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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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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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Nie X, Cai Y, Liu J, Liu X, Zhao J, Yang Z, Wen M, Liu L. Mortality Prediction in Cerebral Hemorrhage Patients Using Machine Learning Algorithms in Intensive Care Units. Front Neurol 2021; 11:610531. [PMID: 33551969 PMCID: PMC7855582 DOI: 10.3389/fneur.2020.610531] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2020] [Accepted: 12/11/2020] [Indexed: 12/12/2022] Open
Abstract
Objectives: This study aims to investigate whether the machine learning algorithms could provide an optimal early mortality prediction method compared with other scoring systems for patients with cerebral hemorrhage in intensive care units in clinical practice. Methods: Between 2008 and 2012, from Intensive Care III (MIMIC-III) database, all cerebral hemorrhage patients monitored with the MetaVision system and admitted to intensive care units were enrolled in this study. The calibration, discrimination, and risk classification of predicted hospital mortality based on machine learning algorithms were assessed. The primary outcome was hospital mortality. Model performance was assessed with accuracy and receiver operating characteristic curve analysis. Results: Of 760 cerebral hemorrhage patients enrolled from MIMIC database [mean age, 68.2 years (SD, ±15.5)], 383 (50.4%) patients died in hospital, and 377 (49.6%) patients survived. The area under the receiver operating characteristic curve (AUC) of six machine learning algorithms was 0.600 (nearest neighbors), 0.617 (decision tree), 0.655 (neural net), 0.671(AdaBoost), 0.819 (random forest), and 0.725 (gcForest). The AUC was 0.423 for Acute Physiology and Chronic Health Evaluation II score. The random forest had the highest specificity and accuracy, as well as the greatest AUC, showing the best ability to predict in-hospital mortality. Conclusions: Compared with conventional scoring system and the other five machine learning algorithms in this study, random forest algorithm had better performance in predicting in-hospital mortality for cerebral hemorrhage patients in intensive care units, and thus further research should be conducted on random forest algorithm.
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Affiliation(s)
- Ximing Nie
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Yuan Cai
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,China National Clinical Research Center for Neurological Diseases, Beijing, China.,Department of Medicine and Therapeutics, Prince of Wales Hospital, Chinese University of Hong Kong, Hong Kong, China
| | - Jingyi Liu
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Xiran Liu
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Jiahui Zhao
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Zhonghua Yang
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Miao Wen
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Liping Liu
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,China National Clinical Research Center for Neurological Diseases, Beijing, China
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Wartenberg KE, Hwang DY, Haeusler KG, Muehlschlegel S, Sakowitz OW, Madžar D, Hamer HM, Rabinstein AA, Greer DM, Hemphill JC, Meixensberger J, Varelas PN. Gap Analysis Regarding Prognostication in Neurocritical Care: A Joint Statement from the German Neurocritical Care Society and the Neurocritical Care Society. Neurocrit Care 2020; 31:231-244. [PMID: 31368059 PMCID: PMC6757096 DOI: 10.1007/s12028-019-00769-6] [Citation(s) in RCA: 34] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
Background/Objective Prognostication is a routine part of the delivery of neurocritical care for most patients with acute neurocritical illnesses. Numerous prognostic models exist for many different conditions. However, there are concerns about significant gaps in knowledge regarding optimal methods of prognostication. Methods As part of the Arbeitstagung NeuroIntensivMedizin meeting in February 2018 in Würzburg, Germany, a joint session on prognostication was held between the German NeuroIntensive Care Society and the Neurocritical Care Society. The purpose of this session was to provide presentations and open discussion regarding existing prognostic models for eight common neurocritical care conditions (aneurysmal subarachnoid hemorrhage, intracerebral hemorrhage, acute ischemic stroke, traumatic brain injury, traumatic spinal cord injury, status epilepticus, Guillain–Barré Syndrome, and global cerebral ischemia from cardiac arrest). The goal was to develop a qualitative gap analysis regarding prognostication that could help inform a future framework for clinical studies and guidelines. Results Prognostic models exist for all of the conditions presented. However, there are significant gaps in prognostication in each condition. Furthermore, several themes emerged that crossed across several or all diseases presented. Specifically, the self-fulfilling prophecy, lack of accounting for medical comorbidities, and absence of integration of in-hospital care parameters were identified as major gaps in most prognostic models. Conclusions Prognostication in neurocritical care is important, and current prognostic models are limited. This gap analysis provides a summary assessment of issues that could be addressed in future studies and evidence-based guidelines in order to improve the process of prognostication.
