Albumin-Anchored Thromboinflammatory Ratios Provide Modest Incremental Prognostic Value Beyond Clinical Severity...

Aneurysmal subarachnoid hemorrhage (aSAH) remains associated with substantial mortality and functional disability despite advances in neurosurgical and intensive care management. Systemic inflammation and thromboinflammatory activation play key roles in early brain injury and secondary complications. We aimed to evaluate the prognostic value of albumin-anchored inflammatory ratios-C-reactive protein/Albumin ratio (CAR) and D-dimer-to-Albumin Ratio (DAR)-for predicting functional outcome and in-hospital mortality in patients with aSAH.

In this retrospective multicenter cohort study, 212 adult patients with radiologically confirmed aSAH were included. Admission laboratory parameters obtained within the first 24 h were analyzed. The primary outcome was poor functional status at discharge (modified Rankin Scale [mRS] ≥ 3); the secondary outcome was in-hospital mortality. Univariable and multivariable logistic regression analyses were performed. Discriminatory performance was evaluated using receiver operating characteristic (ROC) analysis, and incremental prognostic value was assessed through model comparison, calibration analysis, and decision curve analysis.

Poor functional outcome occurred in 88 patients (41.5%), and in-hospital mortality was observed in 36 patients (17.0%). Both CAR and DAR were significantly higher in patients with poor outcomes (p < 0.001 for both). In multivariable analysis, DAR (adjusted OR 1.89, 95% CI 1.32-2.71, p < 0.001) and CAR (adjusted OR 1.11, 95% CI 1.04-1.18, p = 0.002) independently predicted poor functional outcome. ROC analysis demonstrated AUC values of 0.83 (95% CI 0.77-0.89) for CAR and 0.86 (95% CI 0.80-0.91) for DAR. For mortality prediction, DAR achieved an AUC of 0.90 (95% CI 0.85-0.95). The addition of DAR to a clinical model (age, GCS, Hunt-Hess grade) provided a modest but statistically significant improvement in discrimination for poor outcome (AUC increase from 0.89 to 0.92; p = 0.028) and mortality (AUC increase from 0.91 to 0.94; p = 0.031). Reclassification analyses showed a continuous NRI of 0.21 (95% CI 0.05-0.37; p = 0.012) and an IDI of 0.028 (95% CI 0.006-0.050; p = 0.018).

Albumin-anchored inflammatory ratios, particularly DAR, were independently associated with poor functional outcome and in-hospital mortality in patients with aSAH. DAR provides modest incremental prognostic information beyond established clinical severity scores, supported by improvements in reclassification metrics; however, its clinical impact should be interpreted cautiously.