Prediction of Outcome After Aneurysmal Subarachnoid Hemorrhage

Diagnostic value of transcranial doppler to predict delayed cerebral ischemia after aneurysmal subarachnoid hemorrhage : To predict delayed cerebral ischemia

BACKGROUND

Transcranial Doppler (TCD) is a technique to assess blood flow velocity in the cerebral arteries. TCD is frequently used to monitor aneurysmal subarachnoid hemorrhage (aSAH) patients. This study compares TCD-criteria for vasospasm and its association with Delayed Cerebral Ischemia (DCI). An overall score based on flow velocities of various intracranial arteries was developed and evaluated.

METHODS

A retrospective diagnostic accuracy study was conducted between 1998 and 2017 with 621 patients included. Mean flow velocity (MFV) of the cerebral artery was measured between 2-5 days and between 6-9 days after ictus. Cutoff values from the literature, new cutoff values, and a new composite score (Combined Severity Score) were used to predict DCI. Sensitivity, specificity, and area under the curve (AUC) were determined, and logistic regression analysis was performed.

RESULTS

The Combined Severity Score showed an AUC 0.64 (95%CI 0.56-.71) at days 2-5, with sensitivity 0.53 and specificity 0.74. The Combined Severity Score had an adjusted Odds Ratio of 3.41 (95CI 1.86-6.32) for DCI. MCA-measurements yielded the highest AUC to detect DCI at day 2-5: AUC 0.65 (95%CI 0.58-0.73). Optimal cutoff MFV of 83 cm/s for MCA resulted in sensitivity 0.73 and specificity 0.50 at days 2-5.

CONCLUSION

TCD-monitoring of aSAH patients may be a valuable strategy for DCI risk stratification. Lower cutoff values can be used in the early phase after the ictus (day 2-5) than are commonly used now. The Combined Severity Score incorporating all major cerebral arteries may provide a meaningful contribution to interpreting TCD measurements.

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.

Development of a predictive nomogram for 28-day mortality risk in non-traumatic or post-traumatic subarachnoid hemorrhage patients

OBJECTIVE

Subarachnoid hemorrhage (SAH) is associated with high rates of mortality and permanent disability. At present, there are few definite clinical tools to predict prognosis in SAH patients. The current study aims to develop and assess a predictive nomogram model for estimating the 28-day mortality risk in both non-traumatic or post-traumatic SAH patients.

METHODS

The MIMIC-III database was searched to select patients with SAH based on ICD-9 codes. Patients were separated into non-traumatic and post-traumatic SAH groups. Using LASSO regression analysis, we identified independent risk factors associated with 28-day mortality and incorporated them into nomogram models. The performance of each nomogram was assessed by calculating various metrics, including the area under the curve (AUC), net reclassification improvement (NRI), integrated discrimination improvement (IDI), and decision curve analysis (DCA).

RESULTS

The study included 999 patients with SAH, with 631 in the non-traumatic group and 368 in the post-traumatic group. Logistic regression analysis revealed critical independent risk factors for 28-day mortality in non-traumatic SAH patients, including gender, age, glucose, platelet, sodium, BUN, WBC, PTT, urine output, SpO2, and heart rate and age, glucose, PTT, urine output, and body temperature for post-traumatic SAH patients. The prognostic nomograms outperformed the commonly used SAPSII and APSIII systems, as evidenced by superior AUC, NRI, IDI, and DCA results.

CONCLUSION

The study identified independent risk factors associated with the 28-day mortality risk and developed predictive nomogram models for both non-traumatic and post-traumatic SAH patients. The nomogram holds promise in guiding prognosis improvement strategies for patients with SAH.

External Validation of the Modified Southwestern Aneurysm Severity Index in the Barrow Ruptured Aneurysm Trial Surgical Cohort

BACKGROUND AND OBJECTIVES

Predicting functional outcomes after surgical management of ruptured aneurysms is essential. This study sought to validate the modified Southwestern Aneurysm Severity Index (mSASI), which predicts functional outcomes 1 year after treatment.

METHODS

The surgical arm of a randomized controlled trial, the Barrow Ruptured Aneurysm Trial, was used to validate the mSASI model. mSASI scores incorporating the Hunt and Hess scale, Non-Neurological American Society of Anesthesiologists Physical Classification Status, imaging findings, and other modifiers were assigned and evaluated against the Glasgow Outcome Scale (GOS) score at 1 year. The model's performance was assessed for discrimination and calibration. Similar evaluations were constructed using the modified Rankin Scale (mRS) as the 1-year functional outcome measurement. Long-term outcomes (3, 6, 10 years) were also evaluated.

RESULTS

Of 280 clinical trial patients treated surgically, 242 met the inclusion criteria. The mean age was 54.1 ± 12.9 years; 31% were men. Favorable GOS score (4-5) and mRS score (0-2) at 1 year were observed in 73.6% and 66.1% of patients, respectively. The mSASI model predicted unfavorable GOS score at 1 year with fair to good discrimination (area under the curve = 0.75, 95% CI = 0.68-0.82) and accurate calibration (R2 = 0.98). Similar results were obtained when mRS was used as the outcome measure (area under the curve = 0.75, 95% CI = 0.68-0.82; R2 = 0.95).

CONCLUSION

The mSASI model was externally validated in our cohort to predict functional outcomes using the GOS or mRS scores 1 year after surgery. This index may be used for prognosticating outcomes of patients undergoing surgery for ruptured aneurysms at short-term and long-term intervals.

Racial and Socioeconomic Status among a Patient Population Presenting with Aneurysmal Subarachnoid Hemorrhage versus Unruptured Intracranial Aneurysm: A Single-Center Study

Racial and socioeconomic health disparities are well documented in the literature. This study examined patient demographics, including socioeconomic status (SES), among individuals presenting with aneurysmal subarachnoid hemorrhage (aSAH) and unruptured intracranial aneurysm (UIA) to identify factors associated with aSAH presentation. A retrospective assessment was conducted of all patients with aSAH and UIA who presented to a large-volume cerebrovascular center and underwent microsurgical treatment from January 2014 through July 2019. Race and ethnicity, insurance type, and SES data were collected for each patient. Comparative analysis of the aSAH and UIA groups was conducted. Logistic regression models were also employed to predict the likelihood of aSAH presentation based on demographic and socioeconomic factors. A total of 640 patients were included (aSAH group, 251; UIA group, 389). Significant associations were observed between race and ethnicity, SES, insurance type, and aneurysm rupture. Non-White race or ethnicity, lower SES, and having public or no insurance were associated with increased odds of aSAH presentation. The aSAH group had poorer functional outcomes and higher mortality rates than the UIA group. Patients who are non-White, have low SES, and have public or no insurance were disproportionately affected by aSAH, which is historically associated with poorer functional outcomes.

Impaired cerebral autoregulation detected in early prevasospasm period is associated with unfavorable outcome after spontaneous subarachnoid hemorrhage: an observational prospective pilot study

BACKGROUND

Subarachnoid hemorrhage (SAH) patients with cerebral autoregulation (CA) impairment at an early post-SAH period are at high risk of unfavorable outcomes due to delayed cerebral ischemia (DCI) or other complications. Limited evidence exists for an association between early-stage CA impairments and SAH patient outcomes. The objective of this prospective study was to explore associations between CA impairments detected in early post-SAH snapshot examinations and patient outcomes.

METHODS

The pilot observational study included 29 SAH patients whose CA status was estimated 2-3 days after spontaneous aneurysm rupture and a control group of 15 healthy volunteers for comparison. Inflatable leg recovery boots (reboots.com, Germany) were used for the safe controlled generation of arterial blood pressure (ABP) changes necessary for reliable CA examination. At least 5 inflation‒deflation cycles of leg recovery boots with a 2-3 min period were used during examinations. CA status was assessed according to the delay time (∆TCBFV) measured between ABP(t) and cerebral blood flow velocity (CBFV(t)) signals during artificially induced ABP changes at boot deflation cycle. CBFV was measured in middle cerebral artery by using transcranial Doppler device.

RESULTS

Statistically significant differences in ∆TCBFV were found between SAH patients with unfavorable outcomes (∆TCBFV = 1.37 ± 1.23 s) and those with favorable outcomes (∆TCBFV = 2.86 ± 0.99 s) (p < 0.001). Early assessment of baroreflex sensitivity (BRS) during the deflation cycle showed statistically significant differences between the DCI and non-DCI patient groups (p = 0.039).

CONCLUSIONS

A relatively small delay of ∆TCBFV <1.6 s between CBFV(t) and ABP(t) waves could be an early warning sign associated with unfavorable outcomes in SAH patients. The BRS during boot deflation can be used as a biomarker for the prediction of DCI.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT06028906. Registered 31 August 2023 - Retrospectively registered, https://www.

CLINICALTRIALS

gov/study/NCT06028906 .

One-year survival of aneurysmal subarachnoid hemorrhage after airplane transatlantic transfer - a monocenter retrospective study

BACKGROUND

Aneurysmal subarachnoid hemorrhage (aSAH) is preferentially treated by prompt endovascular coiling, which is not available in Guadeloupe. Subsequently, patients are transferred to Paris, France mainland, by commercial airplane (6751 km flight) after being managed according to guidelines. This study describes the characteristics, management and outcomes related to these patients.

METHODS

Retrospective observational cohort study of 148 patients admitted in intensive care unit for a suspected aSAH and transferred by airplane over a 10-year period (2010-2019).

RESULTS

The median [interquartile range] age was 53 [45-64] years and 61% were female. On admission, Glasgow coma scale was 15 [13-15], World Federation of Neurological Surgeons (WFNS) grading scale was 1 [1-3] and Fisher scale was 4 [2-4]. External ventricular drainage and mechanical ventilation were performed prior to the flight respectively in 42% and 47% of patients. One-year mortality was 16% over the study period. By COX logistic regression analysis, acute hydrocephalus (hazard ratio [HR] 2.34, 95% confidence interval [CI] 0.98-5.58) prior to airplane transfer, WFNS grading scale on admission (HR 1.53, 95% CI 1.16-2.02) and age (OR 1.03, 95% 1.00-1.07) were associated with one-year mortality.

