New prognostic score for the prediction of 30-day outcome in spontaneous supratentorial cerebral haemorrhage

Development and validation of a 30-day death nomogram in patients with spontaneous cerebral hemorrhage: a retrospective cohort study

The purpose of this study was to establish and validate a nomogram to estimate the 30-day probability of death in patients with spontaneous cerebral hemorrhage. From January 2015 to December 2017, a cohort of 450 patients with clinically diagnosed cerebral hemorrhage was collected for model development. The minimum absolute contraction and the selection operator (lasso) regression model were used to select the strongest prediction of patients with cerebral hemorrhage. Discrimination and calibration were used to evaluate the performance of the resulting nomogram. After internal validation, the nomogram was further assessed in a different cohort containing 148 consecutive subjects examined between January 2018 and December 2018. The nomogram included five predictors from the lasso regression analysis, including: Glasgow coma scale (GCS), hematoma location, hematoma volume, white blood cells, and D-dimer. Internal verification showed that the model had good discrimination, (the area under the curve is 0.955), and good calibration [unreliability (U) statistic, p = 0.739]. The nomogram still showed good discrimination (area under the curve = 0.888) and good calibration [U statistic, p = 0.926] in the verification cohort data. Decision curve analysis showed that the prediction nomogram was clinically useful. The current study delineates a predictive nomogram combining clinical and imaging features, which can help identify patients who may die of cerebral hemorrhage.

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.

ASPECT scores of patients with focal intracerebral hemorrhage were correlated with their short- and medium-term functional outcomes

PURPOSE

The Alberta Stroke Program Early CT Score (ASPECTS) is widely used to guide thrombolytic therapy and predict the functional outcome of patients with acute ischemic stroke (AIS). Whether ASPECTS can predict the functional outcome of patients with intracerebral hemorrhage (ASPECTS-H) remains unclear.

METHODS

Patients with primary intracerebral hemorrhage (ICH) were collected and retrospectively analyzed. ASPECTS-H was assessed at admission. Patients were followed up at 30 days and 90 days after the onset of ICH. Occurrence of death within 90 days after ICH was the primary endpoint. Modified Rankin Scale (mRS) ≥ 3 was considered a poor functional outcome.

RESULTS

A total of 149 patients met eligibility criteria; 61 (40.9%) had poor functional outcome at 30 days, and 37 (24.8%) had poor functional outcome at 90 days. Using binary logistic regression modeling, we found that a low ASPECTS-H was associated with a poor functional outcome. The risk ratio of a low ASPECTS-H was 2.31 at 30 days (P = 0.000; 95% CI, 1.560-3.421) and 2.711 at 90 days (P = 0.000; 95% CI, 1.677-4.381). The optimal cutoff value of ASPECTS-H to discriminate good and poor 30-day and 90-day outcomes was 7.5 (Sensitivity_30-day = 0.636, 1-Specificity_{30 - day} = 0.311; Sensitivity_90-day = 0.580, 1-Specificity_90-day = 0.270).

CONCLUSIONS

A low ASPECTS-H was an indicator of poor short-term and long-term functional outcomes of ICH.

Validation of SUSPEKT Score in Predicting One-month Mortality of Patients with Hemorrhagic Stroke; a Diagnostic Accuracy Study

INTRODUCTION

Predicting the outcome of patients with intracranial hemorrhage (ICH) is the area of interest for in charge physicians as well as patients and their associates. This study aimed to evaluate the accuracy of SUSPEKT score in predicting one-month outcome of patients with hemorrhagic stroke.

METHODS

This prospective cross sectional study was conducted on > 18 years old patients with non-traumatic supra-tentorial ICH admitted to emergency department, from February 2017 to January 2018. SUSPEKT score was measured for each patient and its screening performance characteristics in prediction of one-month mortality were calculated.

