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Lin K, Gao C, Lin Z, Tang Y, Lin Y, Jiang R. Characteristics, predictors and outcomes of early postoperative cerebral infarction on computed tomography in spontaneous intracerebral hemorrhage. Sci Rep 2024; 14:19526. [PMID: 39174669 PMCID: PMC11341960 DOI: 10.1038/s41598-024-69571-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2024] [Accepted: 08/06/2024] [Indexed: 08/24/2024] Open
Abstract
Early postoperative cerebral infarction (ePCI) is a serious complication of spontaneous intracerebral hemorrhage (SICH). Yet, no study has specifically focused on ePCI among SICH patients. Our study aims to investigate the characteristics, predictors, and outcomes of ePCI observed on computed tomography (CT) within 72 h after surgery in patients with supratentorial SICH. Data from a single-center SICH study conducted from May 2015 to September 2022 were retrospectively analyzed. We described the characteristics of ePCI. Predictors were identified through logistic regression analysis, and the impact of ePCI on six-month mortality was examined using a Cox regression model. Subgroup analyses and the "E-value" approach assessed the robustness of the association between ePCI and mortality. A retrospective analysis of 637 out of 3938 SICH patients found that 71 cases (11.1%) developed ePCI. The majority of ePCI cases occurred on the bleeding side (40/71, 56.3%) and affected the middle cerebral artery (MCA) territory (45/71, 63.4%). Multivariable analysis showed that the Glasgow Coma Scale (GCS) score (odds ratio (OR), 0.62; 95% CI, 0.48-0.8; p < 0.001), bleeding volume (per 100 ml) (OR, 1.17; 95% CI, 1.03-1.32; p = 0.016), hematoma volume (per 10 ml) (OR, 1.14; 95%CI, 1.02-1.28; p = 0.023) and bilateral brain hernia (OR, 6.48; 95%CI, 1.71-24.48; p = 0.006) independently predicted ePCI occurrence. ePCI was significantly associated with increased mortality (adjusted hazard ratio (HR), 3.6; 95% CI, 2.2-5.88; p < 0.001). Subgroup analysis and E-value analysis (3.82-6.66) confirmed the stability of the association. ePCI is a common complication of SICH and can be predicted by low GCS score, significant bleeding, large hematoma volume, and brain hernia. Given its significant increase in mortality, ePCI should be explored in future studies.
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Affiliation(s)
- Kun Lin
- Department of Neurosurgery, The First Affiliated Hospital, Fujian Medical University, 20 Chazhong Road, Fuzhou, 350005, China
- Department of Neurosurgery, Fujian Medical University Provincial Clinical Medical College, 516 Jinrong South Road, Fuzhou, 350028, China
| | - Chuang Gao
- Department of Neurosurgery, Tianjin Medical University General Hospital, 154 Anshan Road, Tianjin, 300052, China
| | - Zhicheng Lin
- Department of Neurosurgery, Fujian Medical University Provincial Clinical Medical College, 516 Jinrong South Road, Fuzhou, 350028, China
| | - Yinhai Tang
- Department of Neurosurgery, Fujian Medical University Provincial Clinical Medical College, 516 Jinrong South Road, Fuzhou, 350028, China
| | - Yuanxiang Lin
- Department of Neurosurgery, The First Affiliated Hospital, Fujian Medical University, 20 Chazhong Road, Fuzhou, 350005, China.
| | - Rongcai Jiang
- Department of Neurosurgery, Tianjin Medical University General Hospital, 154 Anshan Road, Tianjin, 300052, China.
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Deng L, Zhang JT, Lv XN, Li ZQ, Chen C, Hu X, Yin H, Yang TN, Zhang ZH, Li Q. Optimal intraventricular hemorrhage volume cutoff for predicting poor outcome in patients with intracerebral hemorrhage. J Stroke Cerebrovasc Dis 2024; 33:107683. [PMID: 38513767 DOI: 10.1016/j.jstrokecerebrovasdis.2024.107683] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2023] [Revised: 03/15/2024] [Accepted: 03/18/2024] [Indexed: 03/23/2024] Open
Abstract
BACKGROUND AND OBJECTIVES The prognosis of patients with spontaneous intracerebral hemorrhage (ICH) is often influenced by hematoma volume, a well-established predictor of poor outcome. However, the optimal intraventricular hemorrhage (IVH) volume cutoff for predicting poor outcome remains unknown. METHODS We analyzed 313 patients with spontaneous ICH not undergoing evacuation, including 7 cases with external ventricular drainage (EVD). These patients underwent a baseline CT scan, followed by a 24-hour CT scan for measurement of both hematoma and IVH volume. We defined hematoma growth as hematoma growth > 33 % or 6 mL at follow-up CT, and poor outcome as modified Rankin Scale score≥3 at three months. Cutoffs with optimal sensitivity and specificity for predicting poor outcome were identified using receiver operating curves. RESULTS The receiver operating characteristic analysis identified 6 mL as the optimal cutoff for predicting poor outcome. IVH volume> 6 mL was observed in 53 (16.9 %) of 313 patients. Patients with IVH volume>6 mL were more likely to be older and had higher NIHSS score and lower GCS score than those without. IVH volume>6 mL (adjusted OR 2.43, 95 % CI 1.13-5.30; P = 0.026) was found to be an independent predictor of poor clinical outcome at three months in multivariable regression analysis. CONCLUSIONS Optimal IVH volume cutoff represents a powerful tool for improving the prediction of poor outcome in patients with ICH, particularly in the absence of clot evacuation or common use of EVD. Small amounts of intraventricular blood are not independently associated with poor outcome in patients with intracerebral hemorrhage. The utilization of optimal IVH volume cutoffs may improve the clinical trial design by targeting ICH patients that will obtain maximal benefit from therapies.
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Affiliation(s)
- Lan Deng
- Department of Neurology, The First Affiliated Hospital of Chongqing Medical University, Chongqing 400016, China
| | - Jiang-Tao Zhang
- Department of Neurology, Chengde Central Hospital, Chengde 067000, Hebei, China
| | - Xin-Ni Lv
- Department of Neurology, The First Affiliated Hospital of Chongqing Medical University, Chongqing 400016, China
| | - Zuo-Qiao Li
- Department of Neurology, The First Affiliated Hospital of Chongqing Medical University, Chongqing 400016, China
| | - Chu Chen
- Department of Neurology, The First Affiliated Hospital of Chongqing Medical University, Chongqing 400016, China
| | - Xiao Hu
- Department of Neurology, The First Affiliated Hospital of Chongqing Medical University, Chongqing 400016, China
| | - Hao Yin
- Department of Neurology, The First Affiliated Hospital of Chongqing Medical University, Chongqing 400016, China
| | - Tian-Nan Yang
- Department of Neurology, The First Affiliated Hospital of Chongqing Medical University, Chongqing 400016, China
| | - Zhe-Hao Zhang
- Department of Neurology, The First Affiliated Hospital of Chongqing Medical University, Chongqing 400016, China
| | - Qi Li
- Department of Neurology, The Second Affiliated Hospital of Anhui Medical University, Anhui 230601, China.
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Murthy SB. Emergent Management of Intracerebral Hemorrhage. Continuum (Minneap Minn) 2024; 30:641-661. [PMID: 38830066 DOI: 10.1212/con.0000000000001422] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/05/2024]
Abstract
OBJECTIVE Nontraumatic intracerebral hemorrhage (ICH) is a potentially devastating cerebrovascular disorder. Several randomized trials have assessed interventions to improve ICH outcomes. This article summarizes some of the recent developments in the emergent medical and surgical management of acute ICH. LATEST DEVELOPMENTS Recent data have underscored the protracted course of recovery after ICH, particularly in patients with severe disability, cautioning against early nihilism and withholding of life-sustaining treatments. The treatment of ICH has undergone rapid evolution with the implementation of intensive blood pressure control, novel reversal strategies for coagulopathy, innovations in systems of care such as mobile stroke units for hyperacute ICH care, and the emergence of newer minimally invasive surgical approaches such as the endoport and endoscope-assisted evacuation techniques. ESSENTIAL POINTS This review discusses the current state of evidence in ICH and its implications for practice, using case illustrations to highlight some of the nuances involved in the management of acute ICH.
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Wijdicks EFM. The Early Benchmarks of Outcome Determination in Cerebral Hemorrhage. Neurocrit Care 2024:10.1007/s12028-024-01969-5. [PMID: 38684602 DOI: 10.1007/s12028-024-01969-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2024] [Accepted: 02/26/2024] [Indexed: 05/02/2024]
Affiliation(s)
- Eelco F M Wijdicks
- Neurocritical Care Services, Saint Marys Hospital Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA.
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Hwang DY, Kim KS, Muehlschlegel S, Wartenberg KE, Rajajee V, Alexander SA, Busl KM, Creutzfeldt CJ, Fontaine GV, Hocker SE, Madzar D, Mahanes D, Mainali S, Sakowitz OW, Varelas PN, Weimar C, Westermaier T, Meixensberger J. Guidelines for Neuroprognostication in Critically Ill Adults with Intracerebral Hemorrhage. Neurocrit Care 2024; 40:395-414. [PMID: 37923968 PMCID: PMC10959839 DOI: 10.1007/s12028-023-01854-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2023] [Accepted: 09/01/2023] [Indexed: 11/06/2023]
Abstract
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.
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Affiliation(s)
- David Y Hwang
- Division of Neurocritical Care, Department of Neurology, University of North Carolina School of Medicine, 170 Manning Drive, CB# 7025, Chapel Hill, NC, 27599-7025, USA.
| | - Keri S Kim
- Department of Pharmacy Practice, University of Illinois at Chicago College of Pharmacy, Chicago, IL, USA
| | - Susanne Muehlschlegel
- Division of Neurosciences Critical Care, Departments of Neurology and Anesthesiology/Critical Care Medicine, Johns Hopkins Medicine, Baltimore, MD, USA
| | | | | | | | - Katharina M Busl
- Departments of Neurology and Neurosurgery, College of Medicine, University of Florida, Gainesville, FL, USA
| | | | - Gabriel V Fontaine
- Departments of Pharmacy and Neurosciences, Intermountain Health, Salt Lake City, UT, USA
| | - Sara E Hocker
- Department of Neurology, Mayo Clinic, Rochester, MN, USA
| | - Dominik Madzar
- Department of Neurology, University of Erlangen-Nuremberg, Erlangen, Germany
| | - Dea Mahanes
- Departments of Neurology and Neurosurgery, UVA Health, Charlottesville, VA, USA
| | - Shraddha Mainali
- Department of Neurology, Virginia Commonwealth University, Richmond, VA, USA
| | - Oliver W Sakowitz
- Department of Neurosurgery, Neurosurgery Center Ludwigsburg-Heilbronn, Ludwigsburg, Germany
| | | | - Christian Weimar
- Institute of Medical Informatics, Biometry and Epidemiology, University Hospital Essen, Essen, Germany
- BDH-Klinik Elzach, Elzach, Germany
| | - Thomas Westermaier
- Department of Neurosurgery, Helios Amper-Kliniken Dachau, University of Wuerzburg, Würzburg, Germany
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Komolafe MA, Sunmonu T, Akinyemi J, Sarfo FS, Akpalu A, Wahab K, Obiako R, Owolabi L, Osaigbovo GO, Ogbole G, Tiwari HK, Jenkins C, Lackland DT, Fakunle AG, Uvere E, Akpa O, Dambatta HA, Akpalu J, Onasanya A, Olaleye A, Ogah OS, Isah SY, Fawale MB, Adebowale A, Okekunle AP, Arnett D, Adeoye AM, Agunloye AM, Bello AH, Aderibigbe AS, Idowu AO, Sanusi AA, Ogunmodede A, Balogun SA, Egberongbe AA, Rotimi FT, Fredrick A, Akinnuoye AO, Adeniyi FA, Calys-Tagoe B, Adebayo P, Arulogun O, Agbogu-Ike OU, Yaria J, Appiah L, Ibinaiye P, Singh A, Adeniyi S, Olalusi O, Mande A, Balogun O, Akinyemi R, Ovbiagele B, Owolabi M. Clinical and neuroimaging factors associated with 30-day fatality among indigenous West Africans with spontaneous intracerebral hemorrhage. J Neurol Sci 2024; 456:122848. [PMID: 38171072 PMCID: PMC10888524 DOI: 10.1016/j.jns.2023.122848] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2023] [Revised: 12/16/2023] [Accepted: 12/17/2023] [Indexed: 01/05/2024]
Abstract
BACKGROUND Spontaneous intracerebral hemorrhage (ICH) is associated with a high case fatality rate in resource-limited settings. The independent predictors of poor outcome after ICH in sub-Saharan Africa remains to be characterized in large epidemiological studies. We aimed to determine factors associated with 30-day fatality among West African patients with ICH. METHODS The Stroke Investigative Research and Educational Network (SIREN) study is a multicentre, case-control study conducted at 15 sites in Nigeria and Ghana. Adults aged ≥18 years with spontaneous ICH confirmed with neuroimaging. Demographic, cardiovascular risk factors, clinical features and neuroimaging markers of severity were assessed. The independent risk factors for 30-day mortality were determined using a multivariate logistic regression analysis with an adjusted odds ratio (OR) and 95% confidence interval (CI). RESULTS Among 964 patients with ICH, 590 (61.2%) were males with a mean age (SD) of 54.3(13.6) years and a case fatality of 34.3%. Factors associated with 30-day mortality among ICH patients include: Elevated mean National Institute of Health Stroke Scale(mNIHSS);(OR 1.06; 95% CI 1.02-1.11), aspiration pneumonitis; (OR 7.17; 95% CI 2.82-18.24), ICH volume > 30mls; OR 2.68; 95% CI 1.02-7.00)) low consumption of leafy vegetables (OR 0.36; 95% CI 0.15-0.85). CONCLUSION This study identified risk and protective factors associated with 30-day mortality among West Africans with spontaneous ICH. These factors should be further investigated in other populations in Africa to enable the development of ICH mortality predictions models among indigenous Africans.
