Abstract TP349: Improving Utilization of ICU Care: Change in Intracerebral Hemorrhage Admission Protocol at a Comprehensive Stroke Center

Objectives: Non traumatic intracerebral hemorrhage (ICH) is responsible for 10-20% of acute stroke events and carries significant mortality concern. The protocol at our comprehensive stroke centers (CSC) is to admit all ICH patients to Neurosciences Intensive Care Unit (NSICU). We also have a stroke Intermediate Care Unit (IMCU) at our hospital which is a dedicated stroke unit where patients can be closely monitored and maintained on IV nicardipine. Optimal bed utilization is essential at our busy referral center. We aimed to develop criteria to identify ICH patients at low risk for clinical deterioration who could be admitted directly to our IMCU rather than the NSICU thereby improving overall utilization of monitored beds. Methods: Retrospective chart review for patients admitted between July 2018-Dec 2018 was performed. Age, sex, race, presenting Glasgow coma scale (GCS), ICH score, ICH volume, presence of IVH and location of the hemorrhage was documented. Patients who did not need any neurosurgical procedures (external ventricular drain, craniectomy or hematoma evacuation) and were not documented to have acute respiratory failure during their admission were considered appropriate for IMCU admission and were further assessed for hematoma expansion to determine stability throughout their hospital course. Results: 118 patients with ICH were included in the analysis, out of which 61 patients were suitable for IMCU admission. On univariable analysis, patients that had lower ICH scores (0.6±0.7 vs 2.5±0.9) and higher GCS score (14.1±1.4 vs 7.8±3.7) did not need any acute intervention. In this group of patients, only 9 (14.7%) patients had hematoma expansion documented out of which 6 (67%) patients had coagulation abnormalities on admission either due to medications or low platelet count. Conclusions: We conclude that the patients who had admission ICH score < 2, GCS ≥ 12 and no coagulation abnormalities on admission could have safely been admitted to our IMCU instead of the NSICU for further care and management. This would have led to a decrease in ICU admission rate. Application of such separate protocols for stroke IMCU admission vs ICU admission would lead to better utilization of resources at comprehensive stroke centers throughout the country.

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A grading scale for surgically treated patients with spontaneous supratentorial intracerebral hemorrhage: the Surgical Swedish ICH Score

Journal of Neurosurgery ◽

10.3171/2019.5.jns19622 ◽

2020 ◽

Vol 133 (3) ◽

pp. 800-807 ◽

Cited By ~ 3

Author(s):

Andreas Fahlström ◽

Henrietta Nittby Redebrandt ◽

Hugo Zeberg ◽

Jiri Bartek ◽

Andreas Bartley ◽

...

Keyword(s):

Type 2 Diabetes ◽

Intracerebral Hemorrhage ◽

External Validation ◽

Grading Scale ◽

Ich Score ◽

Gcs Score ◽

Strength Of Association ◽

Point Type ◽

Clinical Grading

OBJECTIVEThe authors aimed to develop the first clinical grading scale for patients with surgically treated spontaneous supratentorial intracerebral hemorrhage (ICH).METHODSA nationwide multicenter study including 401 ICH patients surgically treated by craniotomy and evacuation of a spontaneous supratentorial ICH was conducted between January 1, 2011, and December 31, 2015. All neurosurgical centers in Sweden were included. All medical records and neuroimaging studies were retrospectively reviewed. Independent predictors of 30-day mortality were identified by logistic regression. A risk stratification scale (the Surgical Swedish ICH [SwICH] Score) was developed using weighting of independent predictors based on strength of association.RESULTSFactors independently associated with 30-day mortality were Glasgow Coma Scale (GCS) score (p = 0.00015), ICH volume ≥ 50 mL (p = 0.031), patient age ≥ 75 years (p = 0.0056), prior myocardial infarction (MI) (p = 0.00081), and type 2 diabetes (p = 0.0093). The Surgical SwICH Score was the sum of individual points assigned as follows: GCS score 15–13 (0 points), 12–5 (1 point), 4–3 (2 points); age ≥ 75 years (1 point); ICH volume ≥ 50 mL (1 point); type 2 diabetes (1 point); prior MI (1 point). Each increase in the Surgical SwICH Score was associated with a progressively increased 30-day mortality (p = 0.0002). No patient with a Surgical SwICH Score of 0 died, whereas the 30-day mortality rates for patients with Surgical SwICH Scores of 1, 2, 3, and 4 were 5%, 12%, 31%, and 58%, respectively.CONCLUSIONSThe Surgical SwICH Score is a predictor of 30-day mortality in patients treated surgically for spontaneous supratentorial ICH. External validation is needed to assess the predictive value as well as the generalizability of the Surgical SwICH Score.

