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

Abstract

HomeStrokeVol. 34, No. 1The ICH Score: Predicting Mortality and Functional Outcome in an Asian Population Free AccessLetterPDF/EPUBAboutView PDFView EPUBSections ToolsAdd to favoritesDownload citationsTrack citationsPermissions ShareShare onFacebookTwitterLinked InMendeleyReddit Jump toFree AccessLetterPDF/EPUBThe ICH Score: Predicting Mortality and Functional Outcome in an Asian Population Roland Dominic G. Jamora, Emilio M. Kishi-GeneraoJr, Ester S. Bitanga and Robert N. Gan Natalie Emperatriz P. Apaga and Ma. Cristina Z. San Jose Roland Dominic G. JamoraRoland Dominic G. Jamora Department of Neurosciences and Diosdado Macapagal Stroke Center, University of the Philippines, Philippine General Hospital, Manila, Philippines Search for more papers by this author , Emilio M. Kishi-GeneraoJrEmilio M. Kishi-GeneraoJr Department of Neurosciences and Diosdado Macapagal Stroke Center, University of the Philippines, Philippine General Hospital, Manila, Philippines Search for more papers by this author , Ester S. BitangaEster S. Bitanga Department of Neurosciences and Diosdado Macapagal Stroke Center, University of the Philippines, Philippine General Hospital, Manila, Philippines Search for more papers by this author and Robert N. GanRobert N. Gan Department of Neurosciences and Diosdado Macapagal Stroke Center, University of the Philippines, Philippine General Hospital, Manila, Philippines Search for more papers by this author Natalie Emperatriz P. ApagaNatalie Emperatriz P. Apaga Institute for Neurosciences, St Luke’s Medical Center, Quezon City, Philippines Search for more papers by this author and Ma. Cristina Z. San JoseMa. Cristina Z. San Jose Institute for Neurosciences, St Luke’s Medical Center, Quezon City, Philippines Search for more papers by this author Originally published12 Dec 2002https://doi.org/10.1161/01.STR.0000047847.18178.D3Stroke. 2003;34:6–7Other version(s) of this articleYou are viewing the most recent version of this article. Previous versions: December 12, 2002: Previous Version 1 To the Editor:We were impressed by the simplicity yet apparent accuracy of the ICH scoring system proposed by Hemphill and coworkers.1 The score included factors that were found to be independent predictors of poor prognosis not only in their data set but in most other previously published studies as well. In response to their call for its validation in an independent cohort, Fernandes et al2 tested the score on 393 patients admitted to their neurosurgical unit in the United Kingdom. While ICH score was predictive of mortality at neurosurgical discharge, they felt that it was not as useful in predicting independent recovery because of a high rate of unfavorable outcome (severe disability, death, or vegetative state) even at a score of 2.We were interested to see whether the proposed ICH score will prove valid in predicting not only mortality but also eventual functional outcome in our Asian population. Our local data show that intracerebral hemorrhage accounts for approximately 21% of hospitalized stroke cases. For the year 2001, we prospectively collected data on 302 patients with spontaneous ICH consecutively admitted to two major medical centers in the Philippines: the Philippine General Hospital and St Luke’s Medical Center. Data on 30-day mortality and modified Rankin scale (MRS) were complete in only 243 patients.Infratentorial hemorrhage accounted for 12% of our cohort. Yet none of our patients scored 6. Only 3 patients scored 5 (1%), 18 scored 4 (7%), 28 scored 3 (12%), 52 scored 2 (21%), 70 scored 1 (29%), and 72 scored 