Optimal PHASES Scoring for Risk Stratification of Surgically Treated Unruptured Aneurysms

OBJECTIVE

The PHASES (Population, Hypertension, Age, Size, Earlier subarachnoid hemorrhage, Site) score was developed to facilitate risk stratification for management of unruptured intracranial aneurysms (UIAs). This study aimed to identify the optimal PHASES score cutoff for predicting neurologic outcomes in patients with surgically treated aneurysms.

METHODS

All patients who underwent microneurosurgical treatment for UIA at a large quaternary center from January 1, 2014, to December 31, 2020, were retrospectively reviewed. Inclusion criteria included a modified Rankin Scale (mRS) score of ≤2 at admission. The primary outcome was 1-year mRS score, with a "poor" neurologic outcome defined as an mRS score >2.

RESULTS

In total, 375 patients were included in the analysis. The mean (SD) PHASES score for the entire study population was 4.47 (2.67). Of 375 patients, 116 (31%) had a PHASES score ≥6, which was found to maximize prediction of poor neurologic outcome. Patients with PHASES scores ≥6 had significantly higher rates of poor neurologic outcome than patients with PHASES scores <6 at discharge (58 [50%] vs. 90 [35%], P = 0.005) and follow-up (20 [17%] vs. 18 [6.9%], P = 0.002). After adjusting for age, Charlson Comorbidity Index score, nonsaccular aneurysm, and aneurysm size, PHASES score ≥6 remained a significant predictor of poor neurologic outcome at follow-up (odds ratio, 2.75; 95% confidence interval, 1.42-5.36, P = 0.003).

CONCLUSIONS

In this retrospective analysis, a PHASES score ≥6 was associated with significantly greater proportions of poor outcome, suggesting that awareness of this threshold in PHASES scoring could be useful in risk stratification and UIA management.

Mortality After Microsurgical Treatment of Unruptured Intracranial Aneurysms in the Modern Era

BACKGROUND

The incidence of mortality after treatment of unruptured intracranial aneurysms (UIAs) has been described historically. However, many advances in microsurgical treatment have since emerged, and most available data are outdated. We analyzed the incidence of mortality after microsurgical treatment of patients with UIAs treated in the past decade.

METHODS

The medical records of all patients with UIAs who underwent elective treatment at our large quaternary center from January 1, 2014, to December 31, 2020, were reviewed retrospectively. We analyzed mortality at discharge and 1-year follow-up as the primary outcome using univariate to multivariable progression with P < 0.20 inclusion.

RESULTS

During the 7-year study period, 488 patients (mean [SD] age = 58 [12] years) had UIAs treated microsurgically. Of these patients, 61 (12.5%) had a prior subarachnoid hemorrhage. One patient (0.2%) with a dolichoectatic vertebrobasilar aneurysm died while hospitalized, and 7 other patients (8 total; 1.6%) were determined to have died at 1-year follow-up (1 trauma, 2 myocardial infarction, 2 cerebrovascular accident, 1 pulmonary embolism, and 1 subdural hematoma complicated by abscess). On univariate analysis, significant risk factors for mortality at follow-up included diabetes mellitus, preoperative anticoagulant or antiplatelet use, aneurysm calcification, nonsaccular aneurysm, and higher American Society of Anesthesiologists grades (all P < 0.03). On multivariable logistic regression analysis, only nonsaccular aneurysms and higher American Society of Anesthesiologists grades were predictors of mortality.

CONCLUSIONS

A low mortality rate is associated with recent microsurgical treatment of UIAs. However, nonsaccular aneurysms and higher American Society of Anesthesiologists grades appear to be predictors of mortality.