Early Prognostication of 1-Year Outcome After Subarachnoid Hemorrhage: The FRESH Score Validation

J Stroke Cerebrovasc Dis. 2019 Oct;28(10):104280. doi: 10.1016/j.jstrokecerebrovasdis.2019.06.038. Epub 2019 Jul 18.


Background and aim: The FRESH score is a tool to prognosticate long-term outcomes after spontaneous subarachnoid hemorrhage (SAH). Here, for the first time, we aimed to externally validate the disability part of FRESH using its original four score variables.

Methods: A total of 107 patients with SAH were prospectively enrolled in the Yale Acute Brain Injury Biorepository between September 2014 and January 2018. 12-month functional outcome was recorded prospectively by trained study investigators using the modified Rankin Scale (mRS). FRESH-scores were calculated retrospectively using the original score variables. We used R2 statistics to assess goodness of fit, and the area under the receiver operating characteristic curve (AUC) to assess ability of the score to discriminate between favorable and unfavorable (defined as mRS 4-6) outcome.

Results: We identified 86 patients with SAH with complete 1-year follow-up data. Mean age was 60 years, 60% were women. An aneurysmal bleeding source was found in 71% of patients. 80% underwent aneurysm coiling, and 5% clipping. Sixteen percent of patients were considered high grade on admission (Hunt&Hess score 4 or 5). Discrimination of the FRESH score between favorable and unfavorable outcome was high (AUC 90.8%, confidence interval 81.9%-96.5%). Nagelkerke's (.54) and Cox&Snell's R2 (.35) indicated satisfactory fit. Exclusion of patients without aneurysmal etiology of SAH did not significantly alter model performance.

Conclusions: FRESH, a prognostication score of long-term outcomes in patients with SAH showed excellent score performance in this external validation. FRESH may guide the efficient use of hospital resources, family discussions, and stratification of patients in future randomized controlled trials.

Keywords: Subarachnoid hemorrhage; cohort studies; intracranial hemorrhages; patient outcome assessment; prognosis.

Publication types

  • Validation Study

MeSH terms

  • Age Factors
  • Aged
  • Decision Support Techniques*
  • Disability Evaluation*
  • Female
  • Humans
  • Male
  • Middle Aged
  • Predictive Value of Tests
  • Recurrence
  • Reproducibility of Results
  • Retrospective Studies
  • Risk Assessment
  • Risk Factors
  • Subarachnoid Hemorrhage / diagnosis*
  • Subarachnoid Hemorrhage / physiopathology
  • Subarachnoid Hemorrhage / therapy
  • Time Factors
  • Treatment Outcome