Association of nosocomial infections with delayed cerebral ischemia in aneurysmal subarachnoid hemorrhage

OBJECTIVE Delayed cerebral ischemia (DCI) is a recognized complication of aneurysmal subarachnoid hemorrhage (aSAH) that contributes to poor outcome. This study seeks to determine the effect of nosocomial infection on the incidence of DCI and patient outcome. METHODS An exploratory analysis was performed on 156 patients with aSAH enrolled in the Cerebral Aneurysm Renin Angiotensin System study. Clinical and radiographic data were analyzed with univariate analysis to detect risk factors for the development of DCI and poor outcome. Multivariate logistic regression was performed to identify independent predictors of DCI. RESULTS One hundred fifty-three patients with aSAH were included. DCI was identified in 32 patients (20.9%). Nosocomial infection (odds ratio [OR] 3.5, 95% confidence interval [CI] 1.09–11.2, p = 0.04), ventriculitis (OR 25.3, 95% CI 1.39–458.7, p = 0.03), aneurysm re-rupture (OR 7.55, 95% CI 1.02–55.7, p = 0.05), and clinical vasospasm (OR 43.4, 95% CI 13.1–143.4, p < 0.01) were independently associated with the development of DCI. Diagnosis of nosocomial infection preceded the diagnosis of DCI in 15 (71.4%) of 21 patients. Patients diagnosed with nosocomial infection experienced significantly worse outcomes as measured by the modified Rankin Scale score at discharge and 1 year (p < 0.01 and p = 0.03, respectively). CONCLUSIONS Nosocomial infection is independently associated with DCI. This association is hypothesized to be partly causative through the exacerbation of systemic inflammation leading to thrombosis and subsequent ischemia.

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Abstract 195: Nosocomial Infections are Associated with Delayed Cerebral Ischemia in Aneurysmal Subarachnoid Hemorrhage

Stroke ◽

10.1161/str.47.suppl_1.195 ◽

2016 ◽

Vol 47 (suppl_1) ◽

Author(s):

Paul M Foreman ◽

Michelle Chua ◽

Mark R Harrigan ◽

Winfield S Fisher ◽

Nilesh A Vyas ◽

...

Keyword(s):

Subarachnoid Hemorrhage ◽

Cerebral Ischemia ◽

Nosocomial Infection ◽

Aneurysmal Subarachnoid Hemorrhage ◽

Univariate Analysis ◽

Delayed Cerebral Ischemia ◽

Renin Angiotensin System ◽

Angiotensin System ◽

Poor Outcome ◽

Radiographic Data

Background and Purpose: Delayed cerebral ischemia (DCI) is a recognized complication of aneurysmal subarachnoid hemorrhage (aSAH) that contributes to poor outcome. This study seeks to determine the effect of nosocomial infection on the incidence of DCI and patient outcome. Methods and Subjects: An exploratory analysis was performed on 156 aSAH patients enrolled in the Cerebral Aneurysm Renin Angiotensin System (CARAS) study. Clinical and radiographic data were analyzed with univariate analysis to detect risk factors for the development of DCI and poor outcome. Multivariate logistic regression was performed to identify independent predictors of DCI. Results: One hundred and fifty three patients with aSAH were included. Delayed cerebral ischemia was identified in 32 (20.9%) patients. Nosocomial infection, ventriculitis, aneurysm rerupture, and clinical vasospasm were independently associated with the development of DCI [3.5 (1.93 - 6.35), p < 0.00; 25.3 (4.39 - 110.9), p = 0.03; 7.55 (2.72 - 20.9), p = 0.05; 43.4 (23.6 - 79.8), p < 0.00; respectively]. Diagnosis of nosocomial infection preceded the diagnosis of DCI in 15 of 21 (71.4%) patients. Patients diagnosed with nosocomial infection experienced significantly worse outcomes as measured by mRS at discharge and 1 year (p < 0.00 and p = 0.03, respectively). Conclusions: Nosocomial infection is independently associated with DCI. This association is hypothesized to be partly causative through the exacerbation of systemic inflammation leading to thrombosis and subsequent ischemia.

