World Federation Of Neurological Surgeons Scale Research Articles

Longitudinal change of serum AIM2 levels after aneurysmal subarachnoid hemorrhage and its prognostic significance: a two-center prospective cohort study

Absent in melanoma 2 (AIM2) is implicated in neuroinflammation. Here, we explored the prognostic significance of serum AIM2 in human aneurysmal subarachnoid hemorrhage (aSAH). We conducted a consecutive enrollment of 127 patients, 56 of whom agreed with blood-drawings not only at admission but also at days 1, 2, 3, 5, 7 and 10 days after aSAH. Serum AIM2 levels of patients and 56 healthy controls were measured. Disease severity was assessed using the modified Fisher scale (mFisher) and World Federation of Neurological Surgeons Scale (WFNS). Neurological outcome at poststroke 90 days was evaluated via the modified Rankin Scale (mRS). Univariate analysis and multivariate analysis were sequentially done to ascertain relationship between serum AIM2 levels, severity, delayed cerebral ischemia (DCI) and 90-day poor prognosis (mRS scores of 3–6). Patients, in comparison to controls, had a significant elevation of serum AIM2 levels at admission and at days 1, 2, 3, 5, 7 and 10 days after aSAH, with the highest levels at days 1, 2, 3 and 5. AIM2 levels were independently correlated with WFNS scores and mFisher scores. Significantly higher serum AIM2 levels were detected in patients with a poor prognosis than in those with a good prognosis, as well as in patients with DCI than in those without DCI. Moreover, serum AIM2 levels independently predicted a poor prognosis and DCI, and were linearly correlated with their risks. Using subgroup analysis, there were no significant interactions between serum AIM2 levels and age, gender, hypertension and so on. There were substantially high predictive abilities of serum AIM2 for poor prognosis and DCI under the receiver operating characteristic curve. The combination models of DCI and poor prognosis, in which serum AIM2, WFNS scores and mFisher scores were incorporated, showed higher discriminatory efficiencies than anyone of the preceding three variables. Moreover, the models are delineated using the nomogram, and performed well under the calibration curve and decision curve. Serum AIM2 levels, with a substantial enhancement during early phase after aSAH, are closely related to bleeding severity, poor 90-day prognosis and DCI of patients, substantializing serum AIM2 as a potential prognostic biomarker of aSAH.

Elevated Serum NOX2 Levels Contribute to Delayed Cerebral Ischemia and a Poor Prognosis After Aneurysmal Subarachnoid Hemorrhage: A Prospective Cohort Study.

NADPH oxidase 2 (NOX2) is highly expressed in injured brain tissues. We determined serum NOX2 levels of aneurysmal subarachnoid hemorrhage (aSAH) patients and further investigated correlation of serum NOX2 levels with disease severity, delayed cerebral ischemia (DCI) plus prognosis after aSAH. Serum NOX2 levels were measured in 123 aSAH patients and 123 healthy controls. World Federation of Neurological Surgeons scale (WFNS) score and modified Fisher (mFisher) score were utilized to assess disease severity. Modified Rankin scale (mRS) score was used to evaluate the clinical prognosis at 90 days after aSAH. Relations of serum NOX2 levels to DCI and 90-day poor prognosis (mRS score of 3-6) were analyzed using multivariate analysis. Receiver operating characteristic curve (ROC) was built to evaluate the prognostic predictive capability. Serum NOX2 levels in aSAH patients, compared with healthy controls, were significantly increased, and were independently correlated with WFNS score, mFisher score and post-stroke 90-day mRS score. Patients with poor prognosis or DCI had significantly higher serum NOX2 levels than other remainders, and serum NOX2 levels independently predicted 90-day poor prognosis and DCI. Serum NOX2 had high prognosis and DCI predictive abilities, and their areas under ROC curve were similar to those of WFNS score and mFisher score. Serum NOX2 levels are significantly associated with hemorrhage severity, poor 90-day prognosis and DCI in aSAH patients. Hence, complement NOX2 may serve as a potential prognostic biomarker after aSAH.