RESULTS

169 cases with the mean age of 63.09± 15.45 (21 - 96) years were studied (56.8% male). After one month follow up 47 (27.8%) cases had died, 30 (17.7%) cases were bed ridden, and 72 (42.6%) could walk without help or with a cane. Non-survived patients had significantly larger intra-ventricular hemorrhage (IVH) (p < 0.001) and hematoma (p < 0.001) volume, higher serum glucose (p < 0.001) and blood pressure (p = 0.028), higher frequency of IVH (p < 0.001), and higher WBC count (p = 0.037). Sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) of SUSPEKT score at the 65 cut point were 82.97% (95% CI: 68.65% - 91.86%), 74.59% (95% CI: 65.76% - 81.84%), 55.71% (95% CI: 43.38% - 67.40%), and 91.91% (95% CI: 84.23% - 96.16%), respectively.

CONCLUSION

Total accuracy of SUSPEKT score in predicting one-month mortality of non- traumatic ICH patients is in good range and it has 82% sensitivity and 92% NPV in this regard. It seems that we need further studies before applying the score in routine practice.

Abilities of a Densitometric Analysis of Computed Tomography Images and Hemorrhagic Parameters to Predict Outcome Favorability in Patients With Intracerebral Hemorrhage

BACKGROUND

Intracerebral hemorrhage (ICH) is one of the most devastating subtypes of stroke. A rapid assessment of ICH severity involves the use of computed tomography (CT) and derivation of the hemorrhage volume, which is often estimated using the ABC/2 method. However, these estimates are highly inaccurate and may not be feasible for anticipating outcome favorability.

OBJECTIVE

To predict patient outcomes via a quantitative, densitometric analysis of CT images, and to compare the predictive power of these densitometric parameters with the conventional ABC/2 volumetric parameter and segmented hemorrhage volumes.

METHODS

Noncontrast CT images of 87 adult patients with ICH (favorable outcomes = 69, unfavorable outcomes = 12, and deceased = 6) were analyzed. In-house software was used to calculate the segmented hemorrhage volumes, ABC/2 and densitometric parameters, including the skewness and kurtosis of the density distribution, interquartile ranges, and proportions of specific pixels in sets of CT images. Nonparametric statistical analyses were conducted.

RESULTS

The densitometric parameter interquartile range exhibited greatest accuracy (82.7%) in predicting favorable outcomes. The combination of skewness and the interquartile range effectively predicted mortality (accuracy = 83.3%). The actual volume of the ICH exhibited good coherence with ABC/2 (R = 0.79). Both parameters predicted mortality with moderate accuracy (<78%) but were less effective in predicting unfavorable outcomes.

CONCLUSION

Hemorrhage volume was rapidly estimated and effectively predicted mortality in patients with ICH; however, this value may not be useful for predicting favorable outcomes. The densitometric analysis exhibited significantly higher power in predicting mortality and favorable outcomes in patients with ICH.

In-Hospital and Long-Term Prognosis after Spontaneous Intracerebral Hemorrhage among Young Adults Aged 18-65 Years

BACKGROUND

Spontaneous intracerebral hemorrhage (ICH) accounts for 10%-15% of all strokes and has an estimated annual incidence of 5/100,000 in young adults. Limited data on prognosis after ICH in young adults are available. We aimed to identify prognostic predictors after ICH among adults aged 18-65 years.

METHODS

We retrospectively selected all patients with ICH from a prospective single-center registry of adults with first stroke before 65 years between 1997 and 2002. We recorded in-hospital mortality as well as mortality and recurrent stroke after discharge until December 1, 2018. For in-hospital analysis, we compared patients that died in-hospital versus patients discharged alive. For long-term analysis, we compared patients that died in follow-up versus patients still alive. Independent prognostic predictors were identified using multivariate analyses.

RESULTS

Among 161 patients included, 24 (14.9%) died in-hospital. Among in-hospital survivors, 5-year survival was 92.0%, 10-year survival 78.1%, and 15-year survival 62.0%. After median follow-up of 17 years, 47.4% of patients died, 18 patients had ischemic stroke, and 6 recurrent ICH. Regarding in-hospital prognosis, coma at admission (OR .02 [.00-.11]) was independent predictor for mortality whereas alcoholic habits (OR 12.32 [1.82-83.30]) was independent predictor for survival. An increasing age (OR 1.08 [1.03-1.12]), higher blood glucose levels (OR 1.01 [1.00-1.01]), and hypertension (OR 2.21 [1.22-4.00]) were independent predictors of long-term mortality after ICH.