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Affiliation(s)
- Katja E Wartenberg
- Neurocritical Care and Stroke Unit, Department of Neurology, University of Leipzig, Liebigstrasse 20, 04103, Leipzig, Germany.
| | - David Y Hwang
- Department of Neurology, Yale School of Medicine, P.O. Box 208018, New Haven, CT, 06520-8018, USA
| | - Karl Georg Haeusler
- Department of Neurology, Universitätsklinikum Würzburg, Josef-Schneider-Strasse 11, 97080, Würzburg, Germany
| | - Susanne Muehlschlegel
- Department of Neurology, Anesthesiology and Surgery, University of Massachusetts Medical School, 55 Lake Avenue North, Worcester, MA, 01655, USA
| | - Oliver W Sakowitz
- Neurosurgery Center Ludwigsburg-Heilbronn, RKH Klinikum Ludwigsburg, Posilipostrasse 4, 71640, Ludwigsburg, Germany
| | - Dominik Madžar
- Department of Neurology, University of Erlangen, Schwabachanlage 6, 91054, Erlangen, Germany
| | - Hajo M Hamer
- Department of Neurology, University of Erlangen, Schwabachanlage 6, 91054, Erlangen, Germany
| | | | - David M Greer
- Department of Neurology, Boston University Medical Center, 72 East Concord St, Boston, MA, 02118, USA
| | - J Claude Hemphill
- Department of Neurology, University of California San Francisco, 1001 Potrero Ave, San Francisco, CA, 94110, USA
| | - Juergen Meixensberger
- Department of Neurosurgery, University of Leipzig, Liebigstrasse 20, 04103, Leipzig, Germany
| | - Panayiotis N Varelas
- Department of Neurology and Neurosurgery, Henry Ford Hospital, 2799 W. Grand Blvd Neurosurgery - K-11, Detroit, MI, 48202, USA
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Comparison of Conventional Intensive Care Scoring Systems and Prognostic Scores Specific for Intracerebral Hemorrhage in Predicting One-Year Mortality. Neurocrit Care 2020; 34:92-101. [PMID: 32394131 PMCID: PMC7224102 DOI: 10.1007/s12028-020-00987-3] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
Background Specific prognostic models for intracerebral hemorrhage (ICH) have short and simple features, whereas intensive care unit (ICU) severity scales include more complicated parameters. Even though newly developed ICU severity scales have disease-specific properties, they still lack radiologic parameters, which is crucial for ICH. Aims To compare the performance of the Simplified Acute Physiology Score (SAPS) III, Acute Physiology and Chronic Health Evaluation (APACHE) IV, Logistic Organ Dysfunction Score (LODS), ICH, max-ICH, ICH functional outcome score (ICH-FOS), and Essen-ICH for prediction of in-hospital and one-year mortality of patients with ICH. Methods A single-center analysis of 137 patients with ICH was conducted over 5 years. The performance of scoring systems was evaluated with receiver operating characteristic analysis. The independent predictors of one-year mortality were investigated with a multivariate logistic regression analysis. The SAPS-III score was calculated both in the emergency department (ED) and ICU. Results Among the independent variables, the need for mechanical ventilation, hematoma volume, the presence of intraventricular hemorrhage, and hematoma originating from both lobar and nonlobar regions were found as the strongest predictor of one-year mortality. For in-hospital mortality, the discriminative power of SAPS-II, APACHE-IV, and LODS was excellent, and for SAPS-III-ICU and SAPS-III-ED, it was good. For one-year mortality, the discriminative power of SAPS-II, APACHE-IV, LODS, and SAPS-III-ICU was good, and for SAPS-III-ED, Essen-ICH, ICH, max-ICH, and ICH-FOS, it was fair. Conclusions Although all three ICH-specific prognostic scales performed satisfactory results for predicting one-year mortality, the common intensive care severity scoring showed better performance. SAPS-III scores may be recommended for use in EDs after proper customization. Electronic supplementary material The online version of this article (10.1007/s12028-020-00987-3) contains supplementary material, which is available to authorized users.
