The ICH score: predicting mortality and functional outcome in an Asian population

Guidelines for Neuroprognostication in Critically Ill Adults with Intracerebral Hemorrhage

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Clinical Grading Scales and Neuroprognostication in Acute Brain Injury

Prediction of neurological clinical outcome after acute brain injury is critical because it helps guide discussions with patients and families and informs treatment plans and allocation of resources. Numerous clinical grading scales have been published that aim to support prognostication after acute brain injury. However, the development and validation of clinical scales lack a standardized approach. This in turn makes it difficult for clinicians to rely on prognostic grading scales and to integrate them into clinical practice. In this review, we discuss quality measures of score development and validation and summarize available scales to prognosticate outcomes after acute brain injury. These include scales developed for patients with coma, cardiac arrest, ischemic stroke, nontraumatic intracerebral hemorrhage, subarachnoid hemorrhage, and traumatic brain injury; for each scale, we discuss available validation studies.

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

INTRODUCTION

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

METHODS

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

RESULTS

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

CONCLUSION

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

The Intracerebral Hemorrhage Score Overestimates Mortality in Young Adults

OBJECTIVE

To determine whether the intracerebral hemorrhage (ICH) score is accurate in predicting 30-day mortality in young adults, we calculated the ICH score for 156 young adults (aged 18-45) with primary spontaneous ICH and compared predicted to observed 30-day mortality rates.

METHODS

We retrospectively reviewed all patients aged 18-45 consecutively presenting to the University of Iowa from 2009 to 2019 with ICH. We calculated the ICH score and recorded its individual subcomponents for each patient. Poisson regression was used to test the association of ICH score components with 30-day mortality.

RESULTS

We identified 156 patients who met the inclusion criteria; mean± standard deviation (SD) age was 35±8 years. The 30-day mortality rate was 15% (n=24). The ICH score was predictive of 30-day mortality for each unit increase (p= 0.04 for trend), but the observed mortality rates for each ICH score varied considerably from the original ICH score predictions. Most notably, the 30-day mortality rates for ICH scores of 1, 2, and 3 are predicted to be 13%, 26%, and 72% respectively, but were observed in our population to be 0%, 3%, and 41%. An ICH volume of >30cc [relative risk (RR) 28, 95% confidence intervals (CI) 3-315, p=0.01] and a GCS score of <5 (RR 13, 95% CI 0.1-1176, p=0.01) were independently associated with 30-day mortality.

CONCLUSIONS

The ICH score tends to overestimate mortality in young adults. ICH volume and GCS score are the most relevant items in predicting mortality at 30 days in young adults.

Race and in-hospital mortality after spontaneous intracerebral hemorrhage in the Stroke Belt: Secondary analysis of a case-control study

Background and Purpose:

Intracerebral hemorrhage (ICH) accounts for around 10% of stroke, but carries 50% of stroke mortality. ICH characteristics and prognostic factors specific to the Stroke Belt are not well defined by race.

Methods:

Records of patients admitted to the University of Alabama Hospital with ICH from 2017 to 2019 were reviewed. We examined the association of demographics; clinical and radiographic features including stroke severity, hematoma volume, and ICH score; and transfer status with in-hospital mortality and discharge functional status for a biracial population including Black and White patients. Independent predictors of in-hospital mortality and functional outcome were examined using logistic regression.

Results:

Among the 275 ICH cases included in this biracial analysis, Black patients (n = 114) compared to White patients (n = 161) were younger (60.6 vs. 71.4 years, P < 0.0001), more often urban (81% vs. 64%, P < 0.01), more likely to have a history of hypertension (87% vs. 71%, P < 0.01), less often transferred (44% vs. 74%, P < 0.01), and had smaller median initial hematoma volumes (9.1 vs. 12.6 mL, P = 0.041). On multivariable analysis, Glasgow Coma Scale (GCS) for White patients (OR 13.0, P < 0.0001), hyperlipidemia for Black patients (OR 13.9, P = 0.019), and ICH volume for either race (Black patients: OR 1.05, P = 0.03 and White patients: OR 1.04, P < 0.01) were independent predictors of in-hospital mortality.

Conclusions:

Hypertension is more prevalent among Black ICH patients in the Stroke Belt. The addition of hyperlipidemia to the ICH score model improved the prediction of mortality for Black ICH patients. No differences in in-hospital mortality or poor functional outcome were observed by race.

