Initial pupil status is a strong predictor for in-hospital mortality after aneurysmal subarachnoid hemorrhage

Stefan Wolf,Marius M. Mader,Nora F. Dengler,Lasse Dührsen,Jan Regelsberger,Franz L. Ricklefs,Manfred Westphal,Nils O. Schmidt,Patrick Czorlich,Andras Piffko

doi:10.1038/s41598-020-61513-1

Abstract

Prognosis of patients with high-grade aneurysmal subarachnoid hemorrhage (aSAH) is only insufficiently displayed by current standard prognostic scores. This study aims to evaluate the role of pupil status for mortality prediction and provide improved prognostic models. Anonymized data of 477 aSAH patients admitted to our medical center from November 2010 to August 2018 were retrospectively analyzed. Identification of variables independently predicting in-hospital mortality was performed by multivariable logistic regression analysis. Final regression models included Hunt & Hess scale (H&H), pupil status and age or in a simplified variation only H&H and pupil status, leading to the design of novel H&H-Pupil-Age score (HHPA) and simplified H&H-Pupil score (sHHP), respectively. In an external validation cohort of 402 patients, areas under the receiver operating characteristic curves (AUROC) of HHPA (0.841) and sHHP (0.821) were significantly higher than areas of H&H (0.794; p < 0.001) or World Federation of Neurosurgical Societies (WFNS) scale (0.775; p < 0.01). Accordingly, including information about pupil status improves the predictive performance of prognostic scores for in-hospital mortality in patients with aSAH. HHPA and sHHP allow simple, early and detailed prognosis assessment while predictive performance remained strong in an external validation cohort suggesting adequate generalizability and low interrater variability.

Highlights

Prognosis of patients with high-grade aneurysmal subarachnoid hemorrhage is only insufficiently displayed by current standard prognostic scores
A normal pupil status was present in 89.3% whereas unilaterally and bilaterally dilated pupils were present in 6.9% and 3.8% of patients, respectively
Based on the final regression models of Glasgow Coma Scale (GCS)-PA and H&H-Pupil-Age score (HHPA), we developed clinical scoring systems by assigning point values to the categories of the variables according to the regression coefficients

Summary

Introduction

Prognosis of patients with high-grade aneurysmal subarachnoid hemorrhage (aSAH) is only insufficiently displayed by current standard prognostic scores. This study aims to evaluate the role of pupil status for mortality prediction and provide improved prognostic models. Including information about pupil status improves the predictive performance of prognostic scores for in-hospital mortality in patients with aSAH. Given the importance of patient classification according to injury severity and prognosis for clinical routine and study inclusion, evaluation and optimization of prognostic scores for aSAH is an ongoing and desirable endeavor. Further deterioration leads to subsequent change in reactivity and size of the opposite pupil[13] The aim of this retrospective study was to investigate the independent influence of pupil status, www.nature.com/scientificreports evaluate the prognostic value of scores considering pupil status like GCS-P and ECS in patients with aSAH and propose novel aSAH scores for in-hospital mortality prediction

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