Clinical prediction of delayed cerebral ischemia in aneurysmal subarachnoid hemorrhage

Abstract

OBJECTIVE The aim of this study was to derive a clinically applicable decision rule using clinical, radiological, and laboratory data to predict the development of delayed cerebral ischemia (DCI) in aneurysmal subarachnoid hemorrhage (aSAH) patients. METHODS Patients presenting over a consecutive 9-year period with subarachnoid hemorrhage (SAH) and at least 1 angiographically evident aneurysm were included. Variables significantly associated with DCI in univariate analysis underwent multivariable logistic regression. Using the beta coefficients, points were assigned to each predictor to establish a scoring system with estimated risks. DCI was defined as neurological deterioration attributable to arterial narrowing detected by transcranial Doppler ultrasonography, CT angiography, MR angiography, or catheter angiography, after exclusion of competing diagnoses. RESULTS Of 463 patients, 58% experienced angiographic vasospasm with an overall DCI incidence of 21%. Age, modified Fisher grade, and ruptured aneurysm location were significantly associated with DCI. This combination of predictors had a greater area under the receiver operating characteristic curve than the modified Fisher grade alone (0.73 [95% CI 0.67-0.78] vs 0.66 [95% CI 0.60-0.71]). Patients 70 years or older with modified Fisher grade 0 or 1 SAH and a posterior circulation aneurysm had the lowest risk of DCI at 1.2% (0 points). The highest estimated risk was 38% (17 points) in patients 40-59 years old with modified Fisher grade 4 SAH following rupture of an anterior circulation aneurysm. CONCLUSIONS Among patients presenting with aSAH, this score-based clinical prediction tool exhibits increased accuracy over the modified Fisher grade alone and may serve as a useful tool to individualize DCI risk.

New risk score of the early period after spontaneous subarachnoid hemorrhage: For the prediction of delayed cerebral ischemia

“…There would be some potential biases and known and unknown confounders in this study. The patients with WFNS 4‐5 (23.1%) and mFS 3‐4 (63.3%) were consistent with other studies (WFNS: 22.4%‐31.1%; mFS: 56.2%‐77.7%). Additionally, all CT grades were evaluated by two blinded senior neurologists.…”

“…The study has tested the age by continuous variable and categorical variable in univariate analysis. However, consistent with a recent promoted DCI risk score, there was no statistical significance found in our study . The current studies on the prognostic value of age are controversial.…”

“…Conversely, another hypothesis was the cerebral vessels are stiffer (caused by atherosclerosis, collagen fiber increase etc.) in elderly patients, making them more resistant to vasospasms …”

“…Other risk stratification scores usually have a large range of scores, which may inconvenience practitioners and limit their applicability . Unlike other risk stratification scores, we use a dichotomy to divide risk factors into categorical variables (eg, high WFNS and low WFNS), and the variables were only limited to those available within 72 hours after aSAH.…”

“…However, consistent with a recent promoted DCI risk score, there was no statistical significance found in our study. 26 The current studies on the prognostic value of age are controversial. Some studies suggested that older age is associated with lower incidence of DCI, 24 and another study suggested aging patients were more likely to suffer DCI compared with younger patients.…”