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Neurosurgical Review

, Volume 41, Issue 1, pp 241–247 | Cite as

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

  • Ashish Aggarwal
  • Sivashanmugam Dhandapani
  • Kokkula Praneeth
  • Harsimrat Bir Singh Sodhi
  • Sudhir Singh Pal
  • Sachin Gaudihalli
  • N. Khandelwal
  • Kanchan K. Mukherjee
  • M. K. Tewari
  • Sunil Kumar Gupta
  • S. N. Mathuriya
Original Article

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.

Keywords

Aneurysmal subarachnoid hemorrhage Hunt and Hess grading Sans systemic disease World Federation of Neurosurgical Societies scale H&H sans systemic disease Glasgow outcome score 

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

Notes

Compliance with ethical standards

Funding information

No funding was received.

Conflict of interest

The authors declare that they have no conflict of interest.

Ethical approval

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.

Informed consent

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

References

  1. 1.
    Aulmann C, Steudl WI, Feldmann U (1998) Validation of the prognostic accuracy of neurosurgical admission scales after rupture of cerebral aneurysms. Zentralbl Neurochir 59(3):171–180PubMedGoogle Scholar
  2. 2.
    Dhandapani S, Manju D, Sharma B, Mahapatra A (2012a) Prognostic significance of age in traumatic brain injury. J Neurosci Rural Pract 3:131–135CrossRefPubMedPubMedCentralGoogle Scholar
  3. 3.
    Dhandapani SS, Manju D, Mahapatra AK (2012b) The economic divide in outcome following severe head injury. Asian J Neurosurg 7:17–20CrossRefPubMedPubMedCentralGoogle Scholar
  4. 4.
    Dhandapani S, Gupta A, Singh J, Sharma BS, Mahapatra AK, Mehta VS (2013) Spinal dural arterio-venous fistula: Clinico-radiological profile and outcome following surgical occlusion in an Indian neurosurgical center. Neurol India 61(4):406Google Scholar
  5. 5.
    Dhandapani S, Aggarwal A, Srinivasan A, Meena R, Gaudihalli S, Singh H et al (2015a) Serum lipid profile spectrum and delayed cerebral ischemia following subarachnoid hemorrhage: is there a relation? Surg Neurol Int 6:S543–S548CrossRefPubMedPubMedCentralGoogle Scholar
  6. 6.
    Dhandapani S, Goudihalli S, Mukherjee KK, Singh H, Srinivasan A, Danish M et al (2015b) Prospective study of the correlation between admission plasma homocysteine levels and neurological outcome following subarachnoid hemorrhage: a case for the reverse epidemiology paradox? Acta Neurochir 157:399–407CrossRefPubMedGoogle Scholar
  7. 7.
    Dhandapani S, Kapoor A, Gaudihalli S, Dhandapani M, Mukherjee KK, Gupta SK (2015c) Study of trends in anthropometric nutritional indices and the impact of adiposity among patients of subarachnoid hemorrhage. Neurol India 63:531–536CrossRefPubMedGoogle Scholar
  8. 8.
    Dhandapani S, Sarda AC, Kapoor A, Salunke P, Mathuriya SN, Mukherjee KK (2015d) Validation of a new clinico-radiological grading for compound head injury: implications on the prognosis and the need for surgical intervention. World Neurosurg 84:1244–1250CrossRefPubMedGoogle Scholar
  9. 9.
    Drake CG, Hunt WE, Sano K, Kassell N, Teasdale G, Pertuiset B et al (1988) Report of World Federation of Neurological Surgeons Committee on a universal subarachnoid hemorrhage grading scale. J Neurosurg 68(6):985–986Google Scholar
  10. 10.
    Feigin VL, Lawes CM, Bennett DA et al (2003) Stroke epidemiology: a review of population-based studies of incidence, prevalence, and case-fatality in the late 20th century. Lancet Neurol 2:43–53CrossRefPubMedGoogle Scholar
  11. 11.
    Gotoh O, Tamura A, Yasui N, Suzuki A, Hadeishi H, Sano K (1996) Glasgow Coma Scale in the prediction of outcome after early aneurysm surgery. Neurosurgery 39:19–24CrossRefPubMedGoogle Scholar
  12. 12.
    Gupta SK, Ghanta RK, Chhabra R, Mohindra S, Mathuriya SN, Mukherjee KK, Umredkar AU, Singla N (2011) Poor-grade subarachnoid hemorrhage: is surgical clipping worthwhile? Neurol India 59(2):212–217CrossRefPubMedGoogle Scholar
  13. 13.
    Hirai S, Ono J, Yamaura A (1996) Clinical grading and outcome after early surgery in aneurysmal subarachnoid hemorrhage. Neurosurgery 39:441–446PubMedGoogle Scholar
  14. 14.
    Hong CM, Tosun C, Kurland DB, Gerzanich V, Schreibman D, Simard JM (2014) Biomarkers as outcome predictors in subarachnoid hemorrhage—a systematic review. Biomarkers 19(2):95–108CrossRefPubMedPubMedCentralGoogle Scholar
  15. 15.
    Hunt WE, Hess RM (1968) Surgical risk as related to time of intervention in the repair of intracranial aneurysms. J Neurosurg 28:14–20CrossRefPubMedGoogle Scholar
  16. 16.
    Hutchinson PJ, Power DM, Tripathi P, Kirkpatrick PJ (2000) Outcome from poor grade aneurysmal subarachnoid haemorrhage—which poor grade subarachnoid haemorrhage patients benefit from aneurysm clipping? Br J Neurosurg 14(2):5–9Google Scholar
  17. 17.
    Johnston SC, Selvin S, Gress DR (1998) The burden, trends, and demographics of mortality from subarachnoid hemorrhage. Neurology 50:1413–1418CrossRefPubMedGoogle Scholar
  18. 18.
    Kremer C, Groden C, Hansen HC, Grzyska U, Zeumer H (1999) Outcome after endovascular treatment of Hunt and Hess grade IV or V aneurysms: comparison of anterior versus posterior circulation. Stroke 30(12):2617–2622CrossRefPubMedGoogle Scholar
  19. 19.
    Lagares A, Gomez PA, Lobato RD, Alen JF, Alday R, Campollo J (2001) Prognostic factors on hospital admission after spontaneous subarachnoid haemorrhage. Acta Neurochir 143:665–672CrossRefPubMedGoogle Scholar
  20. 20.
    Oshiro EM, Walter KA, Piantadosi S, Witham TF, Tamargo RJ (1997) A new subarachnoid hemorrhage grading system based on the Glasgow Coma Scale: a comparison with the Hunt and Hess and World Federation of Neurological Surgeons Scales in a clinical series. Neurosurgery 41:140–147CrossRefPubMedGoogle Scholar
  21. 21.
    Proust F, Hannequin D, Langlois O, Freger P, Creissard P (1995) Causes of morbidity and mortality after ruptured aneurysm surgery in a series of 230 patients: the importance of control angiography. Stroke 26:1553–1557CrossRefPubMedGoogle Scholar
  22. 22.
    Rosen DS, Macdonald RL (2005) Subarachnoid hemorrhage grading scales: a systematic review. Neurocrit Care 2:110–118CrossRefPubMedGoogle Scholar
  23. 23.
    Rosen DS, Macdonald RL (2004) Grading of subarachnoid hemorrhage: modification of the World Federation of Neurosurgical Societies scale on the basis of data for a large series of patients. Neurosurgery 54:566–575CrossRefGoogle Scholar
  24. 24.
