Initial prognostic factors of aneurysmal subarachnoid hemorrhage

Département d'Anesthésie Réanimation, Hôpital Maison Blanche, CHU Reims.
Neurochirurgie (Impact Factor: 0.41). 02/1994; 40(1):18-30.
Source: PubMed


The purpose of this retrospective study is to explain, using a total of 210 consecutive patients with aneurysmal subarachnoid hemorrhage, the survival by several prognostic factors measured at the admission time. A multivariate analysis using the Cox proportional hazards model allowed one to recognize five prognostic factors: secondary arterial hypertension (risk ratio (RR) = 1.8; p = 0.03), the Hunt and Hess grade-3 (RR = 3.3; p = 0.002), the Hunt and Hess grade-4 (RR = 7.3; p = 0.007), and the hunt and Hess grade-5 (RR = 5.8; p = 0.03), the Fisher grade-3 (RR = 2; p = 0.01), and the Fisher grade-4 (RR = 2; p = 0.001). The determination of a prognostic score for each patient (using the coefficients of selected prognostic factors) allowed one to establish 3 prognostic stages with survival probabilities significantly different (p = 0.00005); stage-1; survival rate after 150 days (SR) = 97 %, confidence interval of 95 % (CI) = [0.90; 0.99], stage-2: SR = 66 %, CI = [0.56; 0.74], stage-3; SR = 34 %, CI = [0.17; 0.54]. The relative death risk for the stage-2 was 14 times higher than that for stage-1 (p = 0.00005), and the relative death risk for the stage-3 was 36 times higher than that for stage-1 (p = 0.00005). The age, the essential arterial hypertension, the sex and the angiographic classification of George have no prognostic value. The rebleeding incidence was correlated with prognostic stages (respectively from stage-1 to the stage-3: 8 %, 14 %, 34 %).(ABSTRACT TRUNCATED AT 250 WORDS)

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    ABSTRACT: Although the Hunt and Hess Scale (HHS) and World Federation of Neurological Surgeons Scale (WFNSS) are the most widely used subarachnoid hemorrhage (SAH) grading systems, neither system has achieved universal acceptance. We propose a simplified grading system based entirely on the Glasgow Coma Scale (GCS), which compresses the 15-point GCS into five grades that are comparable with those of the HHS and WFNSS. We refer to this system as the GCS grading system and present a direct comparison with the HHS and WFNSS for predictive value regarding patient outcome and interrater reliability. We reviewed 291 consecutive patients with aneurysms treated at our institution between January 1992 and January 1996 and compared the admission grades from the GCS, WFNSS, and HHS with outcome measures at discharge from hospitalization. The Glasgow Outcome score was used as the major outcome measure to evaluate the predictive value of the three scales. Mortality and length of stay (LOS) were also evaluated as outcome measures. The predictive value of each scale was tested with an ordinal logistic regression model for Glasgow Outcome score, a logistic regression model for mortality data, and a linear regression model for LOS. Using the logistic regression model, the GCS was the best predictor of discharge Glasgow Outcome score, with an odds ratio of 2.585 (P = 0.0001), compared with 2.311 (P = 0.0001) for the WFNSS and 2.262 (P = 0.0001) for the HHS. Using mortality data in the logistic model, the HHS was the best predictor, with an odds ratio of 3.391 (P = 0.0001), compared with 2.859 (P = 0.0001) for the GCS and 2.560 (P = 0.0001) for the WFNSS. Each of the three scales had a high predictive value for LOS, using a linear model. We discuss, however, the problematic nature of LOS as an outcome measure for SAH. Interrater reliability for each scale was evaluated using kappa statistics, based on 15 additional patients evaluated prospectively, and showed that the GCS grade also had the greatest interrater reliability, with a kappa of 0.46 (P = 0.0002), compared with 0.41 (P = 0.0005) for the HHS and 0.27 (P = 0.027) for the WFNSS. We conclude that the GCS grade has equal or greater predictive value regarding outcome after SAH than do the currently used grading systems and that it has greater reproducibility across observers. Broader familiarity with the GCS among medical and paramedical personnel may further enhance the usefulness of the GCS grade over the HHS and WFNSS in providing a standardized, universally accepted grading system for SAH.
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    ABSTRACT: Follow-up study of patients with surgical repair of aneurysmal subarachnoidal hemorrhage (SAH), looking for clinical outcome predictors. Sixty two patients consecutively admitted to a teaching hospital, from January 1992 to December 1995 were included in the study. We studied preoperative, intraoperative and postoperative features looking for their relationship with the outcome. The ultimate outcome was evaluated by means of Glasgow Outcome Scale on discharge and 6 months later. Smoking (p = 0.0001) and arterial hypertension (AHT) (p = 0.0186) were more frequent in these patients than in general population, but without relationship to the outcome as with the age of the clinical status on admission. The greatest statistical relationship was found between the level of consciousness on postoperative awakening (measured by the Hunt and Hess scale), and the outcome (p = 2.53 x 10(-8). From our results we made an algorithm that correctly assigned 92% of studied patients to their outcome. All patients admitted on with aneurysm SAH deserve intensive care treatment besides their clinical grade. The level of consciousness on postoperative awakening was a good outcome predictor.
    No preview · Article · Jul 1998 · Medicina Clínica
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    No preview · Article · Feb 2000 · Neurosurgery
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