Hakozaki Koichi, Kawakita Fumihiro, Aoki Kazuaki, Suzuki Hidenori
Department of Neurosurgery, Mie University Graduate School of Medicine, 2-174 Edobashi, Tsu 514-8507, Mie, Japan.
J Clin Med. 2025 Apr 15;14(8):2715. doi: 10.3390/jcm14082715.
: The outcome for aneurysmal subarachnoid hemorrhage (SAH) remains poor, particularly for patients presenting with World Federation of Neurological Surgeons (WFNS) grades IV-V. This study was designed to identify independent prognostic factors in this group of patients with poor-grade SAH. : We prospectively analyzed 357 SAH patients with admission WFNS grades IV-V enrolled in nine primary stroke centers in Mie prefecture, Japan, from 2013 to 2022. This study compared clinical variables, including treatments for angiographic vasospasm and delayed cerebral ischemia (DCI), between patients with favorable (modified Rankin Scale [mRS] scores 0-2) and unfavorable (mRS scores 3-6) outcomes at 90 days post-onset. Multivariate analyses were then performed to identify independent determinants of favorable 90-day outcomes, followed by propensity score matching analyses. : The median age was 68 years, and 53.5% of patients had admission WFNS grade V. DCI occurred in 12.9% of patients, and 66.9% had unfavorable outcomes. Independent variables related to unfavorable outcomes were older age, admission WFNS grade V, ventricular drainage, edaravone administration, and delayed cerebral infarction, while those for favorable outcomes were spinal drainage (adjusted odds ratio [aOR] 6.118, 95% confidence interval [CI] 2.687-13.927, < 0.001), modified Fisher grade 3 (aOR 2.929, 95% CI 1.668-5.143, < 0.001), and triple prophylactic anti-DCI medication consisting of cilostazol, fasudil hydrochloride and eicosapentaenoic acid (aOR 1.869, 95% CI 1.065-3.279, = 0.029). Nimodipine is not approved in Japan, and statin and cerebral vasospasm did not influence outcomes. As spinal drainage and the triple prophylactic anti-DCI medication were intervenable variables, propensity score matchings were performed, and they confirmed that both spinal drainage and the triple prophylactic anti-DCI medication were useful to achieve favorable outcomes. : In poor-grade SAH, spinal drainage and the triple prophylactic anti-DCI medication may be effective in improving outcomes, possibly by suppressing DCI pathologies other than cerebral vasospasm.
动脉瘤性蛛网膜下腔出血（SAH）的预后仍然很差，尤其是对于世界神经外科医师联盟（WFNS）分级为IV - V级的患者。本研究旨在确定这组低分级SAH患者的独立预后因素。
我们前瞻性分析了2013年至2022年期间在日本三重县9个初级卒中中心登记入院的357例WFNS分级为IV - V级的SAH患者。本研究比较了发病后90天时预后良好（改良Rankin量表[mRS]评分0 - 2）和预后不良（mRS评分3 - 6）患者的临床变量，包括血管造影性血管痉挛和迟发性脑缺血（DCI）的治疗情况。然后进行多变量分析以确定90天良好预后的独立决定因素，随后进行倾向评分匹配分析。
患者的中位年龄为68岁，53.5%的患者入院时WFNS分级为V级。12.9%的患者发生了DCI，66.9%的患者预后不良。与不良预后相关的独立变量包括年龄较大、入院时WFNS分级为V级、脑室引流、依达拉奉给药和迟发性脑梗死，而与良好预后相关的变量包括腰大池引流（调整后的优势比[aOR]为6.118，95%置信区间[CI]为2.687 - 13.927，<0.001）、改良Fisher分级3级（aOR为2.929，95%CI为1.668 - 5.143，<0.001）以及由西洛他唑、盐酸法舒地尔和二十碳五烯酸组成的三联预防性抗DCI药物（aOR为1.869，95%CI为1.065 - 3.279，=0.029）。尼莫地平在日本未获批准，他汀类药物和脑血管痉挛对预后无影响。由于腰大池引流和三联预防性抗DCI药物是可干预变量，因此进行了倾向评分匹配，结果证实腰大池引流和三联预防性抗DCI药物均有助于实现良好预后。
在低分级SAH中，腰大池引流和三联预防性抗DCI药物可能通过抑制除脑血管痉挛以外的DCI病理过程来有效改善预后。