0 (30%).Overall 30-day mortality in our study was only 23%. The relationship between ICH score and 30-day mortality is shown in Figure 1. We likewise found the score to be predictive of poor functional outcome (MRS ≥4) at discharge and even more so at 30 days after discharge (Figure 2). This is in contrast to the results of Fernandes and coworkers2 who did not find the ICH score to be as helpful in this aspect maybe because they evaluated outcome too early at discharge without accounting for the eventual improvement in function over time. Download figureDownload PowerPointFigure 1. The ICH score and 30-day mortality.Download figureDownload PowerPointFigure 2. The ICH score and proportion of patients with modified Rankin score of ≥4 at discharge and one month after discharge.Our results support the validity of the ICH score in predicting both mortality and eventual early functional outcome in our population. A subsequent analysis of functional outcome at a more meaningful time point, eg, 6 months, may be more revealing as suggested by Hemphill et al.3 As of the moment, however, one should observe caution in unintentionally using the ICH score in making treatment decisions. We propose that future investigations in the role of surgical interventions in intracerebral hemorrhage be stratified according to ICH score. Indeed, the results of such study will help standardize medical and surgical treatment protocols in intracerebral hemorrhage.1 Hemphill JC III, Bonovich DC, Besmertis L, Manley GT, Johnston SC. The ICH score: a simple, reliable grading scale for intracerebral hemorrhage. Stroke. 2001; 32: 891–897.CrossrefMedlineGoogle Scholar2 Fernandes H, Gregson BA, Siddigue MS, Mendelow AD. Testing the ICH score: letter to the editor. Stroke. 2002; 33: 1455–1456.LinkGoogle Scholar3 Hemphill JC III, Bonovich DC, Johnston SC, Manley GT. Testing the ICH score: response. Stroke. 2002; 33: 1455–1456.LinkGoogle ScholarstrokeahaStrokeStrokeStroke0039-24991524-4628Lippincott Williams & WilkinsHemphill J. Claude, , Bonovich David C., , Johnston S. Claiborne, , and Manley Geoffrey T., 01012003ResponseJamora et al describe their study in which they undertook to validate the ICH score in their own population from two medical centers in the Philippines. Overall, they found that the ICH score accurately risk stratified patients with regard to 30-day mortality (the outcome measure used in our original description of the ICH score), and that this risk stratification may extend to functional outcome, at least at 30 days after ICH. This was true despite a different distribution of patient ICH scores and a different 30-day mortality rate between their cohort and the UCSF ICH cohort used for initial development of the ICH score.1 We are pleased that Jamora and colleagues have subjected the ICH score to critical appraisal in their distinct population and believe that their study has several merits worthy of mention.By prospectively gathering data, they avoided biases that might occur in retrospective record review from missing or incomplete data. Also, their Asian population likely represents a group of patients ethnically and culturally distinct from both the UCSF ICH cohort and that of Fernandes et al.2 This suggests that specific culturally unique aspects related to patient or physician decision-making in ICH do not bias the applicability of the ICH score. Finally, they apply a different outcome measure, functional outcome on the modified Rankin Scale, in order to further test the ICH score.Not mentioned in their study is whether they actually used the ICH score for clinical decision making during the period in