Kennison Eric E, Murray Nick M, Collingridge Dave S, Knox Daniel, Fontaine Gabriel V
Department of Neurosciences, Intermountain Medical Center, Murray, UT, USA.
Department of Pharmacy, Intermountain Medical Center, Murray, UT, USA.
Neurocrit Care. 2025 Mar 28. doi: 10.1007/s12028-025-02236-x.
Patients with aneurysmal subarachnoid hemorrhage (aSAH) are often hospitalized for 21 days after aneurysm rupture due to the risk of complications. However, some never experience complications and are unlikely to benefit from a prolonged hospitalization. The aim of this study is to derive a risk assessment model (RAM) using data from the first 14 days of hospitalization to identify low-risk patients for early discharge, at day 15 or after.
Patients ≥ 18 years old with an acute aSAH at a Comprehensive Stroke Center from 2017 to 2024 were included. Baseline demographics, aSAH grading scales, and in-hospital complications requiring intervention were characterized. Complications included: vasospasm, delayed cerebral ischemia (DCI), cerebral salt wasting (CSW), cerebral edema, seizures, arrhythmias, respiratory failure, and hydrocephalus. Binary logistic regression with leave-one-out cross validation (LOOCV) was used to identify an optimal RAM.
Of 165 patients, the mean Hunt Hess Score (HHS) was 2.5 (standard deviation, SD 1.2), modified Fisher Score (mFS) was 3.1 (SD 1), endovascular therapy was used for aneurysm securement in 73% of patients, and 54.5% of patients experienced complications during days 15-21. In bivariate analyses, days 0-14 variables associated with days 15 + complications were the following: HHS, mFS, middle cerebral artery (MCA) aneurysm, clinical or radiologic vasospasm, endovascular therapies, intraventricular hemorrhage, hydrocephalus, presence of external ventricular drain (EVD), mechanical ventilation, vasopressors, hypertonic solutions, antiseizure medications, milrinone, and fludrocortisone (all p < 0.05). LOOCV regression for a best fit RAM included six variables: Sum of Vasopressors, Artery (MCA aneurysm), Fludrocortisone, EVD, Scale (mFS and HHS), "SAFE-SaH" and had an area under the receiver operator characteristics curve of 0.90 (95% confidence interval 0.85-0.95), sensitivity of 0.94, specificity of 0.69, positive predictive value of 79%, and negative predictive value of 91% for predicting complications on day 15 + .
This is the first ever RAM to incorporate clinical data from the first 14 days of hospitalization to identify patients with an aSAH at low risk for complications after day 14. With 94% sensitivity, the RAM classifies patients who will not have complications and may assist in earlier disposition on day 15 or after.
由于存在并发症风险，动脉瘤性蛛网膜下腔出血（aSAH）患者在动脉瘤破裂后通常需住院21天。然而，一些患者从未发生并发症，延长住院时间可能无法使他们受益。本研究的目的是利用住院前14天的数据推导一个风险评估模型（RAM），以识别在第15天或之后可提前出院的低风险患者。
纳入2017年至2024年在综合卒中中心就诊的年龄≥18岁的急性aSAH患者。对基线人口统计学、aSAH分级量表以及需要干预的院内并发症进行特征描述。并发症包括：血管痉挛、迟发性脑缺血（DCI）、脑性盐耗竭（CSW）、脑水肿、癫痫发作、心律失常、呼吸衰竭和脑积水。采用留一法交叉验证（LOOCV）的二元逻辑回归来确定最佳RAM。
165例患者中，平均Hunt Hess评分（HHS）为2.5（标准差，SD 1.2），改良Fisher评分（mFS）为3.1（SD 1），73%的患者采用血管内治疗来确保动脉瘤安全，54.5%的患者在第15 - 21天发生并发症。在双变量分析中，与第15天及以后并发症相关的0 - 14天变量如下：HHS、mFS、大脑中动脉（MCA）动脉瘤、临床或影像学血管痉挛、血管内治疗、脑室内出血、脑积水、外置脑室引流管（EVD）的使用、机械通气、血管升压药、高渗溶液、抗癫痫药物、米力农和氟氢可的松（均p < 0.05）。最佳拟合RAM的LOOCV回归包括六个变量：血管升压药总和、动脉（MCA动脉瘤）、氟氢可的松、EVD、量表（mFS和HHS）、“SAFE - SaH”，其受试者操作特征曲线下面积为0.90（95%置信区间0.85 - 0.95），预测第15天及以后并发症的敏感性为0.94，特异性为0.69，阳性预测值为79%，阴性预测值为91%。
这是首个纳入住院前14天临床数据以识别14天后发生并发症低风险aSAH患者的RAM。该RAM敏感性为94%，可对不会发生并发症的患者进行分类，并有助于在第15天或之后更早安排出院。
