Risk stratification for predicting 30-day mortality of intracerebral hemorrhage

Guidelines for Neuroprognostication in Critically Ill Adults with Intracerebral Hemorrhage

BACKGROUND

The objective of this document is to provide recommendations on the formal reliability of major clinical predictors often associated with intracerebral hemorrhage (ICH) neuroprognostication.

METHODS

A narrative systematic review was completed using the Grading of Recommendations Assessment, Development, and Evaluation methodology and the Population, Intervention, Comparator, Outcome, Timing, Setting questions. Predictors, which included both individual clinical variables and prediction models, were selected based on clinical relevance and attention in the literature. Following construction of the evidence profile and summary of findings, recommendations were based on Grading of Recommendations Assessment, Development, and Evaluation criteria. Good practice statements addressed essential principles of neuroprognostication that could not be framed in the Population, Intervention, Comparator, Outcome, Timing, Setting format.

RESULTS

Six candidate clinical variables and two clinical grading scales (the original ICH score and maximally treated ICH score) were selected for recommendation creation. A total of 347 articles out of 10,751 articles screened met our eligibility criteria. Consensus statements of good practice included deferring neuroprognostication-aside from the most clinically devastated patients-for at least the first 48-72 h of intensive care unit admission; understanding what outcomes would have been most valued by the patient; and counseling of patients and surrogates whose ultimate neurological recovery may occur over a variable period of time. Although many clinical variables and grading scales are associated with ICH poor outcome, no clinical variable alone or sole clinical grading scale was suggested by the panel as currently being reliable by itself for use in counseling patients with ICH and their surrogates, regarding functional outcome at 3 months and beyond or 30-day mortality.

CONCLUSIONS

These guidelines provide recommendations on the formal reliability of predictors of poor outcome in the context of counseling patients with ICH and surrogates and suggest broad principles of neuroprognostication. Clinicians formulating their judgments of prognosis for patients with ICH should avoid anchoring bias based solely on any one clinical variable or published clinical grading scale.

Hospital to Hospital Transfers of Cerebral Hemorrhage: Characteristics of Early Withdrawal of Life-Sustaining Treatment

BACKGROUND

Large intracerebral hemorrhages (ICHs) are associated with significant morbidity and mortality. Patient transfer to higher level centers is common, but care in these centers rarely demonstrably improves morbidity or reduces mortality. Patients may rapidly progress to brain death, but a large number die shortly after transferring because of withdrawal of life-sustaining treatment (WOLST). This outcome may result in poor resource use and unnecessary cost to patients, families, and institutions. We sought to determine clinical and radiographic predictors of early death or WOLST that may alter potential transfer.

METHODS

We performed a retrospective review of patients admitted from outside medical centers to the neurosciences intensive care unit at Saint Marys Mayo Clinic Hospital in Rochester, MN, from January 2014 to December 2019. Patients ≥ 18 years old with a spontaneous ICH were included. Exclusion criteria included trauma, subarachnoid hemorrhage, and subdural hematoma. We identified patients who died or underwent WOLST within 24 h of transfer. Descriptive characteristics of patients and ICH were collected. Data were analyzed with univariable, multivariable, and logistic regression. Predictive modeling was performed. An additional case-matched study was completed to evaluate for characteristics further.

RESULTS

A total of 317 consecutive patients were identified. Forty-two patients were found with early death or WOLST within 24 h of transfer. Do not resuscitate/do not intubate (DNR/DNI) code status (odds ratio [OR] 5.23, confidence interval [CI] 3.31-8.28), anticoagulation use (OR 2.11, CI 1.09-4.09), and lower level of consciousness at presentation based on Glasgow Coma Score (OR 1.41, CI 1.29-1.54) and Full Outline of Unresponsiveness (FOUR) score (OR 1.34, CI 1.26-1.46) were associated with WOLST. Associated characteristics on the computed tomography scan included midline shift (OR 4.64, CI 2.32-9.29), hydrocephalus (OR 9.30, CI 4.56-18.96), and intraventricular extension (OR 5.27, CI 2.60-10.68). Case matching restricted to midline shift demonstrated similarity between patients with aggressive care and WOLST. DNR/DNI code status, warfarin use, ICH score, and composite FOUR score were the best predictive characteristics (area under the curve 0.942).

CONCLUSIONS

Early death or WOLST after ICH within 24 h of presentation was most associated with DNR/DNI code status, warfarin use, ICH score, and lower level of consciousness at presentation. These characteristics may be used by clinicians to guide conversations prior to transfer to tertiary care centers.

ADVISING score: a reliable grading scale based on injury and response for intracerebral haemorrhage

BACKGROUND

Intracerebral haemorrhage (ICH) is the most devastating form of stroke causing high morbidity and mortality. We aimed to develop a novel clinical score incorporating multisystem markers to predict functional dependence at 90 days after ICH.

METHODS

We analysed data from Chinese Cerebral Hemorrhage: Mechanism and Intervention study. Multivariable logistic regression analysis was used to identify the factors associated with 90-day functional dependency (the modified Rankin Scale ≥3) after ICH and develop the ADVISING scoring system. To test the scoring system, a total of 2111 patients from Hubei province were included as the training cohort, and 733 patients from other three provinces in China were included as an external validation cohort.

RESULTS

We found nine variables to be significantly associated with functional dependency and included in the ADVISING score system: age, deep location of haematoma, volume of haematoma, National Institutes of Health Stroke Scale, aspartate transaminase, international normalised ratio, neutrophil-lymphocyte ratio, fasting blood glucose and glomerular filtration rate. Individuals were divided into 12 different categories by using these nine potential predictors. The proportion of patients who were functionally dependent increased with higher ADVISING scores, which showed good discrimination and calibration in both the training cohort (C-statistic, 0.866; p value of Hosmer-Lemeshow test, 0.195) and validation cohort (C-statistic, 0.884; p value of Hosmer-Lemeshow test, 0.853). The ADVISING score also showed better discriminative performance compared with the other five existing ICH scores (p<0.001).

CONCLUSIONS

ADVISING score is a reliable tool to predict functional dependency at 90 days after ICH.

In-hospital outcomes of patients with spontaneous supratentorial intracerebral hemorrhage

Spontaneous intracerebral hemorrhage (ICH) in the brain parenchyma accounts for 16.1% of all stroke types in Taiwan. It is responsible for high morbidity and mortality in some underlying causes. The objective of this study is to discover the predicting factors focusing on in-hospital outcomes of patients with spontaneous supratentorial ICH. Between June 2014 and October 2018, there were a total of 159 patients with spontaneous supratentorial ICH ranging from 27 to 91 years old in our institution. Twenty-three patients died during hospitalization, whereas 59 patients had an extended length of stay of >30 days. The outcomes were measured by inpatient death, length of stay, and activity of daily living (ADL). Both univariate and multivariate binary logistic regression, as well as multivariate linear regression, were used for statistical analysis. Multivariate binary linear regression analysis showed the larger hematoma in initial computed tomography scan of >30 cm3 (odds ratio [OR] = 2.505, P = .013) and concurrent in-hospital infection (OR = 4.173, P = .037) were both statistically related to higher mortality. On the other hand, in-hospital infection (≥17.41 days, P = .000) and surgery (≥11.23 days, P = .001) were correlated with a longer length of stay. Lastly, drastically poor change of ADL (ΔADL <-30) was associated with larger initial ICH (>30 cc, OR = 2.915, P = .049), in-hospital concurrent infection (OR = 4.695, P = .01), and not receiving a rehabilitation training program (OR = 3.473, P = .04). The results of this study suggest that age, prothrombin, initial Glasgow Coma Scale, computed tomography image, location of the lesion, and surgery could predict the mortality and morbidity of the spontaneous ICH, which cannot be reversed at the time of occurrence. However, effective control of international normalized ratio level, careful prevention against infection, and the aid of rehabilitation programs might be important factors toward a decrease of inpatient mortality rate, the length of stay, and ADL recovery.

