Outcome of Patients in Aneurysmal Subarachnoid Haemorrhage Based on WFNS and Fisher Grading
Kaiser Kariem *1, Mohsin Fayaz 2
1,2. Mch Neurosurgery. Shere-i- Kashmir institute of Medical Sciences.
Corresponding Author: Mohsin Fayaz, Mch Neurosurgery. Shere-i- Kashmir institute of Medical Sciences.
Copy Right: © 2023 Mohsin Fayaz, This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
Received Date: May 23, 2023
Published Date: June 01, 2023
Abstract
Background. Outcome after SAH is thus probably determined by multiple independent factors after aneurysmal subarachnoid haemorrhage.
Results. Grade I WFNS score was seen in 37 (56.9%) patients with 1 (1.5%) each having Grade IV and Grade V. Fisher?s Grade III was seen in majority of patients i.e. 43 (66.2%), followed by Grade II in 15 (23.1%) patients, 5 (7.7%) were seen in Grade I and least number i.e. 2 (3.1%) had Grade IV fisher?s. Hydrocephalus was seen as the postoperative complication in 10 (15.4%) patients, followed by infarction in 8 (12.2%) and hematoma in 4 (6.2%) patients, Surgical site infection in 2 (3%), CSF leak and DVT in 1 (1.5%) patient each.
Conclusion. We define good-grade patients as those with WFNS grade I, II, and III and fisher grade I,II and III after clinical assessment , complete resuscitation and optimization of the patient.
Key words. Subarachnoid haemorrhage, cerebrospinal fluid, Aneurysm, WFNS and fisher grading.
Introduction
Subarachnoid haemorrhage (SAH) is a relevant health problem with an approximate incidence of 9 per 100,000 and a mortality rate of about 60% within 6 months. The prognosis is influenced by multiple nonmodifiable factors and by factors that can be influenced by therapeutic interventions and management procedures. Spontaneous intracranial subarachnoid hemorrhage is the presence of blood in the subarachnoid space, bounded by the arachnoid and piamater, due to the rupture of either an aneurysm, arterio-venous malformation, hypertension or an unknown cause.(2 3) Spontaneous SAH is sudden in 90% cases, and is characterized by sudden onset, severe headache of bursting nature in 60% cases, usually in occipital region, irrespective of aneurysmal rupture(1). This can be diagnosed by standard tools like lumbar puncture, CT scan, and cerebral angiography.5 The features of meningeal irritation, minimal neurologic findings of localizing - 2 - value, and presence of blood in cerebrospinal fluid (CSF), along with headache, nausea, vomiting, and transient loss of consciousness are described by two thirds of patients experiencing SAH. (3) Intracranial aneurysms affect 5-10% of the general population. 10 The rate of rupture of an intracranial aneurysm is 0.05% to 6% per year. Smoking, hypertension, heavy alcohol intake and sympathomimetic drug abuse are risk factors for aneurysmal rupture. (1). They are 11 times more likely to rupture in patients with a history of previous subarachnoid haemorrhage (SAH), than in those who do not. Around 20% of patients have more than one aneurysm. There is a male preponderance in the age group below 40 years but females are more affected than males in the age group above 40 years with a ratio of 3:2. 10 The main mode of presentation of a ruptured intracranial aneurysm is subarachnoid haemorrhage (SAH) (2)
Aneurysm rupture itself can cause stress hyperglycaemia, cardiopulmonary complications and increased blood coagulability, which are independent of severity of bleeding or of metabolic syndrome, may elevate the risk of poor outcome. Outcome after SAH is thus probably determined by multiple independent factors after aneurysmal subarachnoid haemorrhage.
Methods
This was a prospective study conducted in the Department of Neurosurgery, Sher-I-Kashmir institute of medical sciences (SKIMS), Kashmir, India. The study extented from January 2014 to December 2018 (5 years). The demographic profile, Glasgow Coma Scale (GCS) score, World Federation of Neurological Surgeons (WFNS) grade, and co-morbid illnesses of the patients were recorded. Computed tomography (CT) scan done on presentation were evaluated, and the Fisher grade and presence of hydrocephalus, acute infarction (related to - 29 - SAH-associated vasospasm or haemotoma) was noted. CT angio was done to ascess the site size neck-fundus ratio of the aneurysm. 640 slice CT angio machine was used. At our institute, we define good-grade patients as those with WFNS grade I, II, and III and fischer grade I,II,III on clinic-radiological assessment after complete resuscitation and optimization of the patient.
The recorded data was compiled and entered in a spreadsheet (Microsoft Excel) and then exported to data editor of SPSS Version 20.0 (SPSS Inc., Chicago, Illinois, USA). Continuous variables were expressed as Mean±SD and categorical variables were summarized as frequencies and percentages
Results and Discussion
All patients, of all age groups, who presented to our institute with a Sub Arachnoid Haemorrhage and were later proved to have aneurysms on CT angiography were included in the study. All patients included in the study were assessed on presentation in the Neurosurgical Emergency unit of our institute. The age, gender, Glasgow Coma Scale (GCS) score, World Federation of Neurological Surgeons (WFNS) grade, and co-morbid illnesses of the patients were recorded after adequate resuscitation and hemodynamic stabilization.
