Max-ICH score

Jacobs, Bradley S.; Poggesi, