Multicenter Validation of the <scp>max‐ICH</scp> Score in Intracerebral Hemorrhage

Sembill, Jochen A.; Castello, Juan Pablo; Sprügel, Maximilian I.; Gerner, Stefan T.; Hoelter, Philip; Lücking, Hannes; Doerfler, Arnd; Schwab, Stefan; Huttner, Hagen B.; Biffi, Alessandro; Kuramatsu, Joji B.

doi:10.1002/ana.25969

Cited by 29 publications

(29 citation statements)

References 37 publications

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“…With the exception of the max-ICH score, which was fully validated recently, none of the scores identified in our literature search provided complete score validation [ 29 ]. Here we chose the Essen-ICH-score to illustrate the three methodological pillars of validation discrimination, calibration, and net benefit analysis.…”

Section: Resultsmentioning

confidence: 99%

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Prognostication after intracerebral hemorrhage: a review

Witsch

Siegerink

Nolte

et al. 2021

Neurol. Res. Pract.

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Background Approximately half of patients with spontaneous intracerebral hemorrhage (ICH) die within 1 year. Prognostication in this context is of great importance, to guide goals of care discussions, clinical decision-making, and risk stratification. However, available prognostic scores are hardly used in clinical practice. The purpose of this review article is to identify existing outcome prediction scores for spontaneous intracerebral hemorrhage (ICH) discuss their shortcomings, and to suggest how to create and validate more useful scores. Main text Through a literature review this article identifies existing ICH outcome prediction models. Using the Essen-ICH-score as an example, we demonstrate a complete score validation including discrimination, calibration and net benefit calculations. Score performance is illustrated in the Erlangen UKER-ICH-cohort (NCT03183167). We identified 19 prediction scores, half of which used mortality as endpoint, the remainder used disability, typically the dichotomized modified Rankin score assessed at variable time points after the index ICH. Complete score validation by our criteria was only available for the max-ICH score. Our validation of the Essen-ICH-score regarding prediction of unfavorable outcome showed good discrimination (area under the curve 0.87), fair calibration (calibration intercept 1.0, slope 0.84), and an overall net benefit of using the score as a decision tool. We discuss methodological pitfalls of prediction scores, e.g. the withdrawal of care (WOC) bias, physiological predictor variables that are often neglected by authors of clinical scores, and incomplete score validation. Future scores need to integrate new predictor variables, patient-reported outcome measures, and reduce the WOC bias. Validation needs to be standardized and thorough. Lastly, we discuss the integration of current ICH scoring systems in clinical practice with the awareness of their shortcomings. Conclusion Presently available prognostic scores for ICH do not fulfill essential quality standards. Novel prognostic scores need to be developed to inform the design of research studies and improve clinical care in patients with ICH.

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Section: Resultsmentioning

confidence: 99%

“…In the 583 patients included in the study conventional prognostication overestimated the observed mortality by 45% and overestimated the observed unfavorable outcome by 10% [ 27 ]. The max-ICH score is the only score that we are aware of that has been fully validated according to the criteria laid out in this review [ 29 ].…”

Section: Discussionmentioning

confidence: 99%

Prognostication after intracerebral hemorrhage: a review

Witsch

Siegerink

Nolte

et al. 2021

Neurol. Res. Pract.

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“…3 6 Moreover, prolonged impairment of consciousness may result in unjustified care limitation and worse patient outcome by selffulfilling prophecy. [7][8][9][10] Amantadine, an N-methyl-D-aspartate receptor antagonist and indirect dopamine agonist, exerts effects on multiple neurotransmitters and is used as neurostimulant in patients with prolonged disorders of consciousness. 11 12 A randomised controlled trial and several observational studies showed that amantadine accelerated functional recovery in TBI.…”

Section: Introductionmentioning

confidence: 99%

Amantadine treatment is associated with improved consciousness in patients with non-traumatic brain injury