which they were prospectively validating this scale. We agree with their comment in the final paragraph of their letter that caution should be exercised in utilizing the ICH score for making treatment decisions in individual patients and assume that this implies that they did not introduce this source of bias into their prospective validation study. Interestingly, although their Figure 2 suggests that the ICH score may risk stratify functional outcome at 30 days as well, it also affirms that 30 days after ICH is probably too early to detect the level of improvement that is best assessed by functional outcome scales such as the modified Rankin Scale.We appreciate that Jamora and colleagues have done what we could not: validate the ICH score in a group of patients geographically remote and culturally distinct from that of our original UCSF ICH cohort. This type of international critical appraisal of clinical grading scales and diagnostic tests is an invaluable way to advance collaboration in stroke. Perhaps more than anything, we hope that this ongoing dialogue about the ICH score has raised awareness and engendered enthusiasm for the daunting task ahead: finding an effective treatment for intracerebral hemorrhage. Previous Back to top Next FiguresReferencesRelatedDetailsCited By Menon G, KS H, Gajula K, Kumar S and Hegde A (2022) Development of an Artificial Intelligence-Based Machine Tool to Predict Outcome in Intracerebral Hemorrhage, Journal of Stroke Medicine, 10.1177/25166085221127861, 5:2, (126-132), Online publication date: 1-Dec-2022. (2022) Multicentre collection of uniform data on patients hospitalised for transient ischaemic attack or stroke in the Philippines: the Philippine Neurological Association One Database-Stroke (PNA1DB-Stroke) protocol, BMJ Open, 10.1136/bmjopen-2021-055954, 12:5, (e055954), Online publication date: 1-May-2022. Maljaars J, Garg A, Molian V, Leira E, Adams H and Shaban A (2021) The Intracerebral Hemorrhage Score Overestimates Mortality in Young Adults, Journal of Stroke and Cerebrovascular Diseases, 10.1016/j.jstrokecerebrovasdis.2021.105963, 30:9, (105963), Online publication date: 1-Sep-2021. Hilton L, Lyerly M and Gropen T (2021) Race and in-hospital mortality after spontaneous intracerebral hemorrhage in the Stroke Belt: Secondary analysis of a case–control study, Journal of Clinical and Translational Science, 10.1017/cts.2021.21, 5:1, . Zyck S, Du L, Gould G, Latorre J, Beutler T, Bodman A and Krishnamurthy S (2020) Scoping Review and Commentary on Prognostication for Patients with Intracerebral Hemorrhage with Advances in Surgical Techniques, Neurocritical Care, 10.1007/s12028-020-00962-y, 33:1, (256-272), Online publication date: 1-Aug-2020. He Y, Liu Q, Wang J, Wang D, Ding H and Wang W (2019) Prognostic value of elevated cardiac troponin I in patients with intracerebral hemorrhage, Clinical Cardiology, 10.1002/clc.23320, 43:4, (338-345), Online publication date: 1-Apr-2020. A. R S and R M (2020) ICH Score and Basal Plasma D-Dimer in Patients with Intracerebral Haemorrhage, Journal of Evolution of Medical and Dental Sciences, 10.14260/jemds/2020/167, 9:9, (768-771), Online publication date: 9-Mar-2020. U.M. P, Bhatia R, Sreenivas V, Singh N, Joseph R, Dash D, Singh R, Tripathi M, Srivastava M, Singh M, Suri A and Prasad K (2019) Validation of ICH and ICH-GS Scores in an Indian Cohort: Impact of Medical and Surgical Management, Journal of Stroke and Cerebrovascular Diseases, 10.1016/j.jstrokecerebrovasdis.2019.05.003, 28:8, (2213-2220), Online publication date: 1-Aug-2019. McCracken D, Lovasik B, McCracken C, Frerich J, McDougal M, Ratcliff J, Barrow