Loss of consciousness at ictus and/or poor World Federation of Neurosurgical Societies grade on admission reflects the impact of EBI and predicts poor outcome in patients with SAH

Abstract

Background: There are many scores and markers that predict poor outcome in patients with subarachnoid hemorrhage (SAH). However, parameters that can predict outcomes in patients with SAH with high specificity and sensitivity, which can be identified in the early postictal state and utilized as a clinical marker of early brain injury (EBI) have not been identified so far. Methods: Thirty-nine patients with SAH due to a saccular intracranial aneurysm rupture were reviewed. We retrospectively analyzed the relationships between patients’ baseline characteristics and patients’ outcomes to identify parameters that could predict patient outcomes in the early postictal state. Results: In the univariate analysis, older age (>65), loss of consciousness (LOC) at ictus, poor initial World Federation of Neurosurgical Societies (WFNS) grade (3–5), and delayed cerebral ischemia (DCI) were associated with poor outcome (GOS 1–3). Statistical analyses revealed that combined LOC at ictus and/or poor initial WFNS grade (3–5) was a more powerful surrogate marker of outcome (OR 15.2 [95% CI 3.1–75.5]) than either LOC at ictus or the poor initial WFNS grade (3–5) alone. Multivariate logistic regression analyses revealed that older age, combined LOC at ictus and/or poor initial WFNS grade, and DCI were independently associated with poor outcome. Conclusion: Combined LOC at ictus and/or poor initial WFNS grade (3–5) reflects the impact of EBI and was a useful surrogate marker of poor prognosis in SAH patients, independent of patients’ age and state of DCI.

Strategies for prevention and treatment of delayed cerebral ischaemia after aneurysmal subarachnoid haemorrhage

“…It is plausible however that a MAP of 60 or lower would increase the risk of DCI, as maintaining a constant cerebral blood flow through cerebral autoregulation becomes impaired with MAP below 60 mm Hg. 43,44 Our results need to be confirmed in future prospective studies.…”

“…Besides, the treatment is associated with serious complications such as pulmonary oedema, cardiac rhythm disorders and posterior reversible encephalopathy syndrome. [38][39][40][41][42][43][44][45][46] Alternative rescue therapy with endovascular treatment such as balloon angioplasty is a non-proven treatment which carries a substantial risk of side-effects. 47,48 To summarise, we are currently able to reduce the risk of DCI only to a minor extent with nimodipine.…”

“…Posterior circulation 88 (26) 18 (26) 70 (26) Neurosurgical treatment b 141 (42) 30 (44) 111 (42) .325…”

“…No. 68 (20) 62 (19) 40 (12) 34 (10) Female sex 47 (69) 43 (69) 28 (70) 24 (71) Age (yr) (mean) (SD) 56.0 (12.7) 55.4 (12.9) 57.9 (12.4) 57.1 (12.8) Hypertension in medical history 24 (35) 21 (34) 18 (45) 15 (44) WFNS favorable on admission (I-III)…”

“…34 (50) 30 (48) 18 (45) 14 (41) Mean TBV (mL) (SD) c 51.6 (27. (18) Anterior circulation 50 (74) 45 (73) 28 (70) 23 (68) Posterior circulation 18 (26) 17 (27) 12 (30) 11 (32) Neurosurgical treatment d 30 (44) 28 (45) 19 (48) 17 (50) Endovascular treatment e 36 (53) 33 (53) 19 (48) 16 (47) Death within 3 days 1 (1) 1 (2) 1 (3) 1 (3)…”