Correlation of Immune-Inflammatory Markers with Clinical Features and Novel Location-Specific Nomograms for Short-Term Outcomes in Patients with Intracerebral Hemorrhage

(1) Background: We investigated the association of four immune-inflammatory markers with clinical features and established location-specific nomograms to predict mortality risk in patients with intracerebral hemorrhage (ICH). (2) Methods: We retrospectively enrolled 613 inpatients with acute ICH. (3) Results: Overall mortality was 22%, which was highest in pontine hemorrhage and lowest in thalamic hemorrhage. All four immune-inflammatory markers exhibited a positive linear correlation with glucose, ICH volume, ICH score, and discharge Modified Rankin Scale (mRS) score. Significant predictors of death due to lobar/putaminal hemorrhage were age, glucose and creatinine levels, initial Glasgow Coma Scale (GCS) score, ICH volume, and presence of intraventricular hemorrhage. None of the immune-inflammatory markers were significant predictors of unfavorable outcome or death. We selected significant factors to establish nomograms for predicting death due to lobar/putaminal, thalamic, pontine, and cerebellar hemorrhages. The C-statistic for predicting death in model I (comprising factors in the establishment of the nomogram) in each type of ICH was higher than that in model II (comprising ICH score alone), except for cerebellar hemorrhage. These nomograms for predicting death had good discrimination (C-index: 0.889 to 0.975) and prediction probabilities (C-index: 0.890 to 0.965). (4) Conclusions: Higher immune-inflammatory markers were associated with larger ICH volume, worse initial GCS, and unfavorable outcomes, but were not independent prognostic predictors. The location-specific nomograms provided novel and accurate models for predicting mortality risk.

Efficacy of Naoxueshu in acute spontaneous intracerebral hemorrhage: a multicenter observational study

OBJECTIVE

To evaluate the efficacy and safety outcome and related risk factors of Naoxueshu in the treatment of acute SICH.

METHODS

Two hundred twenty patients were enrolled in this study. Diagnosis of SICH was based on neuroimaging. All the patients received regular treatment and Naoxueshu oral liquid 10 ml 3 times a day for 14 consecutive days. Surgical intervention was conducted as needed. Efficacy and safety outcomes were evaluated.

RESULTS

Hematoma volume decreased significantly 7 days after Naoxueshu treatment (from 27.3 ± 20.0 to 15.1 ± 15.1 ml, P < 0.0001), and it decreased further in 14-day result (6.9 ± 10.4 ml, P < 0.0001). Patients' neurological function was improved remarkably with NIHSS scores from baseline 13 points to 7-day 7 points (P < 0.0001) and 14-day 4 points (P < 0.0001). Cerebral edema was relieved only 14 days after Naoxueshu treatment (from 3 to 2 points, P < 0.0001). No clinically significant change was found in 7-day and 14-day safety results. Female sex was related independently to large 7-day hematoma volume and worse 7-day NIHSS score while it would not affect patients' 14-day outcomes. Rare cause of SICH (B = 17.4, P = 0.009) alone was related to large 14-day hematoma volume. Worse baseline NIHSS score (B = 0.3, P = 0.003) and early use of Naoxueshu (B = 2.9, P = 0.005) were related to worse 7-day and14-day neurological function.

CONCLUSION

Naoxueshu oral liquid could relieve hematoma volume and cerebral edema safely; meanwhile, it could improve patients' neurological function. Sex, cause of SICH, and time from onset to receive Naoxueshu should be taken into consideration in the treatment of SICH.

The Role of Mfsd2a in Nervous System Diseases

Major facilitator superfamily (MFS) is the maximum and most diversified membrane transporter, acting as uniporters, symporters and antiporters. MFS is considered to have a good development potential in the transport of drugs for the treatment of brain diseases. The major facilitator superfamily domain containing protein 2a (Mfsd2a) is a member of MFS. Mfsd2a-knockout mice have shown a marked decrease of docosahexaenoic acid (DHA) level in brain, exhibiting neuron loss, microcephaly and cognitive deficits, as DHA acts essentially in brain growth and integrity. Mfsd2a has attracted more and more attention in the study of nervous system diseases because of its critical role in maintaining the integrity of the blood-brain barrier (BBB) and transporting DHA, including inhibiting cell transport in central nervous system endothelial cells, alleviating BBB injury, avoiding BBB injury in cerebral hemorrhage model, acting as a carrier etc. Up to now, the clinical research of Mfsd2a in nervous system diseases is rare. This article reviewed the current research progress of Mfsd2a in nervous system diseases. It summarized the physiological functions of Mfsd2a in the occurrence and development of intracranial hemorrhage (ICH), Alzheimer's disease (AD), sepsis-associated encephalopathy (SAE), autosomal recessive primary microcephaly (MCPH) and intracranial tumor, aiming to provide ideas for the basic research and clinical application of Mfsd2a.

Head-to-head comparison of prognostic models of spontaneous intracerebral hemorrhage: tools for personalized care and clinical trial in ICH

To systematically compare 27 ICH models with regard to mortality and functional outcome at 1-month, 3-month and 1-year after ICH. The validation cohort was derived from the Beijing Registration of Intracerebral Hemorrhage. Poor functional outcome was defined as modified Rankin Scale score (mRS) ≥3 at 1-month, 3-month and 1-year after ICH, respectively. The area under the receiver operating characteristic curve (AUROC) and Hosmer-Lemeshow goodness-of-fit test were used to assess model discrimination and calibration. A total number of 1575 patients were included. The mean age was 57.2 ± 14.3 and 67.2% were male. The median NIHSS score on admission was 11 (IQR: 3-21). For predicting mortality at 3-month after ICH, AUROC of 27 ICH models ranged from 0.604 to 0.856. In pairwise comparison, the ICH-FOS (0.856, 95%CI = 0.835-0.878, P < 0.001) showed statistically better discrimination than other models for mortality at 3-month after ICH (all P < 0.05). For predicting poor functional outcome (mRS≥3) at 3-month after ICH, AUROC of 27 ICH models ranged from 0.602 to 0.880. In pairwise comparison with other prediction models, the ICH-FOS was superior in predicting poor functional outcome at 3-month after ICH (all P < 0.001). The ICH-FOS showed the largest Cox and Snell R-square. Similar results were verified for mortality and poor functional outcome at 1-month and 1-year after ICH. Several risk models are externally validated to be effective for risk stratification and outcome prediction after ICH, especially the ICH-FOS, which would be useful tools for personalized care and clinical trial in ICH.

