Intracerebral Hemorrhage Score Research Articles

Trends in the seeking of emergency service for ischemic stroke and its risk factors during the COVID-19 pandemic, a study from Taiwan

Background & Objectives: COVID-19 may influence the health seeking behavior of acute ischemic stroke patients. This study aimed to determine the characteristics of the patients who visited the emergency room in a centre designated for stroke care in Taiwan. Methods: This was a retrospective database-based study comparing the severity of ischemic stroke, intracerebral hemorrhage (ICH), and risk factors of patients seen between 2019 and 2020 in the National Taiwan University Hospital Yunlin Branch. Patients with or without thrombolysis therapy were analysed. Results: The median NIHSS of ischemic stroke patients were lower in 2019 than in 2020 (p = 0.015). The difference was seen in non-thrombolysis patients (2019: 3[1-6] vs. 4 [2-7.5], p = 0.012) but not in thrombolysis patients. The frequency of minor stroke was higher in 2019 (45.1%) than in 2020 (37.9%, p = 0.038). The discharge mRS was lower overall (p = 0.004) and in non-thrombolysis patients (0.003), but not in thrombolysis patients in 2019. As for the ICH patients, the severity of ICH score (p = 0.021) and discharge mRS (p = 0.001) were also lower in 2019. The frequencies of risk factors of stroke were higher in 2019 than in 2020, including smoking (24% vs. 18.2%, p = 0.046), alcohol (11.9% vs. 7.5%, p = 0.039), hypertension (72.9% vs. 66.2%, p = 0.039), history of stroke (16.5% vs. 11.6%, p = 0.047), and atrial fibrillation (11.9% vs. 7.5%, p = 0.039). Conclusions: This study in Taiwan revealed a decline in the willingness to seek emergency services under the influence of COVID-19 among patients with lower stroke severity, especially those with more risk factors.

Association of Serum Bilirubin with the Severity and Outcomes of Intracerebral Hemorrhages

Intracerebral hemorrhage (ICH) is the second most common subtype of stroke, and it is often associated with a high mortality rate and significant morbidity among survivors. Recent studies have shown that bilirubin, a product of heme metabolism, can exhibit cytoprotective, antioxidant and, anti-inflammatory properties. However, little is known about the role of bilirubin in combating several pathophysiological pathways caused by intracerebral bleeding in patients with ICH. In this study, data were collected retrospectively on 276 patients with ICH who were admitted to a university hospital between 5 January 2014 and 31 December 2017. We assessed the relationship between levels of total, direct, and indirect serum bilirubin and assessments of initial stroke severity and clinical outcomes by using Spearman’s rank correlation and Kruskal-Wallis H tests. A secondary examination of the carrier protein albumin was also undertaken. Our study found that higher levels of direct bilirubin were correlated with worse admission Glasgow Coma Scales (GCS) (rs = −0.17, p = 0.011), worse admission ICH Scores (rs = 0.19, p = 0.008), and worse discharge modified Rankin Scales (mRS) (rs = 0.15, p = 0.045). Direct bilirubin was still significantly correlated with discharge mRS after adjusting for temperature at admission (rs = 0.16, p = 0.047), oxygen saturation at admission (rs = 0.15, p = 0.048), white blood cell count (rs = 0.18, p = 0.023), or Troponin T (rs = 0.25, p = 0.001) using partial Spearman’s correlation. No statistical significance was found between levels of total or indirect bilirubin and assessments of stroke severity and outcomes. In contrast, higher levels of albumin were correlated with better admission GCS (rs = 0.13, p = 0.027), discharge GCS (rs = 0.15, p = 0.013), and discharge mRS (rs = −0.16, p = 0.023). We found that levels of total bilirubin, direct bilirubin, and albumin were all significantly related to discharge outcomes classified by discharge destinations (p = 0.036, p = 0.014, p = 0.016, respectively; Kruskal-Wallis H tests). In conclusion, higher direct bilirubin levels were associated with greater stroke severity at presentation and worse outcomes at discharge among patients with ICH. Higher levels of albumin were associated with lower stroke severity and better clinical outcomes. Future prospective studies on the free bioactive bilirubin are needed to better understand the intricate relationships between bilirubin and ICH.

