Cirrhosis Based on Aspartate Aminotransferase to Platelet Ratio Index Is Associated With Increased Mortality After Subarachnoid Hemorrhage

Abstract

Introduction: The aspartate aminotransferase to platelet ratio index (APRI) has been used as a noninvasive marker to identify patients with cirrhosis. Cirrhotic patients are known to have significant mortality from bleeding. We sought to examine if cirrhosis, as defined as an APRI >1, would be associated with outcomes from spontaneous subarachnoid hemorrhage (SAH). Methods: We reviewed prospectively collected data on patients presenting with spontaneous SAH to a single academic institution between January 2013 and March 2015. Patients with SAH due to trauma, primary intracerebral hemorrhage, arteriovenous malformation, or other underlying mass lesion were excluded. Patients were divided into two groups based on APRI >1 or APRI < 1. Demographic, clinical, radiologic, and oucome data was compared between the two groups. Results: 110 patients were included in the analysis, 100 with APRI < 1 and 10 with APRI >1. 76 patients (69%) had an aneurysm identified on angiogram, 24 patients (22%) were angiogram negative for aneurysm, and 10 patients (9%) did not undergo angiography (unknown presence of aneurysm). Baseline age, gender, and Fisher score were similar between the two groups. The APRI >1 group had a higher rate of Hunt and Hess (HH) grade 5 SAH (40%) compared with the APRI < 1 group (11%; p=0.04). The APRI >1 also had significantly lower platelet counts (169±55 vs. 238±86; p=0.003), higher ALT (87±49 vs. 25±13; p=0.003), and higher AST (130±95 vs. 25±13.3; p=0.007). Regarding outcomes, patients with an APRI >1 had significantly higher in-hospital mortality (40%) than patients with APRI < 1 (11%; p=0.02). Median length of stay was found to be shorter in the APRI >1 group (10 vs. 12 days; p=0.05). Patients who died while in the hospital had a significantly higher mean APRI (1.1±1.7) than survivors (0.37±0.37; p < 0.001). Conclusion: Cirrhosis as defined by APRI is associated with higher HH grade and increased mortality after spontaneous SAH. It is possible that cirrhosis, as defined by APRI >1, predisposes patients to higher grade SAH. Further studies are needed to understand the relationship between APRI and SAH outcomes, as APRI may be beneficial for risk stratification in patients with SAH.