Scoping Review and Commentary on Prognostication for Patients with Intracerebral Hemorrhage with Advances in Surgical Techniques

INTRODUCTION

The intracerebral hemorrhage (ICH) score provides an estimate of 30-day mortality for patients with intracerebral hemorrhage in order to guide research protocols and clinical decision making. Several variations of such scoring systems have attempted to optimize its prognostic value. More recently, minimally invasive surgical techniques are increasingly being used with promising results. As more patients become candidates for surgical intervention, there is a need to re-discuss the best methods for predicting outcomes with or without surgical intervention.

METHODS

We systematically performed a scoping review with a comprehensive literature search by two independent reviewers using the PubMed and Cochrane databases for articles pertaining to the "intracerebral hemorrhage score." Relevant articles were selected for analysis and discussion of potential modifications to account for increasing surgical indications.

RESULTS

A total of 64 articles were reviewed in depth and identified 37 clinical grading scales for prognostication of spontaneous intracerebral hemorrhage. The original ICH score remains the most widely used and validated. Various authors proposed modifications for improved prognostic accuracy, though no single scale showed consistent superiority. Most recently, scales to account for advances in surgical techniques have been developed but lack external validation.

CONCLUSION

We provide the most comprehensive review to date of prognostic grading scales for patients with intracerebral hemorrhage. Current prognostic tools for patients with intracerebral hemorrhage remain limited and may overestimate risk of a poor outcome. As minimally invasive surgical techniques are developed, prognostic scales should account for surgical candidacy and outcomes.

Postsurgical functional outcome prediction model using deep learning framework (Prediction One, Sony Network Communications Inc.) for hypertensive intracerebral hemorrhage

BACKGROUND

Reliable prediction models of intracerebral hemorrhage (ICH) outcomes are needed for decision-making of the treatment. Statistically making such prediction models needs a large number of samples and time-consuming statistical analysis. Deep learning (DL), one of the artificial intelligence, is attractive, but there were no reports on DL-based functional outcome prediction models for ICH outcomes after surgery. We herein made a functional outcome prediction model using DLframework, Prediction One (Sony Network Communications Inc., Tokyo, Japan), and compared it to original ICH score, ICH Grading Scale, and FUNC score.

METHODS

We used 140 consecutive hypertensive ICH patients' data in our hospital between 2012 and 2019. All patients were surgically treated. Modified Rankin Scale 0-3 at 6 months was defined as a favorable outcome. We randomly divided them into 100 patients training dataset and 40 patients validation dataset. Prediction One made the prediction model using the training dataset with 5-fold cross-validation. We calculated area under the curves (AUCs) regarding the outcome using the DL-based model, ICH score, ICH Grading Scale, and FUNC score. The AUCs were compared.

RESULTS

The model made by Prediction One using 64 variables had AUC of 0.997 in the training dataset and that of 0.884 in the validation dataset. These AUCs were superior to those derived from ICH score, ICH Grading Scale, and FUNC score.

CONCLUSION

We easily and quickly made prediction models using Prediction One, even with a small single-center dataset. The accuracy of the DL-based model was superior to those of previous statistically calculated models.

Prognostication after intracerebral hemorrhage: a review

Background

Approximately half of patients with spontaneous intracerebral hemorrhage (ICH) die within 1 year. Prognostication in this context is of great importance, to guide goals of care discussions, clinical decision-making, and risk stratification. However, available prognostic scores are hardly used in clinical practice. The purpose of this review article is to identify existing outcome prediction scores for spontaneous intracerebral hemorrhage (ICH) discuss their shortcomings, and to suggest how to create and validate more useful scores.

Main text

Through a literature review this article identifies existing ICH outcome prediction models. Using the Essen-ICH-score as an example, we demonstrate a complete score validation including discrimination, calibration and net benefit calculations. Score performance is illustrated in the Erlangen UKER-ICH-cohort (NCT03183167). We identified 19 prediction scores, half of which used mortality as endpoint, the remainder used disability, typically the dichotomized modified Rankin score assessed at variable time points after the index ICH. Complete score validation by our criteria was only available for the max-ICH score. Our validation of the Essen-ICH-score regarding prediction of unfavorable outcome showed good discrimination (area under the curve 0.87), fair calibration (calibration intercept 1.0, slope 0.84), and an overall net benefit of using the score as a decision tool. We discuss methodological pitfalls of prediction scores, e.g. the withdrawal of care (WOC) bias, physiological predictor variables that are often neglected by authors of clinical scores, and incomplete score validation. Future scores need to integrate new predictor variables, patient-reported outcome measures, and reduce the WOC bias. Validation needs to be standardized and thorough. Lastly, we discuss the integration of current ICH scoring systems in clinical practice with the awareness of their shortcomings.

Conclusion

Presently available prognostic scores for ICH do not fulfill essential quality standards. Novel prognostic scores need to be developed to inform the design of research studies and improve clinical care in patients with ICH.

Supplementary Information

The online version contains supplementary material available at 10.1186/s42466-021-00120-5.

Baseline factors associated with early and late death in intracerebral haemorrhage survivors

Background and purpose

The aim of this study was to determine whether early and late death are associated with different baseline factors in intracerebral haemorrhage (ICH) survivors.

Methods

This was a secondary analysis of the multicentre prospective observational CROMIS‐2 ICH study. Death was defined as ‘early’ if occurring within 6 months of study entry and ‘late’ if occurring after this time point.

Results

In our cohort (n = 1094), there were 306 deaths (per 100 patient‐years: absolute event rate, 11.7; 95% confidence intervals, 10.5–13.1); 156 were ‘early’ and 150 ‘late’. In multivariable analyses, early death was independently associated with age [per year increase; hazard ratio (HR), 1.05, P = 0.003], history of hypertension (HR, 1.89, P = 0.038), pre‐event modified Rankin scale score (per point increase; HR, 1.41, P < 0.0001), admission National Institutes of Health Stroke Scale score (per point increase; HR, 1.11, P < 0.0001) and haemorrhage volume >60 mL (HR, 4.08, P < 0.0001). Late death showed independent associations with age (per year increase; HR, 1.04, P = 0.003), pre‐event modified Rankin scale score (per point increase; HR, 1.42, P = 0.001), prior anticoagulant use (HR, 2.13, P = 0.028) and the presence of intraventricular extension (HR, 1.73, P = 0.033) in multivariable analyses. In further analyses where time was treated as continuous (rather than dichotomized), the HR of previous cerebral ischaemic events increased with time, whereas HRs for Glasgow Coma Scale score, National Institutes of Health Stroke Scale score and ICH volume decreased over time.

Conclusions

We provide new evidence that not all baseline factors associated with early mortality after ICH are associated with mortality after 6 months and that the effects of baseline variables change over time. Our findings could help design better prognostic scores for later death after ICH.

Assessment and Comparison of the Four Most Extensively Validated Prognostic Scales for Intracerebral Hemorrhage: Systematic Review with Meta-analysis

BACKGROUND/OBJECTIVE

Intracerebral hemorrhage (ICH) is a devastating disorder, responsible for 10% of all strokes. Several prognostic scores have been developed for this population to predict mortality and functional outcome. The aim of this study was to determine the four most frequently validated and most widely used scores, assess their discrimination for both outcomes by means of a systematic review with meta-analysis, and compare them using meta-regression.

