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The Role of VASOGRADE as a Simple Grading Scale to Predict Delayed Cerebral Ischemia and Functional Outcome After Aneurysmal Subarachnoid Hemorrhage

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Abstract

Background

The VASOGRADE is a simple aneurysmal subarachnoid hemorrhage (aSAH) grading scale that combines the modified Fisher scale (mFisher) and the World Federation of Neurological Societies (WFNS) grading system, allowing the stratification of delayed cerebral ischemia (DCI) risk. However, the VASOGRADE accuracy in predicting functional outcomes is still to be determined.

Methods

We retrospectively evaluated a multiethnic cohort of consecutive patients with aSAH admitted to a high-volume center in Brazil from January 2016 to January 2019. Patients were classified according to the severity of the clinical presentation (WFNS), the amount of blood in the initial head computerized tomography (mFisher) scan, and the VASOGRADE (green, yellow, red). The primary outcome was to detect DCI-related cerebral infarction, and the secondary outcome was the functional outcome at hospital discharge according to the modified Rankin scale (mRs). Univariate and multivariate logistic regression models were employed.

Results

A total of 212 patients (71.7% female, mean age 52.7 ± 12.8) were included. Sixty-nine patients were classified as VASOGRADE-Green (32.5%), 98 patients as VASOGRADE-Yellow (46.9%), and 45 patients as VASOGRADE-Red (20.6%). DCI-related infarction was present in 39 patients (18.9%). The proportions of patients in the VASOGRADE-Green, VASOGRADE-Yellow, and VASOGRADE-Red categories with DCI-related infarction were 7.7, 61.5, and 30.8%, respectively. After a multivariable analysis including age, sex, aneurysm location, and the VASOGRADE classification as variables, both VASOGRADE-Yellow and VASOGRADE-Red were independently associated with DCI-related infarction (odds ratio [OR] 7.69, 95% confidence interval [CI] 2.13–27.8, and OR 8.07, 95% CI 2.03–32.11, respectively) and unfavorable outcome (OR 4.16, 95% CI 1.33–13.03, and OR 25.57, 95% CI 4.45–147.1, respectively). The VASOGRADE discrimination performance for DCI-related infarction (area under the receiver operating characteristic curve) was 0.67 ± 0.04 (95% CI 0.58–0.75; p = 0.001). VASOGRADE-Red had 97.5% specificity for predicting an unfavorable mRs score at discharge (95% CI 92.8–99.5%). Conversely, VASOGRADE-Green had an excellent specificity for predicting favorable outcome at discharge (mRs score 0–2, 95% CI 82.6–95.5%).

Conclusions

In conclusion, in a multiethnic cohort of patients with aSAH, VASOGRADE-Green predicted the absence of DCI and good clinical outcome at discharge with very high specificity, and patients in this category might be selected for early intensive care unit (ICU) discharge, minimizing costs and medical complications associated with prolonged hospital stay. On the other hand, patients categorized as VASOGRADE-Yellow and VASOGRADE-Red were at the highest risk for DCI. They should, therefore, be selected as a priority for care in high-volume aSAH centers, being aggressively monitored for DCI at the ICU. Such stratification methods are crucial, especially in countries with low financial resources and high health care services demand.

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Acknowledgements

The present work was conducted with the support of the National Council for Scientific and Technological Development–Brazil.

Funding

No funding was required.

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Authors and Affiliations

  1. Department of Neurology and Neurosurgery, Universidade Federal de São Paulo, Sao Paulo, Brazil

    Natália Vasconcellos de Oliveira Souza, Carolina Rouanet, Caio Vinícius Barroso de Lima, Caio Augusto de Souza, Flavio Rezende, Maramelia Miranda Alves, Airton Leonardo de Oliveira Manuel, Feres Chaddad Neto, Michel Frudit & Gisele Sampaio Silva

  2. Department of Neurology and Neurosurgery, Universidade de São Paulo, Sao Paulo, Brazil

    Natália Vasconcellos de Oliveira Souza & Davi Jorge Fontoura Solla

  3. Academic Research Organization, Hospital Israelita Albert Einstein, Sao Paulo, Brazil

    Natália Vasconcellos de Oliveira Souza, Maramelia Miranda Alves, Feres Chaddad Neto, Michel Frudit & Gisele Sampaio Silva

  4. Department of Neurology and Neurosurgery, Federal Univesity of Rio de Janeiro, Rio de Janeiro, Brazil

    Carolina Rouanet

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  1. Natália Vasconcellos de Oliveira Souza
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Contributions

NVOS: was responsible for conception, organization, and execution of the case report project and writing of the first draft of the manuscript, and review and critique of the manuscript. CR: was responsible for organization and execution of the case report project and writing of the first draft of the manuscript. DJFS: was responsible for organization and execution of the case report project and review and critique of the manuscript. CVBL: was responsible for organization and execution of the case report project and review and critique of the manuscript. CAS: was responsible for organization and execution of the case report project and review and critique of the manuscript. FR: was responsible for conception of the case report project and review and critique of the manuscript. MMA: was responsible for conception of the case report project and review and critique of the manuscript. ALOM: was responsible for organization and execution of the case report project and review and critique of the manuscript. FCN: was responsible for conception of the case report project and review and critique of the manuscript. MF: was responsible for conception of the case report project and review and critique of the manuscript. GSS: was responsible for conception, organization, and execution of the case report project, writing of the first draft of the manuscript, and review and critique of the manuscript.

Corresponding author

Correspondence to Natália Vasconcellos de Oliveira Souza.

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Full consent was obtained from the patients and/or family members, and this study was approved by the Ethical Committee of São Paulo Hospital, in accordance with the ethical standards as laid out in the 1964 Declaration of Helsinki and its later amendments.

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Oliveira Souza, N.V., Rouanet, C., Solla, D.J.F. et al. The Role of VASOGRADE as a Simple Grading Scale to Predict Delayed Cerebral Ischemia and Functional Outcome After Aneurysmal Subarachnoid Hemorrhage. Neurocrit Care 38, 96–104 (2023). https://doi.org/10.1007/s12028-022-01577-1

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