ABSTRACT: Background: Most patients with World Federation of Neurological Surgeons (WFNS) grade 5 subarachnoid hemorrhage (SAH) have poor outcomes. Accurate assessment of prognosis is important for treatment decisions and conversations with families regarding goals of care. Unjustified pessimism may lead to “self-fulfilling prophecy,” where withdrawal of life-sustaining measures (WLSM) is invariably followed by death. Methods: We performed a cohort study involving consecutive patients with WFNS grade 5 SAH to identify variables with >= 90% and >= 95% positive predictive value (PPV) for poor outcome (1-year modified Rankin Score >= 4), as well as findings predictive of WLSM. Results: Of 140 patients, 38 (27%) had favorable outcomes. Predictors with >= 95% PPV for poor outcome included unconfounded 72-hour Glasgow Coma Scale motor score <= 4, absence of >= 1 pupillary light reflex (PLR) at 24 hours, and intraventricular hemorrhage (IVH) score of >= 20 (volume >= 54.6 ml). Intracerebral hemorrhage (ICH) volume >= 53 ml had PPV of 92%. Variables associated with WLSM decisions included a poor motor score (p < 0.0001) and radiographic evidence of infarction (p = 0.02). Conclusions: We identified several early predictors with high PPV for poor outcome. Of these, lack of improvement in motor score during the initial 72 hours had the greatest potential for confounding from “self-fulfilling prophecy.” Absence of PLR at 24 hours, IVH score >= 20, and ICH volume >= 53 ml predicted poor outcome without a statistically significant effect on WLSM decisions. More research is needed to validate prognostic variables in grade 5 SAH, especially among patients who do not undergo WLSM.

中文翻译：

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预测 5 级蛛网膜下腔出血不良结局的结果：一项队列研究

摘要： 背景：大多数世界神经外科医生联合会 (WFNS) 5 级蛛网膜下腔出血 (SAH) 患者的预后较差。准确评估预后对于治疗决策以及与家人就护理目标进行对话非常重要。不合理的悲观主义可能会导致“自我实现的预言”，即撤销生命维持措施（WLSM）后必然会导致死亡。 方法：我们进行了一项队列研究，涉及连续 WFNS 5 级 SAH 患者，以确定不良结果阳性预测值 (PPV) >= 90% 和 >= 95% 的变量（1 年修正Rankin 评分 >= 4），以及WLSM 的预测结果。 结果：在 140 名患者中，38 名 (27%) 取得了良好的结果。 PPV >= 95% 的不良结果预测因素包括无混杂的 72 小时格拉斯哥昏迷量表运动评分 <= 4、24 小时时瞳孔对光反射 (PLR) 缺失 >= 1 以及脑室内出血 (IVH) 评分 >= 20 （体积 >= 54.6 毫升）。脑出血 (ICH) 量≥ 53 ml 的 PPV 为 92%。与 WLSM 决策相关的变量包括运动评分较差 (p < 0.0001) 和梗塞的放射学证据 (p = 0.02)。 结论：我们确定了几个具有高 PPV 的不良结果的早期预测因素。其中，最初 72 小时内运动评分缺乏改善最有可能混淆“自我实现的预言”。 24 小时无 PLR、IVH 评分 >= 20 和 ICH 体积 >= 53 ml 预测结果不佳，但对 WLSM 决策没有统计学上的显着影响。需要更多的研究来验证 5 级 SAH 的预后变量，尤其是未接受 WLSM 的患者。