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

Abstract

Objective: The 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 important in guiding conversations around goals of care. We previously demonstrated that incorporating delayed imaging into various prognostication scores for ICH improves the predictive accuracy of 90-day mortality. However, delayed prognostication scores have not been used to predict long-term functional outcomes beyond 90 days.

Design, setting and participants: We analysed data from the ICH Deferoxamine trial to see if delaying the use of prognostication scores to 96 hours after ICH onset will improve performance to predict outcomes at 180 days. 276 patients were included.

Interventions and measurements: We calculated the original ICH score (oICH), modified-ICH score (MICH), max-ICH score and the FUNC score on presentation (baseline), and on day 4 (delayed). Outcomes assessed were mortality and poor functional outcome in survivors (defined as modified Rankin Scale of 4-5) at 180 days. We generated receiver operating characteristic curves, and measured the area under the curve values (AUC) for mortality and functional outcome. We compared baseline and delayed AUCs with non-parametric methods.

Results: At 180 days, 21 of 276 (7.6%) died. Out of the survivors, 54 of 255 had poor functional outcome (21.2%). The oICH, MICH and max-ICH performed significantly better at predicting 180-day mortality when calculated 4 days later compared with their baseline equivalents ((0.74 vs 0.83, p=0.005), (0.73 vs 0.80, p=0.036), (0.74 vs 0.83, p=0.008), respectively). The delayed calculation of these scores did not significantly improve our accuracy for predicting poor functional outcomes.

Conclusion: Delaying the calculation of prognostication scores in acute ICH until day 4 improved prediction of 6-month mortality but not functional outcomes.

Trial registration number: ClinicalTrials.gov Registry (NCT02175225).

Keywords: CT; brain; haemorrhage; stroke.

Figure 1

ROC curves for the association between baseline and delayed ICH score for 30-day (A), 90-day (B) and 180-day mortality (C). ICH, intracerebral haemorrhage; ROC, receiver operating characteristic.

Figure 2

ROC curves for the association between baseline and delayed ICH score for 30-day (A), 90-day (B) and 180-day poor functional outcome (C). ICH, intracerebral haemorrhage; ROC, receiver operating characteristic.