title: Time course of recovery following poor-grade SAH: the incidence of delayed improvement and implications for SAH outcome study design.
abstract: OBJECTIVE
  Data regarding the time course of recovery after poor-grade subarachnoid hemorrhage (SAH) is lacking. Most SAH studies assess outcome at a single time point, often as early as 3 or 6 months following SAH. The authors hypothesized that recovery following poor-grade SAH is a dynamic process and that early outcomes may not always approximate long-term outcomes. To test this hypothesis, they analyzed long-term outcome data from a cohort of patients with poor-grade aneurysmal SAH to determine the incidence and predictors of early and delayed neurological improvement.
  
  
  METHODS
  The authors reviewed outcome data from 88 poor-grade SAH patients enrolled in a prospective SAH treatment trial (the Barrow Ruptured Aneurysm Trial). They assessed modified Rankin Scale (mRS) scores at discharge, 6 months, 12 months, and 36 months after treatment to determine the incidence and predictors of neurological improvement during each interval.
  
  
  RESULTS
  The mean aggregate mRS scores at 6 months (3.31 ± 2.1), 12 months (3.28 ± 2.2), and 36 months (3.17 ± 2.3) improved significantly compared with the mean score at hospital discharge (4.33 ± 1.3, p < 0.001), but they did not differ significantly among themselves. Between discharge and 6 months, 61% of patients improved on the mRS. The incidence of improvement between 6-12 months and 12-36 months was 18% and 19%, respectively. Hunt and Hess Grade IV versus V (OR 6.20, 95% CI 2.11-18.25, p < 0.001) and the absence of large (> 4 cm) (OR 2.76, 95% CI 1.02-7.55, p = 0.05) or eloquent (OR 5.17, 95% CI 1.89-14.10, p < 0.01) stroke were associated with improvement up to 6 months. Age ≤ 65 years (OR 5.56, 95% CI 1.17-26.42, p = 0.02), Hunt and Hess Grade IV versus V (OR 4.17, 95% CI 1.10-15.85, p = 0.03), and absence of a large (OR 8.97, 95% CI 2.65-30.40, p < 0.001) or eloquent (OR 4.54, 95% CI 1.46-14.08, p = 0.01) stroke were associated with improvement beyond 6 months. Improvement beyond 1 year was most strongly predicted by the absence of a large stroke (OR 7.62, 95% CI 1.55-37.30, p < 0.01).
  
  
  CONCLUSIONS
  A substantial minority of poor-grade SAH patients will experience delayed recovery beyond the point at which most studies assess outcome. Younger patients, those presenting in better clinical condition, and those without CT evidence of large or eloquent stroke demonstrated the highest capacity for delayed recovery.
authors.affiliation: Division of Neurological Surgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona 85013, USA.
authors.forename: David A
authors.initials: DA
authors.lastname: Wilson
authors.forename: Peter
authors.initials: P
authors.lastname: Nakaji
authors.forename: Felipe C
authors.initials: FC
authors.lastname: Albuquerque
authors.forename: Cameron G
authors.initials: CG
authors.lastname: McDougall
authors.forename: Joseph M
authors.initials: JM
authors.lastname: Zabramski
authors.forename: Robert F
authors.initials: RF
authors.lastname: Spetzler
mesh_terms: D015331:Cohort Studies; D006801:Humans; D015994:Incidence; D017063:Outcome Assessment, Health Care / Q000592:standards*; D011237:Predictive Value of Tests; D011379:Prognosis; D011446:Prospective Studies; D016032:Randomized Controlled Trials as Topic; D020127:Recovery of Function / Q000502:physiology*; D013345:Subarachnoid Hemorrhage / Q000453:epidemiology* / Q000534:rehabilitation*; D013997:Time Factors; D016896:Treatment Outcome