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Apolipoprotein E genotype and outcome after aneurysmal subarachnoid hemorrhage

Journal of Neurosurgery ◽

10.3171/2008.11.jns081266 ◽

2009 ◽

Vol 110 (5) ◽

pp. 989-995 ◽

Cited By ~ 21

Author(s):

Seppo Juvela ◽

Jari Siironen ◽

Jaakko Lappalainen

Keyword(s):

Subarachnoid Hemorrhage ◽

Cerebral Ischemia ◽

Cerebral Infarction ◽

Apolipoprotein E ◽

Clinical Condition ◽

Aneurysmal Subarachnoid Hemorrhage ◽

Univariate Analysis ◽

Delayed Cerebral Ischemia ◽

Intracerebral Hematoma ◽

Poor Outcome

Object After aneurysmal subarachnoid hemorrhage (SAH), conflicting results concerning an association between the APOE genotype and impaired outcome have been reported. The authors tested prospectively whether APOE ε2 or ε4 allele–containing genotypes (ε2+ and ε4+) affect outcome after SAH. Methods Previous disease histories and clinical and radiological variables were recorded for 105 patients who were admitted within 48 hours after SAH. Fifteen patients (14%) had the ε2+ genotype and 31 (17%) had ε4+ genotypes. Factors predicting poor outcome according to the Glasgow Outcome Scale and cerebral infarction visible on CT scans obtained at 3 months after SAH were tested with multiple logistic regression analyses. Results Apolipoprotein E ε2 or ε4–containing genotypes were not associated with outcome, occurrence of cerebral infarction, or with any of their predictors, either in univariate or multivariate analysis. Poor outcome was predicted independently by the occurrence of intraventricular bleeding and intracerebral hematoma as well as by elevated levels of both plasma glucose and D-dimer, and delayed cerebral ischemia (p < 0.05 for each factor), and in univariate analysis only by clinical condition on admission and patient age. Cerebral infarction was predicted independently according to clinical condition on admission (p < 0.05), amount of subarachnoid blood (p < 0.01), duration of intraoperative parent artery clipping (p < 0.01), and body mass index (p < 0.05). In the univariate analysis only cerebral infarction was also predicted by patient age, intracerebral hematoma, and delayed cerebral ischemia. Conclusions Severity of bleeding for the most part predicts outcome after SAH; APOE polymorphisms seem to have no prognostic value for outcome after SAH. This result was in accordance with the findings from the largest ischemic stroke studies.

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Role of microcirculatory impairment in delayed cerebral ischemia and outcome after aneurysmal subarachnoid hemorrhage

Journal of Cerebral Blood Flow & Metabolism ◽

10.1177/0271678x211045446 ◽

2021 ◽

pp. 0271678X2110454

Author(s):

Masato Naraoka ◽

Naoya Matsuda ◽

Norihito Shimamura ◽

Hiroki Ohkuma

Keyword(s):

Subarachnoid Hemorrhage ◽

Cerebral Ischemia ◽

Aneurysmal Subarachnoid Hemorrhage ◽

Univariate Analysis ◽

Delayed Cerebral Ischemia ◽

Significant Risk ◽

Significant Risk Factor ◽

Microcirculatory Dysfunction ◽

Poor Outcome

Early brain injury (EBI) is considered an important cause of morbidity and mortality after aneurysmal subarachnoid hemorrhage (aSAH). As a factor in EBI, microcirculatory dysfunction has become a focus of interest, but whether microcirculatory dysfunction is more important than angiographic vasospasm (aVS) remains unclear. Using data from 128 cases, we measured the time to peak (TTP) in several regions of interest on digital subtraction angiography. The intracerebral circulation time (iCCT) was obtained between the TTP in the ultra-early phase (the baseline iCCT) and in the subacute phase and/or at delayed cerebral ischemia (DCI) onset (the follow-up iCCT). In addition, the difference in the iCCT was calculated by subtracting the baseline iCCT from the follow-up iCCT. Univariate analysis showed that DCI was significantly increased in those patients with a prolonged baseline iCCT, prolonged follow-up iCCT, increased differences in the iCCT, and with severe aVS. Poor outcome was significantly increased in patients with prolonged follow-up iCCT and increased differences in the iCCT. Multivariate analysis revealed that increased differences in the iCCT were a significant risk factor that increased DCI and poor outcome. The results suggest that the increasing microcirculatory dysfunction over time, not aVS, causes DCI and poor outcome after aneurysmal aSAH.

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Associations between endothelin polymorphisms and aneurysmal subarachnoid hemorrhage, clinical vasospasm, delayed cerebral ischemia, and functional outcome

Journal of Neurosurgery ◽

10.3171/2016.12.jns162594 ◽

2018 ◽

Vol 128 (5) ◽

pp. 1311-1317 ◽

Cited By ~ 6

Author(s):

Christoph J. Griessenauer ◽

Robert M. Starke ◽

Paul M. Foreman ◽

Philipp Hendrix ◽

Mark R. Harrigan ◽

...

