Prognostication after intracerebral hemorrhage: a review

Abstract

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.

Mesenchymal Stem Cell Application and Its Therapeutic Mechanisms in Intracerebral Hemorrhage

“…Intracerebral hemorrhage (ICH) comprises 10–15% of all strokes; more than two million patients worldwide per year suffer from this hemorrhagic type of stroke with a complex pathophysiology and 1-month mortality of about 70% ( Keep et al, 2012 ; Biffi et al, 2015 ; Bosche et al, 2020 ; Schrag and Kirshner, 2020 ; Jain et al, 2021 ; Rajashekar and Liang, 2021 ; Witsch et al, 2021 ). With the development of medical knowledge, the ICH incidence showed an increasing trend worldwide ( van Asch et al, 2010 ; Wu and Anderson, 2020 ), resulting from the spiraling increment of older adults; the application of anticoagulants, antiplatelets, and thrombolytics; and other issues ( Carpenter et al, 2016 ; Wu et al, 2019 ).…”

Plasma PRPC Levels Correlate With Severity and Prognosis of Intracerebral Hemorrhage

“…Spontaneous intracerebral hemorrhage (ICH) is one of the most common severe diseases, characterized by acute onset, high disability and mortality, and poor outcome ( 1 , 2 ). Secondary brain injury caused by ICH is considered to be an important factor affecting the outcome of patients.…”

Delayed perihematomal hypoperfusion is associated with poor outcome in intracerebral haemorrhage

“…2 Despite being less common than ischaemic stroke, ICH accounts for more than half of early deaths for acute cerebrovascular events. 3 Accurate stratification of ICH prognosis is therefore a clinical research priority and is highly desired also in the setting of randomized controlled trials. 4 However, the diagnostic performance of most of the currently available prognostic prediction tools remains suboptimal and precise prediction of ICH outcome remains an unmet need.…”

“…4 However, the diagnostic performance of most of the currently available prognostic prediction tools remains suboptimal and precise prediction of ICH outcome remains an unmet need. 3 Hypoperfusion of the perihaemorrhagic area has been reported in ICH and may be associated with poor functional outcome. 5 However, most of the evidence so far available is limited to the hyperacute phase using baseline perfusion imaging obtained on admission.…”

“…ICH remains a deadly disorder, with up to 40% early mortality and severe long‐term disability in the majority of survivors 2 . Despite being less common than ischaemic stroke, ICH accounts for more than half of early deaths for acute cerebrovascular events 3 . Accurate stratification of ICH prognosis is therefore a clinical research priority and is highly desired also in the setting of randomized controlled trials 4 .…”