Rühl

Kuramatsu

Sembill

et al. 2022

J Neurol Neurosurg Psychiatry

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ObjectiveThis study determined the effect of amantadine treatment on consciousness in patients with non-traumatic brain injury.MethodsWe pooled individual patient data of five single-centre observational studies to determine the effect of amantadine treatment among patients with ischaemic stroke, intracerebral haemorrhage, subarachnoid haemorrhage, community-acquired bacterial meningitis and status epilepticus, admitted between January 2012 and December 2015 and ventilated ≥7 days. Patient selection and multivariable regression modelling were used to adjust for differences in intergroup comparison and for parameters associated with consciousness. Improvement of consciousness 5 days after treatment initiation was defined as primary outcome. Secondary outcomes included Glasgow Coma Scale (GCS) at day 5 and GCS at day 10, rate of ICU delirium, epileptic seizures and all-cause mortality at 90 days.ResultsOverall, 84 of 294 (28.6%) eligible patients received amantadine. Amantadine treatment was associated with improvement of consciousness at day 5 (amantadine: 86.9% vs control: 54.0%; absolute difference: 32.9 (20.0–44.2); adjusted OR (aOR): 5.71 (2.50–13.05), p<0.001). Secondary outcomes showed differences in GCS 5 days (9 (8–11) vs 6 (3–9), p<0.001) and GCS 10 days (10(8–11) vs 9(6–11),p=0.003) after treatment initiation. There were no significant differences regarding all-cause mortality (aOR: 0.89 (0.44–1.82), p=0.758) and ICU delirium (aOR: 1.39 (0.58–3.31), p=0.462). Rate of epileptic seizures after initiation of amantadine treatment was numerically higher in the amantadine group (amantadine: 10.7% vs control: 3.0%; absolute difference: 7.7 (0.3–16.4); aOR: 3.68 (0.86–15.71), p=0.079).ConclusionsAmantadine treatment is associated with improved consciousness among patients with different types of non-traumatic brain injury in this observational cohort analysis. Epileptic seizures should be considered as potential side effects and randomised controlled trials are needed to confirm these findings.

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“…Prediction scores used in the acute phase have limited accuracy for the prediction of 30-day mortality and functional outcome, 19 – 23 and appear especially unreliable for the higher scores that predict poor outcome. 24 Furthermore, these prediction scores do not facilitate physicians in their choice for a certain treatment strategy.…”

Section: Introductionmentioning

confidence: 99%

“…5,7 Current guidelines recommend hyperosmotic therapy if a patient has acute elevated intracranial pressure with signs of herniation, but advice against the use of glucocorticoids. 10,11,17,18 Prediction scores used in the acute phase have limited accuracy for the prediction of 30-day mortality and functional outcome, [19][20][21][22][23] and appear especially unreliable for the higher scores that predict poor outcome. 24 Furthermore, these prediction scores do not facilitate physicians in their choice for a certain treatment strategy.…”

Section: Introductionmentioning

confidence: 99%

Variation in medical management and neurosurgical treatment of patients with supratentorial spontaneous intracerebral haemorrhage

Sondag

Jacobs

Schreuder

et al. 2021

European Stroke Journal

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Introduction The role of surgery in spontaneous intracerebral haemorrhage (sICH) remains controversial. This leads to variation in the percentage of patients who are treated with surgery between countries. Patients and methods We sent an online survey to all neurosurgeons (n = 140) and to a sample of neurologists (n = 378) in Dutch hospitals, with questions on management in supratentorial sICH in general, and on treatment in six patients, to explore current variation in medical and neurosurgical management. We assessed patient and haemorrhage characteristics influencing treatment decisions. Results Twenty-nine (21%) neurosurgeons and 92 (24%) neurologists responded. Prior to surgery, neurosurgeons would more frequently administer platelet-transfusion in patients on clopidogrel (64% versus 13%; p = 0.000) or acetylsalicylic acid (61% versus 11%; p = 0.000) than neurologists. In the cases, neurosurgeons and neurologists were similar in their choice for surgery as initial treatment (24% and 31%; p = 0.12), however variation existed amongst physicians in specific cases. Neurosurgeons preferred craniotomy with haematoma evacuation (74%) above minimally-invasive techniques (5%). Age, Glasgow Coma Scale score and ICH location were important factors influencing decisions on treatment for neurosurgeons and neurologists. 69% of neurosurgeons and 80% of neurologists would randomise patients in a trial evaluating the effect of minimally-invasive surgery on functional outcome. Discussion Our results reflect the lack of evidence about the right treatment strategy in patients with sICH. Conclusion New high quality evidence is needed to guide treatment decisions for patients with ICH. The willingness to randomise patients into a clinical trial on minimally-invasive surgery, contributes to the feasibility of such studies in the future.

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Multicenter Validation of the max‐ICH Score in Intracerebral Hemorrhage

Cited by 29 publications

References 37 publications

Prognostication after intracerebral hemorrhage: a review

Prognostication after intracerebral hemorrhage: a review

Amantadine treatment is associated with improved consciousness in patients with non-traumatic brain injury

Variation in medical management and neurosurgical treatment of patients with supratentorial spontaneous intracerebral haemorrhage

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