High-resolution CT with arch/neck/head CT angiography on a mobile stroke unit

BackgroundMobile stroke units (MSUs) performance dependability and diagnostic yield of 16-slice, ultra-fast CT with auto-injection angiography (CTA) of the aortic arch/neck/circle of Willis has not been previously reported.MethodsWe performed a...

CN-105 in Participants with Acute Supratentorial Intracerebral Hemorrhage (CATCH) Trial.

Endogenous apolipoprotein (apo) E mediates neuroinflammatory responses and recovery after brain injury. Exogenously administered apoE-mimetic peptides effectively penetrate the central nervous system compartment and downregulate acute inflammation. CN-105 is a novel apoE-mimetic pentapeptide with excellent evidence of functional and histological improvement in preclinical models of intracerebral hemorrhage (ICH). The CN-105 in participants with Acute supraTentorial intraCerebral Hemorrhage (CATCH) trial is a first-in-disease-state multicenter open-label trial evaluating safety and feasability of CN-105 administration in patients with acute primary supratentorial ICH. Eligible patients were aged 30-80years, had confirmed primary supratentorial ICH, and were able to intiate CN-105 administration (1.0mg/kg every 6h for 72h) within 12h of symptom onset. A priori defined safety end points, including hematoma volume, pharmacokinetics, and 30-day neurological outcomes, were analyzed. For clinical outcomes, CATCH participants were compared 1:1 with a closely matched contemporary ICH cohort through random selection. Hematoma volumes determined from computed tomography images on days 0, 1, 2, and 5 and ordinal modified Rankin Scale score at 30days after ICH were compared. In 38 participants enrolled across six study sites in the United States, adverse events occurred at an expected rate without increase in hematoma expansion or neurological deterioration. CN-105 treatment had an odds ratio (95% confidence interval) of 2.69 (1.31-5.51) for lower 30-day modified Rankin Scale score, after adjustment for ICH score, sex, and race/ethnicity, as compared with a matched contemporary cohort. CN-105 administration represents an excellent translational candidate for treatment of acute ICH because of its safety, dosing feasibility, favorable pharmacokinetics, and possible improvement in neurological recovery.

Associations between Intensive Lipid-lowering Therapy and Outcomes of Intracerebral Hemorrhage

Background: The intensive lipid-lowering therapy (ILLT), targeting an low-density lipoprotein cholesterol (LDL-C) < 1.80 mmol/L, was a crucial strategy for the secondary prevention of cerebrovascular diseases. But the associations between ILLT and the outcomes after intracerebral hemorrhage (ICH) were unclear. Materials and Methods: Data of the consecutive patients with acute ICH and past medical histories of ischemic stroke from 2017 to 2019 at an academic stroke center in China were analyzed. The study patients were classified according to their baseline LDL-C levels: < 1.80 mmol/Lvs. ≥ 1.80 mmol/L. The outcomes of ICH were compared between the two groups. Multivariate linear mixed effect model with repeated measures adjusting for ICH scores were used to determine the associations between LDL-C levels and the change in NIHSS scores; baseline ICH scores were adjusted in the multi-variable models Results: A total of 197 patients were included in the study, 31 of them had LDL-C < 1.80 mmol/L and 166 had LDL-C ≥ 1.80 mmol/L. We did not test any significant differences regarding the demographic characteristics or vascular risk factors. Medians of the baseline National Institutes of Health Stroke Scale (NIHSS) scores (8 vs. 9, P = 0.79) and ICH scores (1 vs.1, P = 0.26) were similar. But the patients with LDL-C < 1.80 mmol/L had higher risks of secondary intraventricular hemorrhage (13% vs. 4%, P = 0.03). Outcomes of the hemorrhagic stroke at discharge were similar, except the patients with LDL-C ≥ 1.80 mmol/L had significant improvements in their NIHSS scores at discharge (estimated change in means: -2.4, 95% CI: [-4.3, -0.5]), while patients with LDL-C < 1.80 mmol/L did not (estimated change in means: -1.4, 95% CI: [-5.9, 3.0]). Conclusion: ILLT achieved LDL-C < 1.80 mmol/L was associated with limited improvements in the neurological deficits in the patients with ICH.

