Early predictors of functional outcome in poor-grade aneurysmal subarachnoid hemorrhage: a systematic review and meta-analysis

Abstract

Background Patients with poor-grade aneurysmal subarachnoid hemorrhage (aSAH) often receive delayed or no aneurysm treatment, although recent studies suggest that functional outcome following early aneurysm treatment has improved. We aimed to systematically review and meta-analyze early predictors of functional outcome in poor-grade aSAH patients. Methods We included studies investigating the association of early predictors and functional outcome in adult patients with confirmed poor-grade aSAH, defined as World Federation of Neurological Surgeons (WFNS) grade or Hunt and Hess (H–H) grade IV-V. Studies had to use multivariable regression analysis to estimate independent predictor effects of favorable functional outcome measured with the Glasgow Outcome Scale or modified Rankin Scale. We calculated pooled adjusted odds ratios (aOR) and 95% confidence intervals (CI) with random effects models. Results We included 27 studies with 3287 patients. The likelihood of favorable outcome increased with WFNS grade or H–H grade IV versus V (aOR 2.9, 95% CI 1.9–4.3), presence of clinical improvement before aneurysm treatment (aOR 3.3, 95% CI 2.0–5.3), and intact pupillary light reflex (aOR 2.9, 95% CI 1.6–5.1), and decreased with older age (aOR 0.7, 95% CI 0.5–1.0, per decade), increasing modified Fisher grade (aOR 0.4, 95% CI 0.3–0.5, per grade), and presence of intracerebral hematoma on admission imaging (aOR 0.4, 95% CI 0.2–0.8). Conclusions We present a summary of early predictors of functional outcome in poor-grade aSAH patients that can help to discriminate between patients with favorable and with unfavorable prognosis and may aid in selecting patients for early aneurysm treatment.

Factors affecting 30-day mortality in poor-grade aneurysmal subarachnoid hemorrhage: a 10-year single-center experience

“…Several studies in the literature support the fact that IVH ( 25 ) and ICH ( 16 , 18 , 26 ) are negative and critical prognostic factors in aSAH. Compared to the subarachnoid counterpart, we found out that routine analysis of IVH and ICH fractions is a simple, fast and relatively easy-to-learn method for quantitative assessment of the hemorrhagic load on the initial CT scan.…”

“…Notably, in 2022 de Winkel et al published a systematic review and meta-analysis ( 18 ) on early predictors of functional outcome in poor-grade aSAH. This analysis revealed that WFNS grade or Hunt and Hess (HH) grade IV, presence of clinical improvement before aneurysm treatment and intact pupillary light reflex were associated with the likelihood of favorable outcome, while, older age, increasing modified Fisher grade and the presence of intracerebral hematoma on admission imaging decreased the possibility of favorable outcome ( 18 ).…”

“…Notably, in 2022 de Winkel et al published a systematic review and meta-analysis ( 18 ) on early predictors of functional outcome in poor-grade aSAH. This analysis revealed that WFNS grade or Hunt and Hess (HH) grade IV, presence of clinical improvement before aneurysm treatment and intact pupillary light reflex were associated with the likelihood of favorable outcome, while, older age, increasing modified Fisher grade and the presence of intracerebral hematoma on admission imaging decreased the possibility of favorable outcome ( 18 ). Moreover, in 2021 Shen et al ( 2 ) identified a scoring model to predict functional outcomes in poor-grade aSAH including different significant predictors (modified Fisher grade > 2, age ≥ 65 years, conservative treatment, WFNS grade V, delayed cerebral ischemia, shunt-dependent hydrocephalus and cerebral herniation) for poor prognosis (modified Rankin Scale ≥3).…”

Inflammatory Markers as Predictors of Shunt Dependency and Functional Outcome in Patients with Aneurysmal Subarachnoid Hemorrhage

“…Cerebral vasospasm and delayed cerebral ischemia (DCI) are major factors for survival and functional outcome following SAH and have, for many years, been the main focus in SAH research [ 42 , 43 , 44 , 45 ]. Clinical parameters such as Hunt and Hess scores, lower modified Fisher grade, the absence of intracerebral hematoma, intact pupillary light reflexes, and clinical improvement before aneurysm treatment can be used as early clinical predictors of functional outcome and favorable/non-favorable prognosis [ 46 ]. However, other factors such as inflammation have also been shown to be useful predictors of poor outcome in patients with SAH.…”

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

“…IV-V) being associated with poor prognosis [ 7 ]. Nevertheless, different studies have shown that more than 20% of patients with high grade WFNS treated aggressively can recover completely, making initial resuscitation decisions very challenging for clinicians [ 8 , 9 ]. With the aim of improving the prognostic accuracy of patients affected by SAH, modifications of WFNS scale [ 10 ], assessment of the WFNS scale after initial resuscitation [ 9 ] as well as different combined scores [ 11 , 12 ] have been proposed.…”