Plasma cellular prion protein concentrations correlate with severity and prognosis of aneurysmal subarachnoid hemorrhage

BackgroundCellular prion protein (PrPc) is greatly expressed in injured brain tissues. We investigates correlation of plasma PrPc concentrations with severity, delayed cerebral ischemia (DCI) plus prognosis following aneurysmal subarachnoid hemorrhage (aSAH). MethodsPlasma PrPc concentrations were measured in 110 aSAH patients and 110 healthy controls. The World Federation of Neurological Surgeons scale (WFNS) score, Glasgow coma scale (GCS) score, Hunt-Hess score and modified Fisher score were utilized to assess hemorrhagic severity. Relations of plasma PrPc concentrations to DCI and 90-day poor outcome (Glasgow outcome scale score of 1–3) were analyzed using multivariate analysis. Prognostic predictive capabilities were determined under receiver operating characteristic curve. ResultsPlasma PrPc concentrations were significantly higher in patients than in controls. Plasma PrPc concentrations were tightly correlated with WFNS score, GCS score, Hunt-Hess score and modified Fisher score. Plasma PrPc emerged as an independent predictor for 90-day poor outcome, but not for DCI. Plasma PrPc concentrations exhibited similar prognostic predictive abilities, as compared to WFNS score, GCS score, Hunt-Hess score and modified Fisher score. ConclusionsPlasma PrPc concentrations are highly associated with severity and poor outcome after hemorrhagic stroke, indicating that plasma PrPc may serve as a useful prognostic biomarker for aSAH.

A Nomogram for Predicting the Need of Postoperative Tracheostomy in Patients With Aneurysmal Subarachnoid Hemorrhage.

Objective: Early identification for the need of tracheostomy (TT) in aneurysmal subarachnoid hemorrhage (aSAH) patients remains one of the main challenges in clinical practice. Our study aimed to establish and validate a nomogram model for predicting postoperative TT in aSAH patients.Methods: Patients with aSAH receiving active treatment (interventional embolization or clipping) in our institution between June 2012 and December 2018 were retrospectively included. The effects of patients' baseline information, aneurysm features, and surgical factors on the occurrence of postoperative TT were investigated for establishing a nomogram in the training cohort with 393 patients. External validation for the nomogram was performed in the validation cohort with 242 patients.Results: After multivariate analysis, higher age, high neutrophil-to-lymphocyte ratio (NLR), high World Federation of Neurological Surgeons Scale (WFNS), and high Barrow Neurological Institute (BNI) grade were left in the final logistic regression model. The predictive power of the model was excellent in both training cohort and validation cohort [area under the curve (AUC): 0.924, 95% confidence interval [CI]: 0.893–0.948; AUC: 0.881, 95% CI: 0.833–0.919]. A nomogram consisting of these factors had a C-index of 0.924 (95% CI: 0.869–0.979) in the training cohort and was validated in the validation cohort (C-index: 0.881, 95% CI: 0.812–0.950). The calibration curves suggested good match between prediction and observation in both training and validation cohorts.Conclusion: Our study established and validated a nomogram model for predicting postoperative TT in aSAH patients.

Ability of serum annexin A1 to predict 6-month poor clinical outcome following aneurysmal subarachnoid hemorrhage

BackgroundAnnexin A1 might be neuroprotective and serum annexin A1 concentrations were markedly declined after severe traumatic brain injury. We determine dthe ability of serum annexin A1 to assess severity and predict prognosis after aneurysmal subarachnoid hemorrhage (aSAH). MethodsWe included 157 aSAH patients and 157 healthy subjects. Serum annexin A1 measurements were measured. A poor outcome was designated as Glasgow outcome scale score of 1–3. Multivariate logistic regression analysis was applied to identify predictors of a poor 6-month outcome. ResultsSerum annexin A1 concentrations were significantly lower in patients than in controls. Annexin A1 concentrations were strongly correlated with the World Federation of Neurological Surgeons scale (WFNS) score, Hunt-Hess score, Glasgow coma scale score and modified Fisher score. A total of 59 patients (37.6%) experienced a poor outcome. Serum annexin A1, WFNS score and modified Fisher score emerged as the 3 independent predictors for a poor outcome after aSAH. Under ROC curve analysis, serum annexin A1 had a fair accuracy to predict a poor outcome, AUC of serum annexin A1 concentration was equivalent to those of WFNS score and modified Fisher score and AUC of combination of the 3 factors significantly exceeded that of each one alone. ConclusionsAnnexin A1 may be involved in the occurrence and progression of secondary brain injury after aSAH. Detection of serum annexin A1 may have certain ability for assessment of severity and prediction of long-term prognosis following aSAH.

Factors determining outcome of post-angiogram-negative subarachnoid hemorrhage.

