Pre- and Post-Operative Online Prediction of Outcome in Patients Undergoing Endovascular Coiling after Aneurysmal Subarachnoid Hemorrhage: Visual and Dynamic Nomograms

Background: Aneurysmal subarachnoid hemorrhage (aSAH) causes long-term functional dependence and death. Early prediction of functional outcomes in aSAH patients with appropriate intervention strategies could lower the risk of poor prognosis. Therefore, we aimed to develop pre- and post-operative dynamic visualization nomograms to predict the 1-year functional outcomes of aSAH patients undergoing coil embolization. Methods: Data were obtained from 400 aSAH patients undergoing endovascular coiling admitted to the People’s Hospital of Hunan Province in China (2015–2019). The key indicator was the modified Rankin Score (mRS), with 3–6 representing poor functional outcomes. Multivariate logistic regression (MLR)-based visual nomograms were developed to analyze baseline characteristics and post-operative complications. The evaluation of nomogram performance included discrimination (measured by C statistic), calibration (measured by the Hosmer–Lemeshow test and calibration curves), and clinical usefulness (measured by decision curve analysis). Results: Fifty-nine aSAH patients (14.8%) had poor outcomes. Both nomograms showed good discrimination, and the post-operative nomogram demonstrated superior discrimination to the pre-operative nomogram with a C statistic of 0.895 (95% CI: 0.844–0.945) vs. 0.801 (95% CI: 0.733–0.870). Each was well calibrated with a Hosmer–Lemeshow p-value of 0.498 vs. 0.276. Moreover, decision curve analysis showed that both nomograms were clinically useful, and the post-operative nomogram generated more net benefit than the pre-operative nomogram. Web-based online calculators have been developed to greatly improve the efficiency of clinical applications. Conclusions: Pre- and post-operative dynamic nomograms could support pre-operative treatment decisions and post-operative management in aSAH patients, respectively. Moreover, this study indicates that integrating post-operative variables into the nomogram enhanced prediction accuracy for the poor outcome of aSAH patients.

[1]  G. Luijckx,et al.  The Diagnostic Value of Near-Infrared Spectroscopy to Predict Delayed Cerebral Ischemia and Unfavorable Outcome After Subarachnoid Hemorrhage. , 2023, World neurosurgery.

[2]  Jia Zhang,et al.  Predictive nomogram models for unfavorable prognosis after aneurysmal subarachnoid hemorrhage: Analysis from a prospective, observational cohort in China , 2023, CNS neuroscience & therapeutics.

[3]  R. Xu,et al.  Acute Multidisciplinary Management of Aneurysmal Subarachnoid Hemorrhage (aSAH) , 2023, Balkan medical journal.

[4]  Yun-feng Ni,et al.  Predicting checkpoint inhibitors pneumonitis in non-small cell lung cancer using a dynamic online hypertension nomogram. , 2022, Lung cancer.

[5]  Jifang Zhang,et al.  Development and Clinical Translation of a Perioperative Nomogram Incorporating Free Fatty Acids to Predict Poor Outcome of Aneurysmal Subarachnoid Hemorrhage Following Endovascular Treatment , 2021, Frontiers in Neurology.

[6]  Arthur S Slutsky,et al.  A simple nomogram for predicting failure of non-invasive respiratory strategies in adults with COVID-19: a retrospective multicentre study , 2021, The Lancet Digital Health.

[7]  O. Sadan,et al.  Aneurysmal Subarachnoid Hemorrhage: Trends, Outcomes, and Predictions From a 15-Year Perspective of a Single Neurocritical Care Unit , 2020, Neurosurgery.

[8]  Michael L. Martini,et al.  Aneurysmal Subarachnoid Hemorrhage: the Last Decade , 2020, Translational Stroke Research.

[9]  K. Schaller,et al.  Development of a Complication- and Treatment-Aware Prediction Model for Favorable Functional Outcome in Aneurysmal Subarachnoid Hemorrhage Based on Machine Learning. , 2020, Neurosurgery.