Intracranial Hemorrhage in Patients with Coronavirus Disease 2019 (COVID-19): A Case Series

BackgroundThe coronavirus disease 2019 (COVID-19) pandemic is an ongoing public health emergency. While most cases end in asymptomatic or minor illness, there is growing evidence that some COVID-19 infections result in nonconventional dire consequences. We sought to describe the characteristics of patients with intracranial hemorrhage who were infected with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). Also, with the existing literature, we raise the idea of a possible association between SARS-CoV-2 infection and intracranial hemorrhage and propose possible pathophysiological mechanisms connecting the two.MethodsWe retrospectively collected and analyzed intracranial hemorrhage cases who were also positive for SARS-CoV-2 from 4 tertiary-care cerebrovascular centers.ResultsWe identified a total of 19 patients consisting of 11 males (58%) and 8 females (42%). Mean age was 52.2, with 95% younger than 75 years of age. With respect to COVID-19 illness, 50% had mild-to-moderate disease, 21% had severe disease, and 20% had critical disease requiring intubation. Of the 19 cases, 12 patients had intraparenchymal hemorrhage (63%), 6 had subarachnoid hemorrhage (32%), and 1 patient had a subdural hematoma (5%). A total of 43% had an intracerebral hemorrhage score of 0–2 and 57% a score of 3–6. Modified Rankin Scale cores at discharge were 0–2 in 23% and 3–6 in 77%. The mortality rate was 59%.ConclusionsOur series sheds light on a distinct pattern of intracerebral hemorrhage in COVID-19–positive cases compared with typical non–COVID-19 cases, namely the severity of hemorrhage, high mortality rate, and the young age of patients. Further research is warranted to delineate a potential association between SARS-CoV-2 infection and intracranial hemorrhage.

Validation of the ICH score and ICH-GS in a Peruvian surgical cohort: a retrospective study.

The intracerebral hemorrhage (ICH) score and the ICH-grading scale (ICH-GS) are mortality predictor tools developed predominantly in conservatively treated ICH cohorts. We aimed to compare and evaluate the external validity of both models in predicting mortality in patients with ICH undergoing surgical intervention. A retrospective review of all patients presenting with spontaneous ICH admitted to a Peruvian national hospital between January 2018 and March 2020 was conducted. We compared the area under the receiver operating characteristic curve (AUC) for the ICH score and ICH-GS for in-hospital, 30-day, and 6-month mortality prediction. The research protocol was approved by the Institutional Review Board. A total of 73 patients (median age 62years, 56.2% males) were included in the study. The mean ICH and ICH-GS scores were 2.5 and 8.7, respectively. In-hospital, 30-day, and 6-month mortality were 37%, 27.4%, and 37%, respectively. The AUC for in-hospital, 30-day, and 6-month mortality was 0.69, 0.71, and 0.69, respectively, for the ICH score and 0.64, 0.65, and 0.68, respectively, for the ICH-GS score. In this study, the ICH score and ICH-GS had moderate discrimination capacities to predict in-hospital, 30-day, and 6-month mortality in surgically treated patients. Additional studies should assess whether surgical intervention affects the discrimination of these prognostic models in order to develop predictive scores based on specific populations.

