Comparative evaluation of H&H and WFNS grading scales with modified H&H (sans systemic disease): A study on 1000 patients with subarachnoid hemorrhage.

The comparative studies on grading in subarachnoid hemorrhage (SAH) had several limitations such as the unclear grading of Glasgow Coma Scale 15 with neurological deficits in World Federation of Neurosurgical Societies (WFNS), and the inclusion of systemic disease in Hunt and Hess (H&H) scales. Their differential incremental impacts and optimum cut-off values for unfavourable outcome are unsettled. This is a prospective comparison of prognostic impacts of grading schemes to address these issues. SAH patients were assessed using WFNS, H&H (including systemic disease), modified H&H (sans systemic disease) and followed up with Glasgow Outcome Score (GOS) at 3 months. Their performance characteristics were analysed as incremental ordinal variables and different grading scale dichotomies using rank-order correlation, sensitivity, specificity, positive predictive value, negative predictive value, Youden's J and multivariate analyses. A total of 1016 patients were studied. As univariate incremental variable, H&H sans systemic disease had the best negative rank-order correlation coefficient (-0.453) with respect to lower GOS (p < 0.001). As univariate dichotomized category, WFNS grades 3-5 had the best performance index of 0.39 to suggest unfavourable GOS with a specificity of 89% and sensitivity of 51%. In multivariate incremental analysis, H&H sans systemic disease had the greatest adjusted incremental impact of 0.72 (95% confidence interval (CI) 0.54-0.91) against a lower GOS as compared to 0.6 (95% CI 0.45-0.74) and 0.55 (95% CI 0.42-0.68) for H&H and WFNS grades, respectively. In multivariate categorical analysis, H&H grades 4-5 sans systemic disease had the greatest impact on unfavourable GOS with an adjusted odds ratio of 6.06 (95% CI 3.94-9.32). To conclude, H&H grading sans systemic disease had the greatest impact on unfavourable GOS. Though systemic disease is an important prognostic factor, it should be considered distinctly from grading. Appropriate cut-off values suggesting unfavourable outcome for H&H and WFNS were 4-5 and 3-5, respectively, indicating the importance of neurological deficits in addition to level of consciousness.

Serum albumin level in spontaneous subarachnoid haemorrhage: More than a mere nutritional marker!

BACKGROUND: The role of nutritional markers on outcome following subarachnoid hemorrhage (SAH) has been scarcely described. METHODS: This is a prospective study of 273 patients with SAH, in which haemoglobin, serum protein and albumin were measured within 24 hours and again at one week following ictus, and analysed with respect to other variables. New neurologic deficits (NND), infarct, mortality and Glasgow outcome scale (GOS) at 3 months were assessed. RESULTS: The values of haemoglobin, total protein and albumin showed significant (p < .001) decline over the first week of SAH. Patients who developed NND had significantly lower serum albumin levels at admission compared to others (median 3.6 vs 3.9 g/dL, p < .001). Patients having lower albumin (≤3.5 gm/dL) levels at admission had significantly higher rates of NND (52% vs 20%), infarct (35% vs 23%), mortality (28% vs 16%) and unfavourable GOS (38% vs 25%). Hunt & Hess (H&H) grade and Fisher grade also affected all the outcome parameters significantly. Percentage decrease in albumin levels at one week following ictus significantly affected mortality and unfavourable GOS. On multivariate analyses, Fisher grade and lower admission albumin levels had significant impact on NND, while percentage decrease in albumin levels had significant impact on mortality and unfavourable GOS, independent of other nutritional markers and known prognostic variables. CONCLUSIONS: Serum albumin levels following SAH can be useful to predict development of NND, while its further weekly decrease correlates independently with unfavourable outcome at 3 months. Albumin assessment being readily available may serve as more than a mere nutritional parameter in SAH.

Impact of Early Leukocytosis and Elevated High-Sensitivity C-Reactive Protein on Delayed Cerebral Ischemia and Neurologic Outcome After Subarachnoid Hemorrhage.

