Calculation of Prognostic Scores, Using Delayed Imaging, Outperforms Baseline Assessments in Acute Intracerebral Hemorrhage

Background and Purpose— Patients with intracerebral hemorrhage (ICH) are often subject to rapid deterioration due to hematoma expansion. Current prognostic scores are largely based on the assessment of baseline radiographic characteristics and do not account for subsequent changes. We propose that calculation of prognostic scores using delayed imaging will have better predictive values for long-term mortality compared with baseline assessments. Methods— We analyzed prospectively collected data from the multicenter PREDICT study (Prediction of Hematoma Growth and Outcome in Patients With Intracerebral Hemorrhage Using the CT-Angiography Spot Sign). We calculated the ICH Score, Functional Outcome in Patients With Primary Intracerebral Hemorrhage (FUNC) Score, and modified ICH Score using imaging data at initial presentation and at 24 hours. The primary outcome was mortality at 90 days. We generated receiver operating characteristic curves for all 3 scores, both at baseline and at 24 hours, and assessed predictive accuracy for 90-day mortality with their respective area under the curve. Competing curves were assessed with nonparametric methods. Results— The analysis included 280 patients, with a 90-day mortality rate of 25.4%. All 3 prognostic scores calculated using 24-hour imaging were more predictive of mortality as compared with baseline: the area under the curve was 0.82 at 24 hours (95% CI, 0.76–0.87) compared with 0.78 at baseline (95% CI, 0.72–0.84) for ICH Score, 0.84 at 24 hours (95% CI, 0.79–0.89) compared with 0.76 at baseline (95% CI, 0.70–0.83) for FUNC, and 0.82 at 24 hours (95% CI, 0.76–0.88) compared with 0.74 at baseline (95% CI, 0.67–0.81) for modified ICH Score. Conclusions— Calculation of the ICH Score, FUNC Score, and modified ICH Score using 24-hour imaging demonstrated better prognostic value in predicting 90-day mortality compared with those calculated at presentation.

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A Delayed Modified ICH Score Outperforms Baseline Scoring in Acute Intracerebral Hemorrhage

The Neurohospitalist ◽

10.1177/1941874419896715 ◽

2019 ◽

Vol 10 (3) ◽

pp. 217-220

Author(s):

Ronda Lun ◽

Vignan Yogendrakumar ◽

Dylan Blacquiere ◽

Michel Shamy ◽

Grant Stotts ◽

...

Keyword(s):

Intracerebral Hemorrhage ◽

Functional Outcome ◽

Area Under The Curve ◽

Predictive Ability ◽

Patient Characteristics ◽

Prognostic Scores ◽

Secondary Outcome ◽

Predictive Values ◽

Poor Outcome ◽

Acute Intracerebral Hemorrhage

The Modified Intracerebral Hemorrhage (MICH) score is a simple tool created to provide prognostication in basal ganglia hemorrhages. Current prognostic scores, including the MICH, are based on the assessment of baseline patient characteristics, failing to account for significant developments, such as intraventricular extension and clinical deterioration, which may occur over the first 72 hours. We propose to validate the MICH in all hemorrhage locations and hypothesize that its calculation at 72 hours will outperform its baseline counterpart with respect to predicting mortality and functional outcome. We performed a retrospective analysis of collated data from the Virtual International Stroke Trials Archive database. Primary outcome was 90-day mortality. Secondary outcome was poor outcome (modified Rankin Scale 4-6) at 90 days. Receiver operating characteristic curves were generated looking at the predictive ability of the MICH score for mortality and poor outcome, at baseline and at 72 hours. Competing curves were assessed with nonparametric methods. A total of 226 patients were included, with a 90-day mortality of 22.5%. The MICH scores calculated at 72 hours were more predictive of mortality than at baseline (area under the curve [AUC]: 0.89 [95% confidence interval [CI]: 0.83-0.94] vs 0.78 [95% CI: 0.70-0.85]), P < .01. The MICH scores at 72 hours similarly better predicted functional outcome (AUC: 0.78 [95% CI: 0.72-0.84] vs AUC: 0.72 [95% CI: 0.66-0.78]), P = .047. The MICH score has positive prognostic value for mortality and poor functional outcome in all hemorrhage locations. Delaying its calculation resulted in higher predictive values for both and suggests that delaying discussions around withdrawal of care may result in more accurate prognostication in acute intracerebral hemorrhage.

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Predicting long-term outcomes in acute intracerebral haemorrhage using delayed prognostication scores

Stroke and Vascular Neurology ◽

10.1136/svn-2020-000656 ◽

2021 ◽

pp. svn-2020-000656

Author(s):

Ronda Lun ◽

Vignan Yogendrakumar ◽

Tim Ramsay ◽

Michel Shamy ◽

Robert Fahed ◽

...