    Sarrafzadeh A, Haux D, Küchler I, Lanksch WR, Unterberg AW (2004) Poor-grade aneurysmal subarachnoid hemorrhage: relationship of cerebral metabolism to outcome. J Neurosurg 100(3):400–406CrossRefPubMedGoogle Scholar
  25. 25.
    Sano H, Satoh A, Murayama Y, Kato Y, Origasa H, Inamasu J, Nouri M, Cherian I, Saito N, members of the 38 registered institutions and WFNS Cerebrovascular Disease & Treatment Committee (2015) Modified World Federation of Neurosurgical Societies subarachnoid hemorrhage grading system. World Neurosurg 83(5):801–807CrossRefPubMedGoogle Scholar
  26. 26.
    Sato J, Masuzawa H, Shiraishi K, Kanazawa I, Kamitani H (1986) New clinical grading in ruptured cerebral aneurysm. No ShinkeiGeka 14:1183–1187 (Jpn)Google Scholar
  27. 27.
    Srinivasan A, Aggarwal A, Gaudihalli S, Mohanty M, Dhandapani M, Singh H, Mukherjee KK, Dhandapani S (2016) Impact of early leukocytosis and elevated high-sensitivity C-reactive protein on delayed cerebral ischemia and neurologic outcome after subarachnoid hemorrhage. World Neurosurg 90:91–95Google Scholar
  28. 28.
    St Julien J, Bandeen-Roche K, Tamargo RJ (2008) Validation of an aneurismal subarachnoid hemorrhage grading scale in 1532 consecutive patients. Neurosurgery 63(2):204–210CrossRefPubMedGoogle Scholar
  29. 29.
    Takagi K, Tamura A, Nakagomi T et al (1999) How should a subarachnoid hemorrhage grading scale be determined? A combinatorial approach based solely on the Glasgow Coma Scale. J Neurosurg 90:680–687CrossRefPubMedGoogle Scholar
  30. 30.
    Taylor CJ, Robertson F, Brealey D, O’shea F, Stephen T, Brew S, Grieve JP, Smith M, Appleby I (2011) Outcome in poor grade subarachnoid hemorrhage patients treated with acute endovascular coiling of aneurysms and aggressive intensive care. Neurocrit Care 14(3):341CrossRefPubMedGoogle Scholar
  31. 31.
    Tewari M, Aggarwal A, Mathuriya S, Gupta V (2015) The outcome after aneurysmal subarachnoid hemorrhage: a study of various factors. Ann Neurosci 22(2):78–80CrossRefPubMedPubMedCentralGoogle Scholar
  32. 32.
    Wilby MJ, Sharp M, Whitfield PC, Hutchinson PJ, Menon DK, Kirkpatrick PJ (2003) Cost-effective outcome for treating poor-grade subarachnoid hemorrhage. Stroke 34:2508–2511CrossRefPubMedGoogle Scholar
  33. 33.
    Yoshikai S, Nagata S, Ohara S, Yuhi F, Sakata S, Matsuno H (1996) A retrospective analysis of the outcomes of patients with aneurysmal subarachnoid hemorrhages: a focus on the prognostic factors. No ShinkeiGeka 24:733–738 (Jpn)Google Scholar

Copyright information

© Springer-Verlag Berlin Heidelberg 2017

Authors and Affiliations

  • Ashish Aggarwal
    • 1
  • Sivashanmugam Dhandapani
    • 1
  • Kokkula Praneeth
    • 1
  • Harsimrat Bir Singh Sodhi
    • 1
  • Sudhir Singh Pal
    • 2
  • Sachin Gaudihalli
    • 1
  • N. Khandelwal
    • 3
  • Kanchan K. Mukherjee
    • 1
  • M. K. Tewari
    • 1
  • Sunil Kumar Gupta
    • 1
  • S. N. Mathuriya
    • 4
  1. 1.Department of NeurosurgeryPost Graduate Institute of Medical Education and Research (PGIMER)ChandigarhIndia
  2. 2.Department of SurgeryGandhi Medical CollegeBhopalIndia
  3. 3.Department of RadiodiagnosisPost Graduate Institute of Medical Education and Research (PGIMER)ChandigarhIndia
  4. 4.Department of NeurosurgeryMedipulse HospitalJodhpurIndia

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