Dear Sir:
Spontaneous intracerebral hemorrhage (ICH) accounts for approximately 20% of all strokes and is a leading cause of mortality and morbidity worldwide [
In-hospital neurological deterioration affects approximately 10% to 30% of the patients with ICH [
The derivation and internal validation cohorts were obtained from the Beijing Registration of Intracerebral Hemorrhage [
In this study, in-hospital neurological deterioration after ICH was defined as an episode in which a patient experienced a persistent increase in National Institutes of Health Stroke Scale score ≥4, a decline in Glasgow Coma Scale (GCS) score ≥2, or death during hospitalization.
The baseline characteristics of the derivation cohort and the internal and external validation cohorts are presented in
The predictive performance (area under the receiver operating characteristic curve [AUROC]) of the ICH progression score in the derivation (n=1,309) and internal validation cohorts (n=655) was 0.840 (95% confidence interval [CI], 0.813 to 0.867) and 0.845 (95% CI, 0.808 to 0.881) (
To the best of our knowledge, this is the first study to develop a risk score to predict in-hospital neurological deterioration after ICH. The ICH progression score is unique as it was derived from a large, multicenter, and prospective ICH cohort, which included consecutive patients with ICH, was outside of clinical trials, and was more reflective of real-world clinical practice. Additionally, the ICH progression score consists of factors that are readily available at the presentation. Using a simple score, it can easily be applied in clinical practice or clinical trials.
The predictive performance of the ICH progression score was shown to be accurate in risk stratification and outcome prediction in the derivation, internal, and external validation cohorts (AUROC range, 0.810 to 0.845), respectively. In addition, in the sensitivity analysis, the ICH progression score was valid in several prespecified subgroups of patients with different clinical characteristics.
In-hospital neurological deterioration, whether early or late, was significantly associated with short- and long-term death, poor functional outcome, cognition, and quality of life after ICH [
Our study had some limitations. First, we cannot rule out the possibility that additional baseline variables (unmeasured confounders) might have an impact on the risk of in-hospital neurological deterioration after ICH. Second, our study included only hospitalized patients, and patients who died in the emergency department or were treated in outpatient clinics were not included. Finally, both the derivation and validation cohorts were derived from the Asian population.
In summary, the ICH progression score is a valid clinical grading scale for predicting in-hospital neurological deterioration after ICH at presentation and would be a useful tool for personalized care and clinical trials in the prevention of in-hospital neurological deterioration after ICH.
The study protocol was approved by the Institutional Review Board (IRB) of the Beijing Tiantan Hospital (KY2014-023-02). Written informed consent from patients or their legal representatives.
Supplementary materials related to this article can be found online at
Univariable predictor of in-hospital neurological deterioration after ICH in the derivation cohort (n=1,309)
Multivariable predictors of in-hospital neurological deterioration after ICH in the derivation cohort (n=1,309)
Predictive performance of ICH progression score with regard to in-hospital neurological deterioration after ICH
Calibration of the ICH progression score with regard to in-hospital neurological deterioration after ICH
Sensitivity analysis of ICH progression score in the Beijing Registration of Intracerebral Hemorrhage (n=1,964)
Plot of observed versus predicted risk of neurological deterioration after intracerebral hemorrhage (ICH) in the derivation and validation cohorts. Plot of observed versus predicted risk of in-hospital neurological deterioration after ICH in the derivation, internal, and external validation cohorts according to 10 deciles of predicted risk. Overall, there was a very high correlation between the observed and predicted risks in the derivation cohort (A) (n=1,309; r=0.96;
This study was sponsored by the Capital Health Research and Development of Special (2011-2004-03) and the Beijing Municipal Science & Technology Commission (Z131107002213009). This study was partially supported by the Nova Program of the Beijing Science and Technology Commission (2008B30), National Natural Science Foundation of China (81471208, 81641162), Beijing High-level Healthy Human Resource Project (014-3-033), and Shandong Province Key Innovation Project (2019JZZY020901).