The Intracerebral Hemorrhage Score: A Self-Fulfilling Prophecy?

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.

Prognostic value of elevated cardiac troponin I in patients with intracerebral hemorrhage

Background

Although cardiac troponin has been well established as diagnostic and prognostic makers for acute coronary heart disease, the prognostic value of elevated cardiac troponin in patients with intracerebral hemorrhage (ICH) was inconsistent and not systematically evaluated.

Hypothesis

We proposed the hypothesis that the practical utility of cardiac troponin levels for prediction of mortality and poor outcome in ICH patients.

Methods

A total of 1004 patients with ICH were retrospectively reviewed and qualified for further analysis from June 2012 to December 2015. The patients were divided into different groups based on measurements of cardiac troponin I (cTnI) at the time of admission and the following day. Multivariate Cox proportional hazards analysis were performed to determine the independent prognostic value of the cTnI for patients in‐hospital mortality and poor outcomes, the receiver operator characteristic (ROC) analysis was performed to assess the predictive value of cTnI, ICH score, and combination of them.

Results

Serum cTnI level was an independent predictor in‐hospital mortality (positive vs negative, HR (hazard ratios) = 3.44, 95% CI (confidence interval) 1.66‐7.13, P < .001) and poor outcomes in patients with ICH (positive vs negative, HR = 6.69, 95% CI 4.25‐10.52, P < .001). Addition of cTnI to ICH score significantly improved the prognostic discrimination for both in‐hospital mortality and poor outcomes.

Conclusion

Serum cTnI levels may be valuable as predictor for in hospital mortality and poor outcomes and may be useful in the risk stratification of ICH during hospitalization.

Validation of the Intracerebral Hemorrhage Score in Uganda

Background and Purpose- Rates of intracerebral hemorrhage (ICH) are estimated to be highest globally in sub-Saharan Africa. However, outcomes of ICH are poorly described and standard prognostic markers for ICH have not been validated in the region. Methods- We enrolled consecutive patients with computed tomography-confirmed ICH at a referral hospital in southwestern Uganda. We recorded demographic, clinical, and radiographic features of ICH, and calculated ICH scores. We fit Poisson regression models with robust variance estimation to determine predictors of case fatality at 30 days. Results- We enrolled 73 individuals presenting with computed tomography-confirmed ICH (mean age 60 years, 45% [33/73] female, and 14% [10/73] HIV-positive). The median ICH score was 2 (interquartile range, 1-3; range, 0-5). Case fatality at 30 days was 44% (32/73; 95% CI, 33%-57%). The 30-day case fatality increased with increasing ICH score of 0, 1, and 5 from 17%, 23%, to 100%, respectively. In multivariable-adjusted models, ICH score was associated with case fatality (adjusted relative risk, 1.48; 95% CI, 1.23-1.78), as were HIV infection (adjusted relative risk, 1.92; 95% CI, 1.07-3.43) and female sex (adjusted relative risk, 2.17; 95% CI, 1.32-3.59). The ICH score moderately improved with the addition of a point each for female sex and HIV serostatus (0.81 versus 0.73). Conclusions- ICH score at admission is a strong prognostic indicator of 30-day case fatality in Uganda. Our results support its role in guiding the care of patients presenting with ICH in the region.

Advancements in Managing Intracerebral Hemorrhage: Transition from Nihilism to Optimism

There have been significant advancements in the management of intracerebral hemorrhage (ICH) stemming from new knowledge on its pathogenesis. Major clinical trials, such as Surgical Trial in Lobar Intracerebral Hemorrhage (STICH I and II), have shown only a small, albeit clinically relevant, advantage of surgical interventions in specific subsets of patients suffering from ICH. Currently, the aim is to use a minimally invasive and safe trajectory in removing significant brain hematomas with the aid of neuro-endoscopy or precise guidance through neuro-navigation, thereby avoiding a collateral damage to the surrounding normal brain tissue. A fundamental rational to such approach is to safely remove hematoma, preventing the ongoing mass effect resulting in brain herniation, and to minimize deleterious effects of iron released from hematoma to brain cells. The clot lysis process is facilitated with the adjunctive use of recombinant tissue plasminogen activator and sonolysis. Revised recommendations for the management of ICH focus on a holistic approach, with special emphasis on early patient mobilization and graded rehabilitative process. There has been a paradigm shift in the management algorithm, putting emphasis on early and safe removal of brain hematoma and then focusing on the improvement of patients' quality of life. We have made significant progress in transition from nihilism toward optimism, based on evidence-based management of such a severe global health scourge as intracranial hemorrhage.

