Hospital Mortality, Unfavorable Neurologic Outcomes High in Poor Grade Subarachnoid Hemorrhage

Doctor viewing a patient’s brain scans on a computer screen.
A team of investigators sought to evaluate changes in mortality and neurologic outcomes in patients with subarachnoid hemorrhage and identify predictors.

Patients with subarachnoid hemorrhage (SAH) who arrived at hospital admission with a World Federation of Neurological Surgeons (WFNS) score of 5 were associated with worse outcomes, according to study findings published in BMC Neurology.

Study researchers used the WFNS scale to assess patients (N=353) admitted to the intensive care unit with nontraumatic SAH at the Erasmus Hospital in Belgium between 2004 and 2018. Additionally, they evaluated associated clinical outcomes.

Study researchers graded patients as having WFNS of 4 (32%) or 5 (68%). SAH was caused by an aneurysm (84%), arteriovenous malformation (2%), or from undetermined origins (14%). These patients had a mean age of 57 (standard deviation, ±14) years, 42% were men, 41% had hypertension, 15% heart disease, and 10% diabetes.

Stratified by admission date, disease severity scores and use of vasopressors increased over time. Instances of previous neurological disease, cancer, and drug abuse decreased with time.

Unfavorable neurologic outcomes occurred among 74% and mortality among 57% of patients. Of all unfavorable neurologic outcomes and deaths, 77% and 81% were among the patients with a WFNS score of 5, respectively.

Over time, the proportion of patients who had unfavorable neurological outcomes and mortality did not vary significantly. However, patients who were admitted between 2008 and 2011 (hazard ratio [HR], 0.55; 95% CI, 0.34-0.89) or 2016 and 2018 (HR, 0.33; 95% CI, 0.20-0.53) were associated with lower mortality risk compared with patients admitted between 2004 and 2007.

Decreased mortality risk was associated with prophylactic nimodipine (HR, 0.50; 95% CI, 0.35-0.72; P =.001), endovascular treatment (HR, 0.51; 95% CI, 0.36-0.73; P =.001), and hydrocephalus (HR, 0.60; 95% CI, 0.43-0.84; P =.002).

Increased mortality risk was associated with intracranial hypertension (HR, 3.56; 95% CI, 2.33-5.41; P =.001), WFNS score of 5 (HR, 2.12; 95% CI, 1.43-3.14; P =.001), sequential organ failure assessment score (HR, 1.10; 95% CI, 1.03-1.17; P =.006), and age (HR, 1.02; 95% CI, 1.00-1.03; P =.022).

Unfavorable neurological outcomes were associated with intracranial hypertension (HR, 10.15; 95% CI, 5.24-19.66; P =.001), WFNS score of 5 (HR, 3.23; 95% CI, 1.67-6.25; P =.001), and age (HR, 1.04; 95% CI, 1.01-1.06; P =.005). Prophylactic nimodipine decreased risk for unfavorable neurological outcomes (HR, 0.29; 95% CI, 0.11-0.77; P =.013).

This study may have been limited by the exclusion of many additional variables and the subjectivity in deciding specific therapies for patients. It remains unclear whether longer-term outcomes would differ on the basis of WFNS score.

These data indicated patients with SAH who were graded as having a WFNS score of 5 were at increased risk for poorer clinical outcomes and mortality.


Bogossian EG, Diaferia D, Minini A, et al. Time course of outcome in poor grade subarachnoid hemorrhage patients: a longitudinal retrospective study. BMC Neurol. 2021;21(1):196. doi:10.1186/s12883-021-02229-1