Keyword(s):

Functional Outcome ◽

Intracerebral Haemorrhage ◽

Functional Outcomes ◽

Predictive Accuracy ◽

Area Under The Curve ◽

Long Term Outcomes ◽

Poor Functional Outcome ◽

Delayed Imaging ◽

Ich Score

ObjectiveThe concept of the ‘self-fulfilling prophecy’ is well established in intracerebral haemorrhage (ICH). The ability to improve prognostication and prediction of long-term outcomes during the first days of hospitalisation is important in guiding conversations around goals of care. We previously demonstrated that incorporating delayed imaging into various prognostication scores for ICH improves the predictive accuracy of 90-day mortality. However, delayed prognostication scores have not been used to predict long-term functional outcomes beyond 90 days.Design, setting and participantsWe analysed data from the ICH Deferoxamine trial to see if delaying the use of prognostication scores to 96 hours after ICH onset will improve performance to predict outcomes at 180 days. 276 patients were included.Interventions and measurementsWe calculated the original ICH score (oICH), modified-ICH score (MICH), max-ICH score and the FUNC score on presentation (baseline), and on day 4 (delayed). Outcomes assessed were mortality and poor functional outcome in survivors (defined as modified Rankin Scale of 4–5) at 180 days. We generated receiver operating characteristic curves, and measured the area under the curve values (AUC) for mortality and functional outcome. We compared baseline and delayed AUCs with non-parametric methods.ResultsAt 180 days, 21 of 276 (7.6%) died. Out of the survivors, 54 of 255 had poor functional outcome (21.2%). The oICH, MICH and max-ICH performed significantly better at predicting 180-day mortality when calculated 4 days later compared with their baseline equivalents ((0.74 vs 0.83, p=0.005), (0.73 vs 0.80, p=0.036), (0.74 vs 0.83, p=0.008), respectively). The delayed calculation of these scores did not significantly improve our accuracy for predicting poor functional outcomes.ConclusionDelaying the calculation of prognostication scores in acute ICH until day 4 improved prediction of 6-month mortality but not functional outcomes.Trial registration numberClinicalTrials.gov Registry (NCT02175225).

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The predictive accuracy of the black hole sign and the spot sign for hematoma expansion in patients with spontaneous intracerebral hemorrhage

Neurological Sciences ◽

10.1007/s10072-017-3006-6 ◽

2017 ◽

Vol 38 (9) ◽

pp. 1591-1597 ◽

Cited By ~ 21

Author(s):

Zhiyuan Yu ◽

Jun Zheng ◽

Lu Ma ◽

Rui Guo ◽

Mou Li ◽

...

Keyword(s):

Black Hole ◽

Intracerebral Hemorrhage ◽

Predictive Accuracy ◽

Hematoma Expansion ◽

Spontaneous Intracerebral Hemorrhage ◽

Spot Sign

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Abstract WP372: The Acute ICH Growth Score: Simple and Accurate Predictor of Hematoma Expansion in Patients with Acute Intracerebral Hemorrhage

Stroke ◽

10.1161/str.48.suppl_1.wp372 ◽

2017 ◽

Vol 48 (suppl_1) ◽

Author(s):

F S Al-Ajlan ◽

A M Demchuk ◽

R I Aviv ◽

D Rodriguez-Luna ◽

C Molina ◽

...

Keyword(s):

Intracerebral Hemorrhage ◽

Area Under The Curve ◽

Hematoma Expansion ◽

Blood Levels ◽

Spot Sign ◽

Mortality And Morbidity ◽

Hematoma Growth ◽

Acute Intracerebral Hemorrhage ◽

Score Model ◽

Multicenter Prospective Study

Background and Purpose: Acute intracerebral hemorrhage (ICH) hematoma expansion predicts high mortality and morbidity, occurring in a third of patients presenting with this condition. Recent studies correlated ultra-early hematoma growth and hematoma morphologic appearance with ICH expansion. Our purpose was to develop simple and clinically useful score that would predict ICH hematoma expansion accurately. Methods: This cohort included patients with primary or anticoagulation-associated ICH patients presenting <6 hours post ictus prospectively enrolled in the PREDICT study. Patients underwent baseline CT, CT angiography and 24-hour CT for hematoma expansion analysis. A risk score model was developed for predicting hematoma expansion (> 6 ml or > 33%). A 7-point acute ICH growth score was based on ultra-early hematoma growth > 5 mL/hour (yes=1), irregular morphology (yes=1), density heterogeneity (yes=1), presence of fluid-blood levels (yes=1), spot sign (yes=1), and use of anticoagulation (yes=2). Discrimination of the expansion score was assessed. Results: We retrospectively studied 301 primary or anticoagulation-associated intracerebral hemorrhage patients. The 7-point acute ICH growth score demonstrated good discrimination for hematoma expansion>6 mL or 33% (area under the curve of 0.76). Median and significant HE are shown in the table below (p<0.001). Conclusions: In a multicenter prospective study, the ICH expansion score demonstrate good correlation with hematoma expansion, and included recently reported variables such as morphology and ultraearly growth.

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Abstract 1122‐000024: Stereotactic IntraCerebral Underwater Blood Aspiration Improves Survival Following Intracerebral Hemorrhage as Compared to Predicted Mortality

Stroke: Vascular and Interventional Neurology ◽

10.1161/svin.01.suppl_1.000024 ◽

2021 ◽

Vol 1 (S1) ◽

Author(s):

Steven D Shapiro ◽

Miryam Alkayyali ◽

Alexandra Reynolds ◽

Kaitlin Reilly ◽

Magdy Selim ◽

...

