Clinical prediction of delayed cerebral ischemia in aneurysmal subarachnoid hemorrhage

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OBJECTIVE

The aim of this study was to derive a clinically applicable decision rule using clinical, radiological, and laboratory data to predict the development of delayed cerebral ischemia (DCI) in aneurysmal subarachnoid hemorrhage (aSAH) patients.

METHODS

Patients presenting over a consecutive 9-year period with subarachnoid hemorrhage (SAH) and at least 1 angiographically evident aneurysm were included. Variables significantly associated with DCI in univariate analysis underwent multivariable logistic regression. Using the beta coefficients, points were assigned to each predictor to establish a scoring system with estimated risks. DCI was defined as neurological deterioration attributable to arterial narrowing detected by transcranial Doppler ultrasonography, CT angiography, MR angiography, or catheter angiography, after exclusion of competing diagnoses.

RESULTS

Of 463 patients, 58% experienced angiographic vasospasm with an overall DCI incidence of 21%. Age, modified Fisher grade, and ruptured aneurysm location were significantly associated with DCI. This combination of predictors had a greater area under the receiver operating characteristic curve than the modified Fisher grade alone (0.73 [95% CI 0.67–0.78] vs 0.66 [95% CI 0.60–0.71]). Patients 70 years or older with modified Fisher grade 0 or 1 SAH and a posterior circulation aneurysm had the lowest risk of DCI at 1.2% (0 points). The highest estimated risk was 38% (17 points) in patients 40–59 years old with modified Fisher grade 4 SAH following rupture of an anterior circulation aneurysm.

CONCLUSIONS

Among patients presenting with aSAH, this score-based clinical prediction tool exhibits increased accuracy over the modified Fisher grade alone and may serve as a useful tool to individualize DCI risk.

ABBREVIATIONS aSAH = aneurysmal SAH; CBF = cerebral blood flow; DCI = delayed cerebral ischemia; DSA = digital subtraction angiography; EVD = external ventricular drainage; IVH = intraventricular hemorrhage; ROC = receiver operating characteristic; SAH = subarachnoid hemorrhage; TCD = transcranial Doppler; WFNS = World Federation of Neurosurgical Societies.

Article Information

Correspondence Hubert Lee: The Ottawa Hospital, Ottawa, ON, Canada. hulee@toh.on.ca.

INCLUDE WHEN CITING Published online June 8, 2018; DOI: 10.3171/2018.1.JNS172715.

Disclosures Dr. English: support of non–study-related clinical or research effort from Canadian Blood Services and Canadian Institutes of Health Research.

© AANS, except where prohibited by US copyright law.

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Figures

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    Sensitivity and specificity of the delayed cerebral ischemia score for all point cutoffs. Figure is available in color online only.

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