METHODS

PubMed, ISI Web of Knowledge, Scopus, and CENTRAL were searched for studies validating the ICH score, ICH-GS, modified ICH, and the FUNC score in ICH patients. C-statistic was chosen as the measure of discrimination. For each score and outcome, C-statistics were aggregated at four different time points using random effect models, and heterogeneity was evaluated using the I² statistic. Score comparison was undertaken by pooling all C-statistics at different time points using robust variance estimation (RVE) and performing meta-regression, with the score used as the independent variable.

RESULTS

Fifty-three studies were found validating the original ICH score, 14 studies were found validating the ICH-GS, eight studies were found validating the FUNC score, and five studies were found validating the modified ICH score. Most studies attempted outcome prediction at 3 months or earlier. Pooled C-statistics ranged from 0.76 for FUNC functional outcome prediction at discharge to 0.85 for ICH-GS mortality prediction at 3 months, but heterogeneity was high across studies. RVE showed the ICH score retained the highest discrimination for mortality (c = 0.84), whereas the modified ICH score retained the highest discrimination for functional outcome (c = 0.80), but these differences were not statistically significant.

CONCLUSIONS

The ICH score is the most extensively validated score in ICH patients and, in the absence of superior prediction by other scores, should preferably be used. Further studies are needed to validate prognostic scores at longer follow-ups and assess the reasons for heterogeneity in discrimination.

The PLAN score can predict poor outcomes of intracerebral hemorrhage

Background

For patients hospitalized after acute ischemic stroke (AIS), the preadmission comorbidities, level of consciousness (LOC), age and neurologic deficit (PLAN) score can help to identify those who may have a poor outcome. Implementing the PLAN score in other types of stroke may also have predictive value. Our study aimed to evaluate the PLAN score's prognostic accuracy in predicting 1-year mortality and severe disability after intracerebral hemorrhage (ICH).

Methods

We analyzed data found in the China National Stroke Registry (CNSR) of 2,453 hospitalized patients in 132 urban Chinese hospitals, diagnosed with ICH from September 2007 to August 2008. The outcomes analysis included 30-day mortality, modified Rankin Scale score (mRS) of 5-6 at discharge, and 1-year mortality. Univariate and multivariate analysis was performed, and we calculated consistency statistics (C statistic). We evaluated the PLAN score performance using area under the curve (AUC) calculations.

Results

We found that the 30-day mortality was 12.6%, the frequency of a mRS 5-6 at discharge was 20.6%, and 1-year mortality was 21.9%. The PLAN score had good predictive value in 30-day mortality (C statistic, 0.82), death or severe dependence at discharge (0.84), and 1-year mortality (0.82).

Conclusions

In patients hospitalized for ICH, the 30-day mortality, death or severe dependence at discharge and 1-year mortality can be predicted by the PLAN score. Similarly to patients hospitalized after AIS, the PLAN score can help to identify patients likely to have poor outcomes following hospitalization for ICH.

Modifying the Intracerebral Hemorrhage Score to Suit the Needs of the Developing World

Background:

Published literature on intracerebral haemorrhage (ICH) from the Indian subcontinent is very scarce. The study aims to assess the prognostic factors influencing outcome and validating the ICH score which is widely used to prognosticate the disease in this financially constraint population. Prognosticating the outcome at the time of admission is important to customize treatment in a cost-effective manner.

Materials and Methods:

We conducted a prospective study of all Spontaneous ICH patients admitted from February 2015 to May 2016. Data pertaining to patient demographics, clinical findings, biochemical parameters and cranial computed tomography (CT) findings were recorded. mRS (modified Rankin score) was used to assess outcome at discharge and at three month follow up.

Results:

A total of 215 patients with hypertensive haemorrhage were analysed. The mean age of our cohort was 57.64 years and volume of bleed was 24.5ml. 73% pf patients with GCS<8, 46% with Intraventricular extension and 57% with hematoma volume >30 were died at the end of 3 months. Twenty eight patients succumbed during hospitalization while 38 died after their discharge. Mortality rates were 5%,16%, 33%, 54% and 93% for ICH Scores of 0, 1, 2, 3 and 4. The rICH score after modifying the age parameter in the ICH score to 70 years had mortality rates of 6%,15%,25%,51%,75% and 100%.

Conclusion:

ICH Score failed to accurately predict mortality in our cohort. ICH is predominately seen at a younger age group in our country and hence have better outcomes in comparison to the west. We propose a minor modification in the ICH score by reducing the age criteria by 10 years to prognosticate the disease better in our population.

Prognostic models for intracerebral hemorrhage: systematic review and meta-analysis

Background

Prognostic tools for intracerebral hemorrhage (ICH) patients are potentially useful for ascertaining prognosis and recommended in guidelines to facilitate streamline assessment and communication between providers. In this systematic review with meta-analysis we identified and characterized all existing prognostic tools for this population, performed a methodological evaluation of the conducting and reporting of such studies and compared different methods of prognostic tool derivation in terms of discrimination for mortality and functional outcome prediction.

Methods

PubMed, ISI, Scopus and CENTRAL were searched up to 15th September 2016, with additional studies identified using reference check. Two reviewers independently extracted data regarding the population studied, process of tool derivation, included predictors and discrimination (c statistic) using a predesignated spreadsheet based in the CHARMS checklist. Disagreements were solved by consensus. C statistics were pooled using robust variance estimation and meta-regression was applied for group comparisons using random effect models.

Results

Fifty nine studies were retrieved, including 48,133 patients and reporting on the derivation of 72 prognostic tools. Data on discrimination (c statistic) was available for 53 tools, 38 focusing on mortality and 15 focusing on functional outcome. Discrimination was high for both outcomes, with a pooled c statistic of 0.88 for mortality and 0.87 for functional outcome. Forty three tools were regression based and nine tools were derived using machine learning algorithms, with no differences found between the two methods in terms of discrimination (p = 0.490). Several methodological issues however were identified, relating to handling of missing data, low number of events per variable, insufficient length of follow-up, absence of blinding, infrequent use of internal validation, and underreporting of important model performance measures.

Conclusions

Prognostic tools for ICH discriminated well for mortality and functional outcome in derivation studies but methodological issues require confirmation of these findings in validation studies. Logistic regression based risk scores are particularly promising given their good performance and ease of application.

Electronic supplementary material

The online version of this article (10.1186/s12874-018-0613-8) contains supplementary material, which is available to authorized users.

Development and validation of the hypertensive intracerebral hemorrhage prognosis models

To develop and validate the prognosis model of hypertensive intracerebral hemorrhage based on admission characteristics, which would be applied to predict the 3-month outcome.For developing the prognosis models, we studied data from 325 patients with retrospectively consecutive hypertensive intracerebral hemorrhage admitted between 2012 and 2016. The predictive value of admission characteristics was tested in logistic regression models, presenting 3-month outcome as the primary outcome. The performance of the models was tested by discrimination and calibration. After development, internal and external validations were used to test the function.The multivariate analysis of logistic regression indicated that age, Glasgow coma scale score, pupillary light reflex, hypoxemia, intracerebral hemorrhage volume, blood glucose, and D-dimer level were independent factors of the hypertensive intracerebral hemorrhage prognosis model. The prognosis model based on those admission risk factors worked well. The receiver operating characteristic curve was used to analyze the discriminant ability of model A, model A + B, and model A + B + C. Specifically, the area under the receiver operating characteristic curve increased from 0.816 (model A; 95% CI, 0.760-0.872) to 0.913 (model A + B + C; 95% CI, 0.881-0.946), and the models were not overoptimistic and were applicably confirmed by internal and external validations respectively.This prognosis model could be used to predict the prognosis of patients with hypertensive intracerebral hemorrhage early, simply and accurately, contributing to the clinical treatment eventually.