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

Background:

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

Materials and Methods:

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

Results:

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

Conclusion:

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

Validation of the ICH score in patients with spontaneous intracerebral haemorrhage admitted to the intensive care unit in Southern Spain

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.

Race-Specific Predictors of Mortality in Intracerebral Hemorrhage: Differential Impacts of Intraventricular Hemorrhage and Age Among Blacks and Whites

Background

Intracerebral hemorrhage (ICH) carries high risk for short‐term mortality. We sought to identify race‐specific predictors of mortality in ICH patients.

Methods and Results

We used 2 databases, the Johns Hopkins clinical stroke database and the Nationwide Inpatient Sample (NIS). We included 226 patients with the primary diagnosis of spontaneous ICH from our stroke database between 2010 and 2013; in the NIS, 42 077 patients met inclusion criteria. Logistic regression was used to assess differences in predictors of mortality in blacks compared to whites. In our clinical stroke database, Glasgow Coma Scale (GCS; P=0.016), ICH volume (P=0.013), intraventricular haemorrhage (IVH; P=0.023), and diabetes mellitus (P=0.037) were predictors of mortality in blacks, whereas GCS (P=0.007), ICH volume (P=0.005), age (P=0.002), chronic kidney disease (P=0.003), and smoking (P=0.010) predicted mortality in whites. Among patients with IVH, blacks had over 7 times higher odds of mortality compared to whites (odds ratio [OR], 7.27; P value for interaction, 0.017) and were more likely to present with hydrocephalus (OR, 2.76; P=0.026). In the NIS, black ICH patients had higher rates of external ventricular drain (EVD) placement compared to whites (9.7% vs 5.0%; P<0.001) and were more likely to develop hydrocephalus (OR, 1.32; 95% CI, 1.20–1.46). Comparison of a race‐specific ICH score to the original ICH score showed that the various ICH score components have differential relevance for ICH score performance by race.

Conclusions

IVH and age differentially predict mortality among blacks and whites. Blacks have higher rates of obstructive hydrocephalus and more frequently require EVD placement compared to their white counterparts.

VSARICHS: a simple grading scale for vascular structural abnormality-related intracerebral haemorrhage

BACKGROUND AND PURPOSE

Vascular structural abnormality-related intracerebral haemorrhage (VSARICH) accounts for 10-20% of cases of intracerebral haemorrhage (ICH), but none of the grading scales for primary ICH are reliable for VSARICH. This study aimed to propose a grading scale based on clinical and anatomical parameters to predict short-term clinical outcome.

METHODS

Data were prospectively collected from patients with ICH recruited consecutively from 50 secondary and tertiary hospitals in China. Demographic and clinicopathological factors associated with mortality and good clinical outcome were identified and used to develop a grading scale for VSARICH.

RESULTS

The VSARICH was 10.8% and 13% in the derivation (n=335) and validation (n=109) cohorts, respectively. Data from 307 patients with VSARICH in the derivation cohort were used to generate a VSARICH score (VSARICHS) system ranging from 0 to 9. Points were assigned based on the Glasgow Coma Scale (GCS) score on admission (GCS 3-4=4 points; 5-12=2 points; 13-15=0 points), age (≥80 years=2 points; 79-60=1 point; ≤59=0 points), presence of subarachnoid haemorrhage (yes=1 point; no=0 points) and presence of herniation (yes=2 points; no=0 points). VSARICHS showed good discrimination in the derivation cohort (area under the receiver operating characteristic curves, AUCs)AUCs 0.837 for good clinical outcome; 0.942 for mortality) and validation cohort (AUCs 0.813 for good clinical outcome; 0.930 for mortality).

CONCLUSIONS

VSARICHS appears to be a reliable clinical scoring system that may prove useful for guiding risk stratification, clinical treatment and research.

Is the ICH score a valid predictor of mortality in intracerebral hemorrhage?

PURPOSE

The intracerebral hemorrhage (ICH) score utilizes a 0- to 6-point scoring system to predict 30-day mortality in ICH patients. The purpose of this analysis was to (a) validate the ICH score in an international, heterogeneous population of ICH patients; and (b) assess the usefulness of a 72-h ICH score.