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Affiliation(s)
| | - Taofiki Sunmonu
- Department of Medicine, Federal Medical Centre, Owo, Ondo State, Nigeria
| | - Joshua Akinyemi
- Department of Epidemiology and Medical Statistics, College of Medicine, University of Ibadan, Nigeria
| | - Fred S Sarfo
- Department of Medicine, Kwame Nkrumah University of Science and Technology, Kumasi, Ghana
| | - Albert Akpalu
- Department of Medicine, University of Ghana Medical School, Accra, Ghana
| | - Kolawole Wahab
- Department of Medicine, University of Ilorin Teaching Hospital, Ilorin, Nigeria
| | - Reginald Obiako
- Department of Medicine, Ahmadu Bello University, Zaria, Nigeria
| | - Lukman Owolabi
- Department of Medicine, Aminu Kano Teaching Hospital, Kano, Nigeria
| | | | - Godwin Ogbole
- Department of Radiology, University of Ibadan, Nigeria
| | | | | | | | | | - Ezinne Uvere
- College of Medicine, University of Ibadan, Nigeria
| | - Onoja Akpa
- Department of Epidemiology and Medical Statistics, College of Medicine, University of Ibadan, Nigeria
| | | | - Josephine Akpalu
- Department of Medicine, Kwame Nkrumah University of Science and Technology, Kumasi, Ghana
| | - Akinola Onasanya
- Department of Medicine, Federal Medical Centre, Abeokuta, Nigeria
| | - Adeniji Olaleye
- Department of Medicine, University of Ilorin Teaching Hospital, Ilorin, Nigeria
| | | | - Sulaiman Y Isah
- Department of Medicine, Aminu Kano Teaching Hospital, Kano, Nigeria
| | - Micheal B Fawale
- Department of Medicine, Obafemi Awolowo University, Ile-Ife, Osun State, Nigeria
| | - Akintunde Adebowale
- Department of Medicine, Obafemi Awolowo University, Ile-Ife, Osun State, Nigeria
| | - Akinkunmi P Okekunle
- Department of Epidemiology and Medical Statistics, College of Medicine, University of Ibadan, Nigeria
| | - Donna Arnett
- College of Public Health, University of Kentucky, USA
| | | | | | - Abiodun H Bello
- Department of Medicine, University of Ilorin Teaching Hospital, Ilorin, Nigeria
| | - Adeniyi S Aderibigbe
- Department of Radiology, Obafemi Awolowo University, Ile-Ife, Osun State, Nigeria
| | - Ahmed O Idowu
- Department of Medicine, Obafemi Awolowo University, Ile-Ife, Osun State, Nigeria
| | - Ahmad A Sanusi
- Department of Medicine, Obafemi Awolowo University, Ile-Ife, Osun State, Nigeria
| | - Adebimpe Ogunmodede
- Department of Medicine, Obafemi Awolowo University, Ile-Ife, Osun State, Nigeria
| | - Simon A Balogun
- Department of Surgery, Obafemi Awolowo University Teaching Hospital Complex, Ile-Ife, Osun State, Nigeria
| | | | - Folorunso T Rotimi
- Department of Medicine, Federal Medical Centre, Owo, Ondo State, Nigeria
| | - Adeyemi Fredrick
- Department of Medicine, Federal Medical Centre, Owo, Ondo State, Nigeria
| | - Andrew O Akinnuoye
- Department of Medicine, Federal Medical Centre, Owo, Ondo State, Nigeria
| | - Folu A Adeniyi
- Department of Medicine, Federal Medical Centre, Owo, Ondo State, Nigeria
| | - Benedict Calys-Tagoe
- Department of Community Health, University of Ghana Medical School, Accra, Ghana
| | | | | | | | | | - Lambert Appiah
- Department of Medicine, Kwame Nkrumah University of Science and Technology, Kumasi, Ghana
| | - Philip Ibinaiye
- Department of Medicine, Ahmadu Bello University, Zaria, Nigeria
| | - Arti Singh
- Department of Medicine, University of Ghana Medical School, Accra, Ghana
| | - Sunday Adeniyi
- Department of Medicine, University of Ghana Medical School, Accra, Ghana
| | | | - Aliyu Mande
- Department of Medicine, Aminu Kano Teaching Hospital, Kano, Nigeria
| | - Olayemi Balogun
- Department of Medicine, Ahmadu Bello University, Zaria, Nigeria
| | - Rufus Akinyemi
- University College Hospital, Ibadan, Nigeria; Federal Medical Centre, Abeokuta, Nigeria
| | - Bruce Ovbiagele
- Weill Institute for Neurosciences, School of Medicine, University of California, San-Francisco, USA
| | - Mayowa Owolabi
- University College Hospital, Ibadan, Nigeria; Center for Genomic and Precision Medicine, College of Medicine, University of Ibadan, Nigeria.
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Amer HA, El-Jaafary SIM, Sadek HMAEA, Fouad AM, Mohammed SS. Clinical and paraclinical predictors of early neurological deterioration and poor outcome in spontaneous intracerebral hemorrhage. THE EGYPTIAN JOURNAL OF NEUROLOGY, PSYCHIATRY AND NEUROSURGERY 2023; 59:74. [PMID: 37305215 PMCID: PMC10242586 DOI: 10.1186/s41983-023-00675-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2023] [Accepted: 05/28/2023] [Indexed: 06/13/2023] Open
Abstract
Background Spontaneous intracerebral hemorrhage (sICH) is the second most common form of stroke. It is a major cause of morbidity and mortality. Several clinical and radiological parameters are related to its poor outcome. The aim of this study is to elucidate the clinical, laboratory, and radiological factors associated with early neurological deterioration and poor outcome in patients with ICH. Results seventy patients diagnosed with sICH were evaluated within the first 72 h from the onset of symptoms by Clinical, radiological, and laboratory parameters. Patients were assessed for early neurological deterioration (END) during the hospital stay (up to 7 days from admission) using Glasgow coma scale (GSC), and the National Institutes of Health Stroke Scale (NIHSS), and within 3 months from stroke onset using modified Rankin scale (mRS). ICH score and Functional Outcome in Patients with Primary Intracerebral Hemorrhage (FUNC) Score were calculated for prognostication. 27.1% and 71.42% of patients had END and showed unfavorable outcome, respectively. Clinical indices, as NIHSS > 7 on admission and age > 51 years, radiological characteristics, as large hematoma size, leukoaraiosis, and mass effect detected on CT scan, as well as serum biomarkers; serum urea level > 50 mg/dL, high neutrophil:lymphocyte ratio on admission, high ALT and AST, as well as low total, LDL, and HDL cholesterol levels, all were significantly associated with poor outcome in the patients. Stepwise multivariate logistic regression analysis found the presence of aspiration to be an independent predictor of END, and the scores of NIHSS > 7 on admission, age > 51 years, and urea level > 50 mg/dL were independent predictors of poor outcome. Conclusions There are several predictors for END as well as poor outcome in ICH. Some are clinical, others are radiological and laboratory. Aspiration was an independent predictor of END during hospital stay (3-7 days) in patients with ICH, while older age, high NIHSS and urea level on admission were independent predictors of poor outcome.
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Affiliation(s)
| | | | | | - Amr Mohamed Fouad
- Neurology Department, Faculty of Medicine, Cairo University, Giza, Egypt
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KOCATÜRK İ, GÜLTEN S. Immature granulocyte and other markers in prediction of mortality in spontaneous intracerebral hemorrhage. JOURNAL OF HEALTH SCIENCES AND MEDICINE 2023. [DOI: 10.32322/jhsm.1225428] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/08/2023] Open
Abstract
Aim: This study aims to evaluate immature granulocyte count (IG#) and percentage (IG%) in the prediction of mortality in spontaneous intracerebral hemorrhage (SICH).
Material and Method: Demographic characteristics and laboratory test results of patients diagnosed with SICH and admitted to the neurology clinic in a tertiary hospital between January 1, 2020, and January 1, 2022, were recorded. One hundred ten patients were included in the study. While 80 of these patients constituted the group that recovered after treatment, 30 of them formed the group that died despite treatment. IG and other laboratory and clinic parameters were statistically compared in both groups.
Results: Of 110 patients, 45 (42.7%) were female, and 65 (57.3%) were male. IG counts were higher in the non-survival group than in the survival group (p=0.001). When the patients were divided according to low IG% (=0.6), 30 patients were in the high IG# group, and 80 patients were in the low IG% group. White blood cell (WBC), neutrophil count (NEUT#), monocyte count (MONO#), IG#, neutrophil-lymphocyte ratio (NLR), and hemorrhage volume (HV) values were statistically significantly higher in the high IG% group than in the low IG% group; Glasgow coma score (GCS) and percentage of lymphocytes (LYMPH%) values were significantly lower too. In addition, the mortality rate in the high IG# group was significantly higher than the mortality rate in the low IG% group (53.23% vs. 17.5%).
Conclusion: IG is a new, easily accessible, inexpensive, and promising marker for predicting in-hospital mortality in patients with SICH.
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Reddy KK, San Luis C, Goyal P, Elzamly K, Rizvi T, Mamdani A, Nobleza C. Predictors of Early Mortality for Mechanically Ventilated Spontaneous Intracerebral Hemorrhage Patients. Cureus 2022; 14:e27935. [PMID: 35990563 PMCID: PMC9385071 DOI: 10.7759/cureus.27935] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/12/2022] [Indexed: 11/17/2022] Open
Abstract
Introduction Spontaneous intracerebral hemorrhage (sICH) carries a high mortality burden. Limited data are available on early mortality (EM) and sICH. This study attempted to identify the independent predictors of EM and analyze the mortality characteristics for mechanically ventilated patients with sICHs at a tertiary care hospital over a period of five years. Methods An Institutional Review Board (IRB)-approved and Health Insurance Portability and Accountability Act (HIPPA)-compliant retrospective analysis was performed on sICH patients admitted at the University of Mississippi Medical Center Neuroscience Intensive Care Unit between January 1, 2013, to December 31, 2017. Patients were divided into two cohorts: EM cohort (death within seven days of admission) versus survivor cohort (alive more than seven days after admission). Demographic, comorbidity, clinical, and radiographic data were collected for each patient. Outcomes were compared utilizing student t-test or Mann-Whitney U tests for continuous variables. Logistic regression analysis was performed to determine independent predictors of EM. Results A total of 204 mechanically ventilated patients with sICHs, with a mean age of 59.73 (SD ±14.30), mostly African American (137, 67%), were included in the study. The characteristics of the two cohorts were comparable except the EM cohort had a lower proportion of patients with hypertension and end-stage renal disease; lower median Glasgow Coma Score (GCS) on admission; lower proportion of surgical evacuation and external ventricular drain (EVD) placement; higher proportion of lobar hemorrhage, brainstem involvement, midline shift, hydrocephalus, intraventricular hemorrhage component, and right-sided intracerebral hemorrhage (ICH); higher median ICH score; and higher ICH volume compared to the survivor cohort. Overall, the mortality of mechanically ventilated sICH patients in this institution was 53% (N=109), with 47% (N=96) not surviving beyond seven days. Logistic regression analysis revealed that ICH volume and brainstem involvement increased the odds of EM, while a history of hypertension, surgical evacuation, and EVD placement decreased the odds of EM. Conclusions This study on mechanically ventilated sICH patients identified ICH volume and brainstem involvement as independent predictors of increased EM. History of hypertension, EVD placement, and surgical evacuation decreased its odds. Further studies should be conducted to explore potentially modifiable processes that can improve patient outcomes, most importantly EM, especially in this cohort of patients.
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Han Q, Li M, Su D, Fu A, Li L, Chen T. Development and validation of a 30-day death nomogram in patients with spontaneous cerebral hemorrhage: a retrospective cohort study. Acta Neurol Belg 2022; 122:67-74. [PMID: 33566335 DOI: 10.1007/s13760-021-01617-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2020] [Accepted: 01/28/2021] [Indexed: 11/25/2022]
Abstract
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.
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Affiliation(s)
- Qian Han
- Department of Neurosurgery, North China University of Science and Technology Affiliated Hospital, Tangshan, 063000, Hebei, China
| | - Mei Li
- Department of Neurosurgery, North China University of Science and Technology Affiliated Hospital, Tangshan, 063000, Hebei, China
| | - Dongpo Su
- Department of Neurosurgery, North China University of Science and Technology Affiliated Hospital, Tangshan, 063000, Hebei, China
| | - Aijun Fu
- Department of Neurosurgery, North China University of Science and Technology Affiliated Hospital, Tangshan, 063000, Hebei, China
| | - Lin Li
- Department of Neurosurgery, North China University of Science and Technology Affiliated Hospital, Tangshan, 063000, Hebei, China
| | - Tong Chen
- Department of Neurosurgery, North China University of Science and Technology Affiliated Hospital, Tangshan, 063000, Hebei, China.