CONCLUSIONS

Alcoholic habits may influence in-hospital survival after ICH in young adults. Long-term mortality in young adults seems to be lower than in elderly and was predicted by higher blood glucose levels and hypertension.

Correct Outcome Prognostication via Sonographic Volumetry in Supratentorial Intracerebral Hemorrhage

Introduction: The intracerebral hemorrhage (ICH)-score is used for estimation of patients' prognosis. The hemorrhage volume calculated from computed tomography (CT) contributes as one main factor. Several studies have proven that dimensions of an ICH may be displayed sufficiently by transcranial sonography (TCS). Yet, the adequacy of ICH-volumetry via TCS in calculating the ICH-score and its use as prognostic tool has not been studied.

Methods: Forty consecutive patients with supratentorial ICH diagnosed via CT were included in this prospective observational pilot study. 45 examination-series via CT and TCS were done in order to perform an ICH-volumetry and calculate the ICH-score. Volume was calculated using the ABC/2 estimation. Results of both imaging techniques were compared regarding quantification of ICH- volume and correct prognostication. A modified Rankin Scale (mRS)-score of 0–3 points was valued as good outcome.

Results: The imaging techniques did not show a difference in volumetry (p = 0.794) and TCS derived hemorrhage volume correlated significantly with ICH-volume measured on CT-scans. Calculated ICH-scores also did not differ (p = 0.323). Patients with an ICH-score larger than 2 points were predicted to experience a poor outcome at discharge with mRS 4–6 points, and the prognostication of the outcome was correct. Patients with a good outcome showed a smaller ICH-volume (11.2 ± 9.1ml) than patients with a poor outcome (38.2 ± 41.2 ml; p = 0.002).

Conclusion: Volumetry in supratentorial ICH via TCS is feasible and the prognostication with the ICH-score based on its results is comparable to CT-imaging and sufficient.

Early increased neutrophil-to-lymphocyte ratio is associated with poor 3-month outcomes in spontaneous intracerebral hemorrhage

The aim of this study was to evaluate the association of dynamic neutrophil-to-lymphocyte ratio (NLR) with 3-month functional outcomes in patients with sICH. We retrospectively identified 213 consecutive patients with sICH hospitalized in The First Affiliated Hospital of Zhengzhou University from January 2017 to May 2018. Patients were divided into functional independence (FI) or unfavorable prognosis (UP) groups based on 3-month outcomes. Admission leukocyte counts within 24 hours of symptom onset were obtained, and the recorded fraction, of which the numerator is neutrophil and the denominator is lymphocyte, as NLR0. Determined NLR1, NLR3, NLR7, and NLR14 were recorded on day 1 (n = 77), day 3 (n = 126), day 7 (n = 123), and day 14 (n = 105), respectively. The relationships between dynamic NLR or leukocyte counts and clinical features were evaluated using Spearman’s or Kendall’s correlation analysis. Logistic regression analyses were used to identify the risk factors for unfavorable 3-month prognosis. The patients’ dynamic NLR was positively associated with the National Institutes of Health Stroke Scale, ICH score, and hematoma volume at admission, while inversely correlated to the onset GCS score and FI at 3-month follow-up. Furthermore, higher NLR or lower absolute lymphocyte count obtained at admission was independently risk factor for UP at 3 months (adjusted odds ratio [OR]: 1.06, 95% confidence interval [CI]: 1.003, 1.12; OR: 0.41, 95% CI: 0.18, 0.94, respectively). In conclusion, higher NLR and lower lymphocyte counts at early stages were predictive of 3-month unfavorable outcomes in sICH patients.

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.