DATA SOURCES

Analyses were based on data from 399 patients in the Novo Nordisk trial F7ICH-1371. The ICH score's ability to predict mortality was determined by calculating the sensitivity, specificity, and positive predictive value (PPV).

CONCLUSIONS

Both the baseline and 72-h ICH score had high specificity but low sensitivity resulting in an overall PPV of 57%-76%. Specificity of the ICH score was higher in the baseline ICH score (95%) as compared to the 72-h score (89%). Sensitivity of the ICH score was higher in the 72-h ICH score (75%) as compared to the baseline score (36%).

IMPLICATIONS FOR PRACTICE

The baseline ICH score provides reasonable PPV while the 72-h score provides higher sensitivity. ICH scores obtained at baseline and/or 72 h are valid and may help practitioners to more accurately predict 30-day mortality in ICH patients.

Prognostic value of ICH score and ICH-GS score in Chinese intracerebral hemorrhage patients: analysis from the China National Stroke Registry (CNSR)

Purpose

No strongevidenceofefficacycurrently exists for different intracerebral hemorrhage (ICH) scoring system in predicting the prognosis of ICH in the Chinese population. This study aimed to test the accuracyof the ICH score and the ICH grading scale (ICH-GS) score in predicting the favorable prognosis in a large cohort of ICH patients in China.

Methods

This study was a multicenter, prospective cohort study. Patients diagnosed with ICH between September 2007 and August 2008 from the nationwide China National Stroke Registry (CNSR) databasewere screened andenrolled in this study. Demographics of the patients, treatments, mortalityas well as the clinic and radiologic findings of ICH were collected.AnICH score and anICH-GS score were evaluated for all the patients atadmission. Follow-ups were conducted by phone at 3, 6 and 12 months after ICH onset. The modified Rankin scale (mRS) score was used to evaluate favorable functional outcome and was obtained at hospital dischargeand duringthe 3-, 6- and 12-month follow-up visits.

Results

There were 410 (12.6%) in-hospitalmortalityout of a total of 3,255 ICH patients. Thevalues of the Area Under Curve (AUC)at discharge, 3-, 6- and 12-month follow-up for ICH score were 0.72, 0.76, 0.76 and 0.75, respectively; whilethe numbers for the ICH-GS score were 0.71, 0.77, 0.78 and 0.78, respectively. At 6-month and 12-month follow-up, the ICH-GS score presented a significant better value in predicting favorable prognosis than did the ICH score (P=0.0003 and <0.0001, respectively).

Conclusion

Both the ICH and ICH-GS scores were effective inaccurately predicting the favorable functional outcome of ICH in the Chinese population. For mid-term and long-term prediction, the ICH-GS score was superiorover the ICH score.

Decompressive hemicraniectomy without clot evacuation in dominant-sided intracerebral hemorrhage with ICP crisis

Object

Large intracerebral hemorrhage (ICH), compounded by perihematomal edema, can produce severe elevations of intracranial pressure (ICP). Decompressive hemicraniectomy (DHC) with or without clot evacuation has been considered a part of the armamentarium of treatment options for these patients. The authors sought to assess the preliminary utility of DHC without evacuation for ICH in patients with supratentorial, dominant-sided lesions.

Methods

From September 2009 to May 2012, patients with ICH who were admitted to the neurological ICU at Columbia University Medical Center were prospectively enrolled in that institution's ICH Outcomes Project (ICHOP). Five patients with spontaneous supratentorial dominant-sided ICH underwent DHC without clot evacuation for recalcitrant elevated ICP. Data pertaining to the patients' characteristics and outcomes of treatment were prospectively collected.