The authors have no financial conflicts of interest.
In-hospital neurological deterioration after intracerebral hemorrhage (ICH) according to the ICH progression score. The figure shows that the proportion of in-hospital neurological deterioration after ICH increased steadily with higher ICH progression scores in the derivation (n=1,309), internal validation (n=655), and two external valuation cohorts (n=3,255 and n=314).
Baseline characteristics
Characteristic | Overall cohort (n=1,964) | Derivation cohort (n=1,309) | Internal validation cohort (n=655) | External validation cohort-1 (n=3,255) | External validation cohort-2 (n=314) | ||
---|---|---|---|---|---|---|---|
Age (yr) | 56.8±14.4 | 56.8±14.6 | 56.9±13.9 | 0.19 | 62.1±13.1 | 54.7±14.2 | |
Male sex | 1,327 (67.6) | 866 (67.7) | 441 (67.3) | 0.87 | 1,995 (61.3) | 221 (70.4) | |
Onset to hospital (hr) | 4.0 (1.90–11.0) | 4.0 (1.92–11.0) | 3.9 (1.97–11.0) | 0.76 | 10.0 (2.41–29.3) | 78 (24–96) | |
Risk factors | |||||||
Hypertension | 1,367 (69.6) | 908 (69.4) | 459 (70.1) | 0.75 | 2,210 (67.9) | 208 (66.9) | |
Diabetes mellitus | 289 (14.7) | 196 (15.0) | 93 (14.2) | 0.65 | 290 (8.9) | 41 (13.1) | |
Dyslipidemia | 184 (9.4) | 109 (8.3) | 75 (11.5) | 0.03 | 230 (7.1) | 36 (11.5) | |
Atrial fibrillation | 30 (1.5) | 20 (1.5) | 10 (1.5) | 0.99 | 54 (1.7) | 10 (3.2) | |
History of stroke/TIA | 309 (15.7) | 208 (15.9) | 101 (15.4) | 0.79 | 889 (27.3) | 48 (15.3) | |
Myocardial infarction | 38 (1.9) | 20 (1.5) | 18 (2.7) | 0.06 | 204 (6.3) | 26 (8.3) | |
Heart failure | 8 (0.4) | 6 (0.5) | 2 (0.3) | 0.62 | 19 (0.6) | 3 (1.0) | |
Current smoker | 628 (32.0) | 403 (30.8) | 225 (34.4) | 0.11 | 1,228 (37.7) | 120 (38.2) | |
Alcohol consumption | 716 (36.5) | 470 (35.9) | 246 (37.6) | 0.47 | 367 (11.3) | 166 (52) | |
Pre-admission anticoagulation | 21 (1.1) | 14 (1.1) | 7 (1.1) | 0.99 | 32 (1.0) | 5 (1.6) | |
Pre-admission antiplatelet | 277 (14.1) | 181 (13.8) | 96 (14.7) | 0.62 | 291 (8.9) | 25 (7.9) | |
Pre-stroke mRS score | 0 (0–0) | 0 (0–0) | 0 (0–0) | 0.36 | 0 (0–0) | 0 (0–0) | |
Admission NIHSS score | 11 (3–21) | 11 (3–21) | 11 (4–21) | 0.89 | 9 (3–16) | 4 (1–10) | |
Admission GCS score | 14 (8–15) | 14 (8–15) | 14 (9–15) | 0.26 | 14 (9–15) | 15 (14–15) | |
Admission dysphagia | 666 (33.9) | 441 (33.7) | 225 (34.4) | 0.77 | 220 (6.8) | 24 (7.6) | |
Admission SBP (mm Hg) | 165 (147–186) | 164 (146–186) | 167 (150–187) | 0.10 | 160 (147–180) | 158 (140–171) | |
Admission DBP (mm Hg) | 96 (82–109) | 95 (81–108) | 98 (84–110) | 0.10 | 95 (87–106) | 93 (83–104) | |
