Time course of recovery following poor-grade SAH: the incidence of delayed improvement and implications for SAH outcome study design

Clinical article

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Object

Data regarding the time course of recovery after poor-grade subarachnoid hemorrhage (SAH) is lacking. Most SAH studies assess outcome at a single time point, often as early as 3 or 6 months following SAH. The authors hypothesized that recovery following poor-grade SAH is a dynamic process and that early outcomes may not always approximate long-term outcomes. To test this hypothesis, they analyzed long-term outcome data from a cohort of patients with poor-grade aneurysmal SAH to determine the incidence and predictors of early and delayed neurological improvement.

Methods

The authors reviewed outcome data from 88 poor-grade SAH patients enrolled in a prospective SAH treatment trial (the Barrow Ruptured Aneurysm Trial). They assessed modified Rankin Scale (mRS) scores at discharge, 6 months, 12 months, and 36 months after treatment to determine the incidence and predictors of neurological improvement during each interval.

Results

The mean aggregate mRS scores at 6 months (3.31 ± 2.1), 12 months (3.28 ± 2.2), and 36 months (3.17 ± 2.3) improved significantly compared with the mean score at hospital discharge (4.33 ± 1.3, p < 0.001), but they did not differ significantly among themselves. Between discharge and 6 months, 61% of patients improved on the mRS. The incidence of improvement between 6–12 months and 12–36 months was 18% and 19%, respectively. Hunt and Hess Grade IV versus V (OR 6.20, 95% CI 2.11–18.25, p < 0.001) and the absence of large (> 4 cm) (OR 2.76, 95% CI 1.02–7.55, p = 0.05) or eloquent (OR 5.17, 95% CI 1.89–14.10, p < 0.01) stroke were associated with improvement up to 6 months. Age ≤ 65 years (OR 5.56, 95% CI 1.17–26.42, p = 0.02), Hunt and Hess Grade IV versus V (OR 4.17, 95% CI 1.10–15.85, p = 0.03), and absence of a large (OR 8.97, 95% CI 2.65–30.40, p < 0.001) or eloquent (OR 4.54, 95% CI 1.46–14.08, p = 0.01) stroke were associated with improvement beyond 6 months. Improvement beyond 1 year was most strongly predicted by the absence of a large stroke (OR 7.62, 95% CI 1.55–37.30, p < 0.01).

Conclusions

A substantial minority of poor-grade SAH patients will experience delayed recovery beyond the point at which most studies assess outcome. Younger patients, those presenting in better clinical condition, and those without CT evidence of large or eloquent stroke demonstrated the highest capacity for delayed recovery.

Abbreviations used in this paper:BRAT = Barrow Ruptured Aneurysm Trial; mRS = modified Rankin Scale; SAH = subarachnoid hemorrhage.

Article Information

Address correspondence to: Robert F. Spetzler, M.D., Neuroscience Publications, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, 350 West Thomas Road, Phoenix, Arizona 85013. email: neuropub@dignityhealth.org.

Please include this information when citing this paper: published online May 31, 2013; DOI: 10.3171/2013.4.JNS121287.

© AANS, except where prohibited by US copyright law.

Headings

Figures

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    Aggregate cohort mRS score by time point. The mean aggregate mRS score of the entire cohort improved significantly between hospital discharge and 6 months (4.33 ± 1.3 vs 3.31 ± 2.1; *p < 0.001). Mean mRS scores at 12 and 36 months remained significantly improved compared with those at discharge but did not differ significantly compared with any other time point.

  • View in gallery

    Change in individual mRS scores by time interval following hospital discharge. Between discharge (D/C) and 6 months, 46 patients (61%) improved at least one mRS score, 16 (21%) maintained a stable mRS score, and 13 (17%) worsened at least one grade. Between 6 and 12 months, 13 patients (18%) improved at least one mRS score compared with the score at 6 months, 55 (76%) remained stable, and 4 (6%) worsened at least one grade. Between 12 and 36 months, 14 patients (19%) improved at least one mRS grade compared with the score at 12 months, 54 (72%) remained stable, and 7 (9%) worsened at least one grade.

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