Influence of Admission Blood Glucose in Predicting Outcome in Patients With Spontaneous Intracerebral Hematoma

Background and Aims: Hyperglycemia or elevated blood glucose levels have been associated with poor outcomes in patients with ischemic stroke yet control of hyperglycemia has not resulted in good outcomes. High admission blood glucose (ABG) values have been mitigated by other poor prognosticators like large hematoma volume, intraventricular extension (IVE) of hematoma and poor GCS. The aim of this study was to evaluate the effects of blood glucose levels at admission, on mortality and functional outcomes at discharge and 3 months follow up. Methods: This was a retrospective observational study conducted at a tertiary care. Patients with spontaneous SICH were enrolled from a prospective SICH register maintained at our hospital. Blood glucose values were recorded on admission. Patients with traumatic hematomas, vascular malformations, aneurysms, and coagulation abnormalities were excluded from our study. Results: A total of 510 patients were included in the study. We dichotomised our cohort into two groups, group A with ABG>160 mg/dl and group B with ABG<160 mg/dl. Mean blood glucose levels in these two groups were 220.73 mg/dl and 124.37 mg/dl respectively, with group A having twice the mortality. mRS at discharge and 3 months was better in Group B (p ≤ 0.001) as compared to Group A. Age, GCS, volume of hematoma, ABG, IVE and Hydrocephalus were significant predictors of mortality and poor outcome on univariate analysis with a p < 0.05. The relationship between ABG and mortality (P = 0.249, 95% CI 0.948-1.006) and outcome (P = 0.538, 95% CI 0.997-1.005) failed to reach statistical significance on multivariate logistic regression. Age, Volume of hematoma and GCS were stronger predictors of mortality and morbidity. Conclusion: Admission blood glucose levels was not an independent predictor of mortality in our study when adjusted with age, GCS, and hematoma volume. The effect of high ABG on SICH outcome is probably multifactorial and warrants further research.

Validation of Prognostic Models to Predict Early Mortality in Spontaneous Intracerebral Hemorrhage: A Cross-Sectional Evaluation of a Singapore Stroke Database

OBJECTIVE

Numerous scores have been developed for prognostication of outcomes in intracerebral hemorrhage (ICH). Prediction models must be validated internally and externally before they are considered widely applicable. We aim to independently externally validate and compare 3 prediction models (ICH score, ICH grading scale [ICH-GS], and simplified ICH [sICH]) in our population, which has not been previously done.

METHODS

We reviewed 1338 patients with spontaneous ICH consecutively admitted to the National Neuroscience Institute, Singapore, between January 2009 and November 2013. We analyzed prospectively collected data of admission characteristics (clinical, neuroimaging, and laboratory findings). All 3 scores prognosticated 30-day mortality. Validation was based on calibration, goodness-of-fit tests, and discrimination (area under receiver operating characteristic curve [AUC]). Akaike information criterion (AIC) and decision curve analysis (DCA) were used to directly compare the scores.

RESULTS

All 3 models showed good calibration and both the Hosmer-Lemeshow and the le Cessie-van Houwelingen-Copas goodness-of-fit test showed P values >0.05. AUCs ranged from 0.86 to 0.90, indicating good discriminative ability, with the ICH-GS performing the best with the highest AUC, lowest AIC (849), and overall highest net benefit in the DCA.

CONCLUSIONS

This study successfully independently validates the ICH score, ICH-GS, and sICH score in a large patient cohort with spontaneous ICH, which has not been previously done in this non-Western population. We recommend the use of the ICH-GS as a prognostication tool in our patients instead of the widely used ICH score.

Severity assessment in maximally treated ICH patients

Objective:

As common prognostication models in intracerebral hemorrhage (ICH) are developed variably including patients with early (<24 hours) care limitations (ECL), we investigated its interaction with prognostication in maximally treated patients and sought to provide a new unbiased severity assessment tool.

Methods:

This observational cohort study analyzed consecutive ICH patients (n = 583) from a prospective registry over 5 years. We characterized the influence of ECL on overall outcome by propensity score matching and on conventional prognostication using receiver operating characteristic analyses. We established the max-ICH score based on independent predictors of 12-month functional outcome in maximally treated patients and compared it to existing models.

Results:

Prevalence of ECL was 19.2% (n = 112/583) and all of these patients died. Yet propensity score matching displayed that 50.7% (n = 35/69) theoretically could have survived, with 18.8% (n = 13/69) possibly reaching favorable outcome (modified Rankin Scale score 0–3). Conventional prognostication seemed to be confounded by ECL, documented by a decreased predictive validity (area under the curve [AUC] 0.67, confidence interval [CI] 0.61–0.73 vs AUC 0.80, CI 0.76–0.83; p < 0.01), overestimating poor outcome (mortality by 44.8%, unfavorable outcome by 10.1%) in maximally treated patients. In these patients, the novel max-ICH score (0–10) integrates strength-adjusted predictors, i.e., NIH Stroke Scale score, age, intraventricular hemorrhage, anticoagulation, and ICH volume (lobar and nonlobar), demonstrating improved predictive accuracy for functional outcome (12 months: AUC 0.81, CI 0.77–0.85; p < 0.01). The max-ICH score may more accurately delineate potentials of aggressive care, showing favorable outcome in 45.4% (n = 214/471) and a long-term mortality rate of only 30.1% (n = 142/471).

Conclusions:

Care limitations significantly influenced the validity of common prognostication models resulting in overestimation of poor outcome. The max-ICH score demonstrated increased predictive validity with minimized confounding by care limitations, making it a useful tool for severity assessment in ICH patients.

To Explore Intracerebral Hematoma with a Hybrid Approach and Combination of Discriminative Factors

OBJECTIVES

To find discriminative combination of influential factors of Intracerebral hematoma (ICH) to cluster ICH patients with similar features to explore relationship among influential factors and 30-day mortality of ICH.

METHODS

The data of ICH patients are collected. We use a decision tree to find discriminative combination of the influential factors. We cluster ICH patients with similar features using Fuzzy C-means algorithm (FCM) to construct a support vector machine (SVM) for each cluster to build a multi-SVM classifier. Finally, we designate each testing data into its appropriate cluster and apply the corresponding SVM classifier of the cluster to explore the relationship among impact factors and 30-day mortality.

RESULTS

The two influential factors chosen to split the decision tree are Glasgow coma scale (GCS) score and Hematoma size. FCM algorithm finds three centroids, one for high danger group, one for middle danger group, and the other for low danger group. The proposed approach outperforms benchmark experiments without FCM algorithm to cluster training data.

CONCLUSIONS

It is appropriate to construct a classifier for each cluster with similar features. The combination of factors with significant discrimination as input variables should outperform that with only single discriminative factor as input variable.

Clinician judgment vs formal scales for predicting intracerebral hemorrhage outcomes

OBJECTIVE

To compare the performance of formal prognostic instruments vs subjective clinical judgment with regards to predicting functional outcome in patients with spontaneous intracerebral hemorrhage (ICH).

