Hi, my name is Joshua Caterpillar, I'm a fourth-year resident at the Barrow Neurological Institute. I'll be presenting our study titled, The SAFIRE Gradient Scale as a Predictor of Long-Term Outcome for Patients in the Barrow Ruptured Aneurysm Trial. We have no disclosures to report. Introduction. Aneurysmal subarachnoid hemorrhage is a devastating neurosurgical emergency, often resulting in high rates of morbidity and mortality. Studies have attempted to create accurate predictors of patient outcomes. Factors that emerge as potential predictors of outcomes include age, aneurysm size, post-resuscitation complications, hypertension, neurological state of presentation, amount of hemorrhage, and re-bleeding. The SAFIRE Gradient Scale is a bedside prediction model for poor patient outcomes in the acute post-aneurysmal subarachnoid hemorrhage period. It focuses on aneurysmal size, patient age, Fisher grade, and World Federation of Neurosurgical Societies grade, or WFNS grade. A value is assigned to each factor in the scale, and it yields a predictor of poor outcome at two months post-aneurysmal subarachnoid hemorrhage. This grading scale has been externally validated with patients from the International Subarachnoid Aneurysm Trial. The present study attempts to assess the long-term predictive capability of the SAFIRE Gradient Scale using the Barrow Ruptured Aneurysm Trial, BRAT, patient population by comparing patient outcomes at one and six-year follow-up with retrospectively calculated SAFIRE grades. Methods. All patients with a confirmed aneurysmal subarachnoid hemorrhage enrolled in the BRAT were retrospectively analyzed. Patients aged at the time of aneurysmal subarachnoid hemorrhage, WFNS grade, Fisher grade, aneurysmal size, and modified Rankin score at one and six-year follow-up were used for this analysis. Patients with MRF scores were separated into two categories, less than or equal to two, and greater than two, with the less than or equal to two indicating good outcomes and the greater than two indicating poor outcomes. The SAFIRE grades has a one through five scale and is assigned to each patient based on the methods represented in the original manuscript. Here we see Table 1, which shows the predictors composed in the SAFIRE risk chart from the original manuscript, where points are assigned for various different characteristics, such as with increasing age, you get zero with patients less than or equal to 50 versus five with patients greater than or equal to 70. And there's greater points with increasing WFNS grades after resuscitation, with zero with patients with a grade of one versus nine and patients with a grade of five. And there's an increase in points with patients with a greater Fisher grade, with patients with a Fisher grade of four, with two points versus zero in the patients one to three. And lastly, patients with aneurysm sizes that are larger get greater point totals, with zero in the patients with less than 10 millimeters and six in those patients with greater than 20 millimeter diameter. Table 2 shows the SAFIRE grading scale, the scales one to five, one being zero to two points and showing a risk of poor outcome of less than 10% versus five, where it's greater than 15 points and the risk of poor outcome of greater than 90%. Here in Table 3, we see the characteristics of patients with aneurysm, subarachnoid hemorrhage from the BRAT. There was a total of 405 patients who were enrolled in the BRAT who were found to have an actual aneurysm, subarachnoid hemorrhage. And this is broken down by the different categories and characteristics that are used in the SAFIRE grading scale. Table 4 then computed the individual patient's SAFIRE grades and looked at their one-year as well as six-year MRS scores. As you can see, SAFIRE grade one patients had an 18% risk of MRS greater than two at one-year follow-up and 29% risk of MRS greater than two at six-year follow-up versus patients with a four SAFIRE grade had a 43% risk of MRS greater than two at one-year follow-up and a 60% risk of MRS greater than two at six-year follow-up. Table 5 shows the risk factors of high SAFIRE grades and poor outcomes at one-year and six-year follow-up among the BRAT patients. We define this high SAFIRE grade as either a four or five grade and at both that one-year and six-year follow-up, a high SAFIRE grade was found to be a risk factor of an MRS greater than two or a poor outcome at follow-up. Discussion. The SAFIRE grading scale is a simple bed-size assessment that computes the aneurysm size, aneurysm age, Fisher grade, and WFNS grade to predict the two-month pronostic outcome of aneurysm subarachnoid hemorrhage patients. Increasing SAFIRE grades at both one-year and six-year post-aneurysm subarachnoid hemorrhage found to be associated with the increased proportion of a poor outcome in our study. Furthermore, in univariate analysis, there were significantly greater odds of a poor outcome with higher SAFIRE grades defined as either a four or five at both one-year and six-year follow-up. Interesting, the size of the aneurysm was found to be a predictor of poor outcome in the original SAFIRE scale. Relationships between aneurysm size and outcomes is still debated, however. Small non-sacral aneurysms, such as a blister aneurysm, are associated with unusually high rates of mortality and are associated with a higher rate of poor outcome than similarly sized, non-blister type aneurysms. This was not accounted for in the SAFIRE scale. In the SAFIRE scale of prior literature, increasing age is a significant risk factor for a poor outcome. All patients over the age of 70 are grouped together in the SAFIRE scale, potentially leading to overly optimistic outcomes for patients over the age of 80. However, in the present analysis, no patients over the age of 80 were investigated, as the BRAT excluded patients age greater than 80, and yet higher SAFIRE grades were still correlated with worse prognosis. Limitations The BRAT study is a randomized controlled trial, but the data were retrospectively reviewed for this analysis, potentially leading to limitations inherent to all retrospective studies. Patients within the BRAT were assigned to different surgical interventions, with the primary attempt to compare outcomes in endovascular coiling versus microsurgical clipping. Another limitation the data analyzed are for patients treated over a decade ago. Neurosurgery continues to advance and rates of poor outcomes associated with aneurysm subarachnoid hemorrhage decline due to better interventions. In conclusion, the SAFIRE grading scale has been validated as a predictor of patient outcome for two months post-aneurysm subarachnoid hemorrhage. The scale relies on aneurysm size, age of the patient, Fisher grade, and WFNS grade. Our study shows that, additionally, the scale is a predictor of outcome at long-term follow-up, with higher grades associated with unfavorable recoveries. However, the SAFIRE scale does not consider the unique risks associated with various aneurysmal morphologies that may affect outcomes. This may lead to potentially an overly optimistic prediction of recovery for these patients. I would like to thank Dr. Lawden, who is the corresponding author, for this study.

Joshua Caterpillar

Barrow Neurological Institute

SAFIRE Gradient Scale

aneurysmal subarachnoid hemorrhage

long-term outcomes