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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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Ebrahimi K, Vaisi Raigani AA, Jalali R, Rezaei M. Determining and Comparing Predictive and Intensity Value of Severity Scores - "Sequential Organ Failure Assessment Score," "Acute Physiology and Chronic Health Evaluation 4," and "Poisoning Severity Score" - in Short-Term Clinical Outcome of Patients with Poisoning in an ICU. Indian J Crit Care Med 2018; 22:415-421. [PMID: 29962741 PMCID: PMC6020641 DOI: 10.4103/ijccm.ijccm_238_17] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
Introduction: Today, poisoning is one of the problems of society and it is always one of the ten leading causes of death among youth. This study aimed to determine and compare the predictive and intensity value of three standard criteria of “Sequential Organ Failure Assessment (SOFA) score,” “Acute Physiology and Chronic Health Evaluation (APACHE) 4,” and “Poisoning Severity Score (PSS)” in short-term clinical outcome of poisoned patients. Methods: The prospective study conducted on 120 patients of critical care units. Data were collected using a demographic form and three criteria forms. The researcher was visiting the critical care unit daily and was filling out the demographic form of each patient in the first 24 h of hospital admission. The data were analyzed using SPSS version 16. Results: The results showed the mean age of patients was 35.73 ± 18.46 years with the most frequency among male patients (66.7%). The mean of criteria scores of “SOFA score,” “APACHE 4,” and “PSS” was 7.3 ± 2.97, P = 0.009; 62.43 ± 12.48, P = 0.58; and 2.4 ± 0.5, P = 0.001, respectively. The accuracy, sensitivity, specificity, positive and negative predictive values, and area under the curve of “SOFA score,” “APACHE 4,” and “PSS” were 86.2, 70.6, 94.4, 98.6, 36.2, 0.897; 83.5, 90.2, 44.4, 90.2, 44.4, 0.808; and 16.7, 100, 2, 100, 15.3, 0.786, respectively. Predicted mortality rate in “SOFA score” and “APACHE 4” was 18.7% ±20.2% and 2.63% ±2.6%, respectively. Real mortality rate, predictive duration of hospitalization by APACHE 4 criteria, and real duration of hospitalization were 15%, 1.79 ± 1.35, and 4.04 ± 4.08, respectively. Conclusion: The study showed that “SOFA score” was more predictive in clinical outcomes due to poisoning and it is recommended to poisoning centers as effective criteria.
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Affiliation(s)
- Koroush Ebrahimi
- Department of Nursing, School of Nursing and Midwifery, Kermanshah University of Medical Sciences, Kermanshah, Iran
| | - Ali Akbar Vaisi Raigani
- Department of Nursing, School of Nursing and Midwifery, Kermanshah University of Medical Sciences, Kermanshah, Iran
| | - Rostam Jalali
- Department of Nursing, School of Nursing and Midwifery, Kermanshah University of Medical Sciences, Kermanshah, Iran
| | - Mansour Rezaei
- Department of Biostatistics, School of Health, Kermanshah University of Medical Sciences, Kermanshah, Iran
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