D and Pradilla G (2019)(2018) The Intracerebral Hemorrhage Score: A Self-Fulfilling Prophecy?, Neurosurgery, 10.1093/neuros/nyy193, 84:3, (741-748), Online publication date: 1-Mar-2019. Munakomi S and Agrawal A (2019) Advancements in Managing Intracerebral Hemorrhage: Transition from Nihilism to Optimism Medical Science and Research, 10.1007/5584_2019_351, (1-9), . Abdallah A, Chang J, O’Carroll C, Okello S, Olum S, Acan M, Aden A, Chow F and Siedner M (2018) Validation of the Intracerebral Hemorrhage Score in Uganda, Stroke, 49:12, (3063-3066), Online publication date: 1-Dec-2018. Hegde A, Prasad G and Rao S (2018) Predictors of Outcome in Spontaneous Intracerebral Hemorrhage—Role of Oxidative Stress Biomarkers, World Neurosurgery, 10.1016/j.wneu.2018.08.222, 120, (601), Online publication date: 1-Dec-2018. Rodríguez-Fernández S, Castillo-Lorente E, Guerrero-Lopez F, Rodríguez-Rubio D, Aguilar-Alonso E, Lafuente-Baraza J, Gómez-Jiménez F, Mora-Ordóñez J, Rivera-López R, Arias-Verdú M, Quesada-García G, Arráez-Sánchez M and Rivera-Fernández R (2018) Validation of the ICH score in patients with spontaneous intracerebral haemorrhage admitted to the intensive care unit in Southern Spain, BMJ Open, 10.1136/bmjopen-2018-021719, 8:8, (e021719), Online publication date: 1-Aug-2018. Williamson C and Rajajee V (2018) Intracerebral Hemorrhage Prognosis Intracerebral Hemorrhage Therapeutics, 10.1007/978-3-319-77063-5_7, (95-105), . Carter J and Curry W (2017) Intracerebral Hemorrhage, Hospital Medicine Clinics, 10.1016/j.ehmc.2016.08.002, 6:1, (95-111), Online publication date: 1-Jan-2017. Faigle R, Marsh E, Llinas R, Urrutia V and Gottesman R (2016) Race‐Specific Predictors of Mortality in Intracerebral Hemorrhage: Differential Impacts of Intraventricular Hemorrhage and Age Among Blacks and Whites, Journal of the American Heart Association, 5:8, Online publication date: 8-Aug-2016. Lei C, Wu B, Liu M, Cao T, Wang Q, Dong W and Chang X (2014) VSARICHS: a simple grading scale for vascular structural abnormality-related intracerebral haemorrhage, Journal of Neurology, Neurosurgery & Psychiatry, 10.1136/jnnp-2014-308777, 86:8, (911-916), Online publication date: 1-Aug-2015. Meyer D, Begtrup K and Grotta J (2015) Is the ICH score a valid predictor of mortality in intracerebral hemorrhage?, Journal of the American Association of Nurse Practitioners, 10.1002/2327-6924.12198, 27:7, (351-355), Online publication date: 1-Jul-2015. Sanchez Abraham M, Romano L, Latini F, Zorrilla J, Aleman A, Ioli P and Gonorazky S (2014) Correlación de la edad y el volumen de la hemorragia intracraneal espontánea supratentorial, Neurología Argentina, 10.1016/j.neuarg.2013.08.007, 6:1, (23-28), Online publication date: 1-Jan-2014. Wang W, Lu J, Wang C, Wang Y, Li H, Zhao X and Salluh J (2013) Prognostic Value of ICH Score and ICH-GS Score in Chinese Intracerebral Hemorrhage Patients: Analysis From the China National Stroke Registry (CNSR), PLoS ONE, 10.1371/journal.pone.0077421, 8:10, (e77421) Heuts S, Bruce S, Zacharia B, Hickman Z, Kellner C, Sussman E, McDowell M, Bruce R and Connolly E Decompressive hemicraniectomy without clot evacuation in dominant-sided intracerebral hemorrhage with ICP crisis, Neurosurgical Focus, 10.3171/2013.2.FOCUS1326, 34:5, (E4) Appelboom G, Hwang B, Bruce S, Piazza M, Kellner C, Meyers P and Connolly E (2012) Predicting Outcome After Arteriovenous Malformation–Associated Intracerebral Hemorrhage with the Original ICH Score, World Neurosurgery, 10.1016/j.wneu.2011.12.001, 78:6, (646-650), Online publication date: 1-Dec-2012. Appelboom G, Bruce S, Han J, Piazza M, Hwang B, Hickman Z, Zacharia