Reevaluation der Risikofaktoren für schlechtes Outcome bei hochgradigen aSABs: Verbesserung der Behandlungsentscheidungsfindung

Aneurysmal subarachnoid hemorrhage (aSAH) is a cerebrovascular disease associated with significant morbidity and mortality. WFNS grades IV and V are designated as poor-grade aSAH (PGASAH), and are known for an exceptional grim prognosis. To identify individuals who can benefit from further treatment despite PGASAH, we conducted a comprehensive analysis of potential risk factors for poor outcome in this aSAH-subgroup, considering factors available at admission and during the hospital stay.

We utilized an institutional aSAH database covering a 13.5-year period, encompassing over 900 patients. Eligible participants for this study included all patients with PGASAH scheduled for aneurysm treatment, with available data on 6-month follow-up outcomes.The primary endpoint was defined as a poor outcome at the 6-month follow-up defined as the modified Rankin scale>2. We analyzed over 100 potential risk factors, including admission parameters, premorbid conditions, lab results, aSAH-specific parameters, and complications of aSAH, evaluating their influence on the primary endpoint through univariate analysis(UVA). All significant parameters were then included in a two-step multivariate analysis(MVA), first analyzing different subgroups and subsequently incorporating all significant parameters into a final MVA analysis.

A total of 348 patients were eligible for the final analysis. The majority were female(64.9%), with a median age of 55.1 years. In the UVA, we identified 19 potential risk factors. After the second MVA step, we identified age >55 years(p=0.002,aOR=2.44), premorbid cardiac valve disease(p=0.004,aOR=6.50), anisocoria at admission (p=0.025, aOR=2.64), early(<=72h post-aSAH,p<0.001,aOR=5.56) and delayed(>72h,p<0.001,aOR=5.09) cerebral infarction in the follow-up computed tomography scan(s) as independent risk factors for poor outcomes among PGASAH patients. The risk of a poor outcome gradually increased with the accumulation of the three baseline risk factors(cardiac valve diseases,age,anisocoria), resulting in a 50% risk of poor outcome in patients with zero and a 100% risk for patients with all three baseline risk factors.

Despite PGASAH, younger patients without premorbid cardiac valve disease and without anisocoria have a 50% chance of achieving a functional independency 6 months post-aSAH. Knowledge of PGASAH-specific risk factors may enhance counseling for relatives and facilitate informed treatment decisions in this aSAH sub-population.