Keyword(s):

Subarachnoid Hemorrhage ◽

Cerebral Ischemia ◽

Functional Outcome ◽

Aneurysmal Subarachnoid Hemorrhage ◽

Delayed Cerebral Ischemia ◽

Multivariate Logistic Regression Analysis ◽

Renin Angiotensin System ◽

Nucleotide Polymorphisms ◽

Endothelin 1 ◽

Potent Vasoconstrictor

OBJECTIVEEndothelin-1, a potent vasoconstrictor, and its receptors may be involved in the pathogenesis of aneurysmal subarachnoid hemorrhage (aSAH), clinical vasospasm, delayed cerebral ischemia (DCI), and functional outcome following aSAH. In the present study, common endothelin single nucleotide polymorphisms (SNPs) and their relation to aSAH were evaluated.METHODSBlood samples from all patients enrolled in the Cerebral Aneurysm Renin Angiotensin System (CARAS) study were used for genetic evaluation. The CARAS study prospectively enrolled patients with aSAH at 2 academic institutions in the US from 2012 to 2015. Common endothelin SNPs were detected using 5′ exonnuclease (TaqMan) genotyping assays. Analysis of associations between endothelin SNPs and aSAH and its clinical sequelae was performed.RESULTSSamples from 149 patients with aSAH and 50 controls were available for analysis. In multivariate logistic regression analysis, the TG (odds ratio [OR] 2.102, 95% confidence interval [CI] 1.048–4.218, p = 0.036) and TT genotypes (OR 7.884, 95% CI 1.003–61.995, p = 0.05) of the endothelin-1 T/G SNP (rs1800541) were significantly associated with aSAH. There was a dominant effect of the G allele (CG/GG genotypes; OR 4.617, 95% CI 1.311–16.262, p = 0.017) of the endothelin receptor A G/C SNP (rs5335) on clinical vasospasm. Endothelin SNPs were not associated with DCI or functional outcome.CONCLUSIONSCommon endothelin SNPs were found to be associated with presentation with aSAH and clinical vasospasm. Further studies are required to elucidate the relevant pathophysiology and its potential implications in the treatment of patients with aSAH.

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Associations of renin-angiotensin system genetic polymorphisms and clinical course after aneurysmal subarachnoid hemorrhage

Journal of Neurosurgery ◽

10.3171/2016.4.jns16409 ◽

2017 ◽

Vol 126 (5) ◽

pp. 1585-1597 ◽

Cited By ~ 7

Author(s):

Christoph J. Griessenauer ◽

R. Shane Tubbs ◽

Paul M. Foreman ◽

Michelle H. Chua ◽

Nilesh A. Vyas ◽

...

Keyword(s):

Single Nucleotide Polymorphism ◽

Subarachnoid Hemorrhage ◽

Clinical Course ◽

Aneurysmal Subarachnoid Hemorrhage ◽

Delayed Cerebral Ischemia ◽

Renin Angiotensin System ◽

Nucleotide Polymorphism ◽

Single Nucleotide ◽

Angiotensin System ◽

Renin Angiotensin

OBJECTIVERenin-angiotensin system (RAS) genetic polymorphisms are thought to play a role in cerebral aneurysm formation and rupture. The Cerebral Aneurysm Renin Angiotensin System (CARAS) study prospectively evaluated associations of common RAS polymorphisms and clinical course after aneurysmal subarachnoid hemorrhage (aSAH).METHODSThe CARAS study prospectively enrolled aSAH patients at 2 academic centers in the United States. A blood sample was obtained from all patients for genetic evaluation and measurement of plasma angiotensin converting enzyme (ACE) concentration. Common RAS polymorphisms were detected using 5′exonuclease genotyping assays and pyrosequencing. Analysis of associations of RAS polymorphisms and clinical course after aSAH were performed.RESULTSA total of 166 patients were screened, and 149 aSAH patients were included for analysis. A recessive effect of allele I (insertion) of the ACE I/D (insertion/deletion) polymorphism was identified for Hunt and Hess grade in all patients (OR 2.76, 95% CI 1.17–6.50; p = 0.0206) with subsequent poor functional outcome. There was a similar effect on delayed cerebral ischemia (DCI) in patients 55 years or younger (OR 3.63, 95% CI 1.04–12.7; p = 0.0439). In patients older than 55 years, there was a recessive effect of allele A of the angiotensin II receptor Type 2 (AT2) A/C single nucleotide polymorphism (SNP) on DCI (OR 4.70, 95% CI 1.43–15.4; p = 0.0111).CONCLUSIONSBoth the ACE I/D polymorphism and the AT2 A/C single nucleotide polymorphism were associated with an age-dependent risk of delayed cerebral ischemia, whereas only the ACE I/D polymorphism was associated with poor clinical grade at presentation. Further studies are required to elucidate the relevant pathophysiology and its potential implication in the treatment of patients with aSAH.