The Intracerebral Hemorrhage Score Overestimates Mortality in Young Adults

ObjectiveTo determine whether the intracerebral hemorrhage (ICH) score is accurate in predicting 30-day mortality in young adults, we calculated the ICH score for 156 young adults (aged 18-45) with primary spontaneous ICH and compared predicted to observed 30-day mortality rates. MethodsWe retrospectively reviewed all patients aged 18-45 consecutively presenting to the University of Iowa from 2009 to 2019 with ICH. We calculated the ICH score and recorded its individual subcomponents for each patient. Poisson regression was used to test the association of ICH score components with 30-day mortality. ResultsWe identified 156 patients who met the inclusion criteria; mean± standard deviation (SD) age was 35±8 years. The 30-day mortality rate was 15% (n=24). The ICH score was predictive of 30-day mortality for each unit increase (p= 0.04 for trend), but the observed mortality rates for each ICH score varied considerably from the original ICH score predictions. Most notably, the 30-day mortality rates for ICH scores of 1, 2, and 3 are predicted to be 13%, 26%, and 72% respectively, but were observed in our population to be 0%, 3%, and 41%. An ICH volume of >30cc [relative risk (RR) 28, 95% confidence intervals (CI) 3-315, p=0.01] and a GCS score of <5 (RR 13, 95% CI 0.1-1176, p=0.01) were independently associated with 30-day mortality. ConclusionsThe ICH score tends to overestimate mortality in young adults. ICH volume and GCS score are the most relevant items in predicting mortality at 30 days in young adults.

Hypertensive Retinopathy and the Risk of Hemorrhagic Stroke

ObjectiveHemorrhagic stroke (HS) and hypertensive retinopathy are known end organ damage of the brain and eye respectively, with HS having deleterious consequence to the patients. This study is to correlate between hypertensive retinopathy and HS in hypertensive disease. MethodsA control group of hypertensive patients only, and an investigated group of hypertensive HS patients. Fundoscopic examination to determine the grade of retinopathy was performed and then divided into low or high severity hypertensive retinopathy. Clinical and radiological parameter included are demography, vital signs, Glasgow coma scale (GCS) on admission, clot volume, site of clot, Intracerebral hemorrhage (ICH) score and Glasgow outcome scale (GOS). Data were correlated with the severity of hypertensive retinopathy. ResultsFifty patient in the control group and 51 patients in the investigated group were recruited. In the hypertensive HS group, 21 had low severity retinopathy (no or mild retinopathy) accounting for 41.2% and 30 patients had high severity (moderate or severe retinopathy). In the hypertensive patients 49 had low severity and one had high severity (p-value of 0.001). In HS group low severity showed better GCS score of 9–15 on admission (p-value of 0.003), clot volume less than 30 mL (p-value 0.001), and also a better 30 days mortality rate by using the ICH score (p-value 0.006), GOS score of 4 and 5 the low severity retinopathy fair better than the high severity retinopathy (p-value of 0.001), and the relative risk to develop HS in low severity and high severity retinopathy was 0.42 and 29.4, respectively. ConclusionHypertensive retinopathy screening could be used as an indicator in hypertensive patient, to evaluate the risk of developing hypertensive HS in the future.

Short-term outcomes of endoscopic evacuation of supratentorial spontaneous intracerebral hematoma: Early experience from developing country.

Background: Minimally invasive endoscopic hematoma evacuation is a promising treatment option for intracerebral hemorrhage (ICH). However, the technique still needs improvement.Methods: We report our early clinical experience of using this technique to evacuate supratentorial spontaneous intracerebral hematomas and evaluate its short-term outcomes.Results: The study included 15 patients, basal ganglia hematoma was the most common location 62.5%, mean preoperative hematoma volume was 61.07 cc, mean ICH score was 3, and mean rate of hematoma evacuation was 89.27%. Factors that could be related to mortality were Glasgow Coma Score (GCS) on admission (P = 0.001), ICH score (P = 0.004); postoperative GCS (P < 0.001), postoperative hematoma volume (P = 0.006); intraventricular extension (P = 0.001), and rate of evacuation (P = 0.001).Conclusion: Endoscopic technique is a safe surgical option for evacuation of spontaneous supratentorial ICH. This minimally invasive technique could be helpful to provide better short-term outcomes for selected patients. However, in our experience, this minimally invasive technique did not change the outcome for cases presented with poor GCS on admission 4/15. Our results warrant a future prospective, randomized, controlled efficacy trial.

