How should a subarachnoid hemorrhage grading scale be determined? A combinatorial approach based solely on the Glasgow Coma Scale

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Object. The purpose of this study was to present a combinatorial approach used to develop a subarachnoid hemorrhage (SAH) grading scale based on the patient's preoperative Glasgow Coma Scale (GCS) score.

Methods. There are 4094 different combinations that can be used to compress the 13 scores of the GCS into two to 12 grades. Break points, the positions in the scale in which two adjacent scores connote a significantly different outcome, are obtained by a direct comparison of the GCS and the Glasgow Outcome Scale (GOS). Guided by the break points, the number of combinations to be considered can be limited. All possible combinations are statistically analyzed with respect to intergrade differences in outcome. Single combinations, with the maximum number of grades having maximum intergrade outcome differences for each corresponding set of adjacent grades, must be selected. The authors verified the validity of this combinatorial approach by retrospectively analyzing 1398 consecutive patients with aneurysmal SAH who underwent surgery within 7 days of the last hemorrhage episode. The patients' GCS scores were assessed just before surgery and their GOS scores were estimated 6 months post-SAH. The combinatorial approach yields only one acceptable grading scale: I (GCS Score 15); II (GCS Scores 11–14); III (GCS Scores 8–10); IV (GCS Scores 4–7); and V (GCS Score 3).

Conclusions. The combinatorial approach, guided by the break points, is so simple and systematic that it can be used again in the future when revision of the grading scale becomes necessary after development of new and effective treatment modalities that improve patients' overall outcome.

Article Information

Address reprint requests to: Kiyoshi Takagi, M.D., Department of Neurosurgery, Teikyo University School of Medicine, 2–11–1 Kaga, Itabashi-ku, Tokyo, 173–8605, Japan.

© AANS, except where prohibited by US copyright law.

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Figures

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    Graph showing changes in the percentile distribution of GCS scores during the three periods of the study. The patients' GCS scores were evaluated preoperatively. Although the percentiles of GCS Scores 3 and 4 markedly decreased during the late period, the percentile of other preoperative GCS scores showed only slight changes.

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    Bar graph depicting changes in percentile distribution of cases depending on the interval from the latest SAH episode to the operation. The number of cases in which operation was performed on Day 0 increased in the late period.

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    Bar graph demonstrating the relationship between GCS and GOS scores. The GCS scores were evaluated preoperatively and the GOS scores were evaluated 6 months after the latest episode of SAH. The GOS scores are represented numerically: 1, death (D); 2, persistent vegetative state (VS); 3, severe disability (SD); 4, moderate disability (MD); and 5, good recovery (GR). Outcomes of patients with a GCS score of 15 are significantly better than outcomes of those with a GCS score of 14. Data are expressed as the mean ± SEM.

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    Bar graph demonstrating the relationship between the WFNS scale and the GOS. The GOS scores are represented numerically (see legend to Fig. 3 for explanation of abbreviations). There are no significant differences in patient outcomes between WFNS Grades II and III or between Grades III and IV. Data are expressed as the mean ± SEM.

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    Bar graphs showing the relationships betweeen three grades in acceptable combinations of GCS scores with five grades and the GOS. The GOS scores are represented numerically (see legend to Fig. 3 for abbreviations). Combination A displays the highest intergrade outcome differences for each corresponding set of adjacent grades. Data are expressed as the mean ± SEM. *p < 0.005; ***p < 0.000001.

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    Bar graph showing the relationship between GCS-based grades and GOS scores. The GOS scores are represented numerically (see legend to Fig. 3 for abbreviations). The outcome of each grade differs from that of adjacent grades with a high statistical significance. Data are expressed as the mean ± SEM.

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    Bar graph showing the relationship between the GCS-based grading system applied to GCS scores at admission during the acute phase and GOS. The GOS scores are represented numerically (see legend to Fig. 3 for abbreviations). The GCS scores were evaluated at admission during the acute phase of SAH (within 7 days of onset) and GOS scores were evaluated 6 months post-SAH. The outcome of each grade differs from that of adjacent grades with a high statistical significance. Data are expressed as the mean ± SEM.

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