Aim:To determine the risk factors affecting outcome at the end of 90 days of post-angiogram-negative subarachnoid hemorrhage (SAH).Methods:Non-traumatic SAH cases were reviewed from the case records of patients who had reported to the Department of Neurology of a tertiary care hospital and 50 angio-negative SAH cases were included after excluding all the cases with known cause of hemorrhage after doing computed tomography angiography (CTA)/digital subtraction angiography (DSA). The presence of hypertension, diabetes mellitus, coronary artery disease (CAD), history of alcohol and smoking, and various scales like Hunt and Hess Scale (HHS), World Federation of Neurological Surgeons (WFNS), and Fisher scale had been recorded at admission. The outcome was assessed at 90 days post-SAH using the Modified Rankin Scale (mRS).Statistical analyses:The association between the outcome and the factors was assessed using the Pearson Chi-Square test and the risk factors/predictors of outcome were assessed using logistic regression.Results:The following variables were important risk factors for predicting poor outcome of angio-negative SAH (mRS 3 to 6): hypertension (P = 0.011), diabetes mellitus (P = 0.032), being an alcoholic (P = 0.019), HHS grade 4 to 5 (P < 0.01), and WFNS grade 4 to 5 (P < 0.01). On multivariate regression analysis, hypertension (P = 0.032) was an independent predictor of unfavorable outcome.Conclusions:At time of admission, presence of hypertension, diabetes mellitus, history of alcohol consumption, and poor grades of HHS and WFNS scale are predictors of poor outcome of angio-negative SAH.

Ultra-Early Versus Early Aneurysm Surgery After Subarachnoid Hemorrhage: A Retrospective Outcome Analysis

Abstract Object The timing of definitive management of ruptured intracranial aneurysms has been the subject of considerable debate, although the benefits of early surgery (until 72 hours postictus) are widely accepted. The aim of the present study is to evaluate the potential benefit of ultra-early surgery (until 24 hours) when compared with early surgery, in those patients who were treated by surgical clipping at the Neurosurgery Department of the Coimbra Hospital and University Centre. Methods A 17-year database of consecutive ruptured and surgically treated intracranial aneurysms was analyzed. Outcome was measured by the Glasgow Outcome Scale (GOS). Baseline characteristics were analyzed by the Fisher exact test, the chi-squared and Mann-Whitney tests. Logistic regression was used to assess the impact of good grade according to the World Federation of Neurological Surgeons (WFNS) scale and ultra-early surgery in a good GOS outcome. Results 343 patients who were submitted to surgical clipping in the first 72 hours post-ictus were included, 165 of whom have undergone ultra-early surgery. Demographics and preoperative characteristics of ultra-early and early surgery patients were similar. Good-grade patients according to the WFNS scale submitted to ultra-early surgery demonstrated an improved GOS at discharge and at 6 months. Poor-grade patients according to the WFNS scale submitted to ultra-early surgery demonstrated an improved GOS at discharge. Conclusions Ultra-early surgery for aneurysmal subarachnoid hemorrhage patients improves outcome mainly on good-grade patients. Efforts should be made on the logistics of emergency departments to consider achieving treatment on this timeframe as a standard of care.

C-Reactive Protein/Albumin Ratio Correlates With Disease Severity and Predicts Outcome in Patients With Aneurysmal Subarachnoid Hemorrhage.

Aim: The purpose of the present study was to determine if C-reactive protein (CRP)/albumin ratio was associated with disease severity and unfavorable outcome in patients with aneurysmal subarachnoid hemorrhage (aSAH).Methods: One hundred and twenty-three consecutive patients suffering from aSAH were included in the study, which was carried out during the period of June 2016 to September 2018. Clinical and demographic parameters were recorded. CRP and albumin assessments were conducted upon admission. The association of CRP/albumin ratio with the disease severity and 3-month outcomes was evaluated.Results: Higher CRP/albumin ratio was significantly associated with a higher World Federation of Neurological Surgeons Scale (WFNS) grade (p < 0.05). Poor outcome at 3 months was associated with a higher WFNS grade, higher serum glucose, higher CRP level, lower albumin level, higher Fisher score, higher CRP/albumin ratio, symptomatic cerebral vasospasm, intraventricular hemorrhage, delayed cerebral ischemia, and age using univariate analysis. The multivariate binary regression analysis revealed that the CRP/albumin ratio was independently associated with unfavorable outcomes after adjustment for age, WFNS grade, serum glucose, albumin, Fisher score, symptomatic cerebral vasospasm, intraventricular hemorrhage, and delayed cerebral ischemia.Conclusion: Elevated CRP/albumin ratio was associated with disease severity and poor outcomes after aSAH.