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Rebleeding drives poor outcome in aneurysmal subarachnoid hemorrhage independent of delayed cerebral ischemia: a propensity-score matched cohort study

Journal of Neurosurgery ◽

10.3171/2019.4.jns19779 ◽

2020 ◽

Vol 133 (2) ◽

pp. 360-368

Author(s):

Victor M. Lu ◽

Christopher S. Graffeo ◽

Avital Perry ◽

Lucas P. Carlstrom ◽

Leonardo Rangel-Castilla ◽

...

Keyword(s):

Cohort Study ◽

Subarachnoid Hemorrhage ◽

Cerebral Ischemia ◽

Propensity Score ◽

Functional Outcome ◽

Treatment Modality ◽

Aneurysmal Subarachnoid Hemorrhage ◽

Delayed Cerebral Ischemia ◽

Poor Functional Outcome ◽

Poor Outcome

OBJECTIVEDelayed cerebral ischemia (DCI) and aneurysm rebleeding contribute to morbidity and mortality in aneurysmal subarachnoid hemorrhage (aSAH); however, the relationship between their impacts on overall functional outcome is incompletely understood.METHODSThe authors conducted a cohort study of all aSAH during the study period from 2001 to 2016. Primary end points were overall functional outcome and ischemic aSAH sequelae, defined as delayed cerebral ischemia (DCI), DCI with infarction, symptomatic vasospasm (SV), and global cerebral edema (GCE). Outcomes were compared between the rebleed and nonrebleed cohorts overall and after propensity-score matching (PSM) for risk factors and treatment modality. Univariate and multivariate ordered logistic regression analyses for functional outcomes were performed in the PSM cohort to identify predictors of poor outcome.RESULTSFour hundred fifty-five aSAH cases admitted within 24 hours of aneurysm rupture were included, of which 411 (90%) experienced initial aneurysm ruptures only, while 44 (10%) had clinically confirmed rebleeding. In the overall cohort, rebleeding was associated with significantly worse functional outcome, longer intensive care unit length of stay (LOS), and GCE (all p < 0.01); treatment modality, overall LOS, DCI, DCI with infarction, and SV were nonsignificant. In the PSM analysis of 43 matched rebleed and 43 matched nonrebleed cases, only poor functional outcome and GCE remained significantly associated with rebleeding (p < 0.01 and p = 0.02, respectively). Multivariate regression identified that both rebleeding (HR 21.5, p < 0.01) and DCI (HR 10.1, p = 0.01) independently predicted poor functional outcome.CONCLUSIONSRebleeding and DCI after aSAH are highly morbid and potentially deadly events after aSAH, which appear to have independent negative impacts on overall functional outcome. Early rebleeding did not significantly affect the risk of delayed ischemic complications.

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122 Significance of Fluctuations in Serum Sodium Levels Following Aneurysmal Subarachnoid Hemorrhage: An Exploratory Analysis

Neurosurgery ◽

10.1093/neuros/nyx417.122 ◽

2017 ◽

Vol 64 (CN_suppl_1) ◽

pp. 227-227

Author(s):

Matt E Eagles ◽

Michael K Tso ◽

R Loch Macdonald

Keyword(s):