METHODS

This prospective observational study enrolled 121 ICH patients hospitalized at 5 US tertiary care centers. Within 24 hours of each patient's admission to the hospital, one physician and one nurse on each patient's clinical team were each asked to predict the patient's modified Rankin Scale (mRS) score at 3 months and to indicate whether he or she would recommend comfort measures. The admission ICH score and FUNC score, 2 prognostic scales selected for their common use in neurologic practice, were calculated for each patient. Spearman rank correlation coefficients (r) with respect to patients' actual 3-month mRS for the physician and nursing predictions were compared against the same correlation coefficients for the ICH score and FUNC score.

RESULTS

The absolute value of the correlation coefficient for physician predictions with respect to actual outcome (0.75) was higher than that of either the ICH score (0.62, p = 0.057) or the FUNC score (0.56, p = 0.01). The nursing predictions of outcome (r = 0.72) also trended towards an accuracy advantage over the ICH score (p = 0.09) and FUNC score (p = 0.03). In an analysis that excluded patients for whom comfort care was recommended, the 65 available attending physician predictions retained greater accuracy (r = 0.73) than either the ICH score (r = 0.50, p = 0.02) or the FUNC score (r = 0.42, p = 0.004).

CONCLUSIONS

Early subjective clinical judgment of physicians correlates more closely with 3-month outcome after ICH than prognostic scales.

Prognostic Tools for Early Mortality in Hemorrhagic Stroke: Systematic Review and Meta-Analysis

Background and Purpose

Several risk scores have been developed to predict mortality in intracerebral hemorrhage (ICH). We aimed to systematically determine the performance of published prognostic tools.

Methods

We searched MEDLINE and EMBASE for prognostic models (published between 2004 and April 2014) used in predicting early mortality (<6 months) after ICH. We evaluated the discrimination performance of the tools through a random-effects meta-analysis of the area under the receiver operating characteristic curve (AUC) or c-statistic. We evaluated the following components of the study validity: study design, collection of prognostic variables, treatment pathways, and missing data.

Results

We identified 11 articles (involving 41,555 patients) reporting on the accuracy of 12 different tools for predicting mortality in ICH. Most studies were either retrospective or post-hoc analyses of prospectively collected data; all but one produced validation data. The Hemphill-ICH score had the largest number of validation cohorts (9 studies involving 3,819 patients) within our systematic review and showed good performance in 4 countries, with a pooled AUC of 0.80 [95% confidence interval (CI)=0.77-0.85]. We identified several modified versions of the Hemphill-ICH score, with the ICH-Grading Scale (GS) score appearing to be the most promising variant, with a pooled AUC across four studies of 0.87 (95% CI=0.84-0.90). Subgroup testing found statistically significant differences between the AUCs obtained in studies involving Hemphill-ICH and ICH-GS scores (p=0.01).

Conclusions

Our meta-analysis evaluated the performance of 12 ICH prognostic tools and found greater supporting evidence for 2 models (Hemphill-ICH and ICH-GS), with generally good performance overall.

Up-regulation of c-Fos associated with neuronal apoptosis following intracerebral hemorrhage

The proto-oncogene c-Fos is an important member of the activating protein 1 (AP-1) transcription complex involved in major cellular functions such as transformation, proliferation, differentiation, and apoptosis. The expression of c-Fos is very tightly regulated and responses rapidly and transiently to a plethora of apoptotic stimuli. However, it is still unclear how c-Fos functions on neuronal activities following intracerebral hemorrhage (ICH). In the present studies, we uncovered that the up-regulation of c-Fos is related to neuronal apoptosis following ICH probably via FasL/Fas apoptotic pathway. From the results of Western blot and immunohistochemistry, we obtained that c-Fos is significantly up-regulated surrounding the hematoma following ICH and co-locates with active caspase-3 in the neurons. Besides, electrophoretic mobility shift assay exhibits high AP-1 DNA-binding activities in ICH groups due to the increase of c-Fos expression. In addition, there are concomitant up-regulation of Fas ligand (FasL), which is the target protein of AP-1, Fas, active caspase-8, and active caspase-3 in vivo and in vitro studies. What is more, our in vitro study showed that using c-Fos-specific RNA interference in primary cortical neurons, the expression of FasL and active caspase-3 are suppressed. Thus, our results indicated that c-Fos might exert its pro-apoptotic function on neuronal apoptosis following ICH.

Validation of clinical prediction scores in patients with primary intracerebral hemorrhage

BACKGROUND

Initial reports of the FUNC score suggest that it may accurately identify those patients suffering from intracerebral hemorrhage (ICH) with an ultra low chance of functional neurologic recovery. This study's aim is to validate the FUNC score and determine if it accurately identifies the cohort of patients with an ultra low chance of survival with good neurologic recovery.

METHODS

Retrospective review of 501 consecutive primary ICH patients admitted from the Emergency Department to a large healthcare system. Performance of the FUNC, ICH-GS, and oICH scores was determined by calculating areas under the receiver-operator-characteristic curves. Patients with a predicted 100 % chance of poor neurologic outcome (PNO) (FUNC <4 and ICH-GS >10) scores were evaluated to determine if DNR impacted 90 day survival or rate of survival with a Glasgow Outcome Score of <3.

RESULTS

In 366 cases of primary ICH who presented during the study period, 222(61 %) survived to discharge. Both the FUNC (AUC: 0.873) and ICH-GS (AUC: 0.888) outperformed the oICH (AUC: 0.743) in predicting 90-day mortality (p = <0.001). Of 68 patients with a FUNC score <4, 67 (98.5 %) had PNO at discharge. The presence of DNR was not associated with a significant difference in the rate of PNO at discharge (40/40 = 100 % vs. 27/28 = 96.4 % p = 0.42) or 90-day mortality (40/40 = 100 % vs. 21/28 = 75 %, p = 0.06).

CONCLUSION

The FUNC and ICH-GS appear superior to the oICH in predicting outcome in patients with primary ICH. In addition, the FUNC score appears to accurately identify patients with low chance of functional neurologic recovery at discharge.

Hematoma shape, hematoma size, Glasgow coma scale score and ICH score: which predicts the 30-day mortality better for intracerebral hematoma?

PURPOSE

To investigate the performance of hematoma shape, hematoma size, Glasgow coma scale (GCS) score, and intracerebral hematoma (ICH) score in predicting the 30-day mortality for ICH patients. To examine the influence of the estimation error of hematoma size on the prediction of 30-day mortality.

MATERIALS AND METHODS

This retrospective study, approved by a local institutional review board with written informed consent waived, recruited 106 patients diagnosed as ICH by non-enhanced computed tomography study. The hemorrhagic shape, hematoma size measured by computer-assisted volumetric analysis (CAVA) and estimated by ABC/2 formula, ICH score and GCS score was examined. The predicting performance of 30-day mortality of the aforementioned variables was evaluated. Statistical analysis was performed using Kolmogorov-Smirnov tests, paired t test, nonparametric test, linear regression analysis, and binary logistic regression. The receiver operating characteristics curves were plotted and areas under curve (AUC) were calculated for 30-day mortality. A P value less than 0.05 was considered as statistically significant.

RESULTS

The overall 30-day mortality rate was 15.1% of ICH patients. The hematoma shape, hematoma size, ICH score, and GCS score all significantly predict the 30-day mortality for ICH patients, with an AUC of 0.692 (P = 0.0018), 0.715 (P = 0.0008) (by ABC/2) to 0.738 (P = 0.0002) (by CAVA), 0.877 (P<0.0001) (by ABC/2) to 0.882 (P<0.0001) (by CAVA), and 0.912 (P<0.0001), respectively.