CONCLUSION

When necessary, transatlantic air transfer of patients with suspected aSAH after management according to local guidelines seems feasible and safe.

Textbook Outcomes Among Patients with Aneurysmal Subarachnoid Hemorrhage Following Endovascular Treatment

INTRODUCTION

The case fatality rate among patients with aneurysmal subarachnoid hemorrhage (aSAH) has decreased progressively, with numerous patients subjected to contemporary paradigms that minimize the use of agonizing therapeutic processes. The concept of the "Textbook Outcome" (TO), a composite outcome that highlights numerous favorable outcomes, was developed in the context of gastrointestinal tumor surgeries and expeditiously extended across diverse surgical spheres. The aim of this study was to explore the factors hindering the achievement of optimal prognoses in postinterventional aSAH patients, employ textbook outcomes, and establish predictive models.

METHODS

We conducted a retrospective review of data from 1270 aSAH patients who received endovascular treatment between 2012 and 2018. We delineated an exemplary TO within the aSAH domain, characterized by favorable clinical results, minimal complications, and the absence of retreatments. This TO-oriented approach is explained within the manuscript.

RESULTS

The findings revealed that preoperative intraventricular hemorrhage (IVH), preoperative Hunt and Hess grade (H&H) ≥ 3, World Federation of Neurosurgical Societies (WFNS) grade ≥ 3, the presence of blebs on the aneurysm, aneurysms situated at branching sites, and non-stent-assisted endovascular intervention were the strongest risk factors for not achieving textbook outcomes (non-"Textbook Outcome" [N-TO]). Decision curve analysis and calibration analyses revealed strong concordance between the predictions of the N-TO nomogram model and the actual observations.

CONCLUSIONS

Treatment Outcomes hold significant practical value in clinical studies of aSAH patients receiving endovascular treatment. The likelihood of N-TOs was predicted by IVH, H&H grade ≥ 3, WFNS grade ≥ 2, presence o f bleb on the aneurysm, and aneurysms located at branching sites.

Monitoring of Perioperative Microcirculation Dysfunction by Near-Infrared Spectroscopy for Neurological Deterioration and Prognosis of Aneurysmal Subarachnoid Hemorrhage: An Observational, Longitudinal Cohort Study

INTRODUCTION

No evidence has established a direct causal relationship between early microcirculation disturbance after aneurysmal subarachnoid hemorrhage (aSAH) and neurological function prognosis, which is the key pathophysiological mechanism of early brain injury (EBI) in patients with aSAH.

METHODS

A total of 252 patients with aSAH were enrolled in the Neurosurgical Intensive Care Unit of Southwest Hospital between January 2020 and December 2022 and divided into the no neurological deterioration, early neurological deterioration, and delayed neurological deterioration groups. Indicators of microcirculation disorders in EBI included regional cerebral oxygen saturation (rSO2) measured by near-infrared spectroscopy (NIRS), brain oxygen monitoring, and other clinical parameters for evaluating neurological function and determining the prognosis of patients with aSAH.

RESULTS

Our data suggest that the rSO2 is generally lower in patients who develop neurological deterioration than in those who do not and that there is at least one time point in the population of patients who develop neurological deterioration where left and right cerebral hemisphere differences can be significantly monitored by NIRS. An unordered multiple-classification logistic regression model was constructed, and the results revealed that multiple factors were effective predictors of early neurological deterioration: reoperation, history of brain surgery, World Federation of Neurosurgical Societies (WFNS) grade 4-5, Fisher grade 3-4, SAFIRE grade 3-5, abnormal serum sodium and potassium levels, and reduced rSO2 during the perioperative period. However, for delayed neurological deterioration in patients with aSAH, only a history of brain surgery and perioperative RBC count were predictive indicators.

CONCLUSIONS

The rSO2 concentration in patients with neurological deterioration is generally lower than that in patients without neurological deterioration, and at least one time point in the population with neurological deterioration can be significantly monitored via NIRS. However, further studies are needed to determine the role of microcirculation and other predictive factors in the neurocritical management of EBI after aSAH, as these factors can reduce the incidence of adverse outcomes and mortality during hospitalization.

Correlation of Inflammatory Parameters with the Development of Cerebral Vasospasm, Takotsubo Cardiomyopathy, and Functional Outcome after Spontaneous Subarachnoid Hemorrhage

Background: The present work aimed to determine whether a relationship exists between inflammatory parameters and the development of vasospasm (VS) and Takotsubo cardiomyopathy (TTC), as well as clinical outcome, in patients suffering from spontaneous subarachnoid hemorrhage (SAH). Methods: In this study, the authors processed the prospectively collected laboratory and clinical data of spontaneous SAH patients admitted to the neurointensive care unit between March 2015 and October 2023. The highest values of neutrophils (NEUpeak), monocytes (MONOpeak), neutrophil-to-lymphocyte ratio (NLRpeak), and CRP (CRPpeak) during the initial 7 days were correlated with the occurrence of VS and TTC, and with the outcome measures at day 30 after onset. Results: Data were collected from 175 SAH patients. Based on ROC analysis, for the development of VS, MONOpeak was the most accurate indicator (AUC: 0.619, optimal cut-off: 1.45 G/L). TTC with severe left ventricular dysfunction (ejection fraction < 40%) was indicated most sensitively by NEUpeak (ROC: 0.763, optimal cut-off: 12.34 G/L). Both for GOS and Barthel Index at day 30, CRPpeak was the best predictor for the outcome (GOS: ROC: 0.846, optimal cut-off: 78.33 mg/L and Barthel Index: ROC: 0.819, optimal cut-off: 78.33 mg/L). Conclusions: Laboratory parameters referring to inflammation during the initial 7 days after SAH correlate with the development of VS and TTC, and thus may predict functional outcome.

Revisiting the WFNS Score: Native Computed Tomography Imaging Improves Identification of Patients With "False Poor Grade" Aneurysmal Subarachnoid Hemorrhage

BACKGROUND AND OBJECTIVES

In patients suffering from aneurysmal subarachnoid hemorrhage (aSAH), the optimal time to determine the World Federation of Neurosurgical Societies (WFNS) score remains controversial because of possible confounding factors. Goals of this study were (1) to analyze the most sensitive timepoint to determine the WFNS score in patients with aSAH and (2) to evaluate the impact of initial native computed tomography (CT) imaging on reducing the mismatch of "false poor grade" patients.

METHODS

We retrospectively analyzed daily WFNS scores from admission until day 7 in 535 aSAH patients and evaluated their predictive value for the modified Rankin Scale at discharge and 6 months postbleeding. Patients with an initial WFNS score of IV-V who showed improvement to a WFNS score of I-II within the first 7 days (even short-term) were defined as "false poor grade" patients. We tried to identify the "false poor grade" patients using parameters of the initial native CT imaging.

RESULTS

Later determination of the WFNS score (day 1 vs 7; pseudo-R 2 = 0.13 vs 0.21) increasingly improved its predictive value for neurological outcome at discharge ( P < .001). We identified 39 "false poor grade" patients who had significantly better outcomes than "real poor grade" patients (N = 220) (modified Rankin Scale-discharge: 0-2, 56% vs 1%, P < .001; 3-5: 41% vs 56%, P = .12; 6: 3% vs 43%, P < .001). "False poor grade" patients differed significantly in initial CT parameters. A predictive model called "initial CT WFNS" ( ICT WFNS) was developed, incorporating SEBES, Hijdra score, and LeRoux score (sensitivity = 0.95, specificity = 0.84, accuracy = 0.859, F1 = 0.673). ICT WFNS scores of ≤4.6 classified patients as "false poor grade."

CONCLUSION

The initial WFNS score may misclassify a subgroup of patients with aSAH as poor grade, which can be avoided by later determination of the WFNS score, at days 3-4 losing its usefulness. Alternatively, the initial WFNS score can be improved in its predictive value, especially in poor-grade patients, using criteria from the initial native CT imaging, such as the Hijdra, LeRoux, and Subarachnoid Hemorrhage Early Brain Edema score, combined in the ICT WFNS score with even higher predictive power.

Risk factors for poor outcome after aneurysmal subarachnoid hemorrhage in patients with initial favorable neurological status

BACKGROUND

Aneurysmal subarachnoid hemorrhage (aSAH) remains a devastating diagnosis. A poor outcome is known to be highly dependent on the initial neurological status. Our goal was to identify other parameters that favor the risk of complications and poor outcome in patients with aSAH and initially favorable neurologic status.

METHODS

Consecutive aSAH cases treated at our hospital between 01/2003 and 06/2016 with the initial World Federation of Neurosurgical Societies grades I-III were included. Data on demographic characteristics, previous medical history, initial aSAH severity, and functional outcome after aSAH were collected. The study endpoints were the occurrence of cerebral infarcts, in-hospital mortality, and unfavorable outcome at 6 months after aSAH (modified Rankin scale > 3).

RESULTS

In the final cohort (n= 582), the rate of cerebral infarction, in-hospital mortality, and unfavorable outcome was 35.1%, 8.1%, and 17.6% respectively. The risk of cerebral infarction was independently related to the presence of acute hydrocephalus (adjusted odds ratio [aOR]=2.33, p<0.0001), aneurysm clipping (aOR=1.78, p=0.003), and use of calcium channel blockers concomitant to nimodipine (aOR=2.63, p=0.002). Patients' age (>55 years, aOR=4.24, p<0.0001), acute hydrocephalus (aOR=2.43, p=0.036), and clipping (aOR=2.86, p=0.001) predicted in-hospital mortality. Baseline characteristics associated with unfavorable outcome at 6 months were age (aOR=2.77, p=<0.0001), Fisher grades III-IV (aOR=2.81, p=0.016), acute hydrocephalus (aOR=2.22, p=0.012), clipping (aOR=3.98, p<0.0001), admission C-reactive protein>1mg/dL (aOR=1.76, p=0.035), and treatment intervals (aOR=0.64 per-5-year-intervals, p=0.006).

