Multiple aneurysms in subarachnoid hemorrhage - Identification of the ruptured aneurysm, when the bleeding pattern is not self-explanatory - Development of a novel prediction score

Abstract

Background: In aneurysmal subarachnoid hemorrhage (SAH) and multiple intracranial aneurysms (MIAs) identification of the bleeding source cannot always be assessed according to the hemorrhage pattern. Therefore, we developed a statistical model for the prediction of the ruptured aneurysm in patients with SAH and multiple potential bleeding sources at the time of ictus. Methods: Between 2012 and 2015, 252 patients harboring 619 aneurysms were admitted to the authors' institution. Patients were followed prospectively. Aneurysm and patient characteristics, as well as radiological findings were entered into a computerized database. Gradient boosting techniques were used to derive the statistical model for the prediction of the ruptured aneurysm. Based on the statistical prediction model, a scoring system was produced for the use in the clinical setting. The aneurysm with the highest score poses the highest possibility of being the bleeding source. The prediction score was then prospectively applied to 34 patients suffering from SAH and harboring MIAs. Results: According to the statistical prediction model the main factors affecting the rupture in patients harboring multiple aneurysms were: 1) aneurysm size, 2) aneurysm location and 3) aneurysm shape. The prediction score identified correctly the ruptured aneurysm in all the patients that were used in the prospective validation. Even in the five most debatable and challenging cases assessed in the period of prospective validation, for which the score was designed for, the ruptured aneurysm was predicted correctly. Conclusions: This new and simple prediction score might provide additional support for neurovascular teams for treatment decision in SAH patients harboring multiple aneurysms. In a small prospective sample, the prediction score performed with high accuracy but larger cohorts for external validation are warranted.