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11
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Siegel CL, Besbris J, Everett EA, Lavi ES, Mehta AK, Jones CA, Creutzfeldt CJ, Kramer NM. Top Ten Tips Palliative Care Clinicians Should Know About Strokes. J Palliat Med 2021; 24:1877-1883. [PMID: 34704853 DOI: 10.1089/jpm.2021.0449] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Stroke is a common cause of long-term disability and death, which leaves many patients with significant and unique palliative care (PC) needs. Shared decision-making for patients with stroke poses distinct challenges due to the sudden nature of stroke, the uncertainty inherent in prognostication around recovery, and the common necessity of relying on surrogates for decision-making. Patients with stroke suffer from frequently underrecognized symptoms, which PC clinicians should feel comfortable identifying and treating. This article provides 10 tips for palliative clinicians to increase their knowledge and comfort in caring for this important population.
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Affiliation(s)
- Cara L Siegel
- Departments of Neurology and Palliative Care, University of California, Los Angeles, Los Angeles, California, USA
| | - Jessica Besbris
- Departments of Neurology and Supportive Care Medicine, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Elyse A Everett
- Departments of Medicine and Neurology, Washington University in St. Louis, St. Louis, Missouri, USA
| | - Elana S Lavi
- Department of Speech Language Pathology, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Ambereen K Mehta
- Palliative Care Program, Department of General Internal Medicine, Johns Hopkins Bayview Medical Center, Baltimore, Maryland, USA
| | - Christopher A Jones
- Department of Medicine, Duke University School of Medicine, Durham, North Carolina, USA
| | - Claire J Creutzfeldt
- Department of Neurology, Harborview Medical Center, University of Washington, Seattle, Washington, USA
| | - Neha M Kramer
- Departments of Neurology and Internal Medicine, Rush University Medical Center, Chicago, Illinois, USA
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12
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A Novel CT-based Radiomics-Clinical Nomogram for the Prediction of Short-Term Prognosis in Deep Intracerebral Hemorrhage. World Neurosurg 2021; 157:e461-e472. [PMID: 34688936 DOI: 10.1016/j.wneu.2021.10.129] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2021] [Revised: 10/15/2021] [Accepted: 10/16/2021] [Indexed: 01/06/2023]
Abstract
OBJECTIVE To develop and validate a radiomics-clinical nomogram for the prediction of short-term prognosis in patients with deep intracerebral hemorrhage (DICH) on admission. METHODS A total of 326 patients with DICH (development cohort = 187; testing cohort = 81; validation cohort = 58) were retrospectively included. Radiomics features were extracted from computed tomography (CT) images and optimal features were selected using least absolute shrinkage and selection operator regression. A radiomics score (R-score) was developed using the optimal features. Univariate and multivariate analyses were used to determine independent risk factors for poor outcomes at 30 days. A radiomics-clinical (R-C) nomogram was developed and validated in the three cohorts. Receiver operating characteristic curve (ROC), calibration curve and decision curve analyses were conducted to evaluate the performances of the R-C nomogram. RESULTS Only 4 of 396 radiomics features were selected to develop R-scores. Age, onset-to-CT time, Glasgow Coma Scale score, midline shift, and R-score were detected as independent predictors of poor prognosis of DICH. The R-C nomogram was developed by the independent predictors and showed acceptable discrimination with areas under ROCs of 0.80, 0.79, and 0.70 in the development, testing and validation cohorts, respectively. The R-C nomogram showed good agreement between the predicted probability and the actual probability (all P > 0.05) and clinical applicability in each cohort. CONCLUSIONS The R-C nomogram is a stable and effective tool for predicting the short-term prognosis of DICH, which may help clinicians perform individual risk assessments and make decisions for patients with DICH.
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13
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Song J, Nie Y, Qin X, Wang P, Lu H, Gao L. Efficacy of Naoxueshu in acute spontaneous intracerebral hemorrhage: a multicenter observational study. Neurol Sci 2021; 43:1885-1891. [PMID: 34532772 PMCID: PMC8860792 DOI: 10.1007/s10072-021-05582-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2021] [Accepted: 08/26/2021] [Indexed: 11/26/2022]
Abstract
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.
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Affiliation(s)
- Juexian Song
- Department of Neurology, Xuanwu Hospital, Capital Medical University, Beijing, 100053, China
| | - Yuting Nie
- Department of Neurology, Xuanwu Hospital, Capital Medical University, Beijing, 100053, China
| | - Xinzuo Qin
- Department of Neurology, Xuanwu Hospital, Capital Medical University, Beijing, 100053, China
| | - Pingping Wang
- Department of Neurology, Xuanwu Hospital, Capital Medical University, Beijing, 100053, China
| | - Huiqiang Lu
- The Key Laboratory of Development Biology, College of Life Sciences, Jinggangshan University, Ji'an, China
| | - Li Gao
- Department of Neurology, Xuanwu Hospital, Capital Medical University, Beijing, 100053, China.
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14
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Zyck S, Du L, Gould G, Latorre JG, Beutler T, Bodman A, Krishnamurthy S. Scoping Review and Commentary on Prognostication for Patients with Intracerebral Hemorrhage with Advances in Surgical Techniques. Neurocrit Care 2021; 33:256-272. [PMID: 32270428 DOI: 10.1007/s12028-020-00962-y] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
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.
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Affiliation(s)
- Stephanie Zyck
- Department of Neurosurgery, SUNY Upstate Medical University, 750 E Adams St, Syracuse, NY, 13210, USA.
| | - Lydia Du
- Northeast Ohio Medical University, Rootstown, OH, USA
| | - Grahame Gould
- Department of Neurosurgery, SUNY Upstate Medical University, 750 E Adams St, Syracuse, NY, 13210, USA
| | | | - Timothy Beutler
- Department of Neurosurgery, SUNY Upstate Medical University, 750 E Adams St, Syracuse, NY, 13210, USA
| | - Alexa Bodman
- Department of Neurosurgery, Emory University, Atlanta, GA, USA
| | - Satish Krishnamurthy
- Department of Neurosurgery, SUNY Upstate Medical University, 750 E Adams St, Syracuse, NY, 13210, USA
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15
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Zheng Q, Liu X, Yan K, He L, Chen Y. ASPECT scores of patients with focal intracerebral hemorrhage were correlated with their short- and medium-term functional outcomes. Neurol Res 2021; 43:970-976. [PMID: 34240679 DOI: 10.1080/01616412.2021.1948747] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
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 (Sensitivity30-day = 0.636, 1-Specificity30 - day = 0.311; Sensitivity90-day = 0.580, 1-Specificity90-day = 0.270). CONCLUSIONS A low ASPECTS-H was an indicator of poor short-term and long-term functional outcomes of ICH.
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Affiliation(s)
- Qiuyue Zheng
- The Department of Neurology, Affiliated Hospital of Jiangsu University, Zhenjiang, Jiangsu China.,Graduate School, Dalian Medical University, Dalian, Liaoning, China
| | - Xiaojie Liu
- The Department of Neurology, Northern Jiangsu People's Hospital, Yangzhou, Jiangsu China
| | - Ke Yan
- The Department of Neurology, Northern Jiangsu People's Hospital, Yangzhou, Jiangsu China
| | - Liang He
- The Department of Neurology, Northern Jiangsu People's Hospital, Yangzhou, Jiangsu China
| | - Yingzhu Chen
- The Department of Neurology, Northern Jiangsu People's Hospital, Yangzhou, Jiangsu China
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16
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Vedartham V, Kesav P, Maniangatt S, Nagesh C, Sreedharan SE, Jayadevan ER, Sarma S, Sylaja PN. Hypodensities within Hematoma is Time-Dependent and Predicts Outcome after Spontaneous Intracerebral Hemorrhage. Neurol India 2021; 69:676-680. [PMID: 34169867 DOI: 10.4103/0028-3886.319222] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
Background Non-contrast CT (NCCT) brain imaging biomarkers of hematoma expansion in intracerebral hemorrhage (ICH) has gained relevance in recent times. Though intra-hematoma hypodensities (IHH) can predict hematoma expansion and outcome, it is postulated to be time-dependent. Aim To assess the differential prevalence of IHH in spontaneous ICH over time and assess its predictive valve in early hematoma expansion and functional outcome at 3 months. Material and Methods Patients with ICH within 48 h of stroke onset were included. Baseline clinical and demographic data were collected. Baseline NCCT brain was analyzed for hematoma volume, characterization of IHH, with 24-hours follow-up NCCT hematoma volume calculated for identification of hematoma expansion. Poor functional outcome was defined as mRS ≥3. Results Around 92 subjects were included in the study. IHH was found in 40%. Prevalence of IHH was higher in those with baseline NCCT performed within 3 h of symptom onset compared to those beyond 3 h (71% vs 29%, P = 0.002). The hematoma expansion was more common in patients with IHH compared to those without (54% vs 29%; P = 0.02). Multivariate analysis revealed the presence of IHH (rather than pattern or number) to be strongly associated with poor functional outcome at 3 months (OR 3.86; 95% CI: 1.11-13.42, P = 0.03). Conclusion There is a decreasing prevalence of IHH as the time from symptom onset to NCCT increases. Nevertheless, its presence is significantly associated with hematoma expansion and predicted poor short-term functional outcomes in spontaneous ICH.
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Affiliation(s)
- Veena Vedartham
- Comprehensive Stroke Care Program, Department of Neurology, Achutha Menon Centre for Health Science Studies, Sree Chitra Tirunal Institute for Medical Sciences and Technology, Thiruvananthapuram, Kerala, India
| | - Praveen Kesav
- Comprehensive Stroke Care Program, Department of Neurology, Achutha Menon Centre for Health Science Studies, Sree Chitra Tirunal Institute for Medical Sciences and Technology, Thiruvananthapuram, Kerala, India
| | - Sinchu Maniangatt
- Comprehensive Stroke Care Program, Department of Neurology, Achutha Menon Centre for Health Science Studies, Sree Chitra Tirunal Institute for Medical Sciences and Technology, Thiruvananthapuram, Kerala, India
| | - Chinmay Nagesh
- Department of Interventional Radiology, Achutha Menon Centre for Health Science Studies, Sree Chitra Tirunal Institute for Medical Sciences and Technology, Thiruvananthapuram, Kerala, India
| | - Sapna Erat Sreedharan
- Comprehensive Stroke Care Program, Department of Neurology, Achutha Menon Centre for Health Science Studies, Sree Chitra Tirunal Institute for Medical Sciences and Technology, Thiruvananthapuram, Kerala, India
| | - E R Jayadevan
- Department of Interventional Radiology, Achutha Menon Centre for Health Science Studies, Sree Chitra Tirunal Institute for Medical Sciences and Technology, Thiruvananthapuram, Kerala, India
| | - Sankara Sarma
- Department of Biostatistics, Achutha Menon Centre for Health Science Studies, Sree Chitra Tirunal Institute for Medical Sciences and Technology, Thiruvananthapuram, Kerala, India
| | - P N Sylaja
- Comprehensive Stroke Care Program, Department of Neurology, Achutha Menon Centre for Health Science Studies, Sree Chitra Tirunal Institute for Medical Sciences and Technology, Thiruvananthapuram, Kerala, India
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17
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Small C, Attridge RL, Franco-Martinez C, Donnelly J, Barthol C. Prothrombin Complex Concentrate Use in Intracranial Hemorrhage Patients With Cirrhosis Not on Prior Anticoagulation. J Intensive Care Med 2021; 37:633-640. [PMID: 33942655 DOI: 10.1177/08850666211012650] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
BACKGROUND/OBJECTIVE Patients with intracranial hemorrhage (ICH) have a 30-day mortality rate up to 52%, and the risk of mortality is increased in patients with disease-induced coagulopathy such as cirrhosis. The objective of this study was to evaluate whether 4F-PCC administration mitigates hematoma expansion in ICH patients with cirrhosis not currently receiving anticoagulation therapy compared to standard of care therapies. METHODS This was a single-center, retrospective study comparing adult patients with ICH and history of cirrhosis who received 4F-PCC versus standard of care therapies. The primary outcome was rate of ICH expansion within 24 hours after admission. RESULTS A total of 58 patients were included with 21 who received 4FPCC vs 37 who received standard of care therapies. The 4F-PCC group had a significantly higher number of patients with Child Pugh Class C cirrhosis (85.7% vs. 48.6%, P = 0.006), higher baseline INR (1.7 vs. 1.4, P = 0.001) and more patients with a spontaneous cause of hemorrhage (61.9% vs. 29.7%, P = 0.01). Stable follow-up head CT was achieved in 68.4% of patients who received 4F-PCC versus 72.7% of patients treated with standard of care therapies (P = 0.11). Patients who received 4F-PCC had a significantly greater change in INR within 24 hours (-0.2 vs. 0, P = 0.02) and higher rate of mortality (61.9% vs. 18.9%, P = 0.001). Baseline INR > 2 and surgical evacuation for ICH were associated with decreased odds of stable follow-up head CT in the multivariate logistic regression model. CONCLUSIONS A single dose of 4F-PCC did not significantly improve the rate of stable head CT at 24 hours in patients with ICH and cirrhosis. Randomized clinical trials with larger patient populations are warranted to fully determine the role of 4F-PCC in this unique population.
