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      The predictive value of the CTA Vasospasm Score on delayed cerebral ischaemia and functional outcome after aneurysmal subarachnoid hemorrhage

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          Abstract

          Background and purpose

          Delayed cerebral ischaemia (DCI) is a severe complication of aneurysmal subarachnoid hemorrhage that can significantly impact clinical outcome. Cerebral vasospasm is part of the pathophysiology of DCI and therefore a computed tomography angiography (CTA) Vasospasm Score was developed and an exploration was carried out of whether this score predicts DCI and subsequent poor outcome after aneurysmal subarachnoid hemorrhage.

          Methods

          The CTA Vasospasm Score sums the degree of angiographic cerebral vasospasm of 17 intradural arterial segments. The score ranges from 0 to 34 with a higher score reflecting more severe vasospasm. Outcome measures were cerebral infarction due to DCI (CI‐DCI), radiological and clinical DCI, and unfavorable functional outcome defined as a modified Rankin Scale >2 at 6 months. Receiver operating characteristic analyses were used to assess predictive value and to determine optimal cut‐off scores. Inter‐rater reliability was evaluated by Cohen's kappa coefficient.

          Results

          This study included 59 patients. CI‐DCI occurred in eight patients (14%), DCI in 14 patients (24%) and unfavorable outcome in 12 patients (20%). Median CTA Vasospasm Scores were higher in patients with (CI‐)DCI and poor outcome. Receiver operating characteristic analysis revealed the highest area under the curve on day 5: CI‐DCI 0.89 (95% confidence interval [CI] 0.79–0.99), DCI 0.68 (95% CI 0.50–0.87) and functional outcome 0.74 (95% CI 0.57–0.91). Cohen's kappa between the two raters was moderate to substantial (0.57–0.63).

          Conclusions

          This study demonstrates that the CTA Vasospasm Score on day 5 can reliably identify patients with a high risk of developing (CI‐)DCI and unfavorable outcome.

          Abstract

          The CTA Vasospasm Score can reliably identify patients with a low risk of developing cerebral infarction due to delayed cerebral ischaemia and unfavorable outcome after aneurysmal subarachnoid hemorrhage.

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          Most cited references7

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          Outcomes validity and reliability of the modified Rankin scale: implications for stroke clinical trials: a literature review and synthesis.

          Jamie Banks, Charles A. Marotta (2007)
          The modified Rankin scale (mRS), a clinician-reported measure of global disability, is widely applied for evaluating stroke patient outcomes and as an end point in randomized clinical trials. Extensive evidence on the validity of the mRS exists across a large but fragmented literature. As new treatments for acute ischemic stroke are submitted for agency approval, an appreciation of the mRS's attributes, specifically its relationship to other stroke evaluation scales, would be valuable for decision-makers to properly assess the impact of a new drug on treatment paradigms. The purpose of this report is to assemble and systematically assess the properties of the mRS to provide decision-makers with pertinent evaluative information. A Medline search was conducted to identify reports in the peer-reviewed medical literature (1957-2006) that provide information on the structure, validation, scoring, and psychometric properties of the mRS and its use in clinical trials. The selection of articles was based on defined criteria that included relevance, study design and use of appropriate statistical methods. Of 224 articles identified by the literature search, 50 were selected for detailed assessment. Inter-rater reliability with the mRS is moderate and improves with structured interviews (kappa 0.56 versus 0.78); strong test-re-test reliability (kappa=0.81 to 0.95) has been reported. Numerous studies demonstrate the construct validity of the mRS by its relationships to physiological indicators such as stroke type, lesion size, perfusion and neurological impairment. Convergent validity between the mRS and other disability scales is well documented. Patient comorbidities and socioeconomic factors should be considered in properly applying and interpreting the mRS. Recent analyses suggest that randomized clinical trials of acute stroke treatments may require a smaller sample size if the mRS is used as a primary end point rather than the Barthel Index. Multiple types of evidence attest to the validity and reliability of the mRS. The reported data support the view that the mRS is a valuable instrument for assessing the impact of new stroke treatments.
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            Definition of delayed cerebral ischemia after aneurysmal subarachnoid hemorrhage as an outcome event in clinical trials and observational studies: proposal of a multidisciplinary research group.

            Jan van Lanschot, J. P. Dreier, E F Wijdicks … (2010)
            In clinical trials and observational studies there is considerable inconsistency in the use of definitions to describe delayed cerebral ischemia (DCI) after aneurysmal subarachnoid hemorrhage. A major cause for this inconsistency is the combining of radiographic evidence of vasospasm with clinical features of cerebral ischemia, although multiple factors may contribute to DCI. The second issue is the variability and overlap of terms used to describe each phenomenon. This makes comparisons among studies difficult. An international ad hoc panel of experts involved in subarachnoid hemorrhage research developed and proposed a definition of DCI to be used as an outcome measure in clinical trials and observational studies. We used a consensus-building approach. It is proposed that in observational studies and clinical trials aiming to investigate strategies to prevent DCI, the 2 main outcome measures should be: (1) cerebral infarction identified on CT or MRI or proven at autopsy, after exclusion of procedure-related infarctions; and (2) functional outcome. Secondary outcome measure should be clinical deterioration caused by DCI, after exclusion of other potential causes of clinical deterioration. Vasospasm on angiography or transcranial Doppler can also be used as an outcome measure to investigate proof of concept but should be interpreted in conjunction with DCI or functional outcome. The proposed measures reflect the most relevant morphological and clinical features of DCI without regard to pathogenesis to be used as an outcome measure in clinical trials and observational studies.
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              Complications and outcome in patients with aneurysmal subarachnoid haemorrhage: a prospective hospital based cohort study in the Netherlands.

