A Comparison of Computed Tomography-Based Scales with and without Consideration of the Presence or Absence of Intraventricular Hemorrhage in Patients with Aneurysmal Subarachnoid Hemorrhage

A Quantitative Subarachnoid Hemorrhage Grading System, Including Supratentorial and Infratentorial Cisterns, With Multiplanar Computed Tomography Reformations

Background

Subarachnoid hemorrhage (SAH) grading scales typically evaluate a limited number of cisterns on the axial plane. The goal of our study is to apply a simple quantitative yet comprehensive SAH grading scale to all major intracranial cisterns, including the infratentorial cisterns, with multiplanar computed tomography (CT) reformations.

Methodology

We performed a retrospective review of 94 consecutive cases of spontaneous SAH presenting within 72 hours of onset. SAH was categorized into five grades based on the short-axis thickness of SAH in 20 intracranial cisterns measured on the axial, coronal, and sagittal planes. Statistical analysis was performed for inter-rater agreement with kappa statistics, for inter-plane agreement by Spearman correlation statistics, and for inter-rater and inter-plane agreement by Pearson correlation statistics.

Results

The extended kappa coefficient for the three reviewers across all 20 cisterns varied from 0.38 (0.27, 0.50) to 0.59 (0.52, 0.65) on the axial plane. The kappa coefficient for two reviewers varied from 0.46 (0.33, 0.59) to 0.70 (0.60, 0.80) on the coronal plane and from 0.35 (0.20, 0.49) to 0.87 (0.77, 0.96) on the sagittal plane. The average grade of cisterns per case demonstrated mostly excellent correlation between the imaging planes with Spearman correlation statistics (≥0.70). Pairwise concordance correlation coefficient of the total SAH score revealed agreement ranging from 0.81 to 0.90 in all three planes. Pearson correlation statistics of the average total SAH scores revealed excellent correlation among the three planes (≥0.91).

Conclusion

A simple quantitative SAH grading scale can be successfully applied to the supratentorial and infratentorial cisterns in three standard CT imaging planes.

Intraventricular hemorrhage clot clearance rate as an outcome predictor in patients with aneurysmal subarachnoid hemorrhage: A retrospective study

Background

The development of intraventricular hemorrhage (IVH) in aneurysmal subarachnoid hemorrhage (aSAH) is linked with higher mortality and poor neurological recovery. Previous studies have investigated the effect of the amount and distribution of the initial IVH on the prognosis of aSAH. However, no studies have assessed the relationship between the changes in IVH over time and the prognosis of aSAH. The aim of this study was to analyze the effect of the clearance rate of IVH, which can be represented by the IVH clot clearance rate (CCR), on the outcomes of aSAH.

Methods

The IVH CCR was calculated based on the difference between the initial and follow-up modified Graeb scores (mGS), which were assessed by initial and 7-day follow-up brain computed tomography, respectively. Poor functional outcome was defined as a modified Rankin Scale score of 3-6. Univariate and multivariable analyses were performed to assess the relationships between IVH CCR and other risk factors and the prognosis of patients. Receiver operating characteristic curve analysis was performed to identify cut-off values of IVH CCR for predicting poor functional outcome.

Results

In total, 196 consecutive patients were diagnosed with aSAH between January 2014 and March 2018. According to the inclusion and exclusion criteria, 67 patients were finally included in the study. The univariate analysis revealed that a lower IVH CCR (p<0.001), higher initial mGS (p<0.001), older age (p<0.001), higher initial Hunt and Hess grade (p<0.001), presence of delayed infarction (p=0.03), and presence of shunt-dependent hydrocephalus (p=0.004) were significantly related to poor functional outcome. The multivariable analysis revealed that IVH CCR (odds ratio [OR] 0.941; p=0.029), initial mGS (OR 1.632; p=0.043), age (OR 1.561; p=0.007), initial Hunt and Hess grade (OR 227.296; p=0.030), and delayed infarction (OR 5310.632; p=0.023) were independent predictors of poor functional outcome. Optimal cut-off values of IVH CCR and mGS for poor outcome were 36.27%, and 13.5, respectively (all p< 0.001).

Conclusions

The IVH CCR might have an important predictive value on poor functional outcome in patients with aSAH and IVH, along with initial mGS, age, initial Hunt and Hess grade, and delayed infarction.