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384 Post-Operative ICU Admission for Elective Craniotomy for Intra-axial Brain Tumor Resection

Neurosurgery ◽

10.1093/neuros/nyx417.384 ◽

2017 ◽

Vol 64 (CN_suppl_1) ◽

pp. 291-292

Author(s):

Farhan A Mirza ◽

Catherine Y Wang ◽

Thomas Pittman

Keyword(s):

Brain Tumor ◽

Pediatric Patients ◽

Prolonged Mechanical Ventilation ◽

Pediatric Population ◽

External Ventricular Drain ◽

Tumor Resection ◽

Retrospective Chart Review ◽

Icu Admission ◽

Icu Stay ◽

Brain Tumor Resection

Abstract INTRODUCTION We reviewed our practice at the University of Kentucky in order to assess the safety of admitting adult and pediatric patients to floor beds after craniotomy, exclusively for intra-axial brain tumor resection. METHODS Retrospective chart review of patients, adults and pediatric, who underwent craniotomy by a single surgeon (TP) for intra axial brain tumor resection between January 2012 and December 2015. 413 patient charts were reviewed, 16 were omitted due to incomplete records. RESULTS >421 craniotomies for intra axial brain tumor resection were performed. 397 patients underwent surgery, 35 of whom were <18 years of age.188 females and 209 males. 351 patients (331 adults, 20 pediatric) were admitted to floor beds. In this group, length of operation was <4 hours in 346 patients (99.1%) and >4 hours in only 5 patients (0.9%). 3 patients (0.8%) required transfer to ICU within 24 hours of floor admission. 55 adult patients required ICU stay for various reasons: 9 patients had pre-operative or intra operative EVD placement; 15 patients required prolonged ventilation; 1 patient had to be taken back to the operating room for hemorrhage evacuation; 5 had intraventricular tumors and were planned ICU admissions; 26 patients were admitted pre-operatively to an ICU bed on a non neurosurgical service and were returning to their assigned beds. In the pediatric population, 15 patients required ICU stay: 8 were for EVD management and 7 for prolonged operation or frequent neurological evaluations. In this group, the length of operation was <4 hours in 40 patients(57.1%) and >4 hours in 30 patients (42.9%). CONCLUSION Admitting adult and pediatric patients to floor beds after craniotomy for intra-axial brain tumor resection is safe. There are some conditions that mandate ICU admission: these include prolonged mechanical ventilation and the presence of an external ventricular drain.

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P14.86 Bevacizumab-associated intracerebral hemorrhage in patients with CNS malignancy: A single-center retrospective cohort study

Neuro-Oncology ◽

10.1093/neuonc/noz126.321 ◽

2019 ◽

Vol 21 (Supplement_3) ◽

pp. iii88-iii88

Author(s):

N Clarke ◽

M Ruff

Keyword(s):