[10]  G. Murray,et al.  A practical method for dealing with missing Glasgow Coma Scale verbal component scores. , 2020, Journal of neurosurgery.

[11]  Johannes K Richter,et al.  Validation and Optimization of Barrow Neurological Institute Score in Prediction of Adverse Events and Functional Outcome After Subarachnoid Hemorrhage-Creation of the HATCH (Hemorrhage, Age, Treatment, Clinical State, Hydrocephalus) Score. , 2020, Neurosurgery.

[12]  E. Wijdicks,et al.  Rebleeding drives poor outcome in aneurysmal subarachnoid hemorrhage independent of delayed cerebral ischemia: a propensity-score matched cohort study. , 2020, Journal of neurosurgery.

[13]  Yunjun Yang,et al.  Predicting Long-Term Outcomes After Poor-Grade Aneurysmal Subarachnoid Hemorrhage Using Decision Tree Modeling. , 2020, Neurosurgery.

[14]  Amirhossein Jalali,et al.  Visualising statistical models using dynamic nomograms , 2019, PloS one.

[15]  A. Molyneux,et al.  Prediction of Outcome After Aneurysmal Subarachnoid Hemorrhage: Development and Validation of the SAFIRE Grading Scale , 2019, Stroke.

[16]  J. Reisch,et al.  Prediction of Outcomes for Ruptured Aneurysm Surgery: The Southwestern Aneurysm Severity Index , 2019, Stroke.

[17]  B. Zhao,et al.  Poor-Grade Aneurysmal Subarachnoid Hemorrhage: Risk Factors Affecting Clinical Outcomes in Intracranial Aneurysm Patients in a Multi-Center Study , 2019, Front. Neurol..

[18]  E. Steyerberg,et al.  Reporting and Interpreting Decision Curve Analysis: A Guide for Investigators. , 2018, European urology.

[19]  P. Brugger,et al.  The Barrow Neurological Institute Grading Scale as a Predictor for Delayed Cerebral Ischemia and Outcome After Aneurysmal Subarachnoid Hemorrhage: Data From a Nationwide Patient Registry (Swiss SOS) , 2018, Neurosurgery.

[20]  J. Caspers,et al.  Prediction of outcome after aneurysmal subarachnoid haemorrhage using data from patient admission , 2018, European Radiology.

[21]  S. Park.  Nomogram: An analogue tool to deliver digital knowledge. , 2018, The Journal of thoracic and cardiovascular surgery.

[22]  Hester F. Lingsma,et al.  Development and validation of outcome prediction models for aneurysmal subarachnoid haemorrhage: the SAHIT multinational cohort study , 2018, British Medical Journal.

[23]  I. C. van der Schaaf,et al.  Endovascular coiling versus neurosurgical clipping for people with aneurysmal subarachnoid haemorrhage. , 2018, The Cochrane database of systematic reviews.

[24]  C. Oppenheim,et al.  Treatment of cerebral vasospasm following aneurysmal subarachnoid haemorrhage: a systematic review and meta-analysis , 2017, European Radiology.

[25]  R. L. Macdonald,et al.  Spontaneous subarachnoid haemorrhage , 2017, The Lancet.

[26]  B. Zhao,et al.  Preoperative and postoperative predictors of long-term outcome after endovascular treatment of poor-grade aneurysmal subarachnoid hemorrhage. , 2016, Journal of neurosurgery.

[27]  G. E. Vates,et al.  Aneurysmal Subarachnoid Hemorrhage and Neuroinflammation: A Comprehensive Review , 2016, International journal of molecular sciences.

[28]  C. Derdeyn,et al.  Analysis of subarachnoid hemorrhage using the Nationwide Inpatient Sample: the NIS-SAH Severity Score and Outcome Measure. , 2014, Journal of neurosurgery.

[29]  B. Thompson,et al.  Endovascular treatment for aneurysmal subarachnoid hemorrhage in the ninth decade of life and beyond , 2013, Journal of NeuroInterventional Surgery.