Warning headache correlates survival rate in aneurysmal subarachnoid hemorrhage

BackgroundSevere headaches, projectile vomiting, focal neurological deficits and early onset seizure are regarded as early warning symptoms of subarachnoid hemorrhage (SAH). Earlier diagnosis based on such warning symptoms theoretically would improve the clinical prognosis. However, it is still not clear whether the prognosis is correlated with early warning symptoms. Here, we reviewed warning symptoms and other predictive factors in the emergency room (ER) setting and examined their correlations with mortality. MethodsNinety saccular aneurysmal SAH cases were reviewed in a single medical center between January 2011 and December 2013. We examined differences in mortality rate related to warning symptoms, SAH scales, onset-to-ER time, hydrocephalus, and aneurysm size, location, and complexity. Logistic regression analyses were performed to determine the correlations of warning symptoms and other predictive factors with mortality. Receiver operating characteristic (ROC) curve analysis was used to calculate the area the under curve (AUC) of SAH mortality prediction tools. ResultsWarning headache, projectile vomiting, the Hunt and Hess scale, Fisher scale, World Federation of Neurological Surgeons (WFNS) grading scale, and modified WFNS (m-WFNS) scale, body mass index, aneurysm complexity and hydrocephalus were significantly different between the survivors and the decedents. The warning headache and WFNS grade were strongly correlated with mortality. The rate of prognostic prediction improved from 90.4% to 94.6% when warning headache was additionally evaluated. ConclusionsWith growing healthcare costs and recognition of the value of palliative care, early identification via warning headache and a detailed clinical history review is necessary for cases of aSAH.

Results of the surgical treatment of the aneurysms of anterior cerebral artery – anterior communicating artery complex

Objective – to establish the features of clinical presentation and to optimize surgical treatment of arterial aneurysms (AA) of the anterior cerebral artery–anterior connecting artery (ACA–AComA) complex.Materials and methods. The results of surgical treatment of 267 (100 %) patients with AA of the ACA–AComA complex during the period from 01.01.2011 till 31.12.2017 were analyzed. There were 143 (53.6 %) women and 124 (46.4 %) men. Microsurgical clipping was performed in 165 (61.8 %) cases, endovascular coiling in 122 (38.2 %) cases. The organization of the medical care, clinical and instrumental examinations, medical and surgical treatment was done according to the current protocols (the Decree of the Ministry of Health of Ukraine dated April 17, 2014, N 275, EBM Guidelines, 28.8.2017, Juha E. Jääskeläinen).Results. The AA rupture was diagnosed in 238 (89.2 %) patients. 181 (67.9 %) patients were hospitalized till the 28th day since AA rapture. The severity of the patients state according to the level of conscious during hospitalization: in conscious – 92 (34.4 %), obtunded – in 127 (47.6 %), stuporous – in 28 (10.5 %), comatose – 20 (7.5 %). The severity of subarachnoid hemorrhage (SAH) according to WFNS (World Federation of Neurological Surgeons) Grading Scale: grade I – in 63 (23.6 %) patients, grade II – in 43 (16.1 %) patients, grade III – in 78 (29.2 %) patients, grade IV – in 36 (13.5 %) patients, grade V – in 18 (6.8 %) patients. Altered mental status was found in 87 (32.6 %) patients, among them in 29 (10.8 %) patients with non-hemorrhagic presentation. Motor deficiency was diagnosed in 116 (43.4 %) patients, cranial nerve palsy – in 42 (15.7 %) patients, particular visual disturbances – in 28 (10.5 %) cases, oculomotor palsy – in 5 (1, 9 %) cases, visual and oculomotor disturbances – in 9 (3.3 %) cases.Subarachnoid hemorrhage with intracerebral hematoma was detected in 184 (77.3 %) patients. Localization of hematomas: frontal lobes – 161 (87.5 %) cases, corpus callosum – 15 (8.1 %) and/or septum pellucidum – 8 (4.4 %). The intraventricular hemorrhage was diagnosed in 81 (34 %) patients: 1–4 points according to Graeb score – in 32 (39.5 %) patients, 5–8 points – in 27 (33.3 %) patients, 9–12 points – in 22 (27.2 %) patients. Lateral or axial dislocation was found in 28 (11.8 %) cases. Cerebral vasospasm in acute period was observed in 59.7 % of patients, and in 19.3 % of patients in «cold» period.The localization of the AA of ACA–AComA complex (according to M.G. Yasargil): anterior – in 50 (18.7 %) cases, posterior – in 42 (15.7 %), superior – in 98 (36.7 %), inferior – in 35 (13.2 %), mixed projection – 42 (15.7 %) cases. Saccular aneurysms were found in 192 (71.9 %) patients, «complex» AA – in 75 (28.1 %). The size of AA in the most observations (252 (94.3 %)) was less than 15 mm. Hypoplasia or aplasia of one A1 segments of ACA we revealed in 45 (18.9 %) cases.Comorbid conditions: hypertension (HTN) – in 175 (65.5 %) patients, the combination of HTN with ischemic heart disease (IHD) – in 117 (43.8 %), hypertension, HTN in combination with systemic atherosclerosis – in 87 (32.6 %), diabetes mellitus (DM) – in 61 (22.8 %), combination of HTN, IHD, DM and systemic atherosclerosis – in 47 (17.6 %) cases.According to the timing of procedure, there were 54 (20.2 %) emergency procedure, 127 (47.6 %) urgent, and 86 (32.2 %) semi-elective. In 37 (68.5 %) cases, emergency surgical interventions were microsurgical clipping, in 32 (59.3 %) – combined. Class I of occlusion of the treated AA according to Raymond scale was achieved in 93.9 % after microsurgical clipping, and 77.5 % after endovascular coiling. Favorable outcome according to Extended Glasgow Outcome Scale (GOSE) after surgical treatment were achieved in 75.3 % with a total mortality of 7.1 %, and significant differences in outcome in groups with different timing of surgery.Conclusions. It was found that hemorrhagic presentation with the formation of intracerebral hematoma in the frontal lobes, with dislocation syndrome, intraventricular expansion, cerebral vasospasm with clinical manifestations of the I–III grade of SAH of WFNS scale, motor deficiency (43.4 % of cases), cranial nerve palsy (15.7 %) and altered mental status (32.6 %) was typical for AA of ACA–AComA complex. It was found the dependence of outcome after surgical treatment of AA of ACA–AComA complex from the timing and method of surgical procedure. The criteria for the selection of optimal surgical tactic are the type of clinical presentation of the disease, the timing after aneurysms rapture, the severity of the preoperative condition, the presence of cerebral vasospasm, anatomical and topographical characteristics of the aneurysm.