Intracerebral Hemorrhage ◽

Functional Status ◽

Retrospective Chart Review ◽

Primary Diagnosis ◽

Recurrent Glioblastoma ◽

Adult Patients ◽

Single Center ◽

Cns Neoplasms ◽

Ich Score ◽

Cns Malignancy

Abstract BACKGROUND Gliomas are a known risk factor for the development of spontaneous intracranial hemorrhage (ICH) independent of therapies directed against them, with studies reporting an incidence of 1.9–3.8%. Bevacizumab (BEV) is a humanized monoclonal antibody targeting vascular endothelial growth factor (VEGF) FDA approved for recurrent glioblastoma. ICH is commonly considered to be a potential adverse effect of BEV use in patients with glioma, with previous retrospective studies describing incidence of intracerebral hemorrhage ranging from 1.9–3.3%. Material and METHODS We performed a single center (Mayo Clinic, Rochester, MN) retrospective chart review of all patients who received BEV therapy at our institution for a diagnosis of primary CNS malignancy. We used ICD-9 and ICD-10 codes to identify adult patients with primary CNS neoplasms that subsequently developed ICH. RESULTS We screened 10,507 adult patients with a diagnosis of primary CNS neoplasm treated at our center from 01/31/2008 to 12/31/2018 and found 644 patients treated with bevacizumab. Of these, 23 (3.6%) suffered an ICH within 12 weeks of a BEV infusion (median 9 days post infusion, 1–24 IQR). The dose of BEV in all hemorrhages was either 10 mg/kg every two weeks (n = 21) or 15 mg/kg every three weeks (n = 2). No patients treated with infusions at 7.5 mg/kg every three weeks (n = 79) or 5 mg/kg every two weeks (n = 17) suffered ICH events, however this did not meet significance (P = 0.06) when compared to patients on 10 mg/kg or above. The median ICH score was 1 (0–2 IQR). There was an increase in ECOG scores documented at clinical follow up following the hemorrhage compared to the pre-hemorrhage functional status (ECOG 3.28 versus 1.2, p = < 0.0001), with 13 patients (56%) having developed severe debility or death (ECOG 4 n = 3, ECOG 5 n = 10). CONCLUSION In our single-center cohort of patients with a primary diagnosis of CNS neoplasms treated with BEV, ICH occurred in 3.6% of patients. Those who experienced an ICH in proximity to BEV infusion had significant morbidity and mortality with a clear decline in functional status. There was a signal of dose response as far as ICH incidence in our cohort with dosages 10 mg/kg per infusion or above.

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Abstract 3858: Evaluation of Serial Neuroimaging in Patients with Intracerebral Hemorrhage

Stroke ◽

10.1161/str.43.suppl_1.a3858 ◽

2012 ◽

Vol 43 (suppl_1) ◽

Author(s):

Tanzila Shams ◽

Prachi Mehndiratta ◽

Pichet Termsarasab ◽

Hesham Masoud ◽

Siddharth Sehgal ◽

...

Keyword(s):

Basal Ganglia ◽

Intracerebral Hemorrhage ◽

No Value ◽

Retrospective Chart Review ◽

Care Plan ◽

Hematoma Expansion ◽

Imaging Studies ◽

Imaging Characteristics ◽

Neuroimaging Study ◽

The Impact

Introduction: The availability of sophisticated neuroimaging has led to increased utilization of imaging studies, particularly at comprehensive stroke centers. This increase in advanced imaging contributes to healthcare costs and has been questioned in this era of reducing reimbursement. Hypothesis: Multiple neuroimaging studies have limited impact in determining the plan of care for most patients with intracerebral hemorrhage. Methods: An IRB-approved retrospective chart review of all patients with Intracerebral Hemorrhage (ICH, ICD 431) treated at UH-CMC in 2010 collected data on demographics, number of neuroimaging studies and imaging characteristics, and the impact of testing on determining a medical or surgical plan of care. Hemorrhage location dictated one of two groups: basal ganglia and thalamus (BG) versus IVH alone, infratentorial and lobar (NBG). Results: Data was available on 120 (86%) of patients; 74 (62%) were male. Mean volume of ICH on initial CT was significantly smaller at 8.5±11.7cc in 41 BG patients vs 63±27cc in 79 NBG patients (p=0.01). The decision to pursue surgical treatment (extraventricular drainage in 14, craniotomy in 9, or both in 4) was determined prior to a third neuroimaging study. Three or more neuroimaging studies were obtained in 56% of BG and 59% of NBG patients. Hematoma expansion was less likely to occur in BG vs NBG patients, both for significant hematoma expansion (>33% or +12.5cc increase, 5% vs 22%, p=0.05) and nonsignificant hematoma expansion (10-33% increase, 2.4% vs 8.9%, p=0.27). Hematoma expansion was exclusively within the first 2 imaging studies for BG patients but occurred in a delayed fashion in 3 (4%) of NBG patients. MRI was obtained in 17% of BG and 44% of NBG patients; only in 3 of the NBG patients did it identify a vascular malformation which led to surgery in 1 patient. Conclusion: Although more than half of patients with intracerebral hemorrhage underwent three or more neuroimaging studies, 95% of patients’ care plan decisions were determined by the first, and to a lesser extent, the second neuroimaging study. Serial neuroimaging after the second study was of no value in patients with small basal ganglia hemorrhages and impacted the care plan in less than 10% of patients with hemorrhages in alternate locations. Our data suggests many neuroimaging studies can be safely omitted.

