A meta-analysis of more than 4,500 patients, presented recently at the 16th World Stroke Congress (WSC; 23–26 October, Abu Dhabi, United Arab Emirates), has revealed that female sex; disease severity upon admission; presence of vasospasm; and scores on the Fisher grading scale, are all useful predictors of delayed cerebral infarction (DCI) risk following an aneurysmal subarachnoid haemorrhage (SAH).
However, delivering these findings at WSC 2024, Syed Gillani (University of Missouri, Columbia, USA) noted that “significant knowledge gaps exist” regarding predictors of early cerebral infarction (ECI) risk. Gillani went on to state that further large, standardised cohort studies are warranted to guide prognosis and interventions on this front.
“The key takeaway from this analysis is that early clinical severity—as assessed by WFNS [World Federation of Neurological Surgeons], HH [Hunt and Hess] and Fisher scores—along with female sex, vasospasm, and higher Fisher scores, are significant predictors of DCI following aneurysmal SAH,” Gillani commented, speaking to NeuroNews. “These factors should guide monitoring and treatment decisions. Notably, the increased risk of DCI in females highlights the need for heightened vigilance and potentially more aggressive management, regardless of other clinical scores.
“For neurointerventionists, these findings emphasise the importance of utilising prognostic scales early in aneurysmal SAH management to identify high-risk patients. This allows for more focused monitoring and targeted interventions, such as vasospasm prevention and haemodynamic optimisation.
“Moving forward, research should further explore sex-based differences and refine risk models to incorporate additional factors like aneurysm size, location, and early ischaemic changes, ultimately improving patient outcomes through personalised care.”
With predictors of both DCI and ECI among aneurysmal SAH patients remaining “unclear” prior to their analysis, Gillani and colleagues set out to systematically review and synthesise existing literature on these phenomena.
They conducted a comprehensive search of PubMed, Embase, Cochrane Library and Scopus databases from inception to January 2024, with the goal of documenting any observational cohort studies examining predictors of DCI or ECI following aneurysmal SAH through this period. Studies were screened, reviewed, and meta-analysed, adhering to Preferred reporting items for systematic reviews and meta-analyses (PRISMA) and Cochrane guidelines. The data were then pooled as odds ratios (OR) with 95% confidence intervals (CI) using RevMan 5.4 software. Methodologic quality was assessed via the Newcastle-Ottawa scale.
“Our meta-analysis included 12 moderate- to high-quality cohort studies, comprising 4,527 patients,” Gillani and colleagues state.
Regarding DCI predictors, they ultimately found that higher disease severity scores (OR, 1.49; 95% CI, 1.12–1.97; p=0.005) and high Fisher grading scale scores (OR, 2.23; 95% CI, 1.28–3.89; p=0.005) on presentation were “significantly associated” with an increased risk of DCI. They also observed female sex and the presence of vasospasm as having been significantly associated with an increased risk of DCI (OR, 3.04; 95% CI, 1.35–6.88; p=0.007).
In contrast, the investigators found that pre-existing hypertension (p=0.94), aneurysm treatment (p=0.14) and aneurysm location (p=0.16) were among factors that “did not reliably predict DCI risk”.
Regarding ECI predictors, Gillani and colleagues’ pooled analysis demonstrated “no significant associations” between sex (p=0.51), pre-existing hypertension (p=0.63), disease severity (p=0.51), or anterior versus posterior aneurysm location (p=0.86), and the occurrence of ECI in aneurysmal SAH patients.
“While this analysis did not identify strong predictors for ECI, future studies may uncover additional risk factors—especially with larger cohorts and improved methodologies,” Gillani told NeuroNews. “The neurointerventional community remains interested in potential predictors like genetic factors, microvascular changes, advanced imaging markers (e.g. diffusion-weighted imaging), early haematoma expansion, and inflammatory biomarkers. Although data supporting these factors are limited, they represent important areas for further research that may improve risk prediction for ECI in the future.”
In addition to being presented by Gillani at WSC 2024, the results of this systematic review and meta-analysis have now been published in the journal World Neurosurgery.
