Beyond the Initial Ictus: Timing of WFNS Grade Assessment and Outcome Prediction in Aneurysmal Subarachnoid Hemorrhage

Background To identify the clinical timepoint of World Federation of Neurosurgical Societies (WFNS) grading that provides the highest prognostic accuracy for short- and long-term outcomes in aneurysmal subarachnoid hemorrhage (aSAH). Methods In this cohort study of 389 patients, WFNS grades were recorded at first medical contact, hospital admission, immediately pre-occlusion, and 48 h post-occlusion. Functional outcome was assessed using the Glasgow Outcome Scale–Extended (GOSE) and modified Rankin Scale (mRS) at discharge, 1 year, and at least 2 years after ictus. Prognostic performance was evaluated using receiver operating characteristic (ROC) analysis and compared across timepoints with DeLong’s test. Results Prognostic accuracy varied significantly between assessment timepoints. Across all outcomes, WFNS grading at 48 h post-occlusion demonstrated the highest discriminative power. For functional outcome at discharge, the area under the curve (AUC) reached 0.817 for GOSE and 0.845 for mRS, exceeding all values obtained from earlier assessments. The prognostic accuracy remained superior at the 1 year follow-up (GOSE AUC 0.844, mRS AUC 0.823) and at long-term follow-up after 2 years or more (GOSE AUC 0.819, mRS AUC 0.784). DeLong’s Test confirmed the significantly better predictive performance 48 h post-occlusion compared with all earlier timepoints, whereas no significant differences were observed among the earlier timepoints. Conclusions The WFNS assessment at 48 h post-occlusion provides a better prediction of both short- and long-term functional outcomes after aSAH compared with earlier evaluations. This timepoint may more accurately reflect a stabilized neurological status and could be used in addition to the WFNS scale obtained at admission.