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Abstract 3229: Criteria for Appropriate Utilization of Helicopter Interfacility Transfer of ICH Patients

Stroke ◽

10.1161/str.43.suppl_1.a3229 ◽

2012 ◽

Vol 43 (suppl_1) ◽

Author(s):

Dustin J Calhoun ◽

Shana Bogenschneider ◽

Phaniraj Iyengar ◽

Andrew W Asimos

Keyword(s):

Care Center ◽

Tertiary Care ◽

Retrospective Chart Review ◽

High Sensitivity ◽

Brainstem Compression ◽

Tertiary Center ◽

Ich Score ◽

Gcs Score ◽

To Receive ◽

Neurosurgical Intervention

Background: Many intracranial hemorrhage (ICH) patients are emergently transferred to tertiary neurosurgical centers by helicopter emergency medical services (HEMS), yet no guidelines exist for HEMS use in acute ICH. The American Stroke Association (ASA) publishes guidelines for neurosurgical intervention in ICH patients. Additionally, high ICH scores have been shown to predict lethal ICHs. We hypothesized that an algorithm including ASA guideline criteria and ICH score would identify patients for whom HEMS transportation might be appropriate. Objectives: To determine, in ICH patients transferred by HEMS, (1) the sensitivity of ASA guidelines for predicting emergent neurosurgical intervention, and (2) the ability of an ICH score ≥4 to predict early mortality and failure to receive intervention. Methods: We conducted a retrospective chart review of ICH patients transported by HEMS to one tertiary care center between September 2008 and February 2011. We reviewed medical records and brain CTs from the hospital of first presentation to calculate ICH scores and to evaluate for the seven ASA guideline criteria: GCS score ≤8, herniation, intraventricular hemorrhage, hydrocephalus, brainstem compression, lobar clot >30 mL within 1 cm of the paranchymal surface, and cerebellar hemorrhage. We reviewed tertiary center records for neurosurgical interventions and in-hospital mortality. Results: Review of 137 patient records identified 86 patients with an ICH and an available initial brain CT. All patients who received an emergent intervention met at least one of the criteria (sensitivity 100%), while 16 (18.6%) patients transferred by HEMS met no ASA criteria. No patient with an ICH score of ≥4 (n=19) received an emergent neurosurgical intervention, and only one such patient survived to hospital discharge. Comparison of this group to all others produced a hazard ratio of 5.86. Thirty-five (40.7%) patients had either no ASA criteria or an ICH score ≥4. Conclusions: The ASA guidelines have high sensitivity for detecting those patients who will receive emergent neurosurgical intervention after transfer, while patients with ICH scores of ≥4 almost uniformly have lethal hemorrhages and do not undergo emergent intervention. An algorithm including the presence of at least one of the seven ASA ICH neurosurgical intervention criteria and an ICH score <4 can be used to screen for appropriate use of HEMS transport in acute ICH.

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Abstract WP415: Cigarette Smoking as Risk Factor for Hematoma Expansion in Primary Intracerebral Hemorrhage: Analysis From a Randomized Clinical Trial

Stroke ◽

10.1161/str.51.suppl_1.wp415 ◽

2020 ◽

Vol 51 (Suppl_1) ◽

Author(s):

Shahram Majidi ◽

Lydia Foster ◽

Christopher P Kellner ◽

Jose I Suarez ◽

Adnan I Qureshi ◽

...