Haptoglobin genotype and aneurysmal subarachnoid hemorrhage: Individual patient data analysis.

To perform an individual patient-level data (IPLD) analysis and to determine the relationship between haptoglobin (HP) genotype and outcomes after aneurysmal subarachnoid hemorrhage (aSAH). The primary outcome was favorable outcome on the modified Rankin Scale or Glasgow Outcome Scale up to 12 months after ictus. The secondary outcomes were occurrence of delayed ischemic neurologic deficit, radiologic infarction, angiographic vasospasm, and transcranial Doppler evidence of vasospasm. World Federation of Neurological Surgeons (WFNS) scale, Fisher grade, age, and aneurysmal treatment modality were covariates for both primary and secondary outcomes. As preplanned, a 2-stage IPLD analysis was conducted, followed by these sensitivity analyses: (1) unadjusted; (2) exclusion of unpublished studies; (3) all permutations of HP genotypes; (4) sliding dichotomy; (5) ordinal regression; (6) 1-stage analysis; (7) exclusion of studies not in Hardy-Weinberg equilibrium (HWE); (8) inclusion of studies without the essential covariates; (9) inclusion of additional covariates; and (10) including only covariates significant in univariate analysis. Eleven studies (5 published, 6 unpublished) totaling 939 patients were included. Overall, the study population was in HWE. Follow-up times were 1, 3, and 6 months for 355, 516, and 438 patients. HP genotype was not associated with any primary or secondary outcome. No trends were observed. When taken through the same analysis, higher age and WFNS scale were associated with an unfavorable outcome as expected. This comprehensive IPLD analysis, carefully controlling for covariates, refutes previous studies showing that HP1-1 associates with better outcome after aSAH.