CONCLUSIONS

Although cerebral infarction is a common complication in aSAH individuals with favorable initial clinical condition, >80% of these patients show favorable long-term outcome. The knowledge of outcome-relevant baseline characteristics might help to reduce the burden of further complications and poor outcome in aSAH patients who tolerated the initial bleeding event well.

Accurately predicting the risk of unfavorable outcomes after endovascular coil therapy in patients with aneurysmal subarachnoid hemorrhage: an interpretable machine learning model

BACKGROUND

Despite endovascular coiling as a valid modality in treatment of aneurysmal subarachnoid hemorrhage (aSAH), there is a risk of poor prognosis. However, the clinical utility of previously proposed early prediction tools remains limited. We aimed to develop a clinically generalizable machine learning (ML) models for accurately predicting unfavorable outcomes in aSAH patients after endovascular coiling.

METHODS

Functional outcomes at 6 months after endovascular coiling were assessed via the modified Rankin Scale (mRS) and unfavorable outcomes were defined as mRS 3-6. Five ML algorithms (logistic regression, random forest, support vector machine, deep neural network, and extreme gradient boosting) were used for model development. The area under precision-recall curve (AUPRC) and receiver operating characteristic curve (AUROC) was used as main indices of model evaluation. SHapley Additive exPlanations (SHAP) method was applied to interpret the best-performing ML model.

RESULTS

A total of 371 patients were eventually included into this study, and 85.4% of them had favorable outcomes. Among the five models, the DNN model had a better performance with AUPRC of 0.645 (AUROC of 0.905). Postoperative GCS score, size of aneurysm, and age were the top three powerful predictors. The further analysis of five random cases presented the good interpretability of the DNN model.

CONCLUSION

Interpretable clinical prediction models based on different ML algorithms have been successfully constructed and validated, which would serve as reliable tools in optimizing the treatment decision-making of aSAH. Our DNN model had better performance to predict the unfavorable outcomes at 6 months in aSAH patients compared with Yan's nomogram model.

Evaluation of FRESH scores in predicting outcome and quality of life after aneurysmal subarachnoid haemorrhage in a European patient cohort

BACKGROUND

Despite aneurysmal subarachnoid haemorrhage (aSAH) patients often experiencing physical and mental disabilities impacting their quality of life (QoL), routine assessment of long-term QoL data and predictive tools are limited. This study evaluates the newly developed "functional recovery expected after subarachnoid haemorrhage" (FRESH) scores with long-term outcomes and QoL in European aSAH patients.

METHODS

FRESH, FRESH-cog, and FRESH-quol scores were retrospectively obtained from aSAH patients. Patients were contacted, and the modified Rankin Scale (mRS), extended short form-36 (SF-36), and telephone interview for cognitive status (TICS) were collected and performed. The prognostic and empirical outcomes were compared.

RESULTS

Out of 374 patients, 171 patients (54.1%) completed the SF-36, and 154 patients completed the TICS. The SF-36 analysis showed that 32.7% had below-average physical component summary (PCS) scores, and 39.8% had below-average mental component summary (MCS) scores. There was no significant correlation between the FRESH score and PCS (p = 0.09736), MCS (p = 0.1796), TICS (p = 0.7484), or mRS 10-82 months (average 46 months) post bleeding (p = 0.024), respectively. There was also no significant correlation found for "FRESH-cog vs. TICS" (p = 0.0311), "FRESH-quol vs. PCS" (p = 0.0204), "FRESH-quol vs. MCS" (p = 0.1361) and "FRESH-quol vs. TICS" (p = 0.1608).

CONCLUSIONS

This study found no correlation between FRESH scores and validated QoL tools in a European population of aSAH patients. The study highlights the complexity of reliable long-term QoL prognostication in aSAH patients and emphasises the need for further prospective research to also focus on QoL as an important outcome parameter.

Proposed imaging assessment score for aneurysmal subarachnoid hemorrhage correlated with prognosis: Shinshu Aneurysmal subarachnoid hemorrhage score

BACKGROUND

Aneurysmal subarachnoid hemorrhage (aSAH) imaging has been shown to correlate with prognosis. However, no numerical index of bleeding severity has been established. This study aimed to propose a new simple scoring system for computed tomography imaging of aSAH and to confirm its effectiveness in retrospective and prospective studies.

METHODS

We devised an image evaluation system as an objective index. This system was established by scoring six items, with a maximum total of 19 points. Using this score, named the Shinshu Aneurysmal Subarachnoid Hemorrhage Score (S-score), we performed a retrospective study of 210 patients with aSAH at a single institution to confirm its efficacy. Age and World Federation of Neurosurgical Societies grades were adopted as other verification items, and the modified Rankin Scale was used for prognostic evaluation. A multicenter prospective study was then conducted to examine the function of the score by examining 214 patients with aSAH.

RESULTS

In the retrospective study, the threshold of the S-score between good and poor prognoses was 9/19 points. The area under the curve by receiver operating characteristic analysis of the S-score was 0.819, suggesting efficacy, with an odds ratio (OR) of 1.291 (1.077-1.547). In the prospective study, the judgment capability of the S-score was evaluated with a sensitivity of 0.674, specificity of 0.881, positive predictive value of 0.789, negative predictive value of 0.804, false-positive ratio of 0.119, false-negative ratio of 0.325, positive likelihood ratio of 6.072, and negative likelihood ratio of 1.369. S-score showed a significant difference in prognosis. The OR was 1.183 (1.009-1.388).

CONCLUSIONS

The scoring system could contribute to patient prognosis assessment. S-score and its prognostic formulas may serve as an objective source of information in the development of clinical medicine.

Clinical prediction models for aneurysmal subarachnoid hemorrhage: a systematic review update

BACKGROUND

A systematic review of clinical prediction models for aneurysmal subarachnoid hemorrhage (aSAH) reported in 2011 noted that clinical prediction models for aSAH were developed using poor methods and were not externally validated. This study aimed to update the above review to guide the future development of predictive models in aSAH.

METHODS

We systematically searched Embase and MEDLINE databases (January 2010 to February 2022) for articles that reported the development of a clinical prediction model to predict functional outcomes in aSAH. Our reviews are based on the items included in the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement (PRISMA) checklist, and on data abstracted from each study in accord with the Checklist for critical Appraisal and data extraction for systematic Reviews of prediction Modelling Studies (CHARMS) 2014 checklist. Bias and applicability were assessed using the Prediction model Risk Of Bias Assessment Tool (PROBAST).

RESULTS

We reviewed data on 30 466 patients contributing to 29 prediction models abstracted from 22 studies identified from an initial search of 7858 studies. Most models were developed using logistic regression (n=20) or machine learning (n=9) with prognostic variables selected through a range of methods. Age (n=13), World Federation of Neurological Surgeons (WFNS) grade (n=11), hypertension (n=6), aneurysm size (n=5), Fisher grade (n=12), Hunt and Hess score (n=5), and Glasgow Coma Scale (n=8) were the variables most frequently included in the reported models. External validation was performed in only four studies. All but one model had a high or unclear risk of bias due to poor performance or lack of validation.

CONCLUSION

Externally validated models for the prediction of functional outcome in aSAH patients have now become available. However, most of them still have a high risk of bias.

Machine learning to predict mortality for aneurysmal subarachnoid hemorrhage (aSAH) using a large nationwide EHR database

Aneurysmal subarachnoid hemorrhage (aSAH) develops quickly once it occurs and threatens the life of patients. We aimed to use machine learning to predict mortality for SAH patients at an early stage which can help doctors make clinical decisions. In our study, we applied different machine learning methods to an aSAH cohort extracted from a national EHR database, the Cerner Health Facts EHR database (2000-2018). The outcome of interest was in-hospital mortality, as either passing away while still in the hospital or being discharged to hospice care. Machine learning-based models were primarily evaluated by the area under the receiver operating characteristic curve (AUC). The population size of the SAH cohort was 6728. The machine learning methods achieved an average of AUCs of 0.805 for predicting mortality with only the initial 24 hours' EHR data. Without losing the prediction power, we used the logistic regression to identify 42 risk factors, -examples include age and serum glucose-that exhibit a significant correlation with the mortality of aSAH patients. Our study illustrates the potential of utilizing machine learning techniques as a practical prognostic tool for predicting aSAH mortality at the bedside.

Inhibition of GPR17/ID2 Axis Improve Remyelination and Cognitive Recovery after SAH by Mediating OPC Differentiation in Rat Model

Myelin sheath injury contributes to cognitive deficits following subarachnoid hemorrhage (SAH). G protein-coupled receptor 17 (GPR17), a membrane receptor, negatively regulates oligodendrocyte precursor cell (OPC) differentiation in both developmental and pathological contexts. Nonetheless, GPR17's role in modulating OPC differentiation, facilitating remyelination post SAH, and its interaction with downstream molecules remain elusive. In a rat SAH model induced by arterial puncture, OPCs expressing GPR17 proliferated prominently by day 14 post-onset, coinciding with compromised myelin sheath integrity and cognitive deficits. Selective Gpr17 knockdown in oligodendrocytes (OLs) via adeno-associated virus (AAV) administration revealed that reduced GPR17 levels promoted OPC differentiation, restored myelin sheath integrity, and improved cognitive deficits by day 14 post-SAH. Moreover, GPR17 knockdown attenuated the elevated expression of the inhibitor of DNA binding 2 (ID2) post-SAH, suggesting a GPR17-ID2 regulatory axis. Bi-directional modulation of ID2 expression in OLs using AAV unveiled that elevated ID2 counteracted the restorative effects of GPR17 knockdown. This resulted in hindered differentiation, exacerbated myelin sheath impairment, and worsened cognitive deficits. These findings highlight the pivotal roles of GPR17 and ID2 in governing OPC differentiation and axonal remyelination post-SAH. This study positions GPR17 as a potential therapeutic target for SAH intervention. The interplay between GPR17 and ID2 introduces a novel avenue for ameliorating cognitive deficits post-SAH.