Keyword(s):

Risk Factor ◽

Cigarette Smoking ◽

Intracerebral Hemorrhage ◽

Smoking Status ◽

Hematoma Expansion ◽

Primary Analysis ◽

Significant Difference ◽

Former Smokers ◽

Gcs Score ◽

The Impact

Background: Cigarette smoking is a well-known risk factor for ischemic and hemorrhagic stroke. We evaluated the impact of smoking status on hematoma expansion and clinical outcome in patients with primary intracerebral hemorrhage (ICH). Methods: This is a post hoc exploratory analysis of Antihypertensive Treatment at Acute Cerebral Hemorrhage(ATACH)-2 trial. Patients with ICH were randomized into intensive blood pressure lowering(SBP: <139 mmHg) versus Baseline characteristics were compared based on smoking status. Analysis of outcome measures was adjusted for covariates included in the ATACH-2 primary analysis or those associated with smoking status. Results: Of total of 914 patients in the trial with known smoking status, 439 (48%) patients were ever-smokers (264 current smokers and 175 former smokers). Current and former smokers were younger and more likely to be male. There was no difference in the baseline Glasgow Coma Scale(GCS) score and initial hematoma size based on smoking status. Ever-smokers had higher rate of thalamic hemorrhage (42% vs 34%) and intraventricular hemorrhage (29% vs 23%); this rate was highest among former smokers (49% and 35%, respectively). Ever-smokers had higher rate of hematoma expansion in 24 hour [adjusted RR (95% CI): 1.46; (1.05 -2.03)] compared to non-smokers after adjusting for confounding factors. There was no significant difference in the rate of death and disability at 90 days between the two groups [adjusted RR; (95% CI): 1.18; (0.93 -1.50)]. Conclusions: Our analysis demonstrates cigarette smoking as an independent predictor for hematoma expansion. There was no significant difference in death and disability based on smoking status.

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Abstract P436: Outcomes in Intracerebral Hemorrhage Patients Presenting With Impaired Level of Consciousness

Stroke ◽

10.1161/str.52.suppl_1.p436 ◽

2021 ◽

Vol 52 (Suppl_1) ◽

Author(s):

Ayham Alkhachroum ◽

Antonio Bustillo ◽

Negar Asdaghi ◽

Erika T Marulanda-londono ◽

Carolina M Gutierrez ◽

...

Keyword(s):

Length Of Stay ◽

Intracerebral Hemorrhage ◽

Hospital Mortality ◽

Early Recovery ◽

Hospital Size ◽

Stroke Registry ◽

Level Of Consciousness ◽

Chi Squared ◽

Ich Score ◽

Gcs Score

Background: Impaired level of consciousness (LOC) on presentation after intracerebral hemorrhage (ICH) may affect outcomes and the decision to withdraw life-sustaining treatment (WLST). We aim to investigate the outcomes and trends after ICH by the LOC status on presentation. Methods: We studied 37,613 cases with ICH in the Florida Stroke Registry from 2010-2019. Pearson chi-squared and Kruskall-Wallis tests were used to compare descriptive statistics. A multivariable-logistic regression with GEE accounted for basic demographics, comorbidities, ICH severity, hospital size and teaching status. Results: At stroke presentation, 12,272 (33%) cases had impaired LOC (mean age 72, 49% women, 61 white%, 20% Black, 14% Hispanic). Compared to cases with preserved LOC, LOC case were older (72 vs. 70 years old), more women (49% vs. 45%), more likely to have aphasia (38% vs. 16%), had lower GCS score (9 vs. 15), had greater ICH score (3 vs. 1), greater WLST rates (41% vs. 18%), and had greater in-hospital mortality rates (32% vs. 12%). In our adjusted model, no association was found between impaired LOC and in-hospital mortality, or length of stay. Those with preserved LOC were more likely discharged home/rehab (OR 0.4, 95%CI 0.2-0.9, p=0.03) and more likely to ambulate independently (OR 1.6, 95%CI 1.1-2.4, p=0.02). Trend analysis (2010-2019) showed decreased mortality, increased length of stay, and increased rates of discharge to home/rehab in all, regardless of the LOC status. Conclusion: In this large multi-center registry, a third of ICH cases presents with impaired LOC. Although LOC was not associated with significantly more in-hospital morality, LOC was associated with had higher rates of WLST and more disability at discharge. Future efforts should focus on biomarkers of LOC that detect early recovery and reduced disability in ICH patients with impaired LOC.