CONCLUSION

Our study shows that hematoma shape, hematoma size, ICH scores and GCS score all significantly predict the 30-day mortality in an increasing order of AUC. The effect of overestimation of hematoma size by ABC/2 formula in predicting the 30-day mortality could be remedied by using ICH score.

A novel risk score to predict 1-year functional outcome after intracerebral hemorrhage and comparison with existing scores

Introduction

Spontaneous intracerebral hemorrhage (ICH) is one of leading causes of mortality and morbidity worldwide. Several predictive models have been developed for ICH; however, none of them have been consistently used in routine clinical practice or clinical research. In the study, we aimed to develop and validate a risk score for predicting 1-year functional outcome after ICH (ICH Functional Outcome Score, ICH-FOS). Furthermore, we compared discrimination of the ICH-FOS and 8 existing ICH scores with regard to 30-day, 3-month, 6-month, and 1-year functional outcome and mortality after ICH.

Methods

The ICH-FOS was developed based on the China National Stroke Registry, in which eligible patients were randomly divided into derivation (60%) and validation (40%) cohorts. Poor functional outcome was defined as modified Rankin Scale score (mRS) ≥3 at 1 year after ICH. Multivariable logistic regression was performed to determine independent predictors, and β-coefficients were used to generate scoring system of the ICH-FOS. The area under the receiver operating characteristic curve (AUROC) and Hosmer-Lemeshow goodness-of-fit test were used to assess model discrimination and calibration.

Results

The overall 1-year poor functional outcome (mRS ≥ 3) was 46.7% and 44.9% in the derivation (n = 1,953) and validation (n = 1,302) cohorts, respectively. A 16-point ICH-FOS was developed from the set of independent predictors of 1-year poor functional outcome after ICH including age (P < 0.001), admission National Institutes of Health Stroke Scale score (P < 0.001), Glasgow Coma Scale score (P < 0.001), blood glucose (P = 0.002), ICH location (P < 0.001), hematoma volume (P < 0.001), and intraventricular extension (P < 0.001). The ICH-FOS showed good discrimination (AUROC) in the derivation (0.836, 95% CI: 0.819-0.854) and validation (0.830, 95% CI: 0.808-0.852) cohorts. The ICH-FOS was well calibrated (Hosmer-Lemeshow test) in the derivation (P = 0.42) and validation (P = 0.39) cohort. When compared to 8 prior ICH scores, the ICH-FOS showed significantly better discrimination with regard to 1-year functional outcome and mortality after ICH (all P < 0.0001). Meanwhile, the ICH-FOS also demonstrated either comparable or significantly better discrimination for poor functional outcome and mortality at 30-day, 3-month, and 6-month after ICH.

Conclusion

The ICH-FOS is a valid clinical grading scale for 1-year functional outcome after ICH. Further validation of the ICH-FOS in different populations is needed.

Artificial neural networks based early clinical prediction of mortality after spontaneous intracerebral hemorrhage

Numerous outcome prediction models have been developed for mortality and functional outcome after spontaneous intracerebral haemorrhage (ICH). However, no outcome prediction model for ICH has considered the impact of care restriction. To develop and compare results of the artificial neural networks (ANN) and logistic regression (LR) models, based on initial clinical parameters, for prediction of mortality after spontaneous ICH. Analysis has been conducted on consecutive dataset of patients with spontaneous ICH, over 5-year period in tertiary care academic hospital. Patients older than 18 years were eligible for inclusion if they had been presented within 6 h from the start of symptoms and had evidence of spontaneous supratentorial ICH on initial brain computed tomography within 24 h. Initial clinical parameters have been used to develop LR and ANN prediction models for hospital mortality as outcome measure. Models have been accessed for discrimination and calibration abilities. We have analyzed 411 patients (199 males and 212 females) with spontaneous ICH, medically treated and not withdrawn from therapy, with average age of 67.35 years. From them, 256 (62.29%) patients died during hospital treatment and 155 (37.71%) patients survived. In the observed dataset, ANN model overall correctly classified outcome in 93.55% of patients, compared with 79.32% of correct classification for the LR model. Discrimination and calibration parameters indicate that both models show an adequate fit of expected and observed values, with superiority of ANN model. Our results favour the ANN model for prediction of mortality after spontaneous ICH. Further studies of the strengths and limitations of this method are needed with larger prospective samples.

Serum biomarkers of spontaneous intracerebral hemorrhage induced secondary brain injury

Intracerebral hemorrhage (ICH) is a devastating form of stroke associated with a high rate of morbidity and mortality. It is now believed that much of this damage occurs in the subacute period following the initial insult via a cascade of complex pathophysiologic pathways that continues to be investigated. Increased levels of certain serum proteins have been identified as biomarkers that may reflect or directly participate in the inflammation, blood brain barrier disruption, endothelial dysfunction, and neuronal and glial toxicity that occur during this secondary period of cerebral injury. Some of these biomarkers have the potential to serve as therapeutic targets or surrogate endpoints for future research or clinical trials. Others may someday augment current clinical techniques in diagnosis, risk-stratification, prognostication, treatment decision and measurement of therapeutic efficacy. While much work remains to be done, biomarkers show significant potential to expand clinical options and improve clinical management, thereby reducing mortality and improving functional outcomes in ICH patients.

Correlation of leukocytosis with early neurological deterioration following supratentorial intracerebral hemorrhage

Intracerebral hemorrhage (ICH) is a devastating and common admitting diagnosis to intensive care units in the USA. Despite advances in critical care, patients with ICH often experience early neurological deterioration (END) in the first 72 hours after admission due to a variety of factors, including hematoma and cerebral edema evolution. The purpose of this study was to determine factors associated with END after ICH. Using the Duke University Hospital Neuroscience Critical Care Unit Database, we retrospectively identified patients with an admitting diagnosis of supratentorial ICH from January to December 2010, verified by CT imaging. END was defined as a decrease in the Glasgow Coma Scale score of ≥3 or death within the first 72 hours after hemorrhage. The chi-squared or t-test analysis was used to compare the groups, as appropriate. Multiple logistical regression modeling was performed to test for associations between likely predictors of END. Of the 89 subjects admitted with supratentorial ICH, we included 83 in the analysis based on complete datasets. Of these, 31 experienced END within 72 hours after onset of symptoms. ICH score, presence of midline shift on imaging, and white blood cell (WBC) count were used in a regression model for predicting END. WBC count demonstrated the greatest association with END. Patients with ICH are prone to END within the first few days after hemorrhage. Elevated WBC count appears predictive of deterioration. These data demonstrate that heightened inflammatory state after ICH may be related to early deterioration after injury.

A comparative evaluation of existing grading scales in intracerebral hemorrhage

BACKGROUND

In recent years, a multitude of clinical grading scales have been created to help identify patients at greater risk of poor outcome following ICH. We sought to validate and compare eight of the most frequently used ICH grading scales in a prospective cohort.

METHODS

Eight grading scales were calculated for 67 patients with non-traumatic ICH enrolled in the prospective intracerebral hemorrhage outcomes project (ICHOP) database. Receiver operating characteristic (ROC) analysis, including area under the curve (AUC) and maximum Youden Index were used to assess the ability of each score to predict in-hospital mortality, long-term (3 months) mortality, and functional outcome at 3 months (mRS ≥ 3).