Subarachnoid Hemorrhage ◽

Serum Sodium ◽

Aneurysmal Subarachnoid Hemorrhage ◽

Statistical Significance ◽

Univariate Analysis ◽

Delayed Cerebral Ischemia ◽

Exploratory Analysis ◽

Base Line ◽

Poor Outcome ◽

Increased Risk

Abstract INTRODUCTION Changes in serum sodium levels are common following aneurysmal subarachnoid hemorrhage (aSAH), and may be linked to increased morbidity. In this exploratory analysis we assessed whether fluctuations in serum sodium levels after aSAH have an association with clinical outcomes and/or delayed cerebral ischemia (DCI). METHODS We performed a retrospective analysis of data from CONSCIOUS-1 (n = 413), a randomized controlled trial of clazosentan treatment in patients with aSAH. Patient serum sodium levels were checked daily during the hospital stay up to day 14. Mean-per-day fluctuations in serum sodium were calculated by summing the absolute deviation of serum sodium at day 2–14 from day 1 base-line divided by the total number of days with lab values. Logistic regression and LOWESS smoothing curves were used to determine association between serum sodium deviation and poor outcome at 3 months (defined as modified Rankin Scale, mRS> 2) or DCI. RESULTS >Mean-per-day deviation of serum sodium from baseline was associated with poor outcome on univariate analysis (P = 0.028), and maintained statistical significance after correcting for age and World Federation of Neurological Surgeons (WFNS) grade (P = 0.044). A LOWESS smoothing curve showed an increased risk of DCI for patients with greater deviations from their baseline sodium values. Multivariate regression, including WFNS and Fisher Scale grades, demonstrated absolute variation in sodium values to be associated with DCI (P = 0.045). CONCLUSION In this study, greater deviations in serum sodium values independently predicted poor outcome and the development of DCI.

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Role of ABO blood type in delayed cerebral ischemia onset and clinical outcomes after aneurysmal subarachnoid hemorrhage in an ethnic minority urban population

Surgical Neurology International ◽

10.25259/sni_10_2020 ◽

2020 ◽

Vol 11 ◽

pp. 108

Author(s):

Santiago René Unda ◽

Tarini Vats ◽

Rafael De la Garza Ramos ◽

Phillip Cezaryirli ◽

David J. Altschul

Keyword(s):

Subarachnoid Hemorrhage ◽

Cerebral Ischemia ◽

Clinical Outcomes ◽

Aneurysmal Subarachnoid Hemorrhage ◽

Univariate Analysis ◽

Delayed Cerebral Ischemia ◽

Blood Type ◽

Academic Center ◽

Abo Blood Type

Background: In recent years, the role of ABO blood type moved into focus through the discovery of different hemostaseologic properties with importance in many diseases including subarachnoid hemorrhage (SAH). However, the role of ABO blood type in delayed cerebral ischemia (DCI) onset, clinical progress, and outcome after SAH is to date largely unexplored. Our aim was to explore the role of ABO blood group in DCI and clinical outcomes after aneurysmal SAH (aSAH). Methods: A retrospective analysis was made with data collected from patients who presented aSAH at our single- academic center from 2015 to 2018. We included demographic, clinical, and imaging variables in the univariate analysis and in the subsequent multivariate analysis. Results: A total of 204 patients were included in this study. About 17.9% of “O” type patients developed a DCI while DCI was reported in only 8.2% of non-O type patients (P = 0.04). “O” type was an independent risk after in the logistic regression after adjusting for significant factors in the univariate analysis (OR=2.530, 95% CI: 1.040- 6.151, P = 0.41). Compared to “non-O” type patients, “O” type patients had a trend to have poorer outcomes at discharge (25.5% vs. 21.3%, P = 0.489) and at 12–18 months (21.1% vs. 19.5%, P = 0.795). However, there were no significant differences. Conclusion: Our study evidenced that patients with “O” blood type have higher risk of DCI onset after aSAH. Although these findings need to be confirmed, they may aid to improve DCI prevention and outcome predictions.

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Hyperoxemia during the hyperacute phase of aneurysmal subarachnoid hemorrhage is associated with delayed cerebral ischemia and poor outcome: a retrospective observational study

Journal of Neurosurgery ◽

10.3171/2019.9.jns19781 ◽

2019 ◽

pp. 1-8 ◽

Cited By ~ 1

Author(s):

Shinya Fukuda ◽

Yasutaka Koga ◽

Motoki Fujita ◽

Eiichi Suehiro ◽

Kotaro Kaneda ◽

...