Results

The patients' median age was 43 years (range 30–55 years) and the ICH etiology was hypertension in 4 of 5 patients, and systemic lupus erythematosus vasculitis in 1 patient. On admission, the median Glasgow Coma Scale (GCS) score was 7 (range 5–9). The median ICH volume was 53 cm3 (range 28–79 cm3), and the median midline shift was 7.6 mm (range 3.0–11.3 mm). One day after surgery, the median decrease in midline shift was 2.7 mm (range 1.5–4.6 mm), and the median change in GCS score was +1 (range −3 to +5). At discharge, all patients were still alive, and the median GCS score was 10 (range 9–11), the median modified Rankin Scale (mRS) score was 5 (range 5–5), and the median NIHSS (National Institutes of Health Stroke Scale) score was 22 (range 17–27). Six months after hemorrhage, 1 patient had died, 2 were functionally dependent (mRS Score 4–5), and 2 were functionally independent (mRS Score 0–3). Outcomes for the patients treated with DHC were good compared with 1) outcomes for all patients with spontaneous supratentorial ICH admitted during the same period (n = 144) and 2) outcomes for matched patients (dominant ICH, GCS Score 5–9, ICH volume 28–79 cm3, age < 60 years) whose cases were managed nonoperatively (n = 5).

Conclusions

Decompressive hemicraniectomy without clot evacuation appears feasible in patients with large ICH and deserves further investigation, preferably in a randomized controlled setting.

The prediction of 30-day mortality and functional outcome in spontaneous intracerebral hemorrhage with secondary ventricular hemorrhage: a score comparison

The original ICH (oICH) score was tested in different populations and showed good accuracy in the prediction of outcome and 30-day mortality after spontaneous ICH. The oICH was developed to stratify patients with all types of spontaneous intracerebral hemorrhage (SICH). Several modifications of the oICH score exist in the literature.In the current study, we tested the oICH score, two modified ICH scores, and the IVH score on a cohort of 171 patients with SICH and mandatory secondary intraventricular hemorrhage (IVH). Receiver-operating characteristic (ROC) curves were plotted, and the areas under the curves (AUC) were calculated for each score.The calculated AUCs for the prediction of 30-day mortality in the cohort were 0.736, 0.816, 0.805, and 0.836 for the original ICH, the mICH-A, the mICH-B, and the new IVH score, respectively. The best AUC for functional outcome was observed for the mICH-B score (0.823). For the mICH-A and the IVH score, an AUC of 0.811 was calculated.The scores that include the quantification of IVH or the grading of hydrocephalus show good accuracy in the prediction of 30-day mortality and functional outcome at 6 months in SICH with secondary IVH.

Clinical grading scales in intracerebral hemorrhage

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

Determining ICH Score: can we go beyond?

Spontaneous intracerebral hemorrhage (SICH) still presents a great heterogeneity in its clinical evaluation, demonstrating differences in the enrollment criteria used for the study of intracerebral hemorrhage (ICH) treatment. The aim of the current study was to assess the ICH Score, a simple and reliable scale, determining the 30-day mortality and the one-year functional outcome. Consecutive patients admitted with acute SICH were prospectively included in the study. ICH Scores ranged from 0 to 4, and each increase in the ICH Score was associated with an increase in the 30-day mortality and with a progressive decrease in good functional outcome rates. However, the occurrence of a pyramidal pathway injury was better related to worse functional outcome than the ICH Score. The ICH Score is a good predictor of 30-day mortality and functional outcome, confirming its validity in a different socioeconomic populations. The association of the pyramidal pathway injury as an auxiliary variable provides more accurate information about the prognostic evolution.

Prospective validation of the ICH Score for 12-month functional outcome

BACKGROUND

The ICH Score is a commonly used clinical grading scale for outcome after acute intracerebral hemorrhage (ICH) and has been validated for 30-day mortality, but not long-term functional outcome. The goals of this study were to assess whether the ICH Score accurately stratifies patients with regard to 12-month functional outcome and to further delineate the pace of recovery of patients during the first year post-ICH.

METHODS

We performed a prospective observational cohort study of all patients with acute ICH admitted to the emergency departments of San Francisco General Hospital and UCSF Medical Center from June 1, 2001, through May 31, 2004. Components of the ICH Score (admission Glasgow Coma Scale score, initial hematoma volume, presence of intraventricular hemorrhage, infratentorial ICH origin, and age) were recorded along with other clinical characteristics. Patients were then assessed with the modified Rankin Scale (mRS) at hospital discharge, 30 days, and 3, 6, and 12 months post-ICH.

RESULTS

Of 243 patients, 95 (39%) died during initial acute hospitalization. The ICH Score accurately stratified patients with regard to 12-month functional outcome for various dichotomous cutpoints along the mRS (p < 0.05). Many patients continued to improve across the first year, with a small number of patients becoming disabled or dying due to late events unrelated to the initial ICH.

