Risk factors for an unfavorable functional outcome after a non-aneurysmal spontaneous subarachnoid hemorrhage
Elena Kurz (Mainz), Darius Kalasauskas (Mainz), Anna Steklecova (Prague / CZ), David Netuka (Prague / CZ), Wostrack Maria (Essen), Albrecht Carolin (Essen), Wunderlich Silke (Essen), Enayatullah Baki (Essen), Rauschenbach Laurèl (Essen), Ramazan Jabbarli (Essen), Ulrich Sure (Essen), Claudius Thomé (Innsbruck / AT), Christian Preuss-Hernandez (Innsbruck / AT), Abdullah Al Awadhi (Geneva / CH), Eva Cochard (Geneva / CH), Julien Haemmerli (Geneva / CH), Karl Schaller (Geneva / CH), Fritz Becker (Tübingen), Alicia Schulze (Mainz), Florian Ringel (Mainz)
Spontaneous subarachnoid hemorrhages(sSAH) are mostly caused by rupture of cerebral aneurysms. However, in ≈15% the bleeding source cannot be determined in imaging. These non-aneurysmal sSAH(nSAH) are known for lower complication rates and a more favorable outcome. But, cases with a complicated clinical course are not uncommon and difficult to predict. Aim of our study was to analyze patients" and imaging characteristics to identify predictors of a poor outcome after nSAH.
Retrospectively, all patients with nSAH (2010-2021) from 6 neurosurgical departments were analyzed. Demographics, the H&H, Fisher(FS) and WFNS grades, Systemic Inflammatory Response Syndrome (SIRS) and ASA scores were analyzed. Comorbidities, diagnostics, risk factors, treatment methods, complications (cerebral vasospasm(CV), hydrocephalus) and the blood distribution (perimesencephalic vs. diffuse) were analyzed. The outcome was assessed by the modified Rankin Scale(mRS) at 6 months defining an unfavorable outcome as mRS≥3.
474 cases (59.5% male, n=282) with a mean age of 54.5±12.1 years were included. Mean ASA was 2.1±0.73, mean HH,WFNS and FS were 1.6±0.87,1.3±0.86 and 2.7±0.9. 60.3% had diffuse blood distribution. Acute CSF diversion was needed in 16.5% (n=78), a shunt(VP) in 4.2% (n=20). CV were detected in 16.7%(n=79). 11 patients developed DCI(2.3%). 90.2% had a favorable outcome (mRS<2).In univariate analysis the risk for an unfavorable outcome was increased by hypertension(0.0001), diabetes(p<0.0001), cardiac congestion(p<0.0001), peripheral vascular disease(p<0.0001), cerebral insults(p=0.0007), renal failure(p=0.003), leucemia(p=0.0007), ASA(<0.0001), HH(p<0.0001), WFNS(p<0.0001), SIRS(p<0.0001), FS(p<0.0001), intracerebral blood(p<0.0001) a diffuse blood distribution(p<0.0001), DCI(p=0.02) and the need for a VP(p<0.0001). In multivariate analysis exclusively the HH(p=0.03,OR=3.2) correlated significantly with an unfavorable outcome. Intracerebral blood(p=0.06,OR=3.6) and SIRS(p=0.08,OR=2.2) showed a trending association.
In nSAH, several comorbidities, common scores, typical complications, and the blood distribution are associated with an unfavorable outcome. However, in multivariate analysis only the HH was identified as independent predictor. Despite the high number of cases further predictors previously discussed as high-risk parameters as a diffuse blood distribution, CV and the need for VP were not confirmed as significant factors for the outcome after nSAH.
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