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Comparative evaluation of H&H and WFNS grading scales with modified H&H (sans systemic disease): A study on 1000 patients with subarachnoid hemorrhage

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Abstract

The comparative studies on grading in subarachnoid hemorrhage (SAH) had several limitations such as the unclear grading of Glasgow Coma Scale 15 with neurological deficits in World Federation of Neurosurgical Societies (WFNS), and the inclusion of systemic disease in Hunt and Hess (H&H) scales. Their differential incremental impacts and optimum cut-off values for unfavourable outcome are unsettled. This is a prospective comparison of prognostic impacts of grading schemes to address these issues. SAH patients were assessed using WFNS, H&H (including systemic disease), modified H&H (sans systemic disease) and followed up with Glasgow Outcome Score (GOS) at 3 months. Their performance characteristics were analysed as incremental ordinal variables and different grading scale dichotomies using rank-order correlation, sensitivity, specificity, positive predictive value, negative predictive value, Youden’s J and multivariate analyses. A total of 1016 patients were studied. As univariate incremental variable, H&H sans systemic disease had the best negative rank-order correlation coefficient (−0.453) with respect to lower GOS (p < 0.001). As univariate dichotomized category, WFNS grades 3–5 had the best performance index of 0.39 to suggest unfavourable GOS with a specificity of 89% and sensitivity of 51%. In multivariate incremental analysis, H&H sans systemic disease had the greatest adjusted incremental impact of 0.72 (95% confidence interval (CI) 0.54–0.91) against a lower GOS as compared to 0.6 (95% CI 0.45–0.74) and 0.55 (95% CI 0.42–0.68) for H&H and WFNS grades, respectively. In multivariate categorical analysis, H&H grades 4–5 sans systemic disease had the greatest impact on unfavourable GOS with an adjusted odds ratio of 6.06 (95% CI 3.94–9.32). To conclude, H&H grading sans systemic disease had the greatest impact on unfavourable GOS. Though systemic disease is an important prognostic factor, it should be considered distinctly from grading. Appropriate cut-off values suggesting unfavourable outcome for H&H and WFNS were 4–5 and 3–5, respectively, indicating the importance of neurological deficits in addition to level of consciousness.

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Abbreviations

WFNS:

World Federation of Neurosurgical Societies

SAH:

Subarachnoid hemorrhage

H&H:

Hunt and Hess

GOS:

Glasgow Outcome Score

PPV:

Positive predictive value

NPV:

Negative predictive value

CI:

Confidence interval

CT:

Computed tomography

ICH:

Intra-cerebral hemorrhage

ICU:

Intensive care unit

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    Authors and Affiliations

    1. Department of Neurosurgery, Post Graduate Institute of Medical Education and Research (PGIMER), Chandigarh, India

      Ashish Aggarwal, Sivashanmugam Dhandapani, Kokkula Praneeth, Harsimrat Bir Singh Sodhi, Sachin Gaudihalli, Kanchan K. Mukherjee, M. K. Tewari & Sunil Kumar Gupta

    2. Department of Surgery, Gandhi Medical College, Bhopal, MP, India

      Sudhir Singh Pal

    3. Department of Radiodiagnosis, Post Graduate Institute of Medical Education and Research (PGIMER), Chandigarh, India

      N. Khandelwal

    4. Department of Neurosurgery, Medipulse Hospital, Jodhpur, Rajasthan, India

      S. N. Mathuriya

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    1. Ashish Aggarwal
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    Correspondence to Sivashanmugam Dhandapani.

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    All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki Declaration and its later amendments or comparable ethical standards.

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    Informed consent was obtained from either patients or relatives of patients included in the study.

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    Ashish Aggarwal and Sivashanmugam Dhandapani are to be considered first authors.

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    Aggarwal, A., Dhandapani, S., Praneeth, K. et al. Comparative evaluation of H&H and WFNS grading scales with modified H&H (sans systemic disease): A study on 1000 patients with subarachnoid hemorrhage. Neurosurg Rev 41, 241–247 (2018). https://doi.org/10.1007/s10143-017-0843-y

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    • DOI: https://doi.org/10.1007/s10143-017-0843-y

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