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Abstract WP355: Predictors and Outcome of Intubation for Patients with Primary Intracerebral Hemorrhage

Stroke ◽

10.1161/str.48.suppl_1.wp355 ◽

2017 ◽

Vol 48 (suppl_1) ◽

Author(s):

Ayaz Khawaja ◽

Anand Venkatraman ◽

Maira Mirza

Keyword(s):

Intracerebral Hemorrhage ◽

Functional Outcomes ◽

Primary Outcome ◽

Hemorrhagic Transformation ◽

Hematoma Expansion ◽

Optimal Timing ◽

Airway Compromise ◽

Epidural Hemorrhage ◽

Poor Outcomes ◽

Ich Score

Background: Patients with primary intracerebral hemorrhage (pICH) are at risk of airway compromise and commonly undergo intubation. Poor outcomes have been reported for these patients. Factors predicting intubation prior to admission (PTA), and after admission are unknown. These factors may be helpful in predicting which pICH patients require intubation, and its optimal timing. Methods: Patients with pICH directly admitted or transferred from another facility to our center were included. Patients with SAH, SDH, epidural hemorrhage, underlying lesions, or infarct with hemorrhagic transformation were excluded. Intubation note from medical chart was used to determine the timing of intubation. Demographic and clinical data were recorded. The primary outcome was a discharge mRS (dmRS) of 4-6. Results: A total of 370 patients were included. Patients intubated PTA had a lower average GCS (6 vs. 9; p=0.0003) and a higher average NIHSS (26 vs. 18; p=0.0007) than those intubated after admission. Higher incidences of hematoma expansion (30.9% vs. 16.3%; p=0.0253), tracheostomies performed (17.5% vs. 4.8%; p=0.0004), ICH volumes > 30cc (40% vs. 25.5%; p=0.0352), and pneumonia (35.1% vs. 5.4%; p<0.0001) were seen in patients intubation after admission, when compared to other patients. Patients requiring intubation at any time had statistically non-significant higher incidences of cortical and brainstem hemorrhage (see Table 1), compared to patients not intubated. After adjusting for pneumonia and ICH score, intubation is significantly associated with a dmRS of 4-6 (OR 4.87, 95%CI 1.27-18.7, p=0.0208). Conclusions: Lower GCS and higher NIHSS significantly predict intubation in pICH patients PTA. ICH volumes > 30cc, hematoma expansion and pneumonia significantly predict intubation after admission. Intubation is significantly associated with poor functional outcomes independent of ICH score and pneumonia. Location of ICH does not predict intubation.

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Abstract TP378: Intracerebral Hemorrhagic Expansion Occurs in Patients Using Novel Anticoagulants

Stroke ◽

10.1161/str.47.suppl_1.tp378 ◽

2016 ◽

Vol 47 (suppl_1) ◽

Author(s):

Kara R Melmed ◽

Patrick Lyden ◽

Asma Moheet

Keyword(s):

