Hunt and hess scale as a predictor of outcome in subarachnoid haemorrhage

Abstract

Introduction. The severity of clinical presentation is the strongest prognostic indicator in spontaneous subarachnoid haemorrhage (SAH). Many complications can occur during SAH management (rebleeding, vasospasm) and are major predictors of poor outcome. Despite diffICUlties in accurately predict the prognosis of SAH patients, Hunt and Hess is one of the most widely used scales to assess clinical severity at hospital admission. OBJECTIVES. To evaluate Hunt and Hess scale as a predictor of outcome in patients admitted to our ICU with SAH. METHODS. All 54 SAH patients admitted to our 9-bed mixed intensive care unit (ICU) in a 5-year period (January 2008-January 2012) were retrospectively evaluated. Demographic data, severity scores, Hunt and Hess and Glasgow coma scales, length of stay, duration of mechanical ventilation support, complications, mortality and patients status 6 months after hospital discharge were collected. RESULTS. The average age was 51.7 (plus or minus): 13.1 years; 35 (64.8 %) patients were female. Severity scores on admission: APACHE II 19.4 (plus or minus): 8.8, SAPS II 40.3 (plus or minus): 17.2, SOFA 9.9 (plus or minus): 11.7, Glasgow coma scale 6.9 (plus or minus): 3.1 (3-14) and Hunt-Hess scale 4.2 (plus or minus): 0.7 (3-5). Average ICU length of stay (LOS) was 9.1 (plus or minus): 5.7 (1-28) days and hospital LOS 30.3 (plus or minus): 36.1 (2-190) days. Most patients (51 = 94.4 %) needed mechanical ventilation with an average duration of 6.5 (plus or minus): 4.7 days. At least one aneurysm was identified in 49 (90.7 %) patients, an arteriovenous malformation in 2 (3.2 %) and absence of vascular lesions in 3 (5.6 %). Intra-cranial complications included: brain edema 34 (63 %), hydrocephalus 26 (48.1 %), cerebral ischemia 22 (40.7 %), vasospasm 20 (37 %) and re-bleeding 11 (20.4 %). ICU mortality was 31.5 %, hospital mortality 38.9 % and 6 months after discharge mortality 59.3 %. Analysing global mortality, most deaths (90.6 %) occurred in patients with Hunt-Hess 4 and 5.The 22 survivors were observed approximately 6 months after hospital discharge: 13 individuals presented with neurological deficits (Hunt-Hess grade 3 n = 2; grade 4 n = 6; grade 5 n = 5) and 9 without deficits (Hunt-Hess grade 3 n = 4; grade 4 n = 4; grade 5 n = 1). CONCLUSIONS. The majority of patients in our study were poor-grade SAH (Hunt and Hess 4 and 5) and this group was clearly associated with high mortality rate and permanent neurological deficits in survivors. Nevertheless, 16 patients (29.6 %) initially classified as poor-grade SAH actually survived, and 5 (9.2 %) of them without neurological deficits. Aggressive treatment even in poor-grade SAH patients can result in more favourable longterm outcomes than predicted by Hunt and Hess scale.