Correlation of Haematoma Volume with Early Outcome in Surgically Treated Spontaneous Primary Supratentorial Intra-Cerebral Haematomas

Introduction: Spontaneous intracerebral hemorrhage (ICH) comprises 10-15% of all strokes. Aim: To assess the relationship between the haematoma volume and early surgical outcome of patients with spontaneous primary supratentorial intracerebral hemorrhage by Glasgow Outcome Scale at the 30th post ictus day. Methods: This prospective study was done from April 2014 to March 2016 in Department of Neurosurgery, Combined Military Hospital (CMH), Dhaka. Forty seven cases were selected by set down criteria. Glasgow Coma Scale (GCS) score was recorded on admission, haematoma volume was calculated from the CT scan immediately after admission by Modified Ellipsoid Method and the surgical outcome of ICH patients was determined by Glasgow Outcome Scale (GOS) by face to face interview or by structured interview over phone at their 30th post ictus day. Correlation between the haematoma volume and the surgical outcome of ICH was done by Chi-square test. Again the correlations of three variables (haematoma volume, admission GCS and ICH score) with GOS was compared by Spearman’s correlation coefficient test. Results: Patients with haematoma volume of 30cc or more were found to have worst outcome. Conclusion: Relationship between haematoma volume and surgical outcome was found statistically very significant. Risk stratification of the patients with spontaneous primary supratentorial intracerebral hematomas basing on hematoma volume may be used to improve standardization of treatment protocols and clinical research studies. JAFMC Bangladesh. Vol 15, No 1 (June) 2020: 46-49

FUNC SCORE IN PREDICTION INTRACEREBRAL HEMORRHAGE PATIENTS AT HUE CENTRAL HOSPITAL

Introduction: Intracerebral hemorrhage (ICH) remains a cause of significant morbidity and mortality and is associated with long-term disability. Early neurological worsening (ENW) is a major determinant of death in ICH. Besides predicting morbidity, prognosis functional independence is a crucial matter. In 2008, Natalia Sana Rost created FUNC score to predict the likelihood of functional independence. The aim of our study was to evaluate the ability of FUNC score to predict three outcomes of ICH: Early neurological worsening, 30-day morbidity, and 90-day functional independence. And compare to ICH grading scales. Methods: We prospectively characterized 123 consecutive patients with ICH at Hue Central Hospital. ICH and FUNC scores were calculated. Receiver operating characteristic (ROC) analysis, including area under the curve (AUC), was used to assess the ability of each score to predict ENW, 30-day morbidity, and 90-day functional independence. Results: Overall, thirty-day mortality rate was 31.7% (n=39), while 48 (39.0%) patients had good outcome at 90-days (mRS ≤ 2). Thirty-three patients (26.8%) had ENW then all of them died at 30-days after ICH. Intraventricular bleeding involved significantly worse outcomes including ENW, mortality at 30-days after ICH, and poor outcome at 90-days. Worse outcomes had significantly bigger mean hematoma volume in all three outcomes. Both scores were accurate predictors of study outcomes demonstrating excellent discrimination (AUC &gt; 0.80). And FUNC score, which had larger AUCs, predicted ENW, 30-day morbidity, and 90-day functional independence better than ICH score. Conclusions: FUNC scores are appropriate tools to predict ENW, with potential applications to clinical practice and research.

English

BACKGROUND World Health Organisation (WHO) defined stroke as rapidly developing clinical signs of focal disturbance of cerebral function, lasting more than 24 hours or leading to death, with no apparent cause other than vascular origin. Prognostic factors for predicting functional outcome and mortality play a major role in determining the treatment outcome. We intended to study the clinical charecteristics and outcome of patients with intracerebral bleeding coming to emergency room. METHODS Patients more than 18 years of age who were diagnosed to have intracerebral haemorrhage (ICH) on CT brain plain scan were included in the study. Age &lt; 18 years, patients not willing to participate in the study were excluded from the study. Type of clinical presentation, imaging findings, ICH score, and Glasgow coma scale (GCS) score, were calculated for each patient at the time of admission. The condition of the patient, whether death / discharge (alive) was documented in all study population at the time of discharge. RESULTS Hypertension was the most common risk factor present in 68 % of study population. Most of the patients were between 41 - 70 years of age with a male preponderance. High ICH score, low GCS score at the time of admission, presence of intraventricular haemorrhage, and midline shift (P - value 0.000) were significantly associated with poor clinical outcome. Mortality was high in patients with infratentorial bleed and volume &gt; 40 c.c. CONCLUSION Males in their sixth decade were the most affected in our study on ICH. Cerebellar and brainstem haemorrhages had higher mortality, though putamen is the commonest site of haemorrhage, low Glasgow Coma Scores and high ICH scores were associated with increased mortality. KEY WORDS Stroke, Haemorrhage, Intracerebral, Prognosis, Bleed