Keyword(s):

Logistic Regression ◽

Subarachnoid Hemorrhage ◽

Cerebral Ischemia ◽

Aneurysmal Subarachnoid Hemorrhage ◽

Delayed Cerebral Ischemia ◽

Favorable Outcome ◽

Regression Analyses ◽

Poor Outcome ◽

Poor Outcome Group ◽

Outcome Group

OBJECTIVEThe harmful effects of hyperoxemia have been reported in critically ill patients with various disorders, including those with brain injuries. However, the effect of hyperoxemia on aneurysmal subarachnoid hemorrhage (aSAH) patients is unclear. In this study the authors aimed to determine whether hyperoxemia during the hyperacute or acute phase in patients with aSAH is associated with delayed cerebral ischemia (DCI) and poor neurological outcome.METHODSIn this single-center retrospective study, data from patients with aSAH treated between January 2011 and June 2017 were reviewed. The patients were classified into groups according to whether they experienced DCI (DCI group and non-DCI group) and whether they had a poor outcome at discharge (poor outcome group and favorable outcome group). The background characteristics and time-weighted average (TWA) PaO2 during the first 24 hours after arrival at the treatment facility (TWA24h-PaO2) and between the first 24 hours after arrival and day 6 (TWA6d-PaO2), the hyperacute and acute phases, respectively, were compared between the groups. Factors related to DCI and poor outcome were evaluated with logistic regression analyses.RESULTSOf 197 patients with aSAH, 42 patients experienced DCI and 82 patients had a poor outcome at discharge. TWA24h-PaO2 was significantly higher in the DCI group than in the non-DCI group (186 [141–213] vs 161 [138–192] mm Hg, p = 0.029) and in the poor outcome group than in the favorable outcome group (176 [154–205] vs 156 [136–188] mm Hg, p = 0.004). TWA6d-PaO2 did not differ significantly between the groups. Logistic regression analyses revealed that higher TWA24h-PaO2 was an independent risk factor for DCI (OR 1.09, 95% CI 1.01–1.17, p = 0.037) and poor outcome (OR 1.17, 95% CI 1.06–1.29, p = 0.002).CONCLUSIONSHyperoxemia during the first 24 hours was associated with DCI and a poor outcome in patients with aSAH. Excessive oxygen therapy might have an adverse effect in the hyperacute phase of aSAH.

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Clinical prediction of delayed cerebral ischemia in aneurysmal subarachnoid hemorrhage

Journal of Neurosurgery ◽

10.3171/2018.1.jns172715 ◽

2019 ◽

Vol 130 (6) ◽

pp. 1914-1921 ◽

Cited By ~ 7

Author(s):

Hubert Lee ◽

Jeffrey J. Perry ◽

Shane W. English ◽

Fahad Alkherayf ◽

Joanne Joseph ◽

...

Keyword(s):

Subarachnoid Hemorrhage ◽

Cerebral Ischemia ◽

Aneurysmal Subarachnoid Hemorrhage ◽

Characteristic Curve ◽

Univariate Analysis ◽

Laboratory Data ◽

Delayed Cerebral Ischemia ◽

Clinical Prediction ◽

Anterior Circulation ◽

Fisher Grade

OBJECTIVEThe aim of this study was to derive a clinically applicable decision rule using clinical, radiological, and laboratory data to predict the development of delayed cerebral ischemia (DCI) in aneurysmal subarachnoid hemorrhage (aSAH) patients.METHODSPatients presenting over a consecutive 9-year period with subarachnoid hemorrhage (SAH) and at least 1 angiographically evident aneurysm were included. Variables significantly associated with DCI in univariate analysis underwent multivariable logistic regression. Using the beta coefficients, points were assigned to each predictor to establish a scoring system with estimated risks. DCI was defined as neurological deterioration attributable to arterial narrowing detected by transcranial Doppler ultrasonography, CT angiography, MR angiography, or catheter angiography, after exclusion of competing diagnoses.RESULTSOf 463 patients, 58% experienced angiographic vasospasm with an overall DCI incidence of 21%. Age, modified Fisher grade, and ruptured aneurysm location were significantly associated with DCI. This combination of predictors had a greater area under the receiver operating characteristic curve than the modified Fisher grade alone (0.73 [95% CI 0.67–0.78] vs 0.66 [95% CI 0.60–0.71]). Patients 70 years or older with modified Fisher grade 0 or 1 SAH and a posterior circulation aneurysm had the lowest risk of DCI at 1.2% (0 points). The highest estimated risk was 38% (17 points) in patients 40–59 years old with modified Fisher grade 4 SAH following rupture of an anterior circulation aneurysm.CONCLUSIONSAmong patients presenting with aSAH, this score-based clinical prediction tool exhibits increased accuracy over the modified Fisher grade alone and may serve as a useful tool to individualize DCI risk.

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