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Affiliation(s)
- Clay Small
- University Health System, San Antonio, TX, USA.,The University of Texas at Austin College of Pharmacy, Pharmacotherapy Division, Austin, TX, USA
| | - Rebecca L Attridge
- University Health System, San Antonio, TX, USA.,UT Health, San Antonio, TX, USA.,The University of the Incarnate Word Feik School of Pharmacy, San Antonio, TX, USA
| | - Crystal Franco-Martinez
- University Health System, San Antonio, TX, USA.,The University of Texas at Austin College of Pharmacy, Pharmacotherapy Division, Austin, TX, USA
| | - Jonathan Donnelly
- University Health System, San Antonio, TX, USA.,UT Health, San Antonio, TX, USA
| | - Colleen Barthol
- University Health System, San Antonio, TX, USA.,The University of Texas at Austin College of Pharmacy, Pharmacotherapy Division, Austin, TX, USA
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18
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Witsch J, Siegerink B, Nolte CH, Sprügel M, Steiner T, Endres M, Huttner HB. Prognostication after intracerebral hemorrhage: a review. Neurol Res Pract 2021; 3:22. [PMID: 33934715 PMCID: PMC8091769 DOI: 10.1186/s42466-021-00120-5] [Citation(s) in RCA: 26] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2021] [Accepted: 03/19/2021] [Indexed: 12/11/2022] Open
Abstract
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.
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Affiliation(s)
- Jens Witsch
- Department of Neurology, Weill Cornell Medicine, 525 East 68th Street, New York, NY, 10065, USA.
| | - Bob Siegerink
- Center for Stroke Research Berlin, Charité Universitätsmedizin, Berlin, Germany
| | - Christian H Nolte
- Center for Stroke Research Berlin, Charité Universitätsmedizin, Berlin, Germany.,Klinik und Hochschulambulanz für Neurologie, Charité Universitätsmedizin Berlin, Berlin, Germany
| | - Maximilian Sprügel
- Department of Neurology, Universitätsklinikum Erlangen, Erlangen, Germany
| | - Thorsten Steiner
- Department of Neurology, Klinikum Frankfurt Höchst, Frankfurt a. M., Germany.,Department of Neurology, Universität Heidelberg, Heidelberg, Germany
| | - Matthias Endres
- Center for Stroke Research Berlin, Charité Universitätsmedizin, Berlin, Germany.,Klinik und Hochschulambulanz für Neurologie, Charité Universitätsmedizin Berlin, Berlin, Germany.,German Center for Neurodegenerative Diseases (DZNE), Partner Site Berlin, Berlin, Germany.,German Centre for Cardiovascular Research (DZHK), Partner Site Berlin, Berlin, Germany
| | - Hagen B Huttner
- Department of Neurology, Universitätsklinikum Erlangen, Erlangen, Germany
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19
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Liu W, Zhuang X, Zhang L. Prognostic Value of Blood Pressure Variability for Patients With Acute or Subacute Intracerebral Hemorrhage: A Meta-Analysis of Prospective Studies. Front Neurol 2021; 12:606594. [PMID: 33776881 PMCID: PMC7991598 DOI: 10.3389/fneur.2021.606594] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2020] [Accepted: 01/15/2021] [Indexed: 11/29/2022] Open
Abstract
The results on the role of systolic blood pressure (SBP) variability in the functional outcome for patients with intracerebral hemorrhage (ICH) have been inconsistent. Hence, this meta-analysis of prospective studies was conducted to assess the association between SBP variability and poor outcomes in patients with acute or subacute ICH. PubMed, Embase, and the Cochrane Library were electronically searched for eligible studies from their inception to July 2020. The role of SBP variability assessed using standard deviation (SD), coefficient of variation (CV), successive variation (SV), average real variability (ARV), and residual standard deviation (RSD) in the risk of poor functional outcomes were assessed using odds ratio (OR) with 95% confidence interval (CI) through the random-effects model. Seven prospective studies involving 5,201 patients with ICH were selected for the final meta-analysis. Increased SBP variability was associated with an increased risk of poor functional outcomes, regardless of its assessment using SD (OR: 1.38; 95% CI: 1.14–1.68; P = 0.001), CV (OR: 1.98; 95% CI: 1.13–3.47; P = 0.017), SV (OR: 1.30; 95% CI: 1.08–1.58; P = 0.006), ARV (OR: 1.13; 95% CI: 1.03–1.24; P = 0.010), or RSD (OR: 1.22; 95% CI: 1.00–1.50; P = 0.049). Moreover, the role of SBP variability in the risk of poor functional outcomes for patients with ICH was affected by country, study design, mean age, stroke type, outcome definition, and study quality. This study indicated that SBP variability was a predictor of poor outcomes for patients with ICH.
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Affiliation(s)
- Weidong Liu
- Department of Neurosurgery, Liaocheng People's Hospital, Liaocheng, China
| | - Xianbo Zhuang
- Department of Neurology, Liaocheng People's Hospital, Liaocheng, China
| | - Liyong Zhang
- Department of Neurosurgery, Liaocheng People's Hospital, Liaocheng, China
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20
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Godkov I, Dashyan V. Intracerebral hemorrhage grading scales for the prediction of stroke outcome. Zh Nevrol Psikhiatr Im S S Korsakova 2021; 121:15-19. [DOI: 10.17116/jnevro202112112215] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
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21
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Balasa A, Ghiga D, Andone RS, Zahan AE, Florian IA, Chinezu R. Effects of Surgery on the 30-Day Survival Rate in Spontaneous Supratentorial Intracerebral Hemorrhage. Brain Sci 2020; 11:brainsci11010005. [PMID: 33374684 PMCID: PMC7822470 DOI: 10.3390/brainsci11010005] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2020] [Revised: 12/13/2020] [Accepted: 12/21/2020] [Indexed: 12/19/2022] Open
Abstract
Background: Spontaneous intracerebral hemorrhage (ICH) is a severe form of stroke. The efficacy of surgery as ICH treatment is controversial. We sought to compare the 30-day postoperative mortality rate between patients with surgically and medically treated ICH; Methods: This prospective study enrolled patients consecutively diagnosed with ICH and treated between 2017 and 2019. Patients meeting the study surgical indications were assigned to either surgical or medical treatment. The relationship between Glasgow Coma Scale (GCS) score, age, ICH location, ICH volume, and 30-day mortality was analyzed. Results: A total of 174 ICH patients were enrolled in this study. Of these, 136 met the surgery criteria; 65 of these underwent surgery (Group A), and 71 received medical treatment (Group B). Age and ICH location did not modify mortality. Although surgery did not overall improve mortality some better postsurgical outcomes were observed among patients surgically treated with GCS scores of at least 10 points and ICH volumes between 30 to 50 mL; Conclusions: Despite achieving an immediate reduction in intracranial pressure, surgery seems to be advantageous only for patients with ICH volumes between 30 to 50 mL and GCS scores of 10 points or higher.
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Affiliation(s)
- Adrian Balasa
- Department of Neurosurgery, George Emil Palade University of Medicine, Pharmacy, Science and Technology, 540142 Tîrgu Mureș, Romania;
- Department of Neurosurgery, Tîrgu Mureș Clinical Emergency County Hospital, 540136 Tîrgu Mureș, Romania
- Correspondence:
| | - Dana Ghiga
- Department of Medical Informatics and Biostatistics, George Emil Palade University of Medicine, Pharmacy, Sciences and Technology, 540142 Tîrgu Mureș, Romania;
| | - Razvan-Sebastian Andone
- Department of Neurology, Tîrgu Mureș Clinical Emergency County Hospital, 540136 Tîrgu Mureș, Romania;
| | - Ancuta Elena Zahan
- Department of Histology, George Emil Palade University of Medicine, Pharmacy, Science and Technology, 540142 Tîrgu Mureș, Romania;
| | - Ioan Alexandru Florian
- Department of Neurosurgery, Iuliu Haţieganu University of Medicine and Pharmacy, 400012 Cluj-Napoca, Romania;
- Department of Neurosurgery, Cluj-Napoca Clinical Emergency County Hospital, 400006 Cluj-Napoca, Romania
| | - Rares Chinezu
- Department of Neurosurgery, George Emil Palade University of Medicine, Pharmacy, Science and Technology, 540142 Tîrgu Mureș, Romania;
- Department of Neurosurgery, Tîrgu Mureș Clinical Emergency County Hospital, 540136 Tîrgu Mureș, Romania
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22
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Shulman JG, Jara H, Qureshi MM, Lau H, Finn B, Abbas S, Cervantes-Arslanian AM, Mercado M, Greer D, Chapman M, Mian AZ, Takahashi CE. Perihematomal edema surrounding spontaneous intracerebral hemorrhage by CT: Ellipsoidal versus morphometric volumetry. Medicine (Baltimore) 2020; 99:e20951. [PMID: 32664097 PMCID: PMC7360271 DOI: 10.1097/md.0000000000020951] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/01/2022] Open
Abstract
Perihematomal edema (PHE) surrounding intracerebral hemorrhage (ICH) may contribute to disease-associated morbidity. Before quantifying PHE's effects on morbidity, a fast, accurate, and reproducible method for measuring PHE volume is needed. The aim of this study is to demonstrate the use of a semiautomated dual clustering segmentation algorithm to generate PHE volumetrics on noncontrast computed tomography (CT) of the head and compare this technique to physicians' manual calculations.This is a single-center, retrospective imaging study that included head CTs performed from January 2008 to December 2014 on 154 patients with ICH. Subjects ≥ 18 years old who were admitted to the hospital with spontaneous ICH were included. Included subjects had head CTs performed upon admission and within 6 to 24 hours. Two neurologists, 2 neuroradiologists, and a computer program all calculated hemorrhage and PHE volumes. Inter-rater correlation was evaluated using 2 statistical methods: intraclass correlations (ICCs) and limits of agreement (LOA). Additionally, correlation between volumes was separately evaluated using Pearson correlation coefficient.There was an excellent correlation between measurements performed by neurologists and neuroradiologists using ABC/2 for ICH (0.93) and PHE (0.78). There was a good correlation between measurements performed by neurologists using ABC/2 and the volume measurements generated by the algorithm for ICH (0.69) and PHE (0.70). There was a fair correlation between measurements performed by neuroradiologists using ABC/2 and volume measurements generated by the algorithm for ICH (0.47) and good correlation for PHE (0.73).Although the ABC/2 method for measuring PHE is quick and practical, algorithms that do not assume ellipsoidal shape may be more accurate.
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Affiliation(s)
| | | | | | | | | | | | | | | | - David Greer
- Boston University School of Medicine
- Department of Neurology
| | - Margaret Chapman
- Boston University School of Medicine
- Department of Radiology, Boston Medical Center, Boston, MA
| | - Asim Z. Mian
- Boston University School of Medicine
- Department of Radiology, Boston Medical Center, Boston, MA
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23
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Bisson DA, Flaherty ML, Shatil AS, Gladstone D, Dowlatshahi D, Carrozzella J, Zhang L, Hill MD, Demchuck A, Aviv RI. Original and Modified Graeb Score Correlation With Intraventricular Hemorrhage and Clinical Outcome Prediction in Hyperacute Intracranial Hemorrhage. Stroke 2020; 51:1696-1702. [PMID: 32390552 DOI: 10.1161/strokeaha.120.029040] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background and Purpose- The Graeb score is a visual rating scale of intraventricular hemorrhage (IVH) on noncontrast head CT. Little data exist in the hyperacute (<6 hour) period for reliability and predictive value of the modified Graeb Score (mGS) or the original Graeb Score (oGS) for clinical outcomes or their correlation with quantitative IVH volumes. Methods- A retrospective analysis of multicenter prospective intracranial hemorrhage study was performed. oGS and mGS inter-observer agreement and IVH volume correlation on the baseline noncontrast head CT were calculated by intraclass correlation coefficient and Pearson coefficient respectively. Predictors of poor outcome (modified Rankin Scale scores ≥4) at 3 months were identified using a backward stepwise selection multivariable analysis. oGS and mGS performance for modified Rankin Scale scores ≥4 was determined by receiver operating characteristic analysis. Results- One hundred forty-one patients (65±12 years) with median (interquartile range) time to CT of 82.5 (70.3-157.5) minutes were included. IVH was observed in 43 (30%) patients. Inter-observer agreement was excellent for both oGS (intraclass correlation coefficient, 0.90 [95% CI, 0.80-0.95]) and mGS (intraclass correlation coefficient, 0.97 [95% CI, 0.84-0.99]). mGS (R=0.79; P<0.01) correlated better than oGS (R=0.71; P<0.01) with IVH volumes (P=0.02). Models of thresholded oGS and mGS were not different from a model of planimetric baseline intracranial hemorrhage and IVH volume for poor outcome prediction. Area under the curves were 0.70, 0.73, and 0.72, respectively. Conclusions- Excellent correlation for oGS and mGS with IVH volume was seen. Thresholded oGS and mGS are reasonable surrogates for planimetric IVH volume for hyperacute intracranial hemorrhage studies.