BACKGROUND: The role of inflammatory response in the pathophysiology of subarachnoid hemorrhage (SAH) is being increasingly recognized. This study analyzed the impact of cellular and biochemical markers of early inflammatory response to ictus on outcome after SAH. METHODS: Patients with SAH were prospectively studied for markers of early cellular, biochemical, and cytotoxic inflammatory response, including total leukocyte count (TLC), high-sensitivity C-reactive protein (hs-CRP), and lactate dehydrogenase. The relationship of these markers to delayed cerebral ischemia (DCI), new infarct, and Glasgow Outcome Scale (GOS) score at 3 months was studied. RESULTS: The study comprised 246 patients. Of patients, 94 who developed DCI had a significantly higher TLC [± SD] (11.2 × 10(3)/mm(3) [± 4.0] vs. 9.4 × 10(3)/mm(3) [± 2.9], P = 0.001) and 62 with new infarct had significantly higher TLC (11.0 × 10(3)/mm(3) [± 3.6] vs. 9.8 × 10(3)/mm(3) [± 3.4], P = 0.05). GOS score had a significant inverse relationship to TLC at admission. The mean TLC [± SD] was 12.7 × 10(3)/mm(3) [± 4.2], 11.7 × 10(3)/mm(3) [± 3.1], 10.2 × 10(3)/mm(3) [± 3.4], and 9.3 × 10(3)/mm(3) [± 2.8] among patients with GOS scores of 1, 3, 4, and 5 (P < 0.001). hs-CRP showed a trend of an inverse relationship to GOS score in univariate analysis. Lactate dehydrogenase had no relationship with any outcome parameter. In multivariate analysis, higher admission TLC had a significant association with DCI (P = 0.01) and poorer GOS score (P < 0.001), and higher hs-CRP had a significant association with poorer GOS score (P = 0.05). CONCLUSIONS: A leukocytosis response to ictus seems to have a significant independent association with both DCI and poor GOS score, and hs-CRP level had a significant independent association with poor GOS score, indicating preeminence of early cellular response in SAH pathophysiology.

Serum lipid profile spectrum and delayed cerebral ischemia following subarachnoid hemorrhage: Is there a relation?

BACKGROUND: Serum lipid abnormalities are known to be important risk factors for vascular disorders. However, their role in delayed cerebral ischemia (DCI), the major cause of morbidity after subarachnoid hemorrhage (SAH) remains unclear. This study was an attempt to evaluate the spectrum of lipid profile changes in SAH compared to matched controls, and their relation with the occurrence of DCI. METHODS: Admission serum lipid profile levels were measured in patients of SAH and prospectively studied in relation to various factors and clinical development of DCI. RESULTS: Serum triglyceride (TG) levels were significantly lower among SAH patients compared to matched controls (mean [±standard deviation (SD)] mg/dL: 117.3 [±50.4] vs. 172.8 [±89.1], P = 0.002), probably because of energy consumption due to hypermetabolic response. Patients who developed DCI had significantly higher TG levels compared to those who did not develop DCI (mean [±SD] mg/dL: 142.1 [±56] vs. 111.9 [±54], P = 0.05). DCI was noted in 62% of patients with TG >150 mg/dL, compared to 22% among the rest (P = 0.01). Total cholesterol, low-density lipoprotein cholesterol, high-density lipoprotein cholesterol and lipoprotein (a) neither showed a significant difference between SAH and controls and nor any significant association with DCI. Multivariate analysis using binary logistic regression adjusting for the effects of age, sex, systemic disease, World Federation of Neurosurgical Societies grade, Fisher grade, and clipping/coiling, revealed higher TG levels to have significant independent association with DCI (P = 0.01). CONCLUSIONS: Higher serum TG levels appear to be significantly associated with DCI while other lipid parameters did not show any significant association. This may be due to their association with remnant cholesterol or free fatty acid-induced lipid peroxidation.

Study of trends in anthropometric nutritional indices and the impact of adiposity among patients of subarachnoid hemorrhage.

BACKGROUND: Nutritional status and adiposity have not been studied to a significant extent in subarachnoid hemorrhage (SAH). The aim of this study was to determine the trends in anthropometric indices and assess their impact on patients with SAH. METHODS: We prospectively studied in 56 patients with SAH, the triceps skinfold thickness (TSF), mid-arm circumference (MAC), mid-arm muscle circumference (MAMC), and other factors, and their relationship to clinical vasospasm and mortality. RESULTS: The median MAC decreased significantly from 29.3 cm (interquartile range [IQR] 28-31 cm) at admission to 27 cm (IQR 26-29 cm) at 1-week (P < 0.001). The median TSF decreased significantly from 34 mm (IQR 30-40 mm) at admission to 30 mm (IQR 25-35 mm) at 1-week (P < 0.001). MAMC values did not show a significant change over a week. The patients who developed clinical vasospasm had significantly higher median admission TSF of 40 mm (IQR 35-45 mm), compared to the median admission TSF of 35 mm (IQR 30-40 mm) among those who did not develop vasospasm (P = 0.03). MAMC values did not differ significantly in relation to vasospasm. Patients who expired by 3 months had significantly greater fall in median MAMC values at 1-week (7.7% [IQR 5.2-11.5%]), compared to the fall in median MAMC values at 1-week among those who were alive at 3 months (2.6% [IQR 2.1-6.6%]) [P = 0.03]. However, the fall in TSF values did not differ significantly in relation to mortality. In multivariate analysis, only the admission TSF, Hunt and Hess and Fisher grades had a significant association with vasospasm. This association was independent of other prognostic factors and of each other. CONCLUSION: Excessive adiposity of patients, measured as an increased TSF value, is significantly associated with clinical vasospasm independent of other prognostic factors, while fall in MAMC, indicating somatic protein catabolism, has some impact on mortality.