              J. Vermeulen, K. Albrecht, J Haan … (2000)
              The aim of this study was to investigate prospectively in an unselected series of patients with an aneurysmal subarachnoid haemorrhage what at present the complications are, what the outcome is, how many of these patients have "modern treatment"-that is, early obliteration of the aneurysm and treatment with calcium antagonists-what factors cause a delay in surgical or endovascular treatment, and what the estimated effect on outcome will be of improved treatment. A prospective, observational cohort study of all patients with aneurysmal subarachnoid haemorrhage in the hospitals of a specified region in The Netherlands. The condition on admission, diagnostic procedures, and treatments were recorded. If a patient had a clinical deterioration, the change in Glasgow coma score (GCS), the presence of focal neurological signs, the results of additional investigations, and the final diagnosed cause of the deterioration were recorded. Clinical outcome was assessed with the Glasgow outcome scale (GOS) at 3 month follow up. In patients with poor outcome at follow up, the cause was diagnosed. Of the 110 patients, 47 (43%) had a poor outcome. Cerebral ischaemia, 31 patients (28%), was the most often occurring complication. Major causes of poor outcome were the effects of the initial haemorrhage and rebleeding in 34% and 30% of the patients with poor outcome respectively. Of all patients 102 (93%) were treated with calcium antagonists and 45 (41%) patients had early treatment to obliterate the aneurysm. The major causes of delay of treatment were a poor condition on admission or deterioration shortly after admission, in 31% and 23% respectively. In two thirds of the patients with poor outcome the causes of poor outcome are the effects of the initial bleeding and rebleeding. Improved treatment of delayed or postoperative ischaemia will have only minor effects on the outcome of patients with subarachnoid haemorrhage.
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                Author and article information

                Contributors
                J. Joep van der Harst:
                ORCID: https://orcid.org/0000-0001-9472-308X
                j.j.van.der.harst@umcg.nl
                Journal
                Journal ID (nlm-ta): Eur J Neurol
                Journal ID (iso-abbrev): Eur J Neurol
                Journal ID (doi): 10.1111/(ISSN)1468-1331
                Journal ID (publisher-id): ENE
                Title: European Journal of Neurology
                Publisher: John Wiley and Sons Inc. (Hoboken )
                ISSN (Print): 1351-5101
                ISSN (Electronic): 1468-1331
                Publication date (Electronic): 07 November 2021
                Publication date (Print): February 2022
                Volume: 29
                Issue: 2 ( doiID: 10.1111/ene.v29.2 )
                Pages: 620-625
                Affiliations
                [ 1 ] Department of Neurology University of Groningen University Medical Center Groningen Groningen The Netherlands
                [ 2 ] Department of Radiology University of Groningen University Medical Center Groningen Groningen The Netherlands
                [ 3 ] Department of Critical Care University of Groningen University Medical Center Groningen Groningen The Netherlands
                [ 4 ] Department of Neurosurgery University of Groningen University Medical Center Groningen Groningen The Netherlands
                [ 5 ] Department of Epidemiology University of Groningen University Medical Center Groningen Groningen The Netherlands
                Author notes
                [*] [* ] Correspondence

                J. Joep van der Harst, Department of Neurology AB51, University Medical Center Groningen, PO Box 30.001, 9700 RB Groningen, The Netherlands.

                Email j.j.van.der.harst@ 123456umcg.nl

                Author information
                https://orcid.org/0000-0001-9472-308X
                https://orcid.org/0000-0002-0273-2382
                https://orcid.org/0000-0002-0814-5680
                Article
                Publisher ID: ENE15139
                DOI: 10.1111/ene.15139
                PMC ID: 9298005
                PubMed ID: 34644440
                SO-VID: 1d4d89c5-b4f1-4b84-a4d0-35856665026b
                Copyright © © 2021 The Authors. European Journal of Neurology published by John Wiley & Sons Ltd on behalf of European Academy of Neurology.
                License:

                This is an open access article under the terms of the http://creativecommons.org/licenses/by-nc-nd/4.0/ License, which permits use and distribution in any medium, provided the original work is properly cited, the use is non‐commercial and no modifications or adaptations are made.

                History
                Date received : 30 September 2021
                Date accepted : 09 October 2021
                Page count
                Figures: 4, Tables: 2, Pages: 6, Words: 3332
                Categories
                Subject: Short Communication
                Subject: Stroke
                Custom metadata
                source-schema-version-number 2.0
                cover-date February 2022
                details-of-publishers-convertor Converter:WILEY_ML3GV2_TO_JATSPMC version:6.1.7 mode:remove_FC converted:20.07.2022

                ScienceOpen disciplines: Neurology
                Keywords: cerebral infarction,computed tomography angiography,outcome assessment, health care,subarachnoid hemorrhage,vasospasm, intracranial
                Data availability:
                ScienceOpen disciplines: Neurology
                Keywords: cerebral infarction, computed tomography angiography, outcome assessment, health care, subarachnoid hemorrhage, vasospasm, intracranial

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