CONCLUSIONS

The ICH Score is a valid clinical grading scale for long-term functional outcome after acute intracerebral hemorrhage (ICH). Many ICH patients improve after hospital discharge and this improvement may continue even after 6 months post-ICH.

Diretrizes para o manejo de pacientes com hemorragia intraparenquimatosa cerebral espontânea

A hemorragia intraparenquimatosa cerebral (HIC) é o subtipo de AVC de pior prognóstico e com tratamento ainda controverso em diversos aspectos. O comitê executivo da Sociedade Brasileira de Doenças Cerebrovasculares, através de uma revisão ampla dos artigos publicados em revistas indexadas, elaborou sugestões e recomendações que são aqui descritas com suas respectivas classificações de níveis de evidência. Estas diretrizes foram elaboradas com o objetivo de prover o leitor de um racional para o manejo apropriado dos pacientes com HIC, baseado em evidências clínicas.

Predicting recovery after intracerebral hemorrhage--an external validation in patients from controlled clinical trials

BACKGROUND

An early and reliable prognostic indication in stroke patients is potentially useful for initiation of individual treatment and for informing patients and relatives. We recently developed a regression model as well as a simple 11-point predictive score (Essen ICH score) for functional recovery within three months after acute intracerebral hemorrhage (ICH) based on age and the National Institutes of Health Stroke Scale (NIH-SS). Here, we demonstrate the applicability of our models in an independent sample of ICH patients from controlled clinical trials.

METHODS

The prognostic models were used to predict functional recovery in 564 patients from the Virtual International Stroke Trials Archive (VISTA). Furthermore, we tried to improve the accuracy by re-calibration and estimating new model parameters.

FINDINGS

The logistic regression model and the Essen ICH score were able to correctly classify 77.5 % and 76.4 % of patients, respectively. Re-calibration and novel estimation of parameters yielded only a slight improvement of overall predictive accuracy.

INTERPRETATION

For acute ICH patients included in controlled trials, our predictive models based on age and the NIH-SS correctly predict functional recovery after three months and could be useful for future trial design.

Aspects of intracerebral hematomas--an update

BACKGROUND

In Norway, there are approximately 16000 strokes each year and 15% of these are caused by intracerebral hematomas. Intracerebral hemorrhage (ICH) results from the rupture of blood vessels within the brain parenchyma. ICH occurs as a complication of several diseases, the most prevalent of which is chronic hypertension. When hemorrhage develops in the absence of a pre-existing vascular malformation or brain parenchymal lesion, it is denoted primary ICH. Secondary ICH refers to hemorrhage complicating a pre-existing lesion. Primary ICH is the most common type of hemorrhagic stroke, accounting for approximately 10% of all strokes. Despite aggressive management strategies, the 30-day mortality remains high, at almost 50%, with the majority of deaths occurring within the first 2 days. At 6 months, only 20-30% achieve independent status.

MATERIAL AND METHODS

This article is based on clinical experience, modern therapeutic guidelines for the treatment of intracerebral hematomas and up-to-date medical literature found in Medline. The article discusses the pathophysiology, clinical aspects, treatment, and the prognosis of intracerebral hematomas.

RESULTS AND DISCUSSION

Advances in diagnosis, prognosis, pathophysiology, and treatment over the past few decades have significantly advanced our knowledge of ICH; however, much work still needs to be carried out. Future genetic and epidemiologic studies will help identify at-risk populations and hopefully allow for primary prevention. Randomized controlled studies focusing on novel therapeutics should help to minimize secondary injury and hopefully improve morbidity and mortality.

Update on intracerebral haemorrhage

Intracerebral haemorrhage (ICH) is a common and serious disease. About 1 to 2 out of 10 patients with stroke have an ICH. The mortality of ICH is higher than that of ischaemic stroke. Only 31% are functionally independent at 3 months. Only 38% of the patients survive the 1(st) year. The cost of ICH is high. Hypertension is the major risk factor, increasing the risk of ICH about 4x. Up to half of hypertensive patients who suffer a ICH are either unaware of their hypertension, non-compliant with the medication or fail to control periodically their blood pressure levels Microbleeds and white matter changes are MRI markers of the risk of ICH. ICH has 3 main pathophysiological phases: arterial rupture and haematoma formation, haematoma enlargement and peri-haematoma oedema. Up to 40% of the haematomas grow in the first hours post-rupture. ICH growth is associated with early clinical deterioration. Two randomised clinical trials (RCTs) demonstrated that treatment with rFVIIa limited haematoma growth and improved outcome, but was associated with a increase in thromboembolic complications. Ventricular drainage with thrombolytics might improve outcome for patients with intraventricular bleeding. A large RCT and meta-analysis failed to show a benefit of surgery over conservative treatment in acute ICH.