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Affiliation(s)
- Daniel-Alexandre Bisson
- From the Division of Neuroradiology, Department of Medical Imaging (D.-A.B., A.S.S., L.Z.), Sunnybrook Health Sciences centre, and University of Toronto, Canada
| | - Mathew L Flaherty
- Department of Neurology (M.L.F., J.P.B), University of Cincinnati Academic Health Center, OH
| | - Anwar S Shatil
- From the Division of Neuroradiology, Department of Medical Imaging (D.-A.B., A.S.S., L.Z.), Sunnybrook Health Sciences centre, and University of Toronto, Canada
| | - David Gladstone
- Division of Neurology, Department of Medicine (D.G.), Sunnybrook Health Sciences centre, and University of Toronto, Canada
| | - Dar Dowlatshahi
- Department of Medicine (Neurology) (D.D.), University of Ottawa, Ottawa Hospital Research Institute, Canada
| | - Janice Carrozzella
- Department of Neurology (M.L.F., J.P.B), University of Cincinnati Academic Health Center, OH
| | - Liying Zhang
- From the Division of Neuroradiology, Department of Medical Imaging (D.-A.B., A.S.S., L.Z.), Sunnybrook Health Sciences centre, and University of Toronto, Canada
| | - Michael D Hill
- Calgary Stroke Program, Department of Clinical Neurosciences, Department of Radiology, Hotchkiss Brain Institute, University of Calgary, Canada (M.D.H., A.D.)
| | - Andrew Demchuck
- Calgary Stroke Program, Department of Clinical Neurosciences, Department of Radiology, Hotchkiss Brain Institute, University of Calgary, Canada (M.D.H., A.D.)
| | - Richard I Aviv
- Division of Neuroradiology, Department of Radiology (R.I.A.), University of Ottawa, Ottawa Hospital Research Institute, Canada
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24
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Banerjee G, Ambler G, Wilson D, Hostettler IC, Shakeshaft C, Lunawat S, Cohen H, Yousry T, Al-Shahi Salman R, Lip GYH, Houlden H, Muir KW, Brown MM, Jäger HR, Werring DJ. Baseline factors associated with early and late death in intracerebral haemorrhage survivors. Eur J Neurol 2020; 27:1257-1263. [PMID: 32223078 PMCID: PMC7643267 DOI: 10.1111/ene.14238] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2020] [Accepted: 03/20/2020] [Indexed: 11/29/2022]
Abstract
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.
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Affiliation(s)
- G Banerjee
- Department of Brain Repair and Rehabilitation, Stroke Research Centre, UCL Queen Square Institute of Neurology and the National Hospital for Neurology and Neurosurgery, London, UK
| | - G Ambler
- Department of Statistical Science, University College London, London, UK
| | - D Wilson
- Department of Brain Repair and Rehabilitation, Stroke Research Centre, UCL Queen Square Institute of Neurology and the National Hospital for Neurology and Neurosurgery, London, UK.,New Zealand Brain Research Institute, Christchurch, New Zealand
| | - I C Hostettler
- Department of Brain Repair and Rehabilitation, Stroke Research Centre, UCL Queen Square Institute of Neurology and the National Hospital for Neurology and Neurosurgery, London, UK
| | - C Shakeshaft
- Department of Brain Repair and Rehabilitation, Stroke Research Centre, UCL Queen Square Institute of Neurology and the National Hospital for Neurology and Neurosurgery, London, UK
| | - S Lunawat
- Department of Brain Repair and Rehabilitation, Stroke Research Centre, UCL Queen Square Institute of Neurology and the National Hospital for Neurology and Neurosurgery, London, UK
| | - H Cohen
- Haemostasis Research Unit, Department of Haematology, University College London, London, UK
| | - T Yousry
- Lysholm Department of Neuroradiology and the Neuroradiological Academic Unit, Department of Brain Repair and Rehabilitation, UCL Queen Square Institute of Neurology, London, UK
| | - R Al-Shahi Salman
- Centre for Clinical Brain Sciences, School of Clinical Sciences, University of Edinburgh, Edinburgh, UK
| | - G Y H Lip
- Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart & Chest Hospital, Liverpool, UK.,Aalborg Thrombosis Research Unit, Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | - H Houlden
- Department of Molecular Neuroscience, UCL Queen Square Institute of Neurology and the National Hospital for Neurology and Neurosurgery, London, UK
| | - K W Muir
- Institute of Neuroscience & Psychology, University of Glasgow, Elizabeth University Hospital, Queen, Glasgow, UK
| | - M M Brown
- Department of Brain Repair and Rehabilitation, Stroke Research Centre, UCL Queen Square Institute of Neurology and the National Hospital for Neurology and Neurosurgery, London, UK
| | - H R Jäger
- Lysholm Department of Neuroradiology and the Neuroradiological Academic Unit, Department of Brain Repair and Rehabilitation, UCL Queen Square Institute of Neurology, London, UK
| | - D J Werring
- Department of Brain Repair and Rehabilitation, Stroke Research Centre, UCL Queen Square Institute of Neurology and the National Hospital for Neurology and Neurosurgery, London, UK
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25
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González-Henares MA, Clua-Espuny JL, Lorman-Carbo B, Fernández-Saez J, Queralt-Tomas L, Muria-Subirats E, Ballesta-Ors J, Gil-Guillen JV. Risk of Long-Term Mortality for Complex Chronic Patients with Intracerebral Hemorrhage: A Population-Based e-Cohort Observational Study. Adv Ther 2020; 37:833-846. [PMID: 31879838 DOI: 10.1007/s12325-019-01206-y] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2019] [Indexed: 01/31/2023]
Abstract
INTRODUCTION Over recent years there has been growing evidence of increased risk of mortality associated with hemorrhagic stroke among older patients. The main objective of this study is to propose and validate a prognostic life table for complex chronic patients after an intracerebral hemorrhage (ICH) episode in primary care settings. METHODS This was a multicenter and retrospective study (April 1, 2006-December 31, 2016) of a cohort from the general population presenting an episode of ICH from which a predictive model of mortality was obtained using a Cox proportional hazards regression model. In addition, Kaplan-Meier survival curves, the log-rank test, receiver operating characteristic (ROC) curves, and area under the ROC curve (AUC) were used to evaluate the ability to stratify patients according to vital prognosis. We proceeded to external validation of the model through prospective monitoring (January 1, 2013-December 31, 2017) of the population of complex chronic patients with an episode of ICH. RESULTS A total of 3594 people aged ≥ 65 years were identified as complex chronic patients (women 55.9%; mean age, 86.1 ± 8.4 years) of whom 161 suffered hemorrhagic stroke during the study period (January 1, 2013-December 31, 2017). The primary outcome was death from any cause within 5 years of follow-up after an ICH episode. The independent prognostic factors of mortality were age > 80 years (HR 1.048, 95% CI 1.021-1.076, p < 0.001) and HAS-BLED score (HR 1.369, 95% CI 1.057-1.774, p = 0.017). Compared to the general population, the incidence density/1000 person per year (15 vs 0.22) was significantly higher with a significantly lower annual lethality rate (17% vs 49.2%); and both the prognostic factors and the risk of stratified mortality showed different epidemiological patterns. The internal validation of the model was optimal (log-rank < 0.0001) in the general population, but its external validation was not significant in the complex chronic patient population (log-rank p = 0.104). CONCLUSIONS The ICH-AP is a clinical scale that can improve the prognostic prediction of mortality in primary care after an episode of ICH in the general population, but it was not significant in its external validation in a population of complex chronic patients. TRIAL REGISTRATION ClinicalTrials.gov ID: NCT03247049.
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Affiliation(s)
- Maria Antonia González-Henares
- EAP-Alcanar-St Carlos de la Rápita, Catalonian Health Institute, SAP Terres de l'Ebre, Health Department, Generalitat de Catalunya, CAP St Carles de la Rápita, 43540, Sant Carles de la Ràpita, Spain
- Department of Research, ICS Terres de l'Ebre, Research Institute University Primary Care (IDIAP) Jordi Gol, Barcelona, Spain
| | - Jose Luis Clua-Espuny
- Department of Research, ICS Terres de l'Ebre, Research Institute University Primary Care (IDIAP) Jordi Gol, Barcelona, Spain.
- EAP-Tortosa 1-Est Catalonian Health Institute, SAP Terres de l'Ebre, Health Department, Generalitat de Catalunya, CAP Temple, Plaça Carrilet, s/núm, 43500, Tortosa, Spain.
| | - Blanca Lorman-Carbo
- UUDD Tortosa-Terres de l'Ebre, Catalonian Health Institute, SAP Terres de l'Ebre, Health Department, Generalitat de Catalunya, CAP Temple, 43500, Tortosa, Spain
| | - Jose Fernández-Saez
- Unitat de Suport a la Recerca Terres de l'Ebre, Institut Universitari d'Investigació en Atenció Primària (IDIAP) Jordi Gol, Grupo de investigación de Salud Pública, Universidad de Alicante, Alicante, Spain
| | - Lluisa Queralt-Tomas
- EAP-Tortosa-Oest, Catalonian Health Institute, SAP Terres de l'Ebre, Health Department, Generalitat de Catalunya, CAP Xerta, 43592, Xerta, Spain
| | - Eulalia Muria-Subirats
- UUDD Tortosa-Terres de l'Ebre, Catalonian Health Institute, SAP Terres de l'Ebre, Health Department, Generalitat de Catalunya, CAP Temple, 43500, Tortosa, Spain
| | - Juan Ballesta-Ors
- UUDD Tortosa-Terres de l'Ebre, Catalonian Health Institute, SAP Terres de l'Ebre, Health Department, Generalitat de Catalunya, CAP Temple, 43500, Tortosa, Spain
| | - Jose Vicente Gil-Guillen
- Universidad Miguel Hernández, Cátedra Medicina de Familia, Carretera Alicante-Elche s/num, 03202, Elche, Spain
- Clinical Evidence Based Medicine and Emotional Department, Miguel Hernández University, Family and Community Specialty, Elche, Spain
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26
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Gregório T, Pipa S, Cavaleiro P, Atanásio G, Albuquerque I, Chaves PC, Azevedo L. Assessment and Comparison of the Four Most Extensively Validated Prognostic Scales for Intracerebral Hemorrhage: Systematic Review with Meta-analysis. Neurocrit Care 2020; 30:449-466. [PMID: 30426449 DOI: 10.1007/s12028-018-0633-6] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
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.
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Affiliation(s)
- Tiago Gregório
- Department of Internal Medicine, Vila Nova de Gaia Hospital Centre, Rua Conceição Fernandes, 4434-502, Vila Nova de Gaia, Portugal. .,Stroke Unit, Vila Nova de Gaia Hospital Centre, Rua Conceição Fernandes, 4434-502, Vila Nova de Gaia, Portugal.
| | - Sara Pipa
- Department of Internal Medicine, Vila Nova de Gaia Hospital Centre, Rua Conceição Fernandes, 4434-502, Vila Nova de Gaia, Portugal
| | - Pedro Cavaleiro
- Intensive Care Department, Algarve University Hospital Centre, Rua Leão Penedo, 8000-386, Faro, Portugal
| | - Gabriel Atanásio
- Department of Internal Medicine, Vila Nova de Gaia Hospital Centre, Rua Conceição Fernandes, 4434-502, Vila Nova de Gaia, Portugal
| | - Inês Albuquerque
- Department of Internal Medicine, São João Hospital Centre, Alameda Prof. Hernani Monteiro, 4200-319, Porto, Portugal
| | - Paulo Castro Chaves
- Department of Internal Medicine, São João Hospital Centre, Alameda Prof. Hernani Monteiro, 4200-319, Porto, Portugal.,Stroke Unit, São João Hospital Centre, Alameda Prof. Hernani Monteiro, 4200-319, Porto, Portugal.,Department of Surgery and Physiology, Faculty of Medicine, University of Porto, Alameda Prof. Hernani Monteiro, 4200-319, Porto, Portugal
| | - Luís Azevedo
- Centre for Health Technology and Services Research and Department of Community Medicine, Information and Health Decision Sciences, Faculty of Medicine, University of Porto, Alameda Prof. Hernani Monteiro, 4200-319, Porto, Portugal
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27
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McCracken DJ, Lovasik BP, McCracken CE, Frerich JM, McDougal ME, Ratcliff JJ, Barrow DL, Pradilla G. The Intracerebral Hemorrhage Score: A Self-Fulfilling Prophecy? Neurosurgery 2020; 84:741-748. [PMID: 29762777 DOI: 10.1093/neuros/nyy193] [Citation(s) in RCA: 28] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2016] [Accepted: 04/17/2018] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND The ICH Score has become the standard for risk-stratification of 30-d mortality in patients with intracerebral hemorrhage (ICH), but treatment has evolved over the last 17 yr since its inception. We sought to determine if the ICH Score remains an accurate predictor of 30-d mortality in these high acuity patients. OBJECTIVE To determine the role the ICH Score has on mortality in current treatment of patients. METHODS A retrospective review of 554 patients treated for acute, spontaneous ICH at 2 large academic institutions between 2010 and 2014 was carried out. Surgical intervention in the form of external ventricular drain or craniotomy was performed when indicated. All patients were managed medically until discharge or death. RESULTS Over half (53.6%) of the patients presented with ICH of the basal ganglia/thalamus and the majority (71%) presented with ICH Scores of 0 to 2. Overall mortality was 25.1%. Observed mortality in moderate grade ICH Score patients (3 and 4) was lower than expected (49% vs 72%, P < .001) and (71% vs 97%, P < .001) when compared to the original ICH Score results. Despite differences in ICH and intraventricular hemorrhage volume, and Glasgow Coma Scale there was no difference in surgical intervention (12.2% vs 11.8%, P = .94) between the two groups. Withdrawal of care was instituted in 56.6% of all patients who died and increased with ICH Score. CONCLUSION In our cohort, the original ICH score did not accurately predict the mortality rate. Patient survival exceeded ICH Score-predicted mortality regardless of surgical intervention. Reevaluation of predictive scores could be useful to aid in more accurate prognoses.