[30]  R. Macdonald,et al.  Lower incidence of cerebral infarction correlates with improved functional outcome after aneurysmal subarachnoid hemorrhage , 2011, Journal of cerebral blood flow and metabolism : official journal of the International Society of Cerebral Blood Flow and Metabolism.

[31]  T. Schweizer,et al.  Cognitive and Functional Outcome After Aneurysmal Subarachnoid Hemorrhage , 2010, Stroke.

[32]  S. Nomura,et al.  Preoperative Prediction of Outcome in 283 Poor-Grade Patients with Subarachnoid Hemorrhage: A Project of the Chugoku-Shikoku Division of the Japan Neurosurgical Society , 2010, Cerebrovascular Diseases.

[33]  Hester F. Lingsma,et al.  Prediction of 60 day case-fatality after aneurysmal subarachnoid haemorrhage: results from the International Subarachnoid Aneurysm Trial (ISAT) , 2010, European Journal of Epidemiology.

[34]  Ale Algra,et al.  Changes in case fatality of aneurysmal subarachnoid haemorrhage over time, according to age, sex, and region: a meta-analysis , 2009, The Lancet Neurology.

[35]  E. Elkin,et al.  Decision Curve Analysis: A Novel Method for Evaluating Prediction Models , 2006, Medical decision making : an international journal of the Society for Medical Decision Making.

[36]  P. Sandercock,et al.  International subarachnoid aneurysm trial (ISAT) of neurosurgical clipping versus endovascular coiling in 2143 patients with ruptured intracranial aneurysms: a randomised comparison of effects on survival, dependency, seizures, rebleeding, subgroups, and aneurysm occlusion , 2005, The Lancet.

[37]  D. Nichols,et al.  Unruptured intracranial aneurysms: natural history, clinical outcome, and risks of surgical and endovascular treatment , 2003, The Lancet.

[38]  A. Molyneux.  International Subarachnoid Aneurysm Trial (ISAT) of neurosurgical clipping versus endovascular coiling in 2143 patients with ruptured intracranial aneurysms: a randomised trial , 2002, The Lancet.

[39]  P. Koudstaal,et al.  Interobserver variability of cisternal blood on CT after aneurysmal subarachnoid hemorrhage , 2000, Neurology.

[40]  R J Tamargo,et al.  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. , 1997, Neurosurgery.

[41]  S Ekholm,et al.  Analysis of interobserver disagreement in the assessment of subarachnoid blood and acute hydrocephalus on CT scans. , 1996, Neurological research.

[42]  K Sano,et al.  Glasgow Coma Scale in the prediction of outcome after early aneurysm surgery. , 1996, Neurosurgery.

[43]  J. Torner,et al.  Neurologic assessment of subarachnoid hemorrhage in a large patient series. , 1989, Surgical neurology.

[44]  R. Knill-Jones,et al.  Observer variability in grading patients with subarachnoid hemorrhage. , 1982, Journal of neurosurgery.

[45]  B. Jennett,et al.  Assessment of coma and impaired consciousness. A practical scale. , 1974, Lancet.

[46]  L. Mariani,et al.  Predictors of In-Hospital Death After Aneurysmal Subarachnoid Hemorrhage: Analysis of a Nationwide Database (Swiss SOS [Swiss Study on Aneurysmal Subarachnoid Hemorrhage]) , 2018, Stroke.

[47]  H. Vatter,et al.  Poor-Grade Aneurysmal Subarachnoid Hemorrhage: Factors Influencing Functional Outcome--A Single-Center Series. , 2016, World neurosurgery.

[48]  David S. Rosen,et al.  Subarachnoid hemorrhage grading scales , 2005, Neurocritical care.

[49]  Fisher Cm,et al.  Relation of cerebral vasospasm to subarachnoid hemorrhage visualized by computerized tomographic scanning. , 1980, Neurosurgery.