B, Carpenter A, Monahan A, Vaughan K, Badjatia N and Sander Connolly E (2012) Functional outcome prediction following intracerebral hemorrhage, Journal of Clinical Neuroscience, 10.1016/j.jocn.2011.11.005, 19:6, (795-798), Online publication date: 1-Jun-2012. Zorrilla J, Sousa L, Ioli P, Romano L, Spadaro E, Castellino G, Latini F, Abut Á and Gonorazky S (2011) Variables predictivas de letalidad y rendimiento de la escala ReC-HPC en hemorragia intracerebral primaria en pacientes anticoagulados, Neurología Argentina, 10.1016/S1853-0028(11)70021-0, 3:2, (94-99), Online publication date: 1-Apr-2011. Stein M, Luecke M, Preuss M, Scharbrodt W, Joedicke A and Oertel M (2011) The Prediction of 30-Day Mortality and Functional Outcome in Spontaneous Intracerebral Hemorrhage with Secondary Ventricular Hemorrhage: A Score Comparison Trends in Neurovascular Surgery, 10.1007/978-3-7091-0661-7_2, (9-11), . Hwang B, Appelboom G, Kellner C, Carpenter A, Kellner M, Gigante P and Sander Connolly E (2010) Clinical Grading Scales in Intracerebral Hemorrhage, Neurocritical Care, 10.1007/s12028-010-9382-x, 13:1, (141-151), Online publication date: 1-Aug-2010. Pontes-Neto O, Oliveira-Filho J, Valiente R, Friedrich M, Pedreira B, Rodrigues B, Liberato B and Freitas G (2009) Diretrizes para o manejo de pacientes com hemorragia intraparenquimatosa cerebral espontânea, Arquivos de Neuro-Psiquiatria, 10.1590/S0004-282X2009000500034, 67:3b, (940-950), Online publication date: 1-Sep-2009. Patriota G, Silva-Júnior J, Barcellos A, Silva Júnior J, Toledo D, Pinto F and Rotta J (2009) Determining ICH Score: can we go beyond?, Arquivos de Neuro-Psiquiatria, 10.1590/S0004-282X2009000400006, 67:3a, (605-608), Online publication date: 1-Sep-2009. Weimar C, Ziegler A, Sacco R, Diener H and König I (2009) Predicting recovery after intracerebral hemorrhage – An external validation in patients from controlled clinical trials, Journal of Neurology, 10.1007/s00415-009-0115-z, 256:3, (464-469), Online publication date: 1-Mar-2009. Rønning P, Sorteberg W, Nakstad P, Russell D and Helseth E (2008) Aspects of intracerebral hematomas - an update, Acta Neurologica Scandinavica, 10.1111/j.1600-0404.2008.01023.x, 118:6, (347-361), Online publication date: 1-Dec-2008. Rost N, Smith E, Chang Y, Snider R, Chanderraj R, Schwab K, FitzMaurice E, Wendell L, Goldstein J, Greenberg S and Rosand J (2008) Prediction of Functional Outcome in Patients With Primary Intracerebral Hemorrhage, Stroke, 39:8, (2304-2309), Online publication date: 1-Aug-2008. Ferro J (2006) Update on intracerebral haemorrhage, Journal of Neurology, 10.1007/s00415-006-0201-4, 253:8, (985-999), Online publication date: 1-Aug-2006. Weimar C, Roth M, Willig V, Kostopoulos P, Benemann J and Diener H (2006) Development and validation of a prognostic model to predict recovery following intracerebral hemorrhage, Journal of Neurology, 10.1007/s00415-006-0119-x, 253:6, (788-793), Online publication date: 1-Jun-2006. Godoy D, Piñero G and Di Napoli M (2006) Predicting Mortality in Spontaneous Intracerebral Hemorrhage, Stroke, 37:4, (1038-1044), Online publication date: 1-Apr-2006. Badjatia N and Rosand J (2005) Intracerebral Hemorrhage, The Neurologist, 10.1097/01.nrl.0000178757.68551.26, 11:6, (311-324), Online publication date: 1-Nov-2005. Godoy D and Boccio A (2003) ICH Score in a Rural Village in the Republic of Argentina, Stroke, 34:9, (e150-e151), Online publication date: 1-Sep-2003. January 2003Vol 34, Issue 1 Advertisement Article InformationMetrics https://doi.org/10.1161/01.STR.0000047847.18178.D3PMID: 12511740 Originally publishedDecember 12, 2002 PDF download Advertisement