122 Significance of Fluctuations in Serum Sodium Levels Following Aneurysmal Subarachnoid Hemorrhage

Abstract INTRODUCTION Changes in serum sodium levels are common following aneurysmal subarachnoid hemorrhage (aSAH), and may be linked to increased morbidity. In this exploratory analysis we assessed whether fluctuations in serum sodium levels after aSAH have an association with clinical outcomes and/or delayed cerebral ischemia (DCI). METHODS We performed a retrospective analysis of data from CONSCIOUS-1 (n = 413), a randomized controlled trial of clazosentan treatment in patients with aSAH. Patient serum sodium levels were checked daily during the hospital stay up to day 14. Mean-per-day fluctuations in serum sodium were calculated by summing the absolute deviation of serum sodium at day 2–14 from day 1 base-line divided by the total number of days with lab values. Logistic regression and LOWESS smoothing curves were used to determine association between serum sodium deviation and poor outcome at 3 months (defined as modified Rankin Scale, mRS&gt; 2) or DCI. RESULTS &gt;Mean-per-day deviation of serum sodium from baseline was associated with poor outcome on univariate analysis (P = 0.028), and maintained statistical significance after correcting for age and World Federation of Neurological Surgeons (WFNS) grade (P = 0.044). A LOWESS smoothing curve showed an increased risk of DCI for patients with greater deviations from their baseline sodium values. Multivariate regression, including WFNS and Fisher Scale grades, demonstrated absolute variation in sodium values to be associated with DCI (P = 0.045). CONCLUSION In this study, greater deviations in serum sodium values independently predicted poor outcome and the development of DCI.

Early rehabilitation in patients with acute aneurysmal subarachnoid hemorrhage

Purpose: The aim of this study was to describe and quantify the content of early rehabilitation adapted to patients with acute aneurysmal subarachnoid hemorrhage (aSAH) and to assess its feasibility. Methods: This was a prospective, observational study including 37 aSAH patients. Early rehabilitation was applied according to a mobilization algorithm. Clinical parameters, the time that rehabilitation team used on early rehabilitation and progression in mobilization were recorded. The patients’ clinical conditions were graded according to the World Federation of Neurological Surgeons scale (WFNS). Results: Poor-grade patients (WFNS 3, 4, 5) (n = 12) received more rehabilitation (median 412 min) than did good-grade patients (WFNS 1, 2) (median 240 min). Mobilization to 60° of head elevation in good-grade patients began on day one after securing the aneurysm. Out-of-bed mobilization was possible on day three. Poor-grade patients were mobilized to 60° after two days and were out of bed on day seven. At discharge, 67% of poor-grade patients were mobilized to walking versus 78% of good-grade patients. No serious adverse effects to early rehabilitation were observed. Conclusions: Early rehabilitation in aSAH patients is feasible from the first day after securing the aneurysm. The rehabilitation content varied according to the patient’s clinical grade.Implications for RehabilitationEarly rehabilitation is feasible from the first day after securing the ruptured aneurysm in patients with aneurysmal subarachnoid hemorrhage (aSAH).Early rehabilitation requires close monitoring and continuous adjustment for the content and amount according to the patient’s clinical condition.Interdisciplinary collaboration is recommended to match the rehabilitation needs to the medical condition on a daily basis.

The SAH Score: A Comprehensive Communication Tool

The Hunt and Hess grade and World Federation of Neurological Surgeons (WFNS) scale are commonly used to predict mortality after aneurysmal subarachnoid hemorrhage (aSAH). Our objective was to improve the accuracy of mortality prediction compared with the aforementioned scales by creating the "SAH score." The aSAH database at our institution was analyzed for factors affecting in-hospital mortality using multiple logistic regression analysis. Scores were weighted based on relative risk of mortality after stratification of each of these variables. Glasgow Coma Scale (GCS) was subdivided into groups of 3-4 (score=1), 5-8 (score=2), 9-13 (score=3), and 14-15 (score=4). Age was categorized into 4 subgroups: 18-49 (score=1), 50-69 (score=2), 70-79 (score=3), and 80 years or more (score=4). Medical comorbidities were subdivided into none (score=1), 1 (score=2), or 2 or more (score=3). In total, 1134 patients were included; all-cause SAH hospital mortality was 18.3%. Admission GCS, age, and medical comorbidities significantly affected mortality after multivariate analysis (P<.05). Summated scores ranged from 0 to 8 with escalating mortality at higher scores (0=2%, 1=6%, 2=8%, 3=15%, 4=30%, 5=58%, 6=79%, 7=87%, and 8=100%). Positive predictive value (PPV) for scores in the range 7-8 was 88.5%, whereas 6-8 was 83%. Negative predictive value (NPV) was 94% for range 0-2 and 92% for 0-3. The area under the curve (AUC) for the SAH score was .821 (good accuracy), compared with the WFNS scale (AUC .777, fair accuracy) and the Huntand Hess grade (AUC .771, fair accuracy). The SAH score was found to be more accurate in predicting aSAH mortality compared with the Hunt and Hess grade and WFNS scale.