Development and validation of a prognostic model to predict recovery following intracerebral hemorrhage

CONTEXT

While several models have been developed to predict mortality following intracerebral hemorrhage (ICH), the functional outcome and its predictors in surviving patients have been poorly investigated so far.

OBJECTIVES

To identify predictors and validate a prognostic model for independent functional outcome in patients with acute ICH.

DESIGN

An inception cohort was assessed on the National Institutes of Health Stroke Scale (NIH-SS) at admission and followed-up after 100 days.

SETTING

11 neurological departments with an acute stroke unit.

PATIENTS

207 consecutive patients who were neither comatose nor intubated at admission within 6 hours after ICH and with complete follow-up.

RESULTS

After 100 days, 40 patients (19.3 %) had died, 78 (37.7%) had regained functional independence (Barthel Index > or = 95) and 89 (43%) had survived but not recovered. In these patients, age and the NIH-SS total score were identified as independent predictors for functional independence after 100 days. With the predefined cut-off value, the prognosis of 79.8% of all patients could be predicted accurately upon validation in an independent data set of 173 non-comatose patients with acute ICH.

CONCLUSION

Our study provides a validated prognostic model for prediction of complete recovery following ICH which could be very useful for the design of clinical studies.

Predicting mortality in spontaneous intracerebral hemorrhage: can modification to original score improve the prediction?

BACKGROUND AND PURPOSE

A clinical grading scale for intracerebral hemorrhage (ICH), formally ICH score, was recently developed showing to predict 30-day mortality in a simple and reliable manner. The aim of the present study was to validate the original ICH (oICH) score in an independent cohort of patients from a developing country assessing 30-day mortality and 6-month functional outcome and whether its modifications can improve prediction.

METHODS

Consecutive patients admitted with acute ICH between January 1, 2003, and July 31, 2004, were prospectively included. oICH score was applied and 2 modified ICH (mICH) scores were created with the same variables, except localization, of the oICH score but with different cutoff values. Outcome was assessed as 30-day mortality and 6-month good outcome (Glasgow Outcome Scale [GOS] 4 to 5).

RESULTS

A total of 153 patients were included during study period. Thirty-day mortality rate was 34.6% (n=53), and 59 patients (38.6%) had good functional outcome (GOS 4 to 5) at 6 months. The oICH and mICH scores predicted mortality equally well. According to Youden's index (J), the oICH score was a reliable predictor for mortality (J=0.59) but less reliable for predicting good outcome (J=0.54). The mICH scores were equal in predicting mortality but better for predicting good outcome than the oICH score (J=0.60).

CONCLUSIONS

oICH score also confirms its validity in a socially and culturally different population. Modifications of oICH do not improve its 30-day mortality prediction but improve its ability to predict good functional outcome at 6 months.

Intracerebral Hemorrhage

INTRODUCTION

Intracerebral hemorrhage (ICH) occurs from the rupture of small vessels into the brain parenchyma and accounts for approximately 10% of all strokes in the United States, and carries with it a significantly high morbidity and mortality.

SUMMARY

This article reviews the course and management of ICH. The most common chronic vascular diseases that lead to ICH are chronic hypertension and cerebral amyloid angiopathy. Additional factors that predispose to ICH include vascular malformations, chronic alcohol use, hypocholesterolemia, and use of anticoagulant medications. The understanding of mechanisms leading to ICH has advanced significantly, but questions regarding site predilection and timing of spontaneous hemorrhage still remain. Management in the acute setting is first focused on reducing hematoma expansion. Although no specific therapy has yet been proven effective, promising agents, particularly recombinant Factor VIIa, are on the horizon. Subsequent care is focused on controlling hemostasis, hemodynamics, and intracranial pressure in efforts to minimize secondary brain injury.

CONCLUSION

The morbidity and mortality associated with ICH remain high despite recent advances in our understanding of the clinical course of ICH. Novel preventive and acute treatment therapies are needed and may be on the horizon.