Case Series ◽

Retrospective Chart Review ◽

Concomitant Administration ◽

Medical Intervention ◽

Hematoma Expansion ◽

Time Period ◽

Novel Oral Anticoagulant ◽

Significant Difference ◽

Discharge Status ◽

Ich Score

Background: Novel oral anticoagulant (NOAC) use has significantly reduced Intracerebral Hemorrhagic (ICH) risk compared to standard anticoagulant treatment. Increased ICH hematoma expansion (HE) is a known predictor of mortality in warfarin associated ICH. Little is known about ICH expansion in patients using NOACs. Methods: We conducted a retrospective chart review of patients with ICH admitted to CSMC from Oct 2010 through March 2015. We identified patients with concomitant administration of either a NOAC or warfarin and collected data including the following: reason for agent prescription, time to brain imaging, evidence of HE on imaging, and discharge status and mRS at discharge. We defined HE as either relative expansion (≥ 33% increase) or absolute expansion (≥ 12 mL). We compared outcomes of patients with and without HE. Results: Out of 642 patients admitted with ICH within this time period, we identified 7 patients with concomitant NOAC use and a sample of 14 matched patients on warfarin. Patients on NOACs vs warfarin patients had no significant differences in NIHSS or ICH score on presentation (median [IQR] 21 [11,22] vs 16 [5,26] and 2 [1,4] vs 2 [1,2]). 4 out of 7 coagulopathic NOAC patents demonstrated HE, compared to 5 out of the 14 warfarin patients that demonstrated HE, with no significant difference. Of the NOAC subset, the median NIHSS on presentation was 21 [13,23.5] and the median ICH score on presentation was 2 [2,4]. There were no significant differences in mRS on discharge in NOAC patient with HE vs without or warfarin patients with HE vs without (5 [4,6] vs. 5.5 [4.5,6] and 4 [3.5,6] vs 3 [3,5.5]). Conclusions: In our coagulopathic NOAC patient population, HE continues beyond 6 hours in 57% of patients. To our knowledge, this is the largest case series reporting on HE with concomitant NOAC use. This case series was not statistically powered to show significant differences between groups, although outcomes in patients suffering from HE appear to be poor in general. Expansion of the initial hematoma is a possible target for medical intervention. The better outcomes in warfarin patients in our cohort are likely related to the targeted reversal of coagulopathy.

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Refining Prognosis for Intracerebral Hemorrhage by Early Reassessment

Cerebrovascular Diseases ◽

10.1159/000452679 ◽

2017 ◽

Vol 43 (3-4) ◽

pp. 110-116 ◽

Cited By ~ 18

Author(s):

Matthew B. Maas ◽

Brandon A. Francis ◽

Rajbeer S. Sangha ◽

Bryan D. Lizza ◽

Eric M. Liotta ◽

...

Keyword(s):

Intracerebral Hemorrhage ◽

Prognostic Score ◽

Observational Cohort Study ◽

Predictors Of Outcome ◽

Neurologic Injury ◽

Ordinal Regression Model ◽

Observational Cohort ◽

Ich Score ◽

Gcs Score ◽

Z Transformation

Background: Prognostic assessments, which are crucial for decision-making in critical illnesses, have shown unsatisfactory reliability. We compared the accuracy of a widely used prognostic score against a model derived from clinical data obtained 5 days after admission for patients with intracerebral hemorrhage (ICH), a condition for which prognostication has proven notoriously challenging and prone to bias. Methods: Patients enrolled in a prospective observational cohort study of spontaneous ICH underwent hourly Glasgow Coma Scale (GCS) assessment. Outcome was measured at 3 months using the modified Rankin Scale (mRS). We analyzed the change in correlation between GCS and 3-month mRS scores from admission through day 5, and compared the performance of a parsimonious set of day 5 clinical variables against the ICH score. Results: Data was collected on 254 subjects. The ICH score and day 5 GCS score were both correlated with 3-month mRS score (p < 0.001), but the correlation was stronger with day 5 GCS score (p < 0.05 by Fisher z-transformation). Premorbid mRS score, intraventricular hemorrhage and day 5 GCS score were independent predictors of outcome (all p < 0.05 in ordinal regression model). While ICH score correctly classified good (mRS 0-3) vs. poor (mRS 4-6) outcome in 73% of cases, the day 5 model correctly classified 83% of cases. Conclusions: A simple reassessment after 5 days of care significantly improves the accuracy of prognosticating outcome in patients with ICH. These data confirm the feasibility and potential utility of early reassessments in refining prognosis for patients who survive early stabilization of a severe neurologic injury.

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