New Prediction Models of Functional Outcome in Acute Intracerebral Hemorrhage: The dICH Score and uICH Score.

Objectives: The original intracerebral hemorrhage (oICH) score is the severity score most commonly used in clinical intracerebral hemorrhage (ICH) research but may be influenced by hematoma expansion or intraventricular hemorrhage (IVH) growth in acute ICH. Here, we aimed to develop new clinical scores to improve the prediction of functional outcomes in patients with ICH.Methods: Patients admitted to the First Affiliated Hospital of Chongqing Medical University with primary ICH were prospectively enrolled in this study. Hematoma volume was measured using a semiautomated, computer-assisted technique. The dynamic ICH (dICH) score was developed by incorporating hematoma expansion and IVH growth into the oICH score. The ultra-early ICH (uICH) score was developed by adding the independent non-contrast CT markers to the oICH score. Receiver operating characteristic curve analysis was used to compare performance among the oICH score, dICH score, and uICH score.Results: There were 310 patients in this study which included 72 patients (23.2%) with hematoma expansion and 58 patients (18.7%) with IVH growth. Of 31 patients with two or more non-contrast computed tomography markers, 61.3% died, and 96.8% had poor outcomes at 90 days. After adjustment for potential confounding variables, we found that age, baseline Glasgow Coma Scale score, presence of IVH on initial CT, baseline ICH volume, infratentorial hemorrhage, hematoma expansion, IVH growth, blend sign, black hole sign, and island sign could independently predict poor outcomes in multivariate analysis. In comparison with the oICH score, the dICH score and uICH score exhibited better performance in the prediction of poor functional outcomes.Conclusions: The dICH score and uICH score were useful clinical assessment tools that could be used for risk stratification concerning functional outcomes and provide guidance in clinical decision-making in acute ICH.

Postsurgical functional outcome prediction model using deep learning framework (Prediction One, Sony Network Communications Inc.) for hypertensive intracerebral hemorrhage.

Background: Reliable prediction models of intracerebral hemorrhage (ICH) outcomes are needed for decision-making of the treatment. Statistically making such prediction models needs a large number of samples and time-consuming statistical analysis. Deep learning (DL), one of the artificial intelligence, is attractive, but there were no reports on DL-based functional outcome prediction models for ICH outcomes after surgery. We herein made a functional outcome prediction model using DLframework, Prediction One (Sony Network Communications Inc., Tokyo, Japan), and compared it to original ICH score, ICH Grading Scale, and FUNC score.Methods: We used 140 consecutive hypertensive ICH patients’ data in our hospital between 2012 and 2019. All patients were surgically treated. Modified Rankin Scale 0–3 at 6 months was defined as a favorable outcome. We randomly divided them into 100 patients training dataset and 40 patients validation dataset. Prediction One made the prediction model using the training dataset with 5-fold cross-validation. We calculated area under the curves (AUCs) regarding the outcome using the DL-based model, ICH score, ICH Grading Scale, and FUNC score. The AUCs were compared.Results: The model made by Prediction One using 64 variables had AUC of 0.997 in the training dataset and that of 0.884 in the validation dataset. These AUCs were superior to those derived from ICH score, ICH Grading Scale, and FUNC score.Conclusion: We easily and quickly made prediction models using Prediction One, even with a small single-center dataset. The accuracy of the DL-based model was superior to those of previous statistically calculated models.