RESULTS

All scales demonstrated excellent to outstanding discrimination for in-hospital and long-term mortality, with no significant differences between them after controlling for the false discovery rate. All scales demonstrated acceptable to outstanding discrimination for functional outcome at 3 months, with the new ICH score demonstrating significantly lower AUC than 6 of the 8 scores. Essen ICH score was the only score to demonstrate outstanding discrimination for each outcome measure.

CONCLUSION

Though significant differences were minimal in our cohort, we showed the existing selection of ICH grading scales to be useful in stratifying patients according to risk of mortality and poor functional outcome. Continued validation and comparison in large prospective cohorts will bring the goal of a singular prognostic model for ICH closer to fruition.

The prediction of 30-day mortality in patients with primary pontine hemorrhage: a scoring system comparison

BACKGROUND AND PURPOSE

Owing to its low morbidity but high mortality, no accurate scoring system focuses on primary pontine hemorrhage (PPH) has been established. We aim to compare the performances of the Acute Physiology and Chronic Health Evaluation (APACHE) II and the Simplified Acute Physiology Score (SAPS) II with the ICH score in predicting the 30-day mortality in patients with PPH.

METHODS

We conducted a retrospective analysis of patients admitted with a diagnosis of PPH to a university-affiliated hospital in southern China from May 2000 to June 2011. Data related to patient demographics and that necessary to calculate APACHE II, SAPS II, and ICH score were recorded. Performances of these scoring systems were presented as calibration and discrimination, which were measured by the Hosmer-Lemeshow goodness-of-fit test and the area under the receiver operating characteristic (ROC) curve, respectively.

RESULTS

Among 75 patients with PPH finally included, 31 (41.3%) died within 30 days. SAPS II (χ(2) = 6.57, P = 0.682) had the best calibration, followed by APACHE II (χ(2) = 8.06, P = 0.428) and ICH score (χ(2) = 4.94, P = 0.176). Furthermore, in terms of area under the ROC curve, APACHE II (0.919) was more discriminative than SAPS II (0.890) and ICH score (0.844).

CONCLUSIONS

In predicting 30-day mortality in patients with PPH, SAPS II has the best calibration, while APACHE II has the highest discrimination. The ICH score, which is easier and simpler to calculate, should be modified for PPH.

Evaluation of intraventricular hemorrhage assessment methods for predicting outcome following intracerebral hemorrhage

Object

Intraventricular hemorrhage (IVH) associated with intracerebral hemorrhage (ICH) is an independent predictor of poor outcome. Clinical methods for evaluating IVH, however, are not well established. This study sought to determine the best IVH grading scale by evaluating the predictive accuracies of IVH, Graeb, and LeRoux scores in an independent cohort of ICH patients with IVH. Subacute IVH dynamics as well as the impact of external ventricular drain (EVD) placement on IVH and outcome were also investigated.

Methods

A consecutive cohort of 142 primary ICH patients with IVH was admitted to Columbia University Medical Center between February 2009 and February 2011. Baseline demographics, clinical presentation, and hospital course were prospectively recorded. Admission CT scans performed within 24 hours of onset were reviewed for ICH location, hematoma volume, and presence of IVH. Intraventricular hemorrhage was categorized according to IVH, Graeb, and LeRoux scores. For each patient, the last scan performed within 6 days of ictus was similarly evaluated. Outcomes at discharge were assessed using the modified Rankin Scale (mRS). Receiver operating characteristic analysis was used to determine the predictive accuracies of the grading scales for poor outcome (mRS score ≥ 3).

Results

Seventy-three primary ICH patients (51%) had IVH. Median admission IVH, Graeb, and LeRoux scores were 13, 6, and 8, respectively. Median IVH, Graeb and LeRoux scores decreased to 9 (p = 0.005), 4 (p = 0.002), and 4 (p = 0.003), respectively, within 6 days of ictus. Poor outcome was noted in 55 patients (75%). Areas under the receiver operating characteristic curve were similar among the IVH, Graeb, and LeRoux scores (0.745, 0.743, and 0.744, respectively) and within 6 days postictus (0.765, 0.722, 0.723, respectively). Moreover, the IVH, Graeb, and LeRoux scores had similar maximum Youden Indices both at admission (0.515 vs 0.477 vs 0.440, respectively) and within 6 days postictus (0.515 vs 0.339 vs 0.365, respectively). Patients who received EVDs had higher mean IVH volumes (23 ± 26 ml vs 9 ± 11 ml, p = 0.003) and increased incidence of Glasgow Coma Scale scores < 8 (67% vs 38%, p = 0.015) and hydrocephalus (82% vs 50%, p = 0.004) at admission but had similar outcome as those who did not receive an EVD.

Conclusions

The IVH, Graeb, and LeRoux scores predict outcome well with similarly good accuracy in ICH patients with IVH when assessed at admission and within 6 days after hemorrhage. Therefore, any of one of the scores would be equally useful for assessing IVH severity and risk-stratifying ICH patients with regard to outcome. These results suggest that EVD placement may be beneficial for patients with severe IVH, who have particularly poor prognosis at admission, but a randomized clinical trial is needed to conclusively demonstrate its therapeutic value.

Advances in neuroprotective strategies: potential therapies for intracerebral hemorrhage

Intracerebral hemorrhage (ICH) is associated with higher mortality and morbidity than any other form of stroke. However, there currently are no treatments proven to improve outcomes after ICH, and therefore, new effective therapies are urgently needed. Growing insight into ICH pathophysiology has led to the development of neuroprotective strategies that aim to improve the outcome through reduction of secondary pathologic processes. Many neuroprotectants target molecules or pathways involved in hematoma degradation, inflammation or apoptosis, and have demonstrated potential clinical benefits in experimental settings. We extensively reviewed the current understanding of ICH pathophysiology as well as promising experimental neuroprotective agents with particular focus on their mechanisms of action. Continued advances in ICH knowledge, increased understanding of neuroprotective mechanisms, and improvement in the ability to modulate molecular and pathologic events with multitargeting agents will lead to successful clinical trials and bench-to-bedside translation of neuroprotective strategies.

Clinical grading scales in intracerebral hemorrhage

Intracerebral hemorrhage (ICH) carries higher risk of long-term disability and mortality than any other form of stroke. Despite greater understanding of ICH pathophysiology, treatment options for this devastating condition remain limited. Moreover, a lack of a standard, universally accepted clinical grading scale for ICH has contributed to variations in management protocols and clinical trial designs. Grading scales are essential for standardized assessment and communication among physicians, selecting optimized treatment regiments, and designing effective clinical trials. There currently exist a number of ICH grading scales and prognostic models that have been developed for mortality and/or functional outcome, particularly 30 days after the ICH onset. Numerous reliable scales have been externally validated in heterogeneous populations. We extensively reviewed the inherent strengths and limitations of all the existing clinical ICH grading scales based on their development and validation methodology. For all ICH grading scales, we carefully observed study design and the definition and timing of outcome assessment to elucidate inconsistencies in grading scale derivation and application. Ultimately, we call for an expansive, prospective, multi-center clinical outcome study to clearly define all aspects of ICH, establish ideal grading scales, and standardized management protocols to enable the identification of novel and effective therapies in ICH.