .045), higher APACHE II (OR, per 1-point increase, 1.35 [95% CI 1.08-1.78], P = .01), and aneurysmal etiology (OR 4.35 [95% CI 1.01-22.9], P = .048), but not fundus abnormalities (OR 1.56 [95% CI 0.43-5.65], P = .49) or intraocular hemorrhage (OR 1.28 [95% CI 0.26-5.59], P = .75) were associated with poor outcome.

CONCLUSION

Although ocular fundus abnormalities are associated with disease severity in SAH, they do not add value to patients' acute management beyond other risk factors already in use.

Development and external validation of new nomograms by adding ECG changes (ST depression or tall T wave) and age to conventional scoring systems to improve the predictive capacity in patients with subarachnoid haemorrhage: a retrospective, observational study in Korea

OBJECTIVES

To develop new nomograms by adding ECG changes (ST depression or tall T wave) and age to three conventional scoring systems, namely, World Federation of Neurosurgical Societies (WFNS) scale, Hunt and Hess (HH) system and Fisher scale, that can predict prognosis in patients with subarachnoid haemorrhage (SAH) using our preliminary research results and to perform external validation of the three new nomograms.

DESIGN

Retrospective, observational study SETTING: Emergency departments (ED) of two university-affiliated tertiary hospital between January 2009 and March 2015.

PARTICIPANTS

Adult patients with SAH were enrolled. Exclusion criteria were age <19 years, no baseline ECG, cardiac arrest on arrival, traumatic SAH, referral from other hospital and referral to other hospitals from the ED.

PRIMARY OUTCOME MEASURES

The 6 month prognosis was assessed using the Glasgow Outcome Scale (GOS). We defined a poor outcome as a GOS score of 1, 2 or 3.

RESULTS

A total of 202 patients were included for analysis. From the preliminary study, age, ECG changes (ST depression or tall T wave), and three conventional scoring systems were selected to predict prognosis in patients with SAH using multi-variable logistic regression. We developed simplified nomograms using these variables. Discrimination of the developed nomograms including WFNS scale, HH system and Fisher scale was superior to those of WFNS scale, HH system and Fisher scale (0.912 vs 0.813; p<0.001, 0.913 vs 0.826; p<0.001, and 0.885 vs 0.746; p<0.001, respectively). The calibration plots showed excellent agreement. In the external validation, the discrimination of the newly developed nomograms incorporating the three scoring systems was also good, with an area under the receiver-operating characteristic curve value of 0.809, 0.812 and 0.772, respectively.

CONCLUSIONS

We developed and externally validated new nomograms using only three independent variables. Our new nomograms were superior to the WFNS scale, HH systems, and Fisher scale in predicting prognosis and are readily available.

Red Cell Distribution Width After Subarachnoid Hemorrhage

BACKGROUND

High red cell distribution width (RDW) values have been associated with increased hospital mortality in critically ill patients, but few data are available for subarachnoid hemorrhage (SAH).

METHODS

We analyzed an institutional database of adult (>18 y) patients admitted to the Department of Intensive Care after nontraumatic SAH between January 2011 and May 2016. RDW (normal value, 10.9% to 13.4%) was obtained daily from admission for a maximum of 7 days, from routine blood analysis. We recorded the occurrence of delayed cerebral ischemia (DCI), and neurological outcome (assessed using the Glasgow Outcome Scale [GOS]) at 3 months.

RESULTS

A total of 270 patients were included (median age 54 y-121/270 male [45%]), of whom 96 (36%) developed DCI and 109 (40%) had an unfavorable neurological outcome (GOS, 1 to 3). The median RDW on admission was 13.8 [13.3 to 14.5]% and the highest value during the intensive care unit (ICU) stay 14.2 [13.6 to 14.8]%. The RDW was high (>13.4%) in 177 patients (66%) on admission and in 217 (80%) at any time during the ICU stay. Patients with a high RDW on admission were more likely to have an unfavorable neurological outcome. In multivariable regression analysis, older age, a high WFNS grade on admission, presence of DCI or intracranial hypertension, previous neurological disease, vasopressor therapy and a high RDW (OR, 1.1618 [95% CI, 1.213-2.158]; P=0.001) during the ICU stay were independent predictors of unfavorable neurological outcome.

CONCLUSIONS

High RDW values were more likely to result in an unfavorable outcome after SAH. This information could help in the stratification of SAH patients already on ICU admission.