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Herniation World Federation of Neurosurgical Societies Scale Improves Prediction of Outcome in Patients with Poor-Grade Aneurysmal Subarachnoid Hemorrhage

By Currents Editor posted 16 days ago

  

Herniation World Federation of Neurosurgical Societies Scale Improves Prediction of Outcome in Patients with Poor-Grade Aneurysmal Subarachnoid Hemorrhage
Stroke (03/22/22) DOI: 10.1161/STROKEAHA.121.036699
Raabe, Andreas; Beck, Jürgen; Goldberg, Johannes; et al.
https://www.ahajournals.org/doi/10.1161/STROKEAHA.121.036699 

An international prospective multicenter study involving poor-grade aneurysmal subarachnoid hemorrhage patients compared the World Federation of Neurosurgical Societies (WFNS) classification with a modified version, the herniation WFNS scale (hWFNS). The modification requires positive signs of brain stem dysfunction in order to assign grade V aneurysmal subarachnoid hemorrhage. In this study, only patients with positive signs of brain stem dysfunction — as indicated by posturing, anisocoric, or bilateral dilated pupils — were assigned hWFNS grade V. The primary endpoint investigated was the difference in specificity of the two scales with respect to poor outcomes (modified Rankin Scale score 4-6). In all, 237 of 250 patients achieved the primary endpoint. When comparing the WFNS and hWFNS scale following neurological resuscitation, the specificity of predicting poor outcome rose to 0.93 with hWFNS from 0.19 with WFNS. Sensitivity declined from 0.88 to 0.37, while the positive predictive value increased from 61.9 to 88.3. The specificity for mortality rose to 0.93 from 0.19, and the positive predictive value increased to 86.7 from 52.5. Noting the significant improvements in specificity and positive predictive value for poor outcome in grade V patients with the identification of objective positive signs of brain stem dysfunction, the researchers recommend "a simple modification — presence of brain stem signs is required for grade V — should be added to the WFNS classification.

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