The survival and outcome of older patients with primary aneurysmal subarachnoid haemorrhage: a 2-year follow-up, multi-centre, observational study

BACKGROUND AND PURPOSE

The management of older aneurysmal subarachnoid haemorrhage (aSAH) cases is a clinical challenge. This study aimed to analyse the survival and functional outcomes in older aSAH patients (age ≥ 70 years) to provide evidence for making treatment decisions for such patients.

METHODS

We performed a 2-year follow-up analysis of the Chinese Multi-Centre Cerebral Aneurysm Database for older patients suffering from aSAH from 2017 to 2020. A survival analysis was used to investigate the mean survival and hazard ratios for death. Binary logarithmic regression was performed to investigate the odds ratio for independent survival and dependent survival.

RESULTS

A total of 1,136 consecutive older patients with aSAH were assessed in this study, and 944 patients (83.1%) were followed up. The overall mean survival was 37.79 ± 1.04 months. A total of 380 (40.25%) patients died within 2 years after aSAH. In survival analysis, the predictors of mortality were older age, intracerebral haemorrhage (ICH) history, Hunt-Hess (H-H) grade, World Federation of Neurosurgical Societies (WFNS) grade and operative treatment decreased the risk of mortality compared to conservative treatment. In binary logarithmic regression, the predictors of dependent survival were hypertension, diabetes, WFNS grade.

CONCLUSIONS

The risk for 2-year mortality after aSAH increases markedly with older age, ICH history, H-H grade and WFNS grade. Risk factors for 2-year dependent survival were associated with hypertension, diabetes and WFNS grade in older patients with aSAH. Operative treatment markedly decreased mortality but did not significantly decrease the morbidity of dependent survival compared to conservative treatment.

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.

Frailty as a Predictor of Outcomes in Subarachnoid Hemorrhage: A Systematic Review and Meta-Analysis

Frailty is an emerging concept in clinical practice used to predict outcomes and dictate treatment algorithms. Frail patients, especially older adults, are at higher risk for adverse outcomes. Aneurysmal subarachnoid hemorrhage (aSAH) is a neurosurgical emergency associated with high morbidity and mortality rates that have previously been shown to correlate with frailty. However, the relationship between treatment selection and post-treatment outcomes in frail aSAH patients is not established. We conducted a meta-analysis of the relevant literature in accordance with PRISMA guidelines. We searched PubMed, Embase, Web of Science, and Google Scholar using "Subarachnoid hemorrhage AND frailty" and "subarachnoid hemorrhage AND frail" as search terms. Data on cohort age, frailty measurements, clinical grading systems, and post-treatment outcomes were extracted. Of 74 studies identified, four studies were included, with a total of 64,668 patients. Percent frailty was 30.4% under a random-effects model in all aSAH patients (p < 0.001). Overall mortality rate of aSAH patients was 11.7% when using a random-effects model (p < 0.001). There was no significant difference in mortality rate between frail and non-frail aSAH patients, but this analysis only included two studies and should be interpreted cautiously. Age and clinical grading, rather than frailty, independently predicted outcomes and mortality in aSAH patients.

Potential application of peripheral blood biomarkers in intracranial aneurysms

Intracranial aneurysm (IA) counts are increasing yearly, with a high mortality and disability after rupture. Current diagnosis and treatment rely on costly equipment, lacking effective indicators for progression prediction and specific drugs for treatment. Recently, peripheral blood biomarkers, as common clinical test samples, reflecting the immune and inflammatory state of the body in real-time, have shown promise in providing additional information for risk stratification and treatment in IA patients, which may improve their outcomes after aneurysm rupture through anti-inflammatory therapy. Therefore, this paper reviewed the progress of potential biomarkers of IAs, including inflammatory blood indicators, cytokines, and blood lipids, aiming to aid individual management and therapy of aneurysms in clinical practices.

Serum neurofilament light as a predictor of outcome in subarachnoid haemorrhage

BACKGROUND

Prognostication of clinical outcome in patients suffering from aneurysmal subarachnoid haemorrhage (SAH) is a challenge. There are no biochemical markers in routine use that can aid in prognostication. Neurofilament light (NFL) measured in cerebrospinal fluid (CSF) has been associated with clinical outcome in previous studies.

OBJECTIVE

To investigate if serum levels of NFL correlate with CSF levels and long-term clinical outcome in patients suffering from SAH.

METHODS

We conducted an observational cohort study of 88 patients treated for SAH at Umeå University Hospital in 2014-2018. Serum and CSF samples were analysed using an enzyme-linked immunosorbent assay to quantify NFL levels. Outcome was assessed using Glasgow Outcome Scale Extended and dichotomised as favourable or unfavourable. Differences in NFL levels between outcome groups were analysed using repeated measurements ANOVA. Relationship between CSF and serum NFL levels was analysed using Pearson's correlation. A multivariate binary logistic regression model and a receiver operation characteristic curve were used to assess the predictive value of serum NFL.

RESULTS

A significant correlation between serum and CSF-NFL levels could be seen (Pearson's correlation coefficient = 0.7, p < .0001). Mean level of serum NFL was higher in the unfavourable outcome group than the favourable outcome group (p < .0001), in all epochs of SAH, and correlated with initial disease severity on the World Federation of Neurosurgical Societies scale. Serum NFL in the late phase displayed the best predictive potential in a receiver operation characteristic curve analysis (AUC=0.845, p < .0001).

CONCLUSION

Levels of NFL in serum and CSF are correlated. Early serum NFL levels seem to reflect initial tissue damage and serum NFL levels in the late phase may reflect secondary events such as vasospasm or delayed cerebral ischemia. Serum NFL may be used as a prognostic marker of clinical outcome in SAH.

The Diagnostic Value of Near-Infrared Spectroscopy to Predict Delayed Cerebral Ischemia and Unfavorable Outcome After Subarachnoid Hemorrhage

OBJECTIVE

Near-infrared spectroscopy (NIRS) is a noninvasive tool to monitor cerebral regional oxygen saturation. Impairment of microvascular circulation with subsequent cerebral hypoxia during delayed cerebral ischemia (DCI) is associated with poor functional outcome after subarachnoid hemorrhage (SAH). Therefore, NIRS could be useful to predict the risk for DCI and functional outcome. However, only limited data are available on NIRS regional cerebral tissue oxygen saturation (rSO2) distribution in SAH. The aim of this study was to compare the distribution of NIRS rSO2 values in patients with nontraumatic SAH with the occurrence of DCI and functional outcome at 2 months. In addition, the predictive value of NIRS rSO2 was compared with the previously validated SAFIRE grade (derived from Size of the aneurysm, Age, FIsher grade, World Federation of Neurosurgical Societies after REsuscitation).

METHODS

In this study, the rSO2 distribution of patients with and without DCI after SAH was compared. The optimal cutoff points to predict DCI and outcome were assessed, and its predictive value was compared with the SAFIRE grade.

RESULTS

Of 41 patients, 12 developed DCI, and 9 had unfavorable outcome at 60 days. Prediction of DCI with NIRS had an area under the curve of 0.77 (95% confidence interval 0.62-0.92; P = 0.0028) with an optimal cutoff point of 65% (sensitivity 1.00; specificity 0.45). Prediction of favorable outcome with NIRS had an area under the curve of 0.86 (95% confidence interval 0.74-0.98; P = 0.0003) with an optimal cutoff point of 63% (sensitivity 1.00; specificity 0.63). Regression analysis showed that NIRS rSO2 score is complementary to the SAFIRE grade.

CONCLUSIONS

NIRS rSO2 monitoring in patients with SAH may improve prediction of DCI and clinical outcome after SAH.

Prognostic Neuroimaging Biomarkers in Acute Vascular Brain Injury and Traumatic Brain Injury

Prognostic imaging biomarkers after acute brain injury inform treatment decisions, track the progression of intracranial injury, and can be used in shared decision-making processes with families. Herein, key established biomarkers and prognostic scoring systems are surveyed in the literature, and their applications in clinical practice and clinical trials are discussed. Biomarkers in acute ischemic stroke include computed tomography (CT) hypodensity scoring, diffusion-weighted lesion volume, and core infarct size on perfusion imaging. Intracerebral hemorrhage biomarkers include hemorrhage volume, expansion, and location. Aneurysmal subarachnoid biomarkers include hemorrhage grading, presence of diffusion-restricting lesions, and acute hydrocephalus. Traumatic brain injury CT scoring systems, contusion expansion, and diffuse axonal injury grading are reviewed. Emerging biomarkers including white matter disease scoring, diffusion tensor imaging, and the automated calculation of scoring systems and volumetrics are discussed.

Artificial Intelligence and Neurosurgery: Tracking Antiplatelet Response Patterns for Endovascular Intervention

Platelets play a critical role in blood clotting and the development of arterial blockages. Antiplatelet therapy is vital for preventing recurring events in conditions like coronary artery disease and strokes. However, there is a lack of comprehensive guidelines for using antiplatelet agents in elective neurosurgery. Continuing therapy during surgery poses a bleeding risk, while discontinuing it before surgery increases the risk of thrombosis. Discontinuation is recommended in neurosurgical settings but carries an elevated risk of ischemic events. Conversely, maintaining antithrombotic therapy may increase bleeding and the need for transfusions, leading to a poor prognosis. Artificial intelligence (AI) holds promise in making difficult decisions regarding antiplatelet therapy. This paper discusses current clinical guidelines and supported regimens for antiplatelet therapy in neurosurgery. It also explores methodologies like P2Y12 reaction units (PRU) monitoring and thromboelastography (TEG) mapping for monitoring the use of antiplatelet regimens as well as their limitations. The paper explores the potential of AI to overcome such limitations associated with PRU monitoring and TEG mapping. It highlights various studies in the field of cardiovascular and neuroendovascular surgery which use AI prediction models to forecast adverse outcomes such as ischemia and bleeding, offering assistance in decision-making for antiplatelet therapy. In addition, the use of AI to improve patient adherence to antiplatelet regimens is also considered. Overall, this research aims to provide insights into the use of antiplatelet therapy and the role of AI in optimizing treatment plans in neurosurgical settings.