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Affiliation(s)
- D Jay McCracken
- Department of Neurosurgery, Emory University, Atlanta, Georgia
| | - Brendan P Lovasik
- Department of Biostatistics and Bioinformatics, Emory University School of Medicine, Atlanta, Georgia
| | - Courtney E McCracken
- Department of Biostatistics and Bioinformatics, Emory University School of Medicine, Atlanta, Georgia
| | - Jason M Frerich
- Department of Neurosurgery, Emory University, Atlanta, Georgia
| | - Margaret E McDougal
- Department of Biostatistics and Bioinformatics, Emory University School of Medicine, Atlanta, Georgia
| | - Jonathan J Ratcliff
- Department of Emergency Medicine and Neurology, Emory University, Atlanta, Georgia
| | - Daniel L Barrow
- Department of Neurosurgery, Emory University, Atlanta, Georgia
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28
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Dsouza LB, Pathan SA, Bhutta ZA, Thomas SA, Momin U, Mirza S, Elanani R, Qureshi R, Khalaf W, Thomas SH. ABC/2 estimation in intracerebral hemorrhage: A comparison study between emergency radiologists and emergency physicians. Am J Emerg Med 2019; 37:1818-1822. [DOI: 10.1016/j.ajem.2018.12.036] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2018] [Revised: 12/15/2018] [Accepted: 12/18/2018] [Indexed: 11/16/2022] Open
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29
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Original Intracerebral Hemorrhage Score for the Prediction of Short-Term Mortality in Cerebral Hemorrhage. Crit Care Med 2019; 47:857-864. [DOI: 10.1097/ccm.0000000000003744] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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30
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Trifan G, Arshi B, Testai FD. Intraventricular Hemorrhage Severity as a Predictor of Outcome in Intracerebral Hemorrhage. Front Neurol 2019; 10:217. [PMID: 30915027 PMCID: PMC6422963 DOI: 10.3389/fneur.2019.00217] [Citation(s) in RCA: 29] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2019] [Accepted: 02/20/2019] [Indexed: 11/28/2022] Open
Abstract
Background/Objective: Intraventricular hemorrhage (IVH) extension after spontaneous supratentorial intracerebral hemorrhage (sICH) is an independent predictor of worse outcome. However, there is a paucity of data looking at the degree of IVH severity and its impact on outcome. This study addresses the contribution of IVH severity to outcome at time of hospital discharge after sICH. Methods: Two hundred and ten patients were included in the study. Baseline demographic and radiologic characteristics were abstracted. First available CT scans were reviewed for hematoma volume and location, IVH extension and presence of hydrocephalus (HCP). IVH severity was calculated using Graeb scale. Multivariate logistic regression models were developed to investigate the association of IVH severity with poor outcomes at hospital discharge, defined as modified Rankin scale score (mRS) >3. Results: Fifty-three percent of patients had IVH extension while 18% had surgical procedures done. Poor outcome (mRS >3) was seen for 56% of patients. Median IVH extension severity on the Graeb scale was two. Presence of IVH was associated with poor outcome in univariate and multivariate analysis (p < 0.005). Compared to patients with no IVH, IVH severity influenced outcome only when Graeb scores were ≥5 (OR = 1.3, 95% CI 0.49–3.23, p = 0.63, and OR = 2.9, 95% CI, 1.1–7.6, p = 0.03 for Graeb <5 and ≥5, respectively. Conclusions: Higher IVH severity (defined as Graeb score ≥5) is associated with worse outcome at time of hospital discharge, while lower IVH severity (Graeb scores 1–4) has similar outcomes to patients without IVH. IVH severity should be used in favor of IVH presence for prognostication purposes.
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Affiliation(s)
- Gabriela Trifan
- Department of Neurology and Rehabilitation, University of Illinois at Chicago College of Medicine, Chicago, IL, United States
| | - Baback Arshi
- Department of Neurology and Rehabilitation, University of Illinois at Chicago College of Medicine, Chicago, IL, United States
| | - Fernando D Testai
- Department of Neurology and Rehabilitation, University of Illinois at Chicago College of Medicine, Chicago, IL, United States
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31
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Hegde A, Menon G. Modifying the Intracerebral Hemorrhage Score to Suit the Needs of the Developing World. Ann Indian Acad Neurol 2018; 21:270-274. [PMID: 30532355 PMCID: PMC6238559 DOI: 10.4103/aian.aian_419_17] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
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.
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Affiliation(s)
- Ajay Hegde
- Department of Neurosurgery, Kasturba Medical College, Manipal Academy of Higher Education, Manipal, Karnataka, India
| | - Girish Menon
- Department of Neurosurgery, Kasturba Medical College, Manipal Academy of Higher Education, Manipal, Karnataka, India
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Gregório T, Pipa S, Cavaleiro P, Atanásio G, Albuquerque I, Chaves PC, Azevedo L. Prognostic models for intracerebral hemorrhage: systematic review and meta-analysis. BMC Med Res Methodol 2018; 18:145. [PMID: 30458727 PMCID: PMC6247734 DOI: 10.1186/s12874-018-0613-8] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2018] [Accepted: 11/07/2018] [Indexed: 12/23/2022] Open
Abstract
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.
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Affiliation(s)
- Tiago Gregório
- Department of Internal Medicine, Vila Nova de Gaia Hospital Cente, Rua Conceição Fernandes, 4434-502, Vila Nova de Gaia, Portugal. .,Stroke Unit, Vila Nova de Gaia Hospital Center, Rua Conceição Fernandes, 4434-502, Vila Nova de Gaia, Portugal.
| | - Sara Pipa
- Department of Internal Medicine, Vila Nova de Gaia Hospital Cente, Rua Conceição Fernandes, 4434-502, Vila Nova de Gaia, Portugal
| | - Pedro Cavaleiro
- Intensive Care Department, Algarve University Hospital Center, Rua Leão Penedo, 8000-386, Faro, Portugal
| | - Gabriel Atanásio
- Department of Internal Medicine, Vila Nova de Gaia Hospital Cente, Rua Conceição Fernandes, 4434-502, Vila Nova de Gaia, Portugal
| | - Inês Albuquerque
- Department of Internal Medicine, São João Hospital Center, Alameda Prof. Hernani Monteiro, 4200-319, Porto, Portugal
| | - Paulo Castro Chaves
- Department of Internal Medicine, São João Hospital Center, Alameda Prof. Hernani Monteiro, 4200-319, Porto, Portugal.,Stroke Unit, São João Hospital Center, Alameda Prof. Hernani Monteiro, 4200-319, Porto, Portugal.,Department of Surgery and Physiology, Faculty of Medicine, University of Porto, Alameda Prof. Hernani Monteiro, 4200-319, Porto, Portugal
| | - Luís Azevedo
- Center for Health Technology and Services Research & Department of Community Medicine, Information and Health Decision Sciences, Faculty of Medicine, University of Porto, Alameda Prof. Hernani Monteiro, 4200-319, Porto, Portugal
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Race is a Predictor of Withdrawal of Life Support in Patients with Intracerebral Hemorrhage. J Stroke Cerebrovasc Dis 2018; 27:3108-3114. [DOI: 10.1016/j.jstrokecerebrovasdis.2018.07.006] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2018] [Accepted: 07/01/2018] [Indexed: 12/31/2022] Open
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Ding W, Gu Z, Song D, Liu J, Zheng G, Tu C. Development and validation of the hypertensive intracerebral hemorrhage prognosis models. Medicine (Baltimore) 2018; 97:e12446. [PMID: 30278523 PMCID: PMC6181527 DOI: 10.1097/md.0000000000012446] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/30/2018] [Accepted: 08/24/2018] [Indexed: 12/29/2022] Open
Abstract
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.
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Affiliation(s)
- Wu Ding
- Department of Oncological Surgery, Shaoxing Second Hospital
| | - Zhiwei Gu
- Department of Neurosurgery, Shaoxing Central Hospital, Shaoxing
| | - Dagang Song
- Department of Neurosurgery, Shaoxing Central Hospital, Shaoxing
| | - Jiansheng Liu
- Department of Neurosurgery, Shaoxing Central Hospital, Shaoxing
| | - Gang Zheng
- Department of Neurosurgery, Shaoxing Central Hospital, Shaoxing
| | - Chuanjian Tu
- Department of Surgery, Shaoxing Keqiao Women & Children's Hospital, China
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Rodríguez-Fernández S, Castillo-Lorente E, Guerrero-Lopez F, Rodríguez-Rubio D, Aguilar-Alonso E, Lafuente-Baraza J, Gómez-Jiménez FJ, Mora-Ordóñez J, Rivera-López R, Arias-Verdú MD, Quesada-García G, Arráez-Sánchez MÁ, Rivera-Fernández R. Validation of the ICH score in patients with spontaneous intracerebral haemorrhage admitted to the intensive care unit in Southern Spain. BMJ Open 2018; 8:e021719. [PMID: 30104314 PMCID: PMC6091906 DOI: 10.1136/bmjopen-2018-021719] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/18/2018] [Revised: 05/31/2018] [Accepted: 06/22/2018] [Indexed: 01/06/2023] Open
Abstract
OBJECTIVE Validation of the intracerebral haemorrhage (ICH) score in patients with a diagnosis of spontaneous ICH admitted to the intensive care unit (ICU). METHODS A multicentre cohort study was conducted in all consecutive patients with ICH admitted to the ICUs of three hospitals with a neurosurgery department between 2009 and 2012 in Andalusia, Spain. Data collected included ICH, Glasgow Coma Scale (GCS) and Acute Physiology and Chronic Health Evaluation II (APACHE-II) scores. Demographic data, location and volume of haematoma and 30-day mortality rate were also collated. RESULTS A total of 336 patients were included. 105 of whom underwent surgery. Median (IQR) age: 62 (50-70) years. APACHE-II 21(15-26) points, GCS: 7 (4-11) points, ICH score: 2 (2-3) points. 11.1% presented with bilateral mydriasis on admission (mortality rate=100%). Intraventricular haemorrhage was observed in 58.9% of patients. In-hospital mortality was 54.17% while the APACHE-II predicted mortality was 57.22% with a standardised mortality ratio (SMR) of 0.95 (95% CI 0.81 to 1.09) and a Hosmer-Lemenshow test value (H) of 3.62 (no significant statistical difference, n.s.). 30-day mortality was 52.38% compared with the ICH score predicted mortality of 48.79%, SMR: 1.07 (95% CI 0.91 to 1.23), n.s. Mortality was higher than predicted at the lowest scores and lower than predicted in the more severe patients, (H=55.89, p<0.001), Gruppo Italiano per la Valutazione degli Interventi in Terapia Intensiva calibration belt (p<0.001). The area under a receiver operating characteristic (ROC) curve was 0.74 (95% CI 0.69 to 0.79). CONCLUSIONS ICH score shows an acceptable discrimination as a tool to predict mortality rates in patients with spontaneous ICH admitted to the ICU, but its calibration is suboptimal.
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Affiliation(s)
- Sonia Rodríguez-Fernández
- Intensive Care Medicine, Hospital de la Serranía, Ronda, Spain
- Programa de Doctorado, Universidad de Granada, Granada, Spain
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Schmidt FA, Liotta EM, Prabhakaran S, Naidech AM, Maas MB. Assessment and comparison of the max-ICH score and ICH score by external validation. Neurology 2018; 91:e939-e946. [PMID: 30068631 DOI: 10.1212/wnl.0000000000006117] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2017] [Accepted: 06/06/2018] [Indexed: 12/21/2022] Open
Abstract
OBJECTIVE We tested the hypothesis that the maximally treated intracerebral hemorrhage (max-ICH) score is superior to the ICH score for characterizing mortality and functional outcome prognosis in patients with ICH, particularly those who receive maximal treatment. METHODS Patients presenting with spontaneous ICH were enrolled in a prospective observational study that collected demographic and clinical data. Mortality and functional outcomes were measured by using the modified Rankin Scale at 3 months. The ICH score and max-ICH score incorporate measures of symptom severity, age, hematoma volume, hematoma location, and intraventricular hemorrhage, with the max-ICH score also including a term for oral anticoagulation and having 16 score categories vs 11 for the ICH score. We compared the area under the receiver operating characteristic curve (AUC) for the ICH score and max-ICH score for both mortality and poor functional outcome, defined as modified Rankin Scale scores 4-6. RESULTS We analyzed outcomes for 372 patients, including 71 patients (19%) in whom care limitation/withdrawal of life support was instituted. Both the ICH score and max-ICH score showed good prognostic performance for 3-month mortality and poor functional outcomes in the full group as well as the subgroup with maximal treatment (i.e., no care limitations; AUC range 0.80-0.86), with no significant difference in AUC between the scores for either endpoint in either group. CONCLUSIONS External validation with direct comparison of the ICH score and max-ICH score shows that their prognostic performance is not meaningfully different. Alternatives to simple scores are likely needed to improve prognostic estimates for patient care decisions.