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Introduction: The World Federation of Neurological Surgeons (WFNS) Scale and Hunt & Hess Grade rely only on clinical presentation to predict mortality following aneurysmal subarachnoid hemorrhage (aSAH). The proposed SAH score incorporates a combination of admission factors that impact mortality following aSAH. Hypothesis: We hypothesize that SAH score improves accuracy of mortality prediction in comparison to WFNS scale and Hunt & Hess Grade. Methods: Prospectively collected data of aSAH patients admitted to our institution between 1991-2009 were reviewed. We analyzed factors that impacted in-hospital SAH mortality following multiple logistic regression analysis. Scores were ‘weighted’ based on relative risk of mortality following stratification of each of these variables. GCS was subdivided into subgroups of 3-4, 5-8, 9-13 and 14-15; age was also split into 4 subgroups: 18-49, 50-69, 70-79 and >80. Medical co-morbidities were subdivided into none, 1 or >/=2 based on co-morbidities derived either from Charlson index or other factors (hypertension, cocaine) known to impact SAH outcomes, only if they were associated with increased mortality on univariate analysis. Results: 1134 patients were included; all-cause SAH hospital mortality was 18.3%. Admission GCS, age and medical co-morbidities significantly impacted mortality following multivariate analysis (P< 0.05). Association with mortality based on GCS was 7%(14-15; score 0), 18%(9-13; score 1), 40%(5-8; score 2) and 65%(3-4; score 4). Mortality based on age was 13%(18-49; score 0), 18%(50-69; score 1), 34% (70-79; score 2) and 46% (>80; score 3). Relationship of co-morbidities and mortality was 9%(none; score 0), 17%(one; score 1) and 32%(two/more; score 2). Summated Scores ranged from 0-8 with increasing mortality at higher scores (0=2%/ 1=6%/ 2=8%/ 3=13%/ 4=30%/ 5=54%/ 6=80%/ 7=89%/ 8=100%). PPV for scores in the range 7-8 was 90%; 6-8 was 84%. NPV for range 0-2 was 94% and 0-3 was 91%. AUC for SAH score was 0.822 (good accuracy), which was superior to WFNS (AUC 0.777, fair accuracy) and Hunt & Hess Grade (AUC 0.771, fair accuracy). Conclusions: The SAH score is a more accurate model than the WFNS scale and Hunt & Hess Grade in predicting mortality following SAH.

Abstract 2326: Timing of Clinical Grade Assessment and Poor Outcome in Patients with Aneurysmal Subarachnoid Hemorrhage

Introduction: Timing of clinical grading has not been fully studied in patients with aneurysmal subarachnoid hemorrhage (aSAH). Our primary objective was to identify at which time point the clinical assessment using the World Federation of Neurological Surgeons Scale (WFNS) and the Glasgow Coma Scale (GCS) is most predictive of poor functional outcome. Methods: Retrospective cohort study on the association of clinical grading determined at presentation, nadir and post-resuscitation, and poor outcome. Poor functional outcome was defined as Glasgow Outcome Scale score of 1-3 at 6 months. The study was approved by our Institutional Review Board. Results: We identified 186 consecutive patients admitted to a teaching hospital between January 2002 and June 2008. Patients’ mean age was 56.9±13.7 years and 63% of the patients were women. Twenty-four percent had poor functional outcome (mortality was 17%). On univariable logistic regression analyses, GCS determined at presentation (OR=0.80; p&lt;0.0001), nadir (OR=0.73; p&lt;0.0001) and post-resuscitation (OR=0.53; p&lt;0.0001), modified Fisher Scale (OR=2.21;p=0.0013), WFNS assessed at presentation (OR=1.92;p&lt;0.0001), nadir (OR=3.51; &lt;0.0001) and post-resuscitation (OR=3.91; &lt;0.0001), intracerebral hematoma on initial CT (OR=4.55;p&lt;0.0002), acute hydrocephalus (OR=2.29;p=0.0375), and cerebral infarction (OR=4.84; &lt;0.0001) were associated with poor outcome. On multivariable logistic regression analysis, only cerebral infarction (OR=5.80; 0.0013) and WFNS grade post-resuscitation (OR=3.43;&lt;0.0001) were associated with poor outcome. Receiving operating characteristics/area under the curve (AUC) analysis demonstrated that WFNS determined post-resuscitation had a stronger association with poor outcome (AUC=0.90) than WFNS assessed upon admission or at nadir. Conclusions: Timing of WFNS assessment affects its prognostic value. Outcome after aSAH is best predicted by rating WFNS after neurological resuscitation.

