Definition of initial grading, specific events, and overall outcome in patients with aneurysmal subarachnoid hemorrhage. A survey.

Abstract

Scientific communication in medicine can be effective only if reports are based on unequivocal criteria for clinical conditions or specific diagnoses. We reviewed all articles about subarachnoid hemorrhage published in nine neurosurgical or neurological journals from 1985 through 1992 and assessed the presence and the precision of definitions used for reporting the initial grade, the specific complications of rebleeding, delayed cerebral ischemia, and hydrocephalus, and the overall outcome. We identified 184 articles reporting direct observations in at least 10 patients on one or more of these conditions. Of 161 articles reporting the initial condition, only 19% used an unequivocal grading system (World Federation of Neurological Surgeons Scale or Glasgow Coma Scale); this proportion did not increase after 1988, when the World Federation of Neurological Surgeons Scale was introduced. The specific outcome events of rebleeding, ischemia, and hydrocephalus (283 instances) were sufficiently defined in only 31% of instances, incompletely in 22%, and not at all in 47%. The proportions were similar when the results were analyzed according to the type of complication, the year of publication, or per study. The four exclusively neurosurgical journals featured suitable definitions for any of the three outcome events in 20% of 209 instances, whereas the five mainly neurological journals published fewer articles about subarachnoid hemorrhage (74 instances of outcome events) but more often with precise criteria (65%). Overall outcome was adequately reported in 63% of all articles, with an increase over the years (54% in 1985 through 1988, 71% in 1989 through 1992). Reports about subarachnoid hemorrhage require closer scrutiny before publication to ascertain whether the conclusions about specific outcome events are based on unequivocal criteria.

Effect of Cisternal and Ventricular Blood on Risk of Delayed Cerebral Ischemia After Subarachnoid Hemorrhage:

“…More specific criteria for different category levels may lead to improved agreement for CT rating scales in the future 31 ; we intend to prospectively assess the reliability of our new scale in a future analysis. Varying definitions and observer bias may also affect the accuracy of diagnosing DCI, 32 and this limitation may hamper comparisons between different studies. In contrast to others, we included asymptomatic infarction in our definition of DCI 33 and did not require documentation of arterial spasm by TCD (because of its high false-negative rate) or angiography (if it was not performed).…”

Effect of Endothelin-Receptor Antagonists on Delayed Cerebral Ischemia After Aneurysmal Subarachnoid Hemorrhage Remains Unclear

“…Besides DCI, many other terms are used such as "delayed ischemic neurological deficit," "secondary cerebral ischemia," "vasospasm," "clinical vasospasm," "symptomatic vasospasm," "vasospasm-related ischemia," "symptomatic brain ischemia," and "cerebral infarction." The use of so many different terms is problematic, not only because often incomplete or no definitions are described of the terms used, 3,4 but also because often various definitions are used for the same term. The use of different terms and definitions leads to confusion when defining end points in clinical trials and makes it difficult to compare the results of various studies.…”

Myocardial Injury and Left Ventricular Performance After Subarachnoid Hemorrhage

“…Symptomatic vasospasm was recognized by focal neurological signs or deterioration in level of consciousness, with either confirmation of infarction by CT or exclusion of other possible causes of deterioration (eg, rebleeding, hydrocephalus, edema, electrolyte disorder, infection, seizure). 30 Symptomatic vasospasm was diagnosed by physicians (R.A.S. and L.L.)…”