Inversion of T Waves on Admission is Associated with Mortality in Spontaneous Intracerebral Hemorrhage

IntroductionCardiac dysfunction directly caused by spontaneous intracerebral hemorrhage (ICH) is a poorly understood phenomenon, and its impact on outcome is still uncertain. The aim of this study is to investigate the relationship between electrocardiographic (EKG) abnormalities and mortality in ICH. MethodsThis is a retrospective study analyzing EKG patterns on admission in patients admitted with ICH at a tertiary care center over an eight-year period. For each patient, demographics, medical history, clinical presentation, EKG on admission and during hospitalization, and head CT at presentation were reviewed. Mortality was noted. ResultsA total of 301 ICH patients were included in the study. The most prevalent EKG abnormalities were QTc prolongation in 56% of patients (n = 168) followed by inversion of T waves (TWI) in 37% of patients (n = 110). QTc prolongation was associated with ganglionic location (p = 0.03) and intraventricular hemorrhage (IVH) (p = 0.01), TWIs were associated with ganglionic location (p = 0.02), and PR prolongation was associated with IVH (p = 0.01), while QRS prolongation was associated with lobar location (p < 0.01). Volume of ICH, hemispheric laterality, and involvement of insular cortex were not correlated with specific EKG patterns. In a logistic regression model, after correcting for ICH severity and prior cardiac history, presence of TWI was independently associated with mortality (OR: 3.04, CI:1.6–5.8, p < 0.01). Adding TWI to ICH score improved its prognostic accuracy (AUC 0.81, p = 0.04). Disappearance of TWI during hospitalization did not translate into improvement of survival (p = 0.5). ConclusionPresence of TWI on admission is an independent and unmodifiable factor associated with mortality in ICH. Further research is needed to elucidate the pathophysiologic mechanisms underlying electrocardiographic changes after primary intracerebral hemorrhage.

Novel Score for Stratifying Risk of Critical Care Needs in Patients With Intracerebral Hemorrhage.

To develop a risk prediction score identifying patients with intracerebral hemorrhage (ICH) at low risk for critical care. We retrospectively analyzed data of 451 patients with ICH between 2010 and 2018. The sample was randomly divided into a development and a validation cohort. Logistic regression was used to develop a risk score by weighting independent predictors of intensive care unit (ICU) needs according to strength of association. The risk score was tested in the validation cohort and externally validated in a dataset from another institution. The rate of ICU interventions was 80.3%. Systolic blood pressure (SBP), Glasgow Coma Scale (GCS) score, intraventricular hemorrhage (IVH), and ICH volume were independent predictors of critical care, resulting in the following point assignments for the Intensive Care Triaging in Spontaneous Intracerebral Hemorrhage (INTRINSIC) score: SBP 160 to 190 mm Hg (1 point), SBP >190 mm Hg (3 points); GCS 8 to 13 (1 point), GCS <8 (3 points); ICH volume 16 to 40 cm3 (1 point), ICH volume >40 cm3 (2 points); and presence of IVH (1 point), with values ranging between 0 and 9. Among patients with a score of 0 and no ICU needs during their emergency department stay, 93.6% remained without critical care needs. In an external validation cohort of patients with ICH, the INTRINSIC score achieved an area under the receiver operating characteristic curve of 0.823 (95% confidence interval 0.782-0.863). A score <2 predicted the absence of critical care needs with 48.5% sensitivity and 88.5% specificity, and a score <3 predicted the absence of critical care needs with 61.7% sensitivity and 83.0% specificity. The INTRINSIC score identifies patients with ICH who are at low risk for critical care interventions. This study provides Class II evidence that the INTRINSIC score identifies patients with ICH at low risk for critical care interventions.

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

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...

Adapting a Traumatic Brain Injury Goals-of-Care Decision Aid for Critically Ill Patients to Intracerebral Hemorrhage and Hemispheric Acute Ischemic Stroke.