Patients suffering from SAH more often had hypertension recorded at their last examination prior to bleeding than patients who never had SAH. Studies dealing with pathogenesis of arteriosclerosis have pointed to the effect of hypertension in causing intimal lesions. This is turn may activate different pathways like apoptosis, coagulation or protein degradation. Therefore, hypertension is assumed to trigger the initial changes found in the vessel wall of developing aneurysms.59.
Preoperative WFNS grading revealed that higher grade had worse outcome. In our study, grade I WFNS score was seen in 37 (56.9%) patients with 1 (1.5%) each having Grade IV and Grade V. In a study done by (4,5) 64, out of 78 patients in WFNS 1 & 2, 59 patients (75.64%) had favorable outcome while in WFNS grade 3 & 4, this percentage was only 36.66%. A study by 65 found a stepwise increase in the likelihood of an unfavourable outcome with increasing WFNS grade.
In our study, Fisher?s Grade III was seen in majority of patients i.e. 43 (66.2%), followed by Grade II in 15 (23.1%) patients, 5 (7.7%) were seen in Grade I and least number i.e. 2 (3.1%) had Grade IV fisher?s. (6) 47 in a study of 84 patients had 57 patients in grade III, 15 patients in grade II, 7 patients in grade I and 5 patients in grade IV.
Fisher?s Grade III was seen in majority of patients i.e. 43 (66.2%), followed by Grade II in 15 (23.1%) patients, 5 (7.7%) were seen in Grade I and least number i.e. 2 (3.1%) had Grade IV fisher?s.
The most important goal of a vascular neurosurgeon during an intracranial aneurysmal clipping is achieving complete exclusion of the aneurysm from the circulation with preservation of blood flow distal to the aneurysm. Occlusion of the parent vessel or distal branches due to - 5 - improper clip application has been a significant factor in the poor outcome. Similarly, incomplete clipping of an aneurysm has been associated with aneurysmal growth and potential for future rupture. In the literature, partial aneurysm clipping with residual neck has been cited in 4-19% of cases while, in an equally significant population (0.3-12%) inadvertent occlusion of the major vessels occur.
Intraoperative rupture of aneurysm was seen in 4 (5.4%) patients. (7,8) 66 in their study of role of CTA in aneurysmal SAH studied 32 patients and observed that 28 patients were found to have aneurysms while no aneurysm was detected in 4 cases. Out of four aneurysm patients, two had double aneurysm while one patient had three aneurysms. 67 in their study of 35 patients detected 47 aneurysms. 6 patients had 2 aneurysms each and 3 patients had 3 aneurysms each. (9) 68 found 13 aneurysms in 9 of their 17 patients. Middle cerebral artery aneurysms were found to be 4 in number, rest were equally distributed in various vessel territories.
Hydrocephalus was seen as the postoperative complication in 10 (15.4%) patients, followed by infarction in 8 (12.2%) and hematoma in 4 (6.2%) patients, Surgical site infection in 2 (3%), CSF leak and DVT in 1 (1.5%) patient each.
In our study, hydrocephalus was seen as the postoperative complication in (15.4%) patients, followed by hematoma in 4 (6.2%) patients and infarction in 8 (12.5%). (10,11) 81 in their study found 152 of the 718 patients (21.2%) had hydrocephalus and underwent shunting procedures its treatment. Overall rate of shunt dependent - 62 - hydrocephalus for all patients was 19.7% in a study done by (12) 82 . In our study, postoperative infarction was the cause of death in 3 (4.6%) patients, respiratory infection with sepsis was the cause in 2 (3.1%) patients and meningitis was seen in 1 (1.5%) as the cause of death. (12 )83 identified that more than 25% of patients after SAH develop postoperative aspiration pneumonia, which was associated with a significant (9.7%) risk of mortality. The frequency of pulmonary complications among surgical and nonsurgical neurological patients varies widely, from 2.5% to 37%; probably due to the different settings and conditions in which surgeries are preformed, the clinical conditions of patients at the time of surgery, the pre- and postoperative care given to patients, and the definitions adopted for pulmonary complications.
Postoperative infarction was the cause of death in 3 (4.6%) patients, respiratory infection with sepsis was the cause in 2 (3.1%) patients and meningitis was seen in 1 (1.5%) as the cause of death. In infarction patients who expired, one of them was from clip repositioned group and rests of 2 were from non-clip repositioned group.
Conclusion
We define good-grade patients as those with WFNS grade I, II, and III and fisher grade I,II and III after clinical assessment, complete resuscitation and optimization of the patient. WFNS Grade IV and V was associated with the worst prognosis and outcome depending upon the glassgow outcome scale .The prognosis of patients with fisher grade I and II was almost same, however when we correlated WFNS grade with fishers grading, Grade IV and V WFNS grade was associated with worst outcome irrespective of fisher grading after aneurysmal clipping.
List of Abbreviations
SAH; Subarachnoid hemorrhage,
CTA; Computed Tomography Angiography,
WFNS; World Federation of Neurosurgical Society
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