Pre- and Post-Operative Online Prediction of Outcome in Patients Undergoing Endovascular Coiling after Aneurysmal Subarachnoid Hemorrhage: Visual and Dynamic Nomograms

BACKGROUND

Aneurysmal subarachnoid hemorrhage (aSAH) causes long-term functional dependence and death. Early prediction of functional outcomes in aSAH patients with appropriate intervention strategies could lower the risk of poor prognosis. Therefore, we aimed to develop pre- and post-operative dynamic visualization nomograms to predict the 1-year functional outcomes of aSAH patients undergoing coil embolization.

METHODS

Data were obtained from 400 aSAH patients undergoing endovascular coiling admitted to the People's Hospital of Hunan Province in China (2015-2019). The key indicator was the modified Rankin Score (mRS), with 3-6 representing poor functional outcomes. Multivariate logistic regression (MLR)-based visual nomograms were developed to analyze baseline characteristics and post-operative complications. The evaluation of nomogram performance included discrimination (measured by C statistic), calibration (measured by the Hosmer-Lemeshow test and calibration curves), and clinical usefulness (measured by decision curve analysis).

RESULTS

Fifty-nine aSAH patients (14.8%) had poor outcomes. Both nomograms showed good discrimination, and the post-operative nomogram demonstrated superior discrimination to the pre-operative nomogram with a C statistic of 0.895 (95% CI: 0.844-0.945) vs. 0.801 (95% CI: 0.733-0.870). Each was well calibrated with a Hosmer-Lemeshow p-value of 0.498 vs. 0.276. Moreover, decision curve analysis showed that both nomograms were clinically useful, and the post-operative nomogram generated more net benefit than the pre-operative nomogram. Web-based online calculators have been developed to greatly improve the efficiency of clinical applications.

CONCLUSIONS

Pre- and post-operative dynamic nomograms could support pre-operative treatment decisions and post-operative management in aSAH patients, respectively. Moreover, this study indicates that integrating post-operative variables into the nomogram enhanced prediction accuracy for the poor outcome of aSAH patients.

Initial Temporal Muscle Thickness and Area: Poor Predictors of Neurological Outcome in Aneurysmal Subarachnoid Hemorrhage in a Central European Patient Cohort

The temporalis muscle area (TMA) has been proclaimed as a surrogate parameter for estimating skeletal muscle mass. Pilot studies in Asian populations suggested temporal muscle thickness (TMT) and TMA as prognostic factors for neurological outcomes in aneurysmal subarachnoid hemorrhage (aSAH) patients. This study aimed to validate these findings in a larger European patient cohort. We retrospectively analyzed age, sex, aneurysm location, treatment, World Federation of Neurosurgical Societies (WFNS) grade, Fisher score, and modified Rankin Score (mRS) at six months in patients with aSAH. TMT and TMA measurements were obtained from initial native CT scans. Logistic regression with the dichotomized six-month mRS as the outcome incorporating TMT, weighted average of TMT, or TMA as predictors was performed. Of the included 478 patients, 66% were female, the mean age was 56, and 48% of patients had an mRS of three to six after six months. The mean TMT at the level of the Sylvian fissure was 5.9 (±1.7) mm in males and 4.8 (±1.8) mm in females. The mean TMA was 234.5 (±107.9) mm2 in females and 380 (±134.1) mm2 in males. WFNS grade (p < 0.001), Fisher score (p < 0.001), and age (p < 0.05) correlated significantly with the mRS after six months. No correlation was found between mRS after six months and the TMT at the Sylvian fissure (p = 0.3), the weighted average of TMT (p = 0.1), or the TMA (p = 0.1). In this central European patient cohort of 478 individuals, no significant associations were found between TMT/TMA and neurological outcomes following aSAH. Further prospective studies in diverse patient populations are necessary to determine the prognostic value of TMA and TMT in aSAH patients.

Clinical prediction score for prolonged length of hospital stay in aneurysmal subarachnoid hemorrhage

BACKGROUND

Length of stay (LOS) is an important indicator of the optimization of health services and hospital financing efficiency in aneurysmal subarachnoid hemorrhage (aSAH) patients. The purpose of this study was to develop a scoring model to predict the LOS of patients with aSAH.

METHOD

A clinical scoring was developed based on retrospectively collected data from the cerebral aneurysm registry of the National Brain Center Hospital, Jakarta, from January 2019 to June 2022. Multivariate logistic regression was used to determine the odds ratio for risk-adjusted prolonged LOS. LOS predictors were obtained based on the regression coefficients and converted into a point score model.

RESULTS

Of the 209 aSAH patients observed, 117 patients had prolonged LOS (> 14 days of hospital stay). A clinical score was developed with a range of 0-7 points. Four variables were chosen as predictors of prolonged LOS: the presence of high-grade aSAH (1 point), aneurysm treatment (endovascular coiling: 1 point; surgical clipping: 2 points), cardiovascular comorbidities (1 point), and hospital-acquired pneumonia (3 points). The score showed good discrimination with an area under the receiving operating characteristics curve (AUC) of 0.8183 (SE 0.0278) and a p-value for the Hosmer-Lemeshow (HL) goodness-of-fit of 0.9322.

CONCLUSION

This simple clinical score reliably predicted prolonged LOS in aneurysmal subarachnoid hemorrhage cases and may aid clinicians in improving patient outcomes and decreasing healthcare costs.

Serum LDH levels may predict poor neurological outcome after aneurysmal subarachnoid hemorrhage

INTRODUCTION

Serum lactate dehydrogenase (LDH) levels are often elevated in cardiovascular diseases. Their prognostic role after subarachnoid hemorrhage (SAH) remains poorly evaluated.

METHODS

This is a retrospective single-center study of patients with non-traumatic SAH admitted to the intensive care unit (ICU) of an University Hospital from 2007 to 2022. Exclusion criteria were pregnancy and incomplete medical records or follow-up data. Baseline information, clinical data, radiologic data, the occurrence of neurological complications as well as serum LDH levels during the first 14 days of ICU stay were collected. Unfavorable neurological outcome (UO) at 3 months was defined as a Glasgow Outcome Scale of 1-3.

RESULTS

Five hundred and forty-seven patients were included; median serum LDH values on admission and the highest LDH values during the ICU stay were 192 [160-230] IU/L and 263 [202-351] IU/L, respectively. The highest LDH value was recorded after a median of 4 [2-10] days after ICU admission. LDH levels on admission were significantly higher in patients with UO. When compared with patients with favorable outcome (FO), patients with UO had higher serum LDH values over time. In the multivariate logistic regression model, the highest LDH value over the ICU stay (OR 1.004 [95% CI 1.002 - 1.006]) was independently associated with the occurrence of UO; the area under the receiving operator (AUROC) curve for the highest LDH value over the ICU stay showed a moderate accuracy to predict UO (AUC 0.76 [95% CI 0.72-0.80]; p < 0.001), with an optimal threshold of > 272 IU/L (69% sensitivity and 74% specificity).

CONCLUSIONS

The results in this study suggest that high serum LDH levels are associated with the occurrence of UO in SAH patients. As a readily and available biomarker, serum LDH levels should be evaluated to help with the prognostication of SAH patients.

Telephone triage service use is associated with better outcomes among patients with cerebrovascular diseases: a propensity score analysis using population-based data

Introduction

The telephone triage service is an emergency medical system through which citizens consult telephone triage nurses regarding illness, and the nurses determine the urgency and need for an ambulance. Despite being introduced in several countries, its impact on emergency patients has not been reported. We aimed to determine the effect of the telephone triage service on the outcomes of hospitalized patients diagnosed with cerebrovascular disease upon arrival after being transported by an ambulance.

Methods

This retrospective study included patients with cerebrovascular disease who were transported by ambulance between January 2016 and December 2019. The primary outcome was discharge to home by day 21 of hospitalization. A total of 344 patients who used the telephone triage service were propensity score-matched to 344 patients who directly called for an ambulance.

Results

Telephone triage service use was associated with discharge to home by hospital day 21 (crude odd ratio: 1.8; 95% confidence interval: 1.3-2.4) and was not significantly associated with survival on hospital day 21 in multivariate regression analysis.

Conclusion

The prognoses of cerebral infarction, intracerebral hemorrhage, and subarachnoid hemorrhage depend on the time from symptom onset to treatment. Telephone triage services may allow patients to receive treatment more rapidly than traditional ambulance requests, resulting in improved patient outcomes. The findings of this study suggest that the use of telephone triage services is associated with improved outcomes in patients with cerebrovascular disease and indicate that the costs for medical expenses and disability may be greatly reduced in an aging society.

Prospective, multicentre study of screening, investigation and management of hyponatraemia after subarachnoid haemorrhage in the UK and Ireland

BACKGROUND

Hyponatraemia often occurs after subarachnoid haemorrhage (SAH). However, its clinical significance and optimal management are uncertain. We audited the screening, investigation and management of hyponatraemia after SAH.

METHODS

We prospectively identified consecutive patients with spontaneous SAH admitted to neurosurgical units in the United Kingdom or Ireland. We reviewed medical records daily from admission to discharge, 21 days or death and extracted all measurements of serum sodium to identify hyponatraemia (<135 mmol/L). Main outcomes were death/dependency at discharge or 21 days and admission duration >10 days. Associations of hyponatraemia with outcome were assessed using logistic regression with adjustment for predictors of outcome after SAH and admission duration. We assessed hyponatraemia-free survival using multivariable Cox regression.