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Affiliation(s)
- Felix A Schmidt
- From the Department of Neurology (F.A.S.), Charité - Universitätsmedizin Berlin, Department of Neurology, NeuroCure Clinical Research Center, and the Berlin Institute of Health Berlin, Germany; and Division of Stroke and Critical Care (E.M.L., S.P., A.M.N., M.B.M.), Department of Neurology, Northwestern University, Chicago, IL
| | - Eric M Liotta
- From the Department of Neurology (F.A.S.), Charité - Universitätsmedizin Berlin, Department of Neurology, NeuroCure Clinical Research Center, and the Berlin Institute of Health Berlin, Germany; and Division of Stroke and Critical Care (E.M.L., S.P., A.M.N., M.B.M.), Department of Neurology, Northwestern University, Chicago, IL
| | - Shyam Prabhakaran
- From the Department of Neurology (F.A.S.), Charité - Universitätsmedizin Berlin, Department of Neurology, NeuroCure Clinical Research Center, and the Berlin Institute of Health Berlin, Germany; and Division of Stroke and Critical Care (E.M.L., S.P., A.M.N., M.B.M.), Department of Neurology, Northwestern University, Chicago, IL
| | - Andrew M Naidech
- From the Department of Neurology (F.A.S.), Charité - Universitätsmedizin Berlin, Department of Neurology, NeuroCure Clinical Research Center, and the Berlin Institute of Health Berlin, Germany; and Division of Stroke and Critical Care (E.M.L., S.P., A.M.N., M.B.M.), Department of Neurology, Northwestern University, Chicago, IL
| | - Matthew B Maas
- From the Department of Neurology (F.A.S.), Charité - Universitätsmedizin Berlin, Department of Neurology, NeuroCure Clinical Research Center, and the Berlin Institute of Health Berlin, Germany; and Division of Stroke and Critical Care (E.M.L., S.P., A.M.N., M.B.M.), Department of Neurology, Northwestern University, Chicago, IL.
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Ng D, Churilov L, Mitchell P, Dowling R, Yan B. The CT Swirl Sign Is Associated with Hematoma Expansion in Intracerebral Hemorrhage. AJNR Am J Neuroradiol 2017; 39:232-237. [PMID: 29217744 DOI: 10.3174/ajnr.a5465] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2017] [Accepted: 09/19/2017] [Indexed: 01/13/2023]
Abstract
BACKGROUND AND PURPOSE Hematoma expansion is an independent determinant of poor clinical outcome in intracerebral hemorrhage. Although the "spot sign" predicts hematoma expansion, the identification requires CT angiography, which limits its general accessibility in some hospital settings. Noncontrast CT, without the need for CT angiography, may identify sites of active extravasation, termed the "swirl sign." We aimed to determine the association of the swirl sign with hematoma expansion. MATERIALS AND METHODS Patients with spontaneous intracerebral hemorrhage between 2007 and 2014 who underwent an initial and subsequent noncontrast CT at a single center were retrospectively identified. The swirl sign, on noncontrast CT, was defined as iso- or hypodensity within a hyperdense region that extended across 2 contiguous 5-mm axial CT sections. RESULTS A total of 212 patients met the inclusion criteria. The swirl sign was identified in 91 patients with excellent interobserver agreement (κ = 0.87). The swirl sign was associated with larger initial hematoma (P < .001) and earlier initial CT (P < .001) and hematoma expansion (P = .028). Multivariable regression modeling demonstrated that if one assumed similar initial hematoma volume, onset-to-first scan, and time between CT scans, the median absolute hematoma growth was 5.77 mL (95% CI, 2.37-9.18 mL; P = .001) and relative growth was 35.6% (95% CI, 18.5%-52.6%; P < .001) higher in patients with the swirl sign compared with those without. CONCLUSIONS The NCCT swirl sign was reliably identified and is associated with hematoma expansion. We propose that the swirl sign be included in risk stratification of intracerebral hemorrhage and considered for inclusion in clinical trials.
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Affiliation(s)
- D Ng
- From the Department of Radiology (D.N., P.M., R.D., B.Y.)
| | - L Churilov
- Statistics and Decision Analysis (L.C.), Florey Institute of Neuroscience and Mental Health, Heidelberg, Victoria, Australia
| | - P Mitchell
- From the Department of Radiology (D.N., P.M., R.D., B.Y.)
| | - R Dowling
- From the Department of Radiology (D.N., P.M., R.D., B.Y.)
| | - B Yan
- From the Department of Radiology (D.N., P.M., R.D., B.Y.) .,Melbourne Brain Centre (B.Y.), University of Melbourne, Royal Melbourne Hospital, Parkville, Victoria, Australia
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Lampert J, Bikdeli B, Green P, Baldwin MR. Systemic thrombolysis in a patient with massive pulmonary embolism and recent glioblastoma multiforme resection. BMJ Case Rep 2017; 2017:bcr-2017-221578. [PMID: 29191822 DOI: 10.1136/bcr-2017-221578] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
Abstract
While trials of systemic thrombolysis for submassive and massive pulmonary embolism (PE) report intracranial haemorrhage (ICH) rates of 2%-3%, the risk of ICH in patients with recent brain surgery or intracranial neoplasm is unknown since these patients were excluded from these trials. We report a case of massive PE treated with systemic thrombolysis in a patient with recent neurosurgery for an intracranial neoplasm. We discuss the risks and benefits of systemic thrombolysis for massive PE in the context of previous case reports, prior cohort studies and trials, and current guidelines. There may be times when the immediate risk of death from massive PE outweighs the risk of ICH from systemic thrombolysis, even when guideline-listed major contraindications exist. This case provides an example of how the haemodynamic benefit of systemic thrombolysis outweighed the impact of ICH in a patient who had undergone recent neurosurgical resection of a glioblastoma multiforme tumour.
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Affiliation(s)
- Joshua Lampert
- Department of Internal Medicine, Columbia University Medical Center, New York City, New York, USA
| | - Behnood Bikdeli
- Division of Cardiology, Columbia University Medical Center, New York, NY
| | - Philip Green
- Division of Cardiology, Columbia University Medical Center, New York, NY
| | - Matthew R Baldwin
- Division of Pulmonary and Critical Care Medicine, Columbia University College of Physicians and Surgeons, New York, NY
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Validation of Prognostic Models to Predict Early Mortality in Spontaneous Intracerebral Hemorrhage: A Cross-Sectional Evaluation of a Singapore Stroke Database. World Neurosurg 2017; 109:e601-e608. [PMID: 29054778 DOI: 10.1016/j.wneu.2017.10.039] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2017] [Revised: 10/06/2017] [Accepted: 10/09/2017] [Indexed: 11/21/2022]
Abstract
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.
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Comparison of all 19 published prognostic scores for intracerebral hemorrhage. J Neurol Sci 2017; 379:103-108. [DOI: 10.1016/j.jns.2017.05.034] [Citation(s) in RCA: 39] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2017] [Revised: 04/17/2017] [Accepted: 05/16/2017] [Indexed: 12/21/2022]
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Sembill JA, Gerner ST, Volbers B, Bobinger T, Lücking H, Kloska SP, Schwab S, Huttner HB, Kuramatsu JB. Severity assessment in maximally treated ICH patients. Neurology 2017; 89:423-431. [DOI: 10.1212/wnl.0000000000004174] [Citation(s) in RCA: 65] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2016] [Accepted: 03/27/2017] [Indexed: 12/21/2022] Open
Abstract
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.
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Pan K, Panwar A, Roy U, Das BK. A Comparison of the Intracerebral Hemorrhage Score and the Acute Physiology and Chronic Health Evaluation II Score for 30-Day Mortality Prediction in Spontaneous Intracerebral Hemorrhage. J Stroke Cerebrovasc Dis 2017; 26:2563-2569. [PMID: 28684377 DOI: 10.1016/j.jstrokecerebrovasdis.2017.06.005] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2017] [Revised: 05/10/2017] [Accepted: 06/01/2017] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND The intracerebral hemorrhage (ICH) score is well established as a reliable prognostic score in ICH, whereas recently, Acute Physiology and Chronic Health Evaluation II (APACHE II) has been observed to have a better discrimination in predicting mortality in primary pontine hemorrhage. Further, physiological parameters of APACHE II have been associated with outcome in ICH. This study is the first to observe a direct comparison between APACHE II and ICH scores in predicting 30-day mortality in spontaneous intracerebral hemorrhage (SICH). MATERIALS AND METHODS This study was a prospective observational study where we compared the receiver operating characteristic (ROCs) of baseline ICH and APACHE II scores in patients with SICH for predicting 30-day mortality outcome. RESULTS We observed that both APACHE II and ICH scores were good for predicting 30-day mortality with both having an area under the ROC curve of more than .8 (.831 [95% confidence interval {CI}, .740-.922; P <.001] and .892 [95% CI, .757-.932; P <.001], respectively). However, the ICH score was better discriminative (area under the curve AUC, .892 versus .831; P = .040) and better calibrated (P = .037 versus P = .089, Hosmer-Lemeshow goodness-of-fit test for logistic regression) for the same. Both APACHE II and ICH scores had a sensitivity of 87% at cutoff values of 19 and 3, respectively; however, the ICH score had a better specificity (90% versus 76.5%). CONCLUSION The ICH score was observed to have a better discrimination and calibration for predicting 30-day mortality in SICH.
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Affiliation(s)
- Koushik Pan
- Department of Neurology, Institute of Post Graduate Medical Education and Research (IPGMER), Kolkata, India
| | - Ajay Panwar
- Department of Neurology, Kakatiya Medical College and Mahatma Gandhi Memorial Hospital, Warangal, India.
| | - Ujjawal Roy
- Department of Neurology, Institute of Post Graduate Medical Education and Research (IPGMER), Kolkata, India
| | - Bidyut K Das
- Department of General Medicine, Calcutta National Medical College and Hospital, Kolkata, India
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Lo YT, See AAQ, King NKK. Decompressive Craniectomy in Spontaneous Intracerebral Hemorrhage: A Case-Control Study. World Neurosurg 2017; 103:815-820.e2. [DOI: 10.1016/j.wneu.2017.04.025] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2016] [Revised: 04/03/2017] [Accepted: 04/06/2017] [Indexed: 11/15/2022]
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Behrouz R, Misra V, Godoy DA, Topel CH, Masotti L, Klijn CJ, Smith CJ, Parry-Jones AR, Slevin MA, Silver B, Willey JZ, Masjuán Vallejo J, Nzwalo H, Popa-Wagner A, Malek AR, Hafeez S, Di Napoli M. Clinical Course and Outcomes of Small Supratentorial Intracerebral Hematomas. J Stroke Cerebrovasc Dis 2017; 26:1216-1221. [DOI: 10.1016/j.jstrokecerebrovasdis.2017.01.010] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2016] [Accepted: 01/13/2017] [Indexed: 11/28/2022] Open
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Phan TG, Chen J, Beare R, Ma H, Clissold B, Van Ly J, Srikanth V. Classification of Different Degrees of Disability Following Intracerebral Hemorrhage: A Decision Tree Analysis from VISTA-ICH Collaboration. Front Neurol 2017; 8:64. [PMID: 28293215 PMCID: PMC5329022 DOI: 10.3389/fneur.2017.00064] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2016] [Accepted: 02/13/2017] [Indexed: 12/04/2022] Open
Abstract
Background and purpose Prognostication following intracerebral hemorrhage (ICH) has focused on poor outcome at the expense of lumping together mild and moderate disability. We aimed to develop a novel approach at classifying a range of disability following ICH. Methods The Virtual International Stroke Trial Archive collaboration database was searched for patients with ICH and known volume of ICH on baseline CT scans. Disability was partitioned into mild [modified Rankin Scale (mRS) at 90 days of 0–2], moderate (mRS = 3–4), and severe disabilities (mRS = 5–6). We used binary and trichotomy decision tree methodology. The data were randomly divided into training (2/3 of data) and validation (1/3 data) datasets. The area under the receiver operating characteristic curve (AUC) was used to calculate the accuracy of the decision tree model. Results We identified 957 patients, age 65.9 ± 12.3 years, 63.7% males, and ICH volume 22.6 ± 22.1 ml. The binary tree showed that lower ICH volume (<13.7 ml), age (<66.5 years), serum glucose (<8.95 mmol/l), and systolic blood pressure (<170 mm Hg) discriminate between mild versus moderate-to-severe disabilities with AUC of 0.79 (95% CI 0.73–0.85). Large ICH volume (>27.9 ml), older age (>69.5 years), and low Glasgow Coma Scale (<15) classify severe disability with AUC of 0.80 (95% CI 0.75–0.86). The trichotomy tree showed that ICH volume, age, and serum glucose can separate mild, moderate, and severe disability groups with AUC 0.79 (95% CI 0.71–0.87). Conclusion Both the binary and trichotomy methods provide equivalent discrimination of disability outcome after ICH. The trichotomy method can classify three categories at once, whereas this action was not possible with the binary method. The trichotomy method may be of use to clinicians and trialists for classifying a range of disability in ICH.