Hematoma location | 0.91 | ||||||
Supratentorial ICH | 1,752 (89.2) | 1,167 (89.2) | 585 (89.3) | 2,862 (87.9) | 282 (89.8) | ||
Infratentorial ICH | 212 (10.8) | 142 (10.8) | 70 (10.7) | 393 (12.1) | 32 (10.2) | ||
Hematoma volume (cm3) | 15.8 (6.0–38.6) | 15.5 (5.9–37.0) | 16.7 (6.6–40.0) | 0.20 | 12.6 (5.5–28.0) | 15 (10–30) | |
Intraventricular extension | 655 (33.4) | 430 (32.8) | 225 (34.4) | 0.51 | 962 (29.6) | 109 (34.7) | |
Subarachnoid extension | 264 (13.4) | 182 (13.9) | 82 (12.5) | 0.39 | 190 (5.8) | 30 (9.6) | |
Admission WBC (109/L) | 9.79 (7.35–13.0) | 9.68 (7.29–12.9) | 10.0 (7.56–13.0) | 0.26 | 8.7 (6.7–11.3) | 8.83 (7.34–11.0) | |
Admission glucose (mmol/L) | 7.31 (6.08–9.20) | 7.26 (6.05–9.10) | 7.49 (6.13–9.40) | 0.20 | 6.3 (5.7–7.5) | 5.04 (4.37–6.07) | |
Admission creatinine (μmol/L) | 63.4 (52.7–77.0) | 63.1 (52.3–76.6) | 63.9 (53.8–77.0) | 0.17 | 77.0 (62.0–92.0) | 61.7 (52.1–72.1) | |
Etiology diagnosis | 0.86 | ||||||
Primary ICH | 1,785 (90.9) | 1,193 (91.1) | 592 (90.4) | - | 277 (88.2) | ||
Secondary ICH | 159 (8.1) | 103 (7.3) | 56 (8.5) | - | 34 (10.8) | ||
Primary IVH | 20 (1.0) | 13 (1.0) | 7 (1.1) | - | … | ||
Withdrawal of medical care | 139 (7.1) | 99 (7.6) | 40 (6.1) | 0.24 | 404 (12.4) | 21 (6.7) | |
Surgical treatment | 366 (18.6) | 251 (19.2) | 115 (17.6) | 0.39 | 206 (6.3) | 43 (13.7) | |
Length of hospital stay | 16 (8–22) | 16 (9–22) | 16 (8–22) | 0.99 | 18 (11–26) | 14 (12–18) | |
In-hospital neurological deterioration | 373 (19.0) | 250 (19.1) | 123 (18.8) | 0.87 | 476 (14.6) | 18 (5.7) |
Values are presented as mean±standard deviation, median (interquartile range), or number (%).
TIA, transient ischemic attack; mRS, modified Rankin Scale; NIHSS, National Institutes of Health Stroke Scale; GCS, Glasgow Coma Scale; SBP, systolic blood pressure; DBP, diastolic blood pressure; ICH, intracerebral hemorrhage; WBC, white cell count; IVH, intraventricular hemorrhage.
Scoring system of the intracerebral hemorrhage progression score
Item | Score |
---|---|
Age ≥80 years | 2 |
Male sex (yes) | 2 |
History of diabetes mellitus (yes) | 2 |
History of atrial fibrillation (yes) | 7 |
Admission GCS score ≤8 (yes) | 6 |
Dysphagia on admission (yes) | 3 |
Infratentorial hematoma location (yes) | 2 |
Hematoma volume (mL) | |
Superatentorial ≤39 or infratentorial ≤4 | 0 |
Superatentorial 40–69 or infratentorial 5–10 | 4 |
Superatentorial ≥70 or infratentorial ≥11 | 5 |
Blood glucose >11.1 mmol/L | 3 |
Total | 32 |
GCS, Glasgow Coma Scale.