Unilateral craniotomy for bilateral cerebral aneurysms

Multiple intracranial aneurysms located bilaterally in the anterior circulation are usually clipped sequentially by separate craniotomies or a bilateral craniotomy. However, in selected patients, bilateral aneurysms can be clipped on both sides in a single sitting through a unilateral approach and unilateral craniotomy without causing morbidity. We present our technique and results of bilateral aneurysms clipped through a unilateral craniotomy from the ruptured aneurysm side. Ten patients (between 2006 and 2008) aged 20 years to 67 years with bilateral supratentorial anterior circulation saccular aneurysms, World Federation of Neurological Surgeons Scale (WFNS) score subarachnoid hemorrhage (SAH) grades 1 and 3, Fisher grades 2 and 3, were operated with unilateral orbito–pterional craniotomy and clipping of bilateral aneurysms. A total of 23 aneurysms, 12 located contralaterally, were successfully clipped with a good outcome in nine patients and no mortality at all. We therefore conclude that the unilateral orbito–pterional approach can be safely employed in selected patients harboring bilateral supratentorial saccular aneurysms and presenting with SAH, having WFNS grade 1 to 3, Fisher grade up to grade 3. The brain must be lax intra-operatively. Wide opening of the basal cisterns, 3rd ventriculostomy, and clipping of ruptured aneurysms are the important steps to be performed first before clipping the contralateral aneurysm thus avoiding a second craniotomy.

A predictive value of hyponatremia for poor outcome and cerebral infarction in high-grade aneurysmal subarachnoid haemorrhage patients

BackgroundThe clinical significance of hyponatremia has not been investigated in high-grade aneurysmal subarachnoid haemorrhage (aSAH) patients. Thus, we assessed the predictive value of hyponatremia for poor outcome or cerebral infarction...

A predictive tool by fuzzy logic for outcome of patients with intracranial aneurysm

We aimed to investigate if the outcome of the patients with intracranial aneurysm could be predicted by fuzzy logic approach. Two hundred and forty two patients with the diagnosis of intracranial aneurysm were assessed retrospectively between January 2001 and December 2005. We recorded World Federation of Neurological Surgeons Scale (WFNSS), Fisher Scale and age at admission and Glasgow Outcome Score (GOS) at discharge from hospitalization for all the patients. We developed fuzzy sets by dividing WFNSS into four groups as good, fair, bad and very bad; age into three groups as young, middle and old; Fisher scale into three groups as few, moderate and large; outcome score into four groups as bad, fair, good and very good. We calculated the outcome of the patient with these sets by fuzzy model. Predicted outcome by fuzzy logic approach correlated with observed outcome scores of the patients ( p > 0, 05), including 95% confidence interval. We showed that outcome of the patients with aneurysm can be predicted by fuzzy logic approach, accurately.

Validation of a Prognostic Subarachnoid Hemorrhage Grading Scale Derived Directly From the Glasgow Coma Scale

A new Glasgow Coma Scale-based scale has been developed to predict patient outcome in subarachnoid hemorrhage by calculating cut-off points by which 2 consecutive categories corresponded to a statistically significant different outcome. We assessed the external validity of this Prognosis on Admission of Aneurysmal Subarachnoid Hemorrhage (PAASH) scale and compared it to the commonly used World Federation of Neurological Surgeons scale. From our database of subarachnoid hemorrhage patients we retrieved data on all patients admitted between November 2000 and March 2006. By means of logistic regression, we calculated OR with corresponding 95% CI for poor outcome at 3 months for each category in comparison with the lowest category of both scales. Areas under the curve of the corresponding receiver operator characteristic curve were calculated. We included 537 patients. For the PAASH scale, OR ranged from 3.9 (95% CI, 2.4 to 6.2) to 84 (95% CI, 25 to 287) and increased more evenly than for the World Federation of Neurological Surgeons (WFNS) scale, with OR ranging from 2.3 (95% CI, 1.3 to 4.1) to 69 (95% CI, 31 to 157). Areas under the curve were 0.81 (95% CI, 0.77 to 0.84) for the PAASH and 0.82 (95% CI, 0.79 to 0.86) for the WFNS scale. Both PAASH and WFNS scales have a good discriminatory ability for patient prognosis. Because the OR of the PAASH increase more gradually, it is slightly preferable to the WFNS scale.