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Affiliation(s)
- Thanh G Phan
- Neurosciences, Monash Health , Melbourne, VIC , Australia
| | - Jian Chen
- Department of Medicine, School of Clinical Sciences, Monash University , Clayton, VIC , Australia
| | - Richard Beare
- Department of Medicine, School of Clinical Sciences, Monash University , Clayton, VIC , Australia
| | - Henry Ma
- Neurosciences, Monash Health, Melbourne, VIC, Australia; Department of Medicine, School of Clinical Sciences, Monash University, Clayton, VIC, Australia
| | - Benjamin Clissold
- Neurosciences, Monash Health, Melbourne, VIC, Australia; Department of Medicine, School of Clinical Sciences, Monash University, Clayton, VIC, Australia
| | - John Van Ly
- Neurosciences, Monash Health, Melbourne, VIC, Australia; Department of Medicine, School of Clinical Sciences, Monash University, Clayton, VIC, Australia
| | - Velandai Srikanth
- Neurosciences, Monash Health, Melbourne, VIC, Australia; Department of Medicine, Central Clinical School, Monash University, Frankston, VIC, Australia
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Shotar E, Debarre M, Sourour NA, Di Maria F, Gabrieli J, Nouet A, Chiras J, Degos V, Clarençon F. Retrospective study of long-term outcome after brain arteriovenous malformation rupture: the RAP score. J Neurosurg 2017; 128:78-85. [PMID: 28106499 DOI: 10.3171/2016.9.jns161431] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVE The authors aimed to design a score for stratifying patients with brain arteriovenous malformation (BAVM) rupture, based on the likelihood of a poor long-term neurological outcome. METHODS The records of consecutive patients with BAVM hemorrhagic events who had been admitted over a period of 11 years were retrospectively reviewed. Independent predictors of a poor long-term outcome (modified Rankin Scale score ≥ 3) beyond 1 year after admission were identified. A risk stratification scale was developed and compared with the intracranial hemorrhage (ICH) score to predict poor outcome and inpatient mortality. RESULTS One hundred thirty-five patients with 139 independent hemorrhagic events related to BAVM rupture were included in this analysis. Multivariate logistic regression followed by stepwise analysis showed that consciousness level according to the Glasgow Coma Scale (OR 6.5, 95% CI 3.1-13.7, p < 10-3), hematoma volume (OR 1.8, 95% CI 1.2-2.8, p = 0.005), and intraventricular hemorrhage (OR 7.5, 95% CI 2.66-21, p < 10-3) were independently associated with a poor outcome. A 12-point scale for ruptured BAVM prognostication was constructed combining these 3 factors. The score obtained using this new scale, the ruptured AVM prognostic (RAP) score, was a stronger predictor of a poor long-term outcome (area under the receiver operating characteristic curve [AUC] 0.87, 95% CI 0.8-0.92, p = 0.009) and inpatient mortality (AUC 0.91, 95% CI 0.85-0.95, p = 0.006) than the ICH score. For a RAP score ≥ 6, sensitivity and specificity for predicting poor outcome were 76.8% (95% CI 63.6-87) and 90.8% (95% CI 81.9-96.2), respectively. CONCLUSIONS The authors propose a new admission score, the RAP score, dedicated to stratifying the risk of poor long-term outcome after BAVM rupture. This easy-to-use scoring system may help to improve communication between health care providers and consistency in clinical research. Only external prospective cohorts and population-based studies will ensure full validation of the RAP scores' capacity to predict outcome after BAVM rupture.
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Affiliation(s)
| | | | | | | | - Joseph Gabrieli
- Departments of1Interventional Neuroradiology.,3Paris VI University, Pierre et Marie Curie, Paris, France
| | | | - Jacques Chiras
- Departments of1Interventional Neuroradiology.,3Paris VI University, Pierre et Marie Curie, Paris, France
| | - Vincent Degos
- 2Neurosurgical Anesthesiology and Critical Care, and.,3Paris VI University, Pierre et Marie Curie, Paris, France
| | - Frédéric Clarençon
- Departments of1Interventional Neuroradiology.,3Paris VI University, Pierre et Marie Curie, Paris, France
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Weng X, Tan Y, Chu X, Wu XF, Liu R, Tian Y, Li L, Guo F, Ouyang Q, Li L. N-methyl-D-aspartic acid receptor 1 (NMDAR1) aggravates secondary inflammatory damage induced by hemin-NLRP3 pathway after intracerebral hemorrhage. Chin J Traumatol 2017; 18:254-8. [PMID: 26777707 DOI: 10.1016/j.cjtee.2015.11.010] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023] Open
Abstract
OBJECTIVE Inflammation plays a critical role in secondary brain damage after intracerebral hemorrhage (ICH). However, the mechanisms of inflammatory injury following ICH are still unclear, particularly the involvement of NLRP3 inflammasome, which are crucial to sterile inflammatory responses. In this study, we aim to test the hypothesis that NLRP3 signaling pathway takes a vital position in ICH-induced secondary inflammatory damage and detect the role of N-methyl-D-aspartic acid receptor 1 (NMDAR1) in this progress. METHODS ICH was induced in mice by microinjection of hemin into the striatum. The protein levels of NMDAR1, NMDAR1 phosphorylation, NLRP3 and IL-1b were measured by Western blot. The binding of NMDAR1 to NLRP3 was detected by immunoprecipitation. RESULTS The expression of NMDAR1, NMDAR1 phosphorylation, NLRP3 and IL-1b were rapidly increased after ICH. Hemin treatment enhanced NMDAR1 expression and NMDAR1 phosphorylation, as well in cultured microglial cells treated by hemin. Hemin up regulated NLRP3 and IL-1b level, which was reversed by MK801 (NMDAR antagonist) in vitro. Hemin also promoted the binding of NMDAR1 to NLRP3. CONCLUSION Our findings suggest that NMDAR1 plays a pivotal role in hemin-induced NLRP3-mediated inflammatory damage through synergistic activation.
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Affiliation(s)
- Xun Weng
- State Key Laboratory of Trauma, Burns and Combined Injury, Research Institute of Surgery/Daping Hospital, Third Military Medical University, China
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Sandeep YS, Guru MR, Jena RK, Kiran Kumar VA, Agrawal A. Clinical study to assess the outcome in surgically managed patients of spontaneous intracerebral hemorrhage. Int J Crit Illn Inj Sci 2017; 7:218-223. [PMID: 29291174 PMCID: PMC5737063 DOI: 10.4103/ijciis.ijciis_22_17] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
Introduction Spontaneous intracerebral hemorrhage (SICH) subtype of stroke is characterized by bleeding into brain parenchyma which is not accompanied by trauma. Emergency surgical evacuation of large size SICH increases the chances of survival but does not help in functional recovery of the patients. The present study was conducted to assess the outcome of surgical management in patients with SICH. Materials and Methods All patients who were diagnosed with SICH and underwent surgical evacuation of the hematoma included in the study. The outcome at 1 month was obtained through follow-up visits/telephonic interview when the former is not available. The primary outcome measure was in hospital mortality/condition at the time of discharge/neurological deficit/modified Rankin Scale (mRS) at 1 month follow-up. Results Out of 87 patients, 49 patients (63%) were male and 38 patients (37%) were females, male to female ratio was 1.2:0.8. Nearly 42% patient had systolic blood pressure with in normal range; however, in almost 50% of the cases, the systolic blood pressure at the time of admission was more than 140 mmHg. mRS was assessed for the patients at the time of admission, 39% patients had slight disability, 15% patients had moderate disability, 11% patients had moderately severe disability, and 33% patients had severe disability. Mortality was relatively higher in patients who had admission systolic blood pressure more than 140 mmHg (51% vs. 43%). mRS was assessed for the patients at the time of discharge after completion surgery and the severity of scale. Conclusions Hypertension was found to be most common comorbid illness followed by smoking, alcohol intake, and diabetes mellitus. Hematoma was evacuated in 58% of the cases; it was supplement with decompressive craniectomy in 12% of the cases. Morality was relatively higher in patients who had admission systolic blood pressure more than 140 mmHg. Mortality was highest in <40 years age group in age group of 40-65 years, the mortality was 30.6%, and in >65 years age group, mortality was 15.4%; however, this was not statistically significant. Only 10% of patients can recover and live independently at 1 month, and only 20% of the survivors were independent at 6 months.
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Affiliation(s)
- Yashwanth S Sandeep
- Department of Neurosurgery, Narayana Medical College and Hospital, Nellore, Andhra Pradesh, India
| | - M Raja Guru
- Department of Neurology, Narayana Medical College and Hospital, Nellore, Andhra Pradesh, India
| | - Ranjan Kumar Jena
- Department of Neurosurgery, Narayana Medical College and Hospital, Nellore, Andhra Pradesh, India
| | | | - Amit Agrawal
- Department of Neurosurgery, Narayana Medical College and Hospital, Nellore, Andhra Pradesh, India
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Rose DZ, Decker DA, Wilson KP, Ramos-Canseco J. Adding Salt to the Wounds. Neurohospitalist 2017; 7:6-8. [DOI: 10.1177/1941874416674410] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Affiliation(s)
- David Z. Rose
- Department of Neurology, Morsani College of Medicine, University of South Florida, Tampa, FL, USA
| | - David A. Decker
- Department of Neurology, Florida Hospital Tampa, Tampa, FL, USA
| | - Karen P. Wilson
- Department of Neurology, Morsani College of Medicine, University of South Florida, Tampa, FL, USA
| | - Juan Ramos-Canseco
- Department of Neurology, Morsani College of Medicine, University of South Florida, Tampa, FL, USA
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Wakai T, Narasimhan P, Sakata H, Wang E, Yoshioka H, Kinouchi H, Chan PH. Hypoxic preconditioning enhances neural stem cell transplantation therapy after intracerebral hemorrhage in mice. J Cereb Blood Flow Metab 2016; 36:2134-2145. [PMID: 26661220 PMCID: PMC5363661 DOI: 10.1177/0271678x15613798] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/22/2015] [Revised: 09/08/2015] [Accepted: 09/21/2015] [Indexed: 01/06/2023]
Abstract
Previous studies have shown that intraparenchymal transplantation of neural stem cells ameliorates neurological deficits in animals with intracerebral hemorrhage. However, hemoglobin in the host brain environment causes massive grafted cell death and reduces the effectiveness of this approach. Several studies have shown that preconditioning induced by sublethal hypoxia can markedly improve the tolerance of treated subjects to more severe insults. Therefore, we investigated whether hypoxic preconditioning enhances neural stem cell resilience to the hemorrhagic stroke environment and improves therapeutic effects in mice. To assess whether hypoxic preconditioning enhances neural stem cell survival when exposed to hemoglobin, neural stem cells were exposed to 5% hypoxia for 24 hours before exposure to hemoglobin. To study the effectiveness of hypoxic preconditioning on grafted-neural stem cell recovery, neural stem cells subjected to hypoxic preconditioning were grafted into the parenchyma 3 days after intracerebral hemorrhage. Hypoxic preconditioning significantly enhanced viability of the neural stem cells exposed to hemoglobin and increased grafted-cell survival in the intracerebral hemorrhage brain. Hypoxic preconditioning also increased neural stem cell secretion of vascular endothelial growth factor. Finally, transplanted neural stem cells with hypoxic preconditioning exhibited enhanced tissue-protective capability that accelerated behavioral recovery. Our results suggest that hypoxic preconditioning in neural stem cells improves efficacy of stem cell therapy for intracerebral hemorrhage.
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Affiliation(s)
- Takuma Wakai
- Department of Neurosurgery, Department of Neurology and Neurological Sciences, and Program in Neurosciences, Stanford University School of Medicine, Stanford, California, USA
| | - Purnima Narasimhan
- Department of Neurosurgery, Department of Neurology and Neurological Sciences, and Program in Neurosciences, Stanford University School of Medicine, Stanford, California, USA
| | - Hiroyuki Sakata
- Department of Neurosurgery, Department of Neurology and Neurological Sciences, and Program in Neurosciences, Stanford University School of Medicine, Stanford, California, USA
| | - Eric Wang
- Department of Neurosurgery, Stanford University School of Medicine, Stanford, California, USA
| | - Hideyuki Yoshioka
- Department of Neurosurgery, Interdisciplinary Graduate School of Medicine and Engineering, University of Yamanashi, Japan
| | - Hiroyuki Kinouchi
- Department of Neurosurgery, Interdisciplinary Graduate School of Medicine and Engineering, University of Yamanashi, Japan
| | - Pak H Chan
- Department of Neurosurgery, Department of Neurology and Neurological Sciences, and Program in Neurosciences, Stanford University School of Medicine, Stanford, California, USA
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