Primary cCT Imaging Based Clinico-Neurological Assessment-Calling for Addition of Telestroke Video Consultation in Patients With Intracerebral Hemorrhage

Background and Purpose: Intracerebral hemorrhage (ICH) requires rapid decision making to decrease morbidity and mortality although time frame and optimal therapy are still ill defined. Ideally, specialized neurologists, neurosurgeons, and (neuro-) radiologists who know the patient's clinical status and their cerebral computed tomography imaging (cCT) make a joint decision on the clinical management. However, in telestroke networks, a shift toward cCT imaging criteria used for decision making can be observed for practical reasons. Here we investigated the “reverse correlation” from cCT imaging to the actual clinical presentation as evaluated by the Glasgow Coma Scale (GCS) and the National Institutes of Health Stroke Scale (NIHSS).

Methods: CCT images and basic information (age, sex, and time of onset) of 50 patients with hypertensive and lobar ICH were presented to 14 experienced neurologists and 15 neurosurgeons. Based on this information, the NIHSS and GCS scores were estimated for each patient. The differences between the actual GCS and NIHSS scores and the cCT-imaging-based estimated scores were plotted in a bland-Altman plot.

Results: The average estimated GCS score mainly based on cCT imaging was 12. 4 ± 2.8 (actual value: 13.0 ± 2.5; p = 0.100), the estimated NIHSS score was 13.9 ± 9.1 (actual value: 10.8 ± 7.3; p < 0.001). Thus, in cCT-imaging-based evaluation, the neurological status of patients especially employing the NIHSS was estimated poorer, particularly in patients with lobar ICH. “Reverse clinical” evaluation based on cCT-imaging alone may increase the rate of intubation and secondary transferal and neurosurgical treatment. Telestroke networks should consider both, videoassessment of the actual clinical picture and cCT-imaging findings to make appropriate acute treatment decisions.

Emergency department DNR order in patients with spontaneous intracerebral hemorrhage

OBJECTIVES

To explore the determinant factors and prognostic significance of emergency department do-not-resuscitate (ED-DNR) orders for patients with spontaneous intracerebral hemorrhage (SICH).

METHODS

Consecutive adult SICH patients treated in our ED from January 1, 2012 to December 31, 2016 were selected as the eligible cases from our hospital's stroke database. Patients' information was comprehensively reviewed from the database and medical and nursing charts. ED-DNR orders were defined as DNR orders written during ED stay. Multiple logistic regression analysis was used to identify significant determinants of ED-DNR orders. Thirty- and 90-day neurological outcomes were analyzed to test the prognosis impact of ED-DNR orders.

RESULTS

Among 835 enrolled patients, 112 (12.1%) had ED-DNR orders. Significant determinant factors of ED-DNR orders were age, ambulatory status before the event, brain computed tomography findings of midline shift, intraventricular extension, larger hematoma size, and ED arrival GCS ≤8. Patients with and without ED-DNR orders had a similar 30-day death rate if they had the same initial ICH score point. During 30 to 90days, patients with ED-DNR orders had a significantly increased mortality rate. However, the rate of improvement in neurological status between the two groups was not significantly different.

CONCLUSIONS

Older and sicker SICH patients had higher rate of ED-DNR orders. The mortality rates between patients with and without ED-DNR orders for each ICH score point were not significantly different. During the 30-to-90-day follow-up, the rates of neurological improvement in both groups were similar.

Trends in the treatment of risk factors for stroke in a Czech stroke unit

The goal of this study is to evaluate therapeutic trends for several diseases that represent risk factors for stroke. The relative frequency of therapy with compounds that influence the risk factors for stroke was monitored in a group of 3,290 patients who were hospitalised in the Stroke Unit at the University Hospital in Hradec Kralove between 2005 and 2012. For most drugs monitored, the reasons for the significant decrease or increase in use were causes other than the reduction of stroke risk. Despite this finding, the majority of statistically significant changes had, according to review of comparative studies, a positive effect on prevention of stroke. Motivation to change treatment of stroke risk factors, such as hypertension, diabetes mellitus and hypercholesterolemia, was mainly aimed at sufficient disease management with a minimum of adverse effects. On the other hand, optimization of stroke recurrence and economic factors were motivations to treatment changes in prevention with antiplatelets. Antidiabetics were associated with an increase in metformin use and reduction in insulin use. For antihypertensives, the most significant reduction was associated with the use of diuretics, although calcium channel blockers and beta-blockers are also less used. Additionally, the use of the ACE inhibitor ramipril increased