Families in the neurologic ICU urgently request goals-of-care decision support and shared decision-making tools. We recently developed a goals-of-care decision aid for surrogates of critically ill traumatic brain injury patients using a systematic development process adherent to the International Patient Decision Aid Standards. To widen its applicability, we adapted this decision aid to critically ill patients with intracerebral hemorrhage and large hemispheric acute ischemic stroke. Prospective observational study. Two academic neurologic ICUs. Twenty family members of patients in the neurologic ICU were recruited from July 2018 to October 2018. None. We reviewed the existing critically ill traumatic brain injury patients decision aid for content and changed: 1) the essential background information, 2) disease-specific terminology to "hemorrhagic stroke" and "ischemic stroke", and 3) disease-specific prognosis tailored to individual patients. We conducted acceptability and usability testing using validated scales. All three decision aids contain information from validated, disease-specific outcome prediction models, as recommended by international decision aid standards, including careful emphasis on their uncertainty. We replaced the individualizable icon arrays graphically depicting probabilities of a traumatic brain injury patient's prognosis with icon arrays visualizing intracerebral hemorrhage and hemispheric acute ischemic stroke prognostic probabilities using high-quality disease-specific data. We selected the Intracerebral Hemorrhage Score with validated 12-month outcomes, and for hemispheric acute ischemic stroke, the 12-month outcomes from landmark hemicraniectomy trials. Twenty family members participated in acceptability and usability testing (n = 11 for the intracerebral hemorrhage decision aid; n = 9 for the acute ischemic stroke decision aid). Median usage time was 22 minutes (interquartile range, 16-26 min). Usability was excellent (median System Usability Scale = 84/100 [interquartile range, 61-93; with > 68 indicating good usability]); 89% of participants graded the decision aid content as good or excellent, and greater than or equal to 90% rated it favorably for information amount, balance, and comprehensibility. We successfully adapted goals-of-care decision aids for use in surrogates of critically ill patients with intracerebral hemorrhage and hemispheric acute ischemic stroke and found excellent usability and acceptability. A feasibility trial using these decision aids is currently ongoing to further validate their acceptability and test their feasibility for use in busy neurologic ICUs.

Abstract P428: The Intracerebral Hemorrhage Score Overestimates Mortality in Young Adults

Introduction: The intracerebral hemorrhage (ICH) score is a widely used scoring system for predicting mortality in patients with ICH. This score has been validated for use in adults of all ages with ICH, but not specifically for use in populations of young adults (age 18-45). We aimed to determine the validity of the ICH score when applied to young adults with ICH. Methods: This was a retrospective analysis of all patients aged 18-45 with spontaneous ICH consecutively admitted to our institution from 2009-2019. We calculated the ICH score for each patient, recording the individual subcomponents, and analyzed the scores for prediction of mortality at 30 days. We also analyzed the individual subcomponents of the score for effect on mortality. Results: We identified 156 patients (mean age 35 +/- 7.8; 67 were female, 103 were white) to include in our study. The 30-day mortality rate was 15% (n=24); these patients had a mean age of 34.9 +/- 7.8, compared to survivors who had mean age 35.4 +/- 7.8 (p=0.797). ICH scores were predictive of mortality (p=0.036 for trend); however, the actual mortality rates in our population were substantially lower than those predicted by the ICH score. Specifically, patients in our population with scores of 1, 2, or 3 had 30-day mortality rates of 0%, 3%, and 41%, compared to the current ICH score mortality predictions of 13%, 26%, and 72%, respectively. Scores of 4 and 5 in our population were more closely aligned to current ICH predictions (85% and 100% compared to 97% and 100%, respectively). Of the ICH score subcomponents, ICH volume &gt;30mL (p=0.007) and Glasgow Coma Scale (GCS) scores of 3 or 4 (p=0.014) were the strongest predictors of mortality at 30 days. Conclusion: The ICH score is predictive of mortality for adults of all ages, but the specific mortality rates associated with this scoring system vary considerably when applied to young adults (age 18-45). This over-estimation should be taken into consideration when applying the predictions of the ICH score to young adults with ICH; additionally, special attention should be given to ICH volume &gt;30mL and very low GCS scores, as these were the strongest predictors of early mortality.