Keyword(s):

Intracerebral Hemorrhage ◽

Absolute Risk ◽

Absolute Risk Reduction ◽

Hospital Length Of Stay ◽

Neurological Injury ◽

Hematoma Expansion ◽

Spot Sign ◽

Continuous Irrigation ◽

Discharge Disposition ◽

Ich Score

Introduction : Intracerebral hemorrhage (ICH) is a devastating form of neurological injury with substantial mortality. Recent publications on minimal invasive surgery (MIS) for hematoma evacuation have suggested survival benefits in select patients. Since 2015, our center has been performing an MIS technique using continuous irrigation with aspiration through an endoscope (SCUBA). SCUBA does not require a stability scan and can be performed despite hematoma expansion, intraventricular hemorrhage or radiographic spot sign. We present the 30‐day mortality of our initial experience and compare it to predicted mortality by presenting ICH score. Methods : We performed a retrospective review of consecutively admitted patients with spontaneous non‐traumatic supratentorial ICH who underwent SCUBA between 12/2015 – 03/2019. The primary outcome was observed 30‐day mortality compared to predicted mortality by ICH score on presentation. Key secondary outcomes were operative markers, hospital length of stay, and discharge disposition. Results : One hundred and fifteen patients were identified, with mean (SD) ICH volume of 51.4mL (33.9mL) and median ICH score of 2. The median evacuation was 97% of the hematoma volume and 85% of patients had a residual clot burden of less than 15mL. Twelve patients died within one month of SCUBA for an overall mortality rate of 10.4%. This was significantly lower than the predicted mortality by ICH score of 35.1%, with an absolute risk reduction of 24.7%. When analyzed by presenting ICH score, significant mortality benefits were observed for all ICH scores > 2, with more pronounced differences at higher ICH scores (Table 1). Conclusions : This study suggests that MIS with the SCUBA technique for ICH may reduce predicted 30‐day mortality, with a number need to treat of 4 to prevent one mortality. Further evaluation of this technique in a randomized clinical trial is required.

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Different criteria for defining “spot sign” in intracerebral hemorrhage show different abilities to predict hematoma expansion and clinical outcomes: a systematic review and meta-analysis

Neurosurgical Review ◽

10.1007/s10143-021-01503-7 ◽

2021 ◽

Author(s):

Chunyan Lei ◽

Jia Geng ◽

Zhao Qi ◽

Lianmei Zhong

Keyword(s):

Systematic Review ◽

Intracerebral Hemorrhage ◽

Clinical Outcomes ◽

Meta Analysis ◽

Hematoma Expansion ◽

Spot Sign

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Predictive accuracy of risk scales following self-harm: Multicentre, prospective cohort study

The British Journal of Psychiatry ◽

10.1192/bjp.bp.116.189993 ◽

2017 ◽

Vol 210 (6) ◽

pp. 429-436 ◽

Cited By ~ 35

Author(s):

Leah Quinlivan ◽

Jayne Cooper ◽

Declan Meehan ◽

Damien Longson ◽

John Potokar ◽

...

Keyword(s):

Cohort Study ◽

Prospective Cohort Study ◽

Prospective Cohort ◽

Predictive Accuracy ◽

Area Under The Curve ◽

Global Scale ◽

National Guidelines ◽

Liaison Psychiatry ◽

Predictive Values ◽

Self Harm

BackgroundScales are widely used in psychiatric assessments following self-harm. Robust evidence for their diagnostic use is lacking.AimsTo evaluate the performance of risk scales (Manchester Self-Harm Rule, ReACT Self-Harm Rule, SAD PERSONS scale, Modified SAD PERSONS scale, Barratt Impulsiveness Scale); and patient and clinician estimates of risk in identifying patients who repeat self-harm within 6 months.MethodA multisite prospective cohort study was conducted of adults aged 18 years and over referred to liaison psychiatry services following self-harm. Scale a priori cut-offs were evaluated using diagnostic accuracy statistics. The area under the curve (AUC) was used to determine optimal cut-offs and compare global accuracy.ResultsIn total, 483 episodes of self-harm were included in the study. The episode-based 6-month repetition rate was 30% (n = 145). Sensitivity ranged from 1% (95% CI 0–5) for the SAD PERSONS scale, to 97% (95% CI 93–99) for the Manchester Self-Harm Rule. Positive predictive values ranged from 13% (95% CI 2–47) for the Modified SAD PERSONS Scale to 47% (95% CI 41–53) for the clinician assessment of risk. The AUC ranged from 0.55 (95% CI 0.50–0.61) for the SAD PERSONS scale to 0.74 (95% CI 0.69–0.79) for the clinician global scale. The remaining scales performed significantly worse than clinician and patient estimates of risk (P < 0.001).ConclusionsRisk scales following self-harm have limited clinical utility and may waste valuable resources. Most scales performed no better than clinician or patient ratings of risk. Some performed considerably worse. Positive predictive values were modest. In line with national guidelines, risk scales should not be used to determine patient management or predict self-harm.

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