RESULTS

175/407 (43%) patients admitted to 24 neurosurgical units developed hyponatraemia. 5976 serum sodium measurements were made. Serum osmolality, urine osmolality and urine sodium were measured in 30/166 (18%) hyponatraemic patients with complete data. The most frequently target daily fluid intake was >3 L and this did not differ during hyponatraemic or non-hyponatraemic episodes. 26% (n/N=42/164) patients with hyponatraemia received sodium supplementation. 133 (35%) patients were dead or dependent within the study period and 240 (68%) patients had hospital admission for over 10 days. In the multivariable analyses, hyponatraemia was associated with less dependency (adjusted OR (aOR)=0.35 (95% CI 0.17 to 0.69)) but longer admissions (aOR=3.2 (1.8 to 5.7)). World Federation of Neurosurgical Societies grade I-III, modified Fisher 2-4 and posterior circulation aneurysms were associated with greater hazards of hyponatraemia.

CONCLUSIONS

In this comprehensive multicentre prospective-adjusted analysis of patients with SAH, hyponatraemia was investigated inconsistently and, for most patients, was not associated with changes in management or clinical outcome. This work establishes a basis for the development of evidence-based SAH-specific guidance for targeted screening, investigation and management of high-risk patients to minimise the impact of hyponatraemia on admission duration and to improve consistency of patient care.

Lumbar puncture-verified subarachnoid hemorrhage: bleeding sources, need of radiological examination, and functional recovery

BACKGROUND

The primary aim was to determine the diagnostic yield of vascular work-up, the clinical course during neurointensive care (NIC), and rate of functional recovery for patients with computed tomography (CT)-negative, lumbar puncture (LP)-verified SAH.

METHODS

In this retrospective study, 1280 patients with spontaneous SAH, treated at our NIC unit, Uppsala University Hospital, Sweden, between 2008 and 2018, were included. Demography, admission status, radiological examinations (CT angiography (CTA) and digital subtraction angiography (DSA)), treatments, and functional outcome (GOS-E) at 12 months were evaluated.

RESULTS

Eighty (6%) out of 1280 SAH patients were computed tomography (CT)-negative, LP-verified cases. Time between ictus and diagnosis was longer for the LP-verified SAH cohort in comparison to the CT-positive patients (median 3 vs 0 days, p < 0.001). One fifth of the LP-verified SAH patients exhibited an underlying vascular pathology (aneurysm/AVM), which was significantly less common than for the CT-verified SAH cohort (19% vs. 76%, p < 0.001). The CTA- and DSA-findings were consistent in all of the LP-verified cases. The LP-verified SAH patients exhibited a lower rate of delayed ischemic neurological deficits, but no difference in rebleeding rate, compared to the CT-verified cohort. At 1-year post-ictus, 89% of the LP-verified SAH patients had recovered favorably, but 45% of the cases did not reach good recovery. Having an underlying vascular pathology and an external ventricular drainage were associated with worse functional recovery (p = 0.02) in this cohort.

CONCLUSIONS

LP-verified SAH constituted a small proportion of the entire SAH population. Having an underlying vascular pathology was less frequent in this cohort, but still occurred in one out of five patients. Despite the small initial bleeding in the LP-verified cohort, many of these patients did not reach good recovery at 1 year, this calls for more attentive follow-up and rehabilitation in this cohort.

Additive prognostic impact of the cerebrospinal fluid arginine/ornithine ratio to established clinical scores in aneurysmal subarachnoid hemorrhage

Cerebrospinal fluid (CSF) metabolites are increasingly recognized as prognostic factors in aneurysmal subarachnoid hemorrhage (SAH). The CSF arginine/ornithine ratio (Arg/Orn) was shown to predict cerebral vasospasms and clinical outcome in SAH. The additive prognostic value of Arg/Orn over established prognostic scores has not been investigated. CSF Arg/Orn and the established prognostic scores SAH, FRESH, SAH-PDS, HAIR, Rosen-McDonald, Hunt and Hess, WFNS and modified Fisher scale were determined in a prospective cohort of patients with aneurysmal SAH. Logistic regression models to predict a favorable outcome, defined as a modified Rankin Scale score of 0-3 at 3  months follow-up, were constructed for each score, both with and without the addition of Arg/Orn. The impact of Arg/Orn was assessed comparing logistic regression models containing the respective score with and without Arg/Orn with the likelihood ratio chi-squared test. CSF Arg/Orn and clinical scores were determined in 38 SAH patients. Arg/Orn was an independent predictor of clinical outcome when added to established prognostic scores (p < 0.05) with the exception of HAIR (p = 0.078). All models were significantly improved if Arg/Orn was added as a covariable (p < 0.05). The results of this study confirm Arg/Orn as an independent prognostic factor and its addition improves established prognostic models in SAH.

Adverse events associated with microsurgial treatment for ruptured intracerebral aneurysms: a prospective nationwide study on subarachnoid haemorrhage in Sweden

BACKGROUND

Adverse events (AEs) or complications may arise secondary to the treatment of aneurysmal subarachnoid haemorrhage (SAH). The aim of this study was to identify AEs associated with microsurgical occlusion of ruptured aneurysms, as well as to analyse their risk factors and impact on functional outcome.

METHODS

Patients with aneurysmal SAH admitted to the neurosurgical centres in Sweden were prospectively registered during a 3.5-year period (2014-2018). AEs were categorised as intraoperative or postoperative. A range of variables from patient history and SAH characteristics were explored as potential risk factors for an AE. Functional outcome was assessed approximately 1 year after the bleeding using the extended Glasgow Outcome Scale.

RESULTS

In total, 1037 patients were treated for ruptured aneurysms, of which, 322 patients were treated with microsurgery. There were 105 surgical AEs in 97 patients (30%); 94 were intraoperative AEs in 79 patients (25%). Aneurysm rerupture occurred in 43 patients (13%), temporary occlusion of the parent artery >5 min in 26 patients (8%) and adjacent vessel injury in 25 patients (8%). High Fisher grade and brain oedema on CT were related to increased risk of AEs. At follow-up, 38% of patients had unfavourable outcome. Patients suffering AEs were more likely to have unfavourable outcome (OR 2.3, 95% CI 1.10 to 4.69).

CONCLUSION

Intraoperative AEs occurred in 25% of patients treated with microsurgery for ruptured intracerebral aneurysm in this nationwide survey. Although most operated patients had favourable outcome, AEs were associated with increased risk of unfavourable outcome.

Antithrombotic agent usage before ictus in aneurysmal subarachnoid hemorrhage: relation to hemorrhage severity, clinical course, and outcome

BACKGROUND

The number of patients with aneurysmal subarachnoid hemorrhage (aSAH) who are on antithrombotic agents before ictus is rising. However, their effect on early brain injury and disease development remains unclear. The primary aim of this study was to determine if antithrombotic agents (antiplatelets and anticoagulants) were associated with a worse initial hemorrhage severity, rebleeding rate, clinical course, and functional recovery after aSAH.

METHODS

In this observational study, those 888 patients with aSAH, treated at the neurosurgical department, Uppsala University Hospital, between 2008 and 2018 were included. Demographic, clinical, radiological (Fisher and Hijdra score), and outcome (Extended Glasgow Outcome Scale one year post-ictus) variables were assessed.

RESULTS

Out of 888 aSAH patients, 14% were treated with antithrombotic agents before ictus. Seventy-five percent of these were on single therapy of antiplatelets, 23% on single therapy of anticoagulants, and 3% on a combination of antithrombotic agents. Those with antithrombotic agents pre-ictus were significantly older and exhibited more co-morbidities and a worse coagulation status according to lab tests. Antithrombotic agents, both as one group and as subtypes (antiplatelets and anticoagulants), were not associated with hemorrhage severity (Hijdra score/Fisher) nor rebleeding rate. The clinical course did not differ in terms of delayed ischemic neurological deficits or last-tier treatment with thiopental and decompressive craniectomy. These patients experienced a higher mortality and lower rate of favorable outcome in univariate analyses, but this did not hold true in multiple logistic regression analyses after adjustment for age and co-morbidities.

CONCLUSIONS

After adjustment for age and co-morbidities, antithrombotic agents before aSAH ictus were not associated with worse hemorrhage severity, rebleeding rate, clinical course, or long-term functional recovery.

Comparing radiographic scores for prediction of complications and outcome of aneurysmal subarachnoid hemorrhage: Which performs best?

BACKGROUND AND PURPOSE

Aneurysmal subarachnoid hemorrhage (aSAH) is characterized by high morbidity and mortality proceeding from the initial severity and following complications of aSAH. Various scores have been developed to predict these risks. We aimed to analyze the clinical value of different radiographic scores for prognostication of aSAH outcome.

METHODS

Initial computed tomography scans (≤48 h after ictus) of 745 aSAH cases treated between January 2003 and June 2016 were reviewed with regard to Subarachnoid Hemorrhage Early Brain Edema Score (SEBES), and Claassen, Barrow Neurological Institute (BNI), Hijdra, original Graeb and Fisher scale scores. The primary endpoints were development of delayed cerebral ischemia (DCI), in-hospital mortality and unfavorable outcome (modified Rankin Scale score >3) at 6 months after subarachnoid hemorrhage. Secondary endpoints included the different complications that can occur during aSAH. Clinically relevant cutoffs were defined using receiver-operating characteristic curves. The radiographic scores with the highest values for area under the curve (AUC) were included in the final multivariate analysis.

RESULTS

The Hijdra sum score had the most accurate predictive value and independent associations with all primary endpoints: DCI (AUC 0.678, adjusted odds ratio [aOR] 2.83; p < 0.0001); in-hospital mortality (AUC 0.704, aOR 2.83; p < 0.0001) and unfavorable outcome (AUC 0.726, aOR 2.91; p < 0.0001). Multivariate analyses confirmed the independent predictive value of the radiographic scales for risk of decompressive craniectomy (SEBES and Fisher score), cerebral vasospasm (SEBES, BNI score and Fisher score) and shunt dependency (Hijdra ventricle score and Fisher score) after aSAH.

CONCLUSIONS

Initial radiographic severity of aSAH was independently associated with occurrence of different complications during aSAH and the final outcome. The Hijdra sum score showed the highest diagnostic accuracy and robust predictive value for early detection of risk of DCI, in-hospital mortality and unfavorable outcome after aSAH.

Strokes and Predictors of Outcomes

Stroke is a leading cause of long-term disability and fifth leading cause of death. Acute ischemic stroke, intracerebral hemorrhage, and subarachnoid hemorrhage, the 3 subtypes of strokes, have varying treatment modalities. Common themes in management advocate for early interventions to reduce morbidity and mortality but not all perception is supported through randomized controlled trials. Each stroke subtype has varying premorbid-related and ictus-related outcome predictive models that have differing sensitivities and specificities.

A novel visual dynamic nomogram to online predict the risk of unfavorable outcome in elderly aSAH patients after endovascular coiling: A retrospective study

Background

Aneurysmal subarachnoid hemorrhage (aSAH) is a significant cause of morbidity and mortality throughout the world. Dynamic nomogram to predict the prognosis of elderly aSAH patients after endovascular coiling has not been reported. Thus, we aimed to develop a clinically useful dynamic nomogram to predict the risk of 6-month unfavorable outcome in elderly aSAH patients after endovascular coiling.

Methods

We conducted a retrospective study including 209 elderly patients admitted to the People's Hospital of Hunan Province for aSAH from January 2016 to June 2021. The main outcome measure was 6-month unfavorable outcome (mRS ≥ 3). We used multivariable logistic regression analysis and forwarded stepwise regression to select variables to generate the nomogram. We assessed the discriminative performance using the area under the curve (AUC) of receiver-operating characteristic and the risk prediction model's calibration using the Hosmer-Lemeshow goodness-of-fit test. The decision curve analysis (DCA) and the clinical impact curve (CIC) were used to measure the clinical utility of the nomogram.

Results

The cohort's median age was 70 (interquartile range: 68-74) years and 133 (36.4%) had unfavorable outcomes. Age, using a ventilator, white blood cell count, and complicated with cerebral infarction were predictors of 6-month unfavorable outcome. The AUC of the nomogram was 0.882 and the Hosmer-Lemeshow goodness-of-fit test showed good calibration of the nomogram (p = 0.3717). Besides, the excellent clinical utility and applicability of the nomogram had been indicated by DCA and CIC. The eventual value of unfavorable outcome risk could be calculated through the dynamic nomogram.

Conclusion

This study is the first visual dynamic online nomogram that accurately predicts the risk of 6-month unfavorable outcome in elderly aSAH patients after endovascular coiling. Clinicians can effectively improve interventions by taking targeted interventions based on the scores of different items on the nomogram for each variable.

Is sex a predictor for delayed cerebral ischaemia (DCI) and hydrocephalus after aneurysmal subarachnoid haemorrhage (aSAH)? A systematic review and meta-analysis

OBJECTIVES

DCI and hydrocephalus are the most common complications that predict poor outcomes after aSAH. The relationship between sex, DCI and hydrocephalus are not well established; thus, we aimed to examine sex differences in DCI and hydrocephalus following aSAH in a systematic review and meta-analysis.

METHODS

A systematic search was conducted using the PubMed, Scopus and Medline databases from inception to August 2022 to identify cohort, case control, case series and clinical studies reporting sex and DCI, acute and chronic shunt-dependent hydrocephalus (SDHC). Random-effects meta-analysis was used to pool estimates for available studies.

RESULTS

There were 56 studies with crude estimates for DCI and meta-analysis showed that women had a greater risk for DCI than men (OR 1.24, 95% CI 1.11-1.39). The meta-analysis for adjusted estimates for 9 studies also showed an association between sex and DCI (OR 1.61, 95% CI 1.27-2.05). For acute hydrocephalus, only 9 studies were included, and meta-analysis of unadjusted estimates showed no association with sex (OR 0.95, 95%CI 0.78-1.16). For SDHC, a meta-analysis of crude estimates from 53 studies showed that women had a somewhat greater risk of developing chronic hydrocephalus compared to men (OR 1.14, 95% CI 0.99-1.31). In meta-analysis for adjusted estimates from 5 studies, no association of sex with SDHC was observed (OR 0.87, 95% CI 0.57-1.33).

CONCLUSIONS

Female sex is associated with the development of DCI; however, an association between sex and hydrocephalus was not detected. Strategies to target females to reduce the development of DCI may decrease overall morbidity and mortality after aSAH.

Improving the models for prognosis of aneurysmal subarachnoid hemorrhage with the neutrophil-to-albumin ratio

Objective

Many peripheral inflammatory markers were reported to be associated with the prognosis of aneurysmal subarachnoid hemorrhage (aSAH). We aimed to identify the most promising inflammatory factor that can improve existing predictive models.

Methods

The study was based on data from a 10 year retrospective cohort study at Sichuan University West China Hospital. We selected the well-known SAFIRE and Subarachnoid Hemorrhage International Trialists' (SAHIT) models as the basic models. We compared the performance of the models after including the inflammatory markers and that of the original models. The developed models were internally and temporally validated.

Results

A total of 3,173 patients were included in this study, divided into the derivation cohort (n = 2,525) and the validation cohort (n = 648). Most inflammatory markers could improve the SAH model for mortality prediction in patients with aSAH, and the neutrophil-to-albumin ratio (NAR) performed best among all the included inflammatory markers. By incorporating NAR, the modified SAFIRE and SAHIT models improved the area under the receiver operator characteristics curve (SAFIRE+NAR vs. SAFIRE: 0.794 vs. 0.778, p = 0.012; SAHIT+NAR vs. SAHIT: 0.831 vs. 0.819, p = 0.016) and categorical net reclassification improvement (SAFIRE+NAR: 0.0727, p = 0.002; SAHIT+NAR: 0.0810, p < 0.001).

Conclusion

This study illustrated that among the inflammatory markers associated with aSAH prognosis, NAR could improve the SAFIRE and SAHIT models for 3 month mortality of aSAH.

External Validation of the HATCH (Hemorrhage, Age, Treatment, Clinical State, Hydrocephalus) Score for Prediction of Functional Outcome After Subarachnoid Hemorrhage

BACKGROUND

The Hemorrhage, Age, Treatment, Clinical State, Hydrocephalus (HATCH) Score has previously shown to predict functional outcome in aneurysmal subarachnoid hemorrhage (aSAH).

OBJECTIVE

To validate the HATCH score.

METHODS

This is a pooled cohort study including prospective collected data on 761 patients with aSAH from 4 different hospitals. The HATCH score for prediction of functional outcome was validated using calibration and discrimination analysis (area under the curve). HATCH score model performance was compared with the World Federation of Neurosurgical Societies and Barrow Neurological Institute score.

RESULTS

At the follow-up of at least 6 months, favorable (Glasgow Outcome Score 4-5) and unfavorable functional outcomes (Glasgow Outcome Score 1-3) were observed in 512 (73%) and 189 (27%) patients, respectively. A higher HATCH score was associated with an increased risk of unfavorable outcome with a score of 1 showing a risk of 1.3% and a score of 12 yielding a risk of 67%. External validation showed a calibration intercept of -0.07 and slope of 0.60 with a Brier score of 0.157 indicating good model calibration and accuracy. With an area under the curve of 0.81 (95% CI 0.77-0.84), the HATCH score demonstrated superior discriminative ability to detect favorable outcome at follow-up compared with the World Federation of Neurosurgical Societies and Barrow Neurological Institute score with 0.72 (95% CI 0.67-0.75) and 0.63 (95% CI 0.59-0.68), respectively.

CONCLUSION

This multicenter external validation analysis confirms the HATCH score to be a strong independent predictor for functional outcome. Its incorporation into daily practice may be of benefit for goal-directed patient care in aSAH.

Machine learning for outcome prediction of neurosurgical aneurysm treatment: Current methods and future directions

INTRODUCTION

Machine learning algorithms have received increased attention in neurosurgical literature for improved accuracy over traditional predictive methods. In this review, the authors sought to assess current applications of machine learning for outcome prediction of neurosurgical treatment of intracranial aneurysms and identify areas for future research.

METHODS

A PRISMA-compliant systematic review of the PubMed, MEDLINE, and EMBASE databases was conducted for all studies utilizing machine learning for outcome prediction of intracranial aneurysm treatment. Patient characteristics, machine learning methods, outcomes of interest, and accuracy metrics were recorded from included studies.

RESULTS

16 studies were ultimately included in qualitative synthesis. Studies primarily analyzed angiographic outcomes, functional outcomes, or complication prediction using clinical, radiological, or composite variables. The majority of included studies utilized supervised learning algorithms for analysis of dichotomized outcomes.

CONCLUSIONS

Commonly included variables were demographics, presentation variables (including ruptured or unruptured status), and treatment used. Areas for future research include increased generalizability across institutions and for smaller datasets, as well as development of front-end tools for clinical applicability of published algorithms.

Spontaneous subarachnoid haemorrhage

Subarachnoid haemorrhage (SAH) is the third most common subtype of stroke. Incidence has decreased over past decades, possibly in part related to lifestyle changes such as smoking cessation and management of hypertension. Approximately a quarter of patients with SAH die before hospital admission; overall outcomes are improved in those admitted to hospital, but with elevated risk of long-term neuropsychiatric sequelae such as depression. The disease continues to have a major public health impact as the mean age of onset is in the mid-fifties, leading to many years of reduced quality of life. The clinical presentation varies, but severe, sudden onset of headache is the most common symptom, variably associated with meningismus, transient or prolonged unconsciousness, and focal neurological deficits including cranial nerve palsies and paresis. Diagnosis is made by CT scan of the head possibly followed by lumbar puncture. Aneurysms are commonly the underlying vascular cause of spontaneous SAH and are diagnosed by angiography. Emergent therapeutic interventions are focused on decreasing the risk of rebleeding (ie, preventing hypertension and correcting coagulopathies) and, most crucially, early aneurysm treatment using coil embolisation or clipping. Management of the disease is best delivered in specialised intensive care units and high-volume centres by a multidisciplinary team. Increasingly, early brain injury presenting as global cerebral oedema is recognised as a potential treatment target but, currently, disease management is largely focused on addressing secondary complications such as hydrocephalus, delayed cerebral ischaemia related to microvascular dysfunction and large vessel vasospasm, and medical complications such as stunned myocardium and hospital acquired infections.

Serum Levels of Myo-inositol Predicts Clinical Outcome 1 Year After Aneurysmal Subarachnoid Hemorrhage

BACKGROUND

Early prognostication of long-term outcome in patients suffering from spontaneous subarachnoid hemorrhage (SAH) remains a challenge. No biomarkers are routinely used for prognostication. A previous study has indicated that the metabolite myo-inositol (MI) may be used to predict long-term outcome.

OBJECTIVE

To investigate if MI measured in serum correlates with long-term clinical outcome in patients suffering from SAH.

METHODS

We conducted an observational cohort study including 88 patients treated for SAH at Umeå University Hospital. Serum samples were collected in the hospital, and a gas chromatography/mass spectroscopy method was used to quantitatively measure MI. Patients were assessed after 1 year using the Glasgow Outcome Scale Extended and dichotomized to favorable or unfavorable outcome. Differences in MI levels between the 2 groups were analyzed.

RESULTS

There was no difference in MI levels between the groups upon admission. Myo-inositol levels decreased over time in the entire study population. The decrease was significantly larger in the unfavorable outcome group. A receiver operating characteristics analysis yielded an area under the curve of 0.903 (CI 0.8-1.0, P < .001) for the MI value on day 7 to predict favorable outcome after 1 year.

CONCLUSION

Myo-inositol measured in serum may aid prognostication of outcome in patients with SAH. The mechanism behind this remains unclear, although it can be theorized to reflect processes leading to delayed cerebral ischemia, which affects long-term outcome. This is the first study to quantitively measure MI in serum for prognostication of outcome in patients with SAH.

Exploration of Risk Factors for Poor Prognosis of Non-Traumatic Non-Aneurysmal Subarachnoid Hemorrhage

Background: Subarachnoid hemorrhage (SAH) is a devastating neurological disease associated with high rates of mortality and disability. Aneurysms are the main cause of non-traumatic subarachnoid hemorrhages. However, non-traumatic non-aneurysmal subarachnoid hemorrhage (naSAH), another clinical type of SAH, has been poorly studied for its prognosis and risk factors. Method and result: We collected demographic and clinical variables for 126 naSAH and 89 aneurysmal subarachnoid hemorrhage (aSAH) patients, including age and gender; hospitalization days; hematological indicators; clinical score scales; past medical history; and personal history. We found that the monocytes in naSAH (0.50 ± 0.26) patients were lower than in aSAH patients (0.60 ± 0.27). The prevalence of diabetes in naSAH (30.2%) patients was higher than in aSAH (14.5%) patients. The naSAH patients were divided into good and poor outcome groups based on the modified Rankin Scale at the 90th day (90-day mRS) after discharge. A univariate analysis showed that there were significant differences in age, white blood cell count (WBC), monocyte count, D-dipolymer, neuron-specific enolase (NSE), random blood glucose (RBG), aspartate transaminase (AST), urea and free triiodothyronine (FT3) between the two groups. A logistic regression showed that aging and high level NSE were independent risk factors for a poor outcome. The predictive ability of age (area under curve (AUC) = 0.71) and NSE (AUC = 0.68) were analyzed by a receiver operating characteristic (ROC) curve. The results of the logistic regression suggested that age, D-dipolymer, NSE, RBG, urea and FT3 distinguished and predicted the prognosis of naSAH. The discriminant analysis of the above variables revealed that the discriminant accuracy was 80.20%. Conclusions: Compared with aSAHs, naSAHs are more likely to occur in patients with diabetes, and the level of monocytes is lower. Moreover, the prognosis of elderly patients with an naSAH is relatively poor, and the level of NSE in the course of the disease also reflects the prognosis. Multivariate comprehensive analysis is helpful to judge the prognosis of patients at a small cost.

An accurate prognostic prediction for aneurysmal subarachnoid hemorrhage dedicated to patients after endovascular treatment

Background

Endovascular treatment for aneurysmal subarachnoid hemorrhage (aSAH) has high fatality and permanent disability rates. It remains unclear how the prognosis is determined by the complex interaction between clinical severity and aneurysm characteristics.

Objective

This study aimed to design an accurate prognostic prediction model for aSAH patients after endovascular treatment and elucidate the interaction between clinical severity and aneurysm characteristics.

Methods

We used a clinically homogeneous data set with 1029 aSAH patients who received endovascular treatment to develop prognostic models. Aneurysm characteristics were measured by variables, such as aneurysm size, neck size, and dome-to-neck ratio, while clinical severity on admission was measured by both comorbidities and neurological condition. In total, 18 clinical variables were used for prognostic prediction. Considering the imbalance between the favorable and the poor outcomes in this clinical population, both ensemble learning and deep reinforcement learning approaches were used for prediction.

Results

The random forest (RF) model was selected as the best approach for the prognostic prediction for all patients and also for patients with good-grade aSAH. Using an independent test data set, the model made accurate predictions (AUC = 0.869 ± 0.036, sensitivity = 0.709 ± 0.087, specificity = 0.805 ± 0.034) with the clinical severity on admission as a leading contributor to the prediction. For patients with good-grade aSAH, the RF model performed the best (AUC = 0.805 ± 0.034, sensitivity = 0.620 ± 0.172, specificity = 0.696 ± 0.043) with aneurysm characteristics as leading contributors. The classic scoring systems failed in this patient group (AUC < 0.600; sensitivity = 0.000, specificity = 1.000).

Conclusion

The proposed prognostic prediction model outperformed the classic scoring systems for patients with aSAH after endovascular treatment, especially when the classic scoring systems failed to make any informative prediction for patients with good-grade aSAH, who constitute the majority group (79%) of this clinical population.

C-reactive protein elevation predicts in-hospital deterioration after aneurysmal subarachnoid hemorrhage: a retrospective observational study

Background

There is increasing evidence that inflammation plays a role in the pathogenesis of aneurysmal subarachnoid hemorrhage (aSAH) and in the development of delayed cerebral ischemia (DCI). However, the assessment and interpretation of classically defined inflammatory parameters is difficult in aSAH patients. The objective of this study was to investigate the relationship between easily assessable findings (hyperventilation, fever, white blood cell count (WBC), and C-reactive protein (CRP)) and the occurrence of DCI and unfavorable neurological outcome at discharge in aSAH patients.

Methods

Retrospective analysis of prospectively collected data from a single center cohort. We evaluated the potential of clinical signs of inflammation (hyperventilation, fever) and simple inflammatory laboratory parameters CRP and WBC to predict unfavorable outcomes at discharge and DCI in a multivariate analysis. A cutoff value for CRP was calculated by Youden’s J statistic. Outcome was measured using the modified Rankin score at discharge, with an unfavorable outcome defined as modified Rankin scale (mRS) > 3.

Results

We included 97 consecutive aSAH patients (63 females, 34 males, mean age 58 years) in the analysis. Twenty-one (22%) had major disability or died by the time of hospital discharge. Among inflammatory parameters, CRP over 100 mg/dl on day 2 was an independent predictor for worse neurological outcome at discharge. The average C-reactive protein level in the first 14 days was higher in patients with a worse neurological outcome (96.6, SD 48.3 vs 56.3 mg/dl, SD 28.6) in the first 14 days after aSAH. C-reactive protein on day 2 was an indicator of worse neurological outcome. No inflammatory parameter was an independent predictor of DCI. After multivariate adjustment, DCI, increased age, and more than 1 day of mechanical ventilation were significant predictors of worse neurological outcome.

Conclusions

Early elevated CRP levels were a significant predictor of worse neurological outcome at hospital discharge and may be a useful marker of later deterioration in aSAH.

Could outcomes of intracranial aneurysms be better predict using serum creatinine and glomerular filtration rate?

Purpose:

To analyze the role of serum creatinine levels as a biomarker of intracranial aneurysm outcomes.

Methods:

This is a prospective analysis of outcomes of patients with intracranial aneurysm. One hundred forty-seven patients with serum creatinine at admission and 6 months follow up were included. Linear and logistic regressions were used to analyze the data. Modified Rankin scale (mRS) was used to assess outcome.

Results:

Creatinine level was not directly related to aneurysm outcome nor aneurysm rupture (p > 0.05). However, patients with a glomerular filtration rate (GFR) lower than 72.50 mL·min^–1 had an odds ratio (OR) of 3.049 (p = 0.006) for worse outcome. Similarly, aneurysm rupture had an OR of 2.957 (p = 0.014) for worse outcomes. Stepwise selection model selected 4 variables for outcomes prediction: serum creatinine, sex, hypertension and treatment. Hypertensive patients had, on average, an increase in 0.588 in mRS (p = 0.022), while treatment with microsurgery had a decrease in 0.555 (p = 0.038).

Conclusions:

Patients with higher GFR had better outcomes after 6 months. Patients with higher GFR had better outcomes after 6 months. Creatinine presented an indirect role in GFR values and should be included in models for outcome prediction.