title: Infarct volume predicts delayed recovery in patients with subarachnoid hemorrhage and severe neurological deficits.
abstract: BACKGROUND
  Recovery is common after subarachnoid hemorrhage (SAH), even in patients who are severely disabled at hospital discharge. Little is known about predictors of late recovery in such patients, even though such knowledge may influence treatment decisions. We hypothesized that cerebral infarction volume would be associated with 3 months outcomes in patients who are severely disabled at 14 days.
  
  
  METHODS
  We prospectively identified consecutive aneurysmal SAH patients, documented the development of cerebral infarction, and ascertained the modified Rankin Scale (mRS) at 14 days and 3 months. We included patients with mRS 4 or 5 and NIH Stroke Scale (NIHSS) at least 8 on hospital day 14 (i.e., severe neurologic impairment) and calculated infarct volume in a semi-automated fashion using CT imaging. We explored outcome determinants with ordinal regression.
  
  
  RESULTS
  At 14 days, 66 patients were severely disabled, 65 (98.5 %) of whom had mRS of 5; the median NIHSS was 21 [14-24]. At 3 months, 20 (32.8 %) of the 61 patients with known outcomes were independent. Larger infarction volumes were associated with death (20.4 vs. 0.85 mL, P = 0.02). In ordinal regression, increased infarct volume was associated with the worse mRS after correction for WFNS grade, age, and withdrawal of life support (OR 1.01 per mL of infarct, 95 % CI 1.01-1.03, P = 0.01).
  
  
  CONCLUSIONS
  After SAH, even with severe neurological injury at 14 days, good recovery is frequent and is associated with lower infarction volume. These data may help clinicians inform surrogate decision makers as they plan the future care of such severely disabled patients.
authors.affiliation: Section on Neurocritical Care, Ken & Ruth Davee Department of Neurology, Northwestern University Feinberg School of Medicine, 710 North Lake Shore Drive, 11th Floor, Chicago, IL, 60611, USA, neil-rosenberg@fsm.northwestern.edu.
authors.forename: Neil F
authors.initials: NF
authors.lastname: Rosenberg
authors.forename: Storm M
authors.initials: SM
authors.lastname: Liebling
authors.forename: Adam R
authors.initials: AR
authors.lastname: Kosteva
authors.forename: Matthew B
authors.initials: MB
authors.lastname: Maas
authors.forename: Shyam
authors.initials: S
authors.lastname: Prabhakaran
authors.forename: Andrew M
authors.initials: AM
authors.lastname: Naidech
mesh_terms: D000328:Adult; D000368:Aged; D002544:Cerebral Infarction / Q000209:etiology / Q000473:pathology* / Q000503:physiopathology*; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D063868:Patient Outcome Assessment; D011237:Predictive Value of Tests; D011379:Prognosis; D011446:Prospective Studies; D020127:Recovery of Function / Q000502:physiology*; D012720:Severity of Illness Index; D013345:Subarachnoid Hemorrhage / Q000150:complications / Q000473:pathology* / Q000503:physiopathology*; D013997:Time Factors; D014057:Tomography, X-Ray Computed / Q000295:instrumentation / Q000379:methods*