Textbook Outcomes Among Patients with Aneurysmal Subarachnoid Hemorrhage Following Endovascular Treatment

Abstract

Introduction: The case fatality rate among patients with aneurysmal subarachnoid hemorrhage (aSAH) has decreased progressively, with numerous patients subjected to contemporary paradigms that minimize the use of agonizing therapeutic processes. The concept of the "Textbook Outcome" (TO), a composite outcome that highlights numerous favorable outcomes, was developed in the context of gastrointestinal tumor surgeries and expeditiously extended across diverse surgical spheres. The aim of this study was to explore the factors hindering the achievement of optimal prognoses in postinterventional aSAH patients, employ textbook outcomes, and establish predictive models.

Methods: We conducted a retrospective review of data from 1270 aSAH patients who received endovascular treatment between 2012 and 2018. We delineated an exemplary TO within the aSAH domain, characterized by favorable clinical results, minimal complications, and the absence of retreatments. This TO-oriented approach is explained within the manuscript.

Results: The findings revealed that preoperative intraventricular hemorrhage (IVH), preoperative Hunt and Hess grade (H&H) ≥ 3, World Federation of Neurosurgical Societies (WFNS) grade ≥ 3, the presence of blebs on the aneurysm, aneurysms situated at branching sites, and non-stent-assisted endovascular intervention were the strongest risk factors for not achieving textbook outcomes (non-"Textbook Outcome" [N-TO]). Decision curve analysis and calibration analyses revealed strong concordance between the predictions of the N-TO nomogram model and the actual observations.

Conclusions: Treatment Outcomes hold significant practical value in clinical studies of aSAH patients receiving endovascular treatment. The likelihood of N-TOs was predicted by IVH, H&H grade ≥ 3, WFNS grade ≥ 2, presence o f bleb on the aneurysm, and aneurysms located at branching sites.

Keywords: Aneurysm; Aneurysmal subarachnoid hemorrhage; Endovascular treatment; Nomogram; Textbook outcomes.

Fig. 1

Flow chart of patient selection, including the exclusion criteria for enrolled patients and the basis for grouping “Textbook Outcome” (TO) and non-“Textbook Outcome” (N-TO) patients. aSAH Aneurysmal subarachnoid hemorrhage, mRS modified Rankin Scale

Fig. 2

A nomogram derived from the model was used to predict non-“Textbook Outcome” (N-TO) occurrence. This nomogram is based on the independent variables within the model, excluding the surgical approach. Points corresponding to the magnitude of the regression coefficients are assigned for each level of the factors. These scores are subsequently aggregated to yield a total score, which indicates the probability of N-TO prediction. H&H Hunt and Hess (grade), WFNS World Federation of Neurosurgical Societies (grade)

Fig. 3

Receiver operating characteristic curve analysis demonstrated that the established predictive model had an area under the curve (AUC) of 0.747 (95% confidence interval 0.720–0.773; P < 0.001). Decision curve analysis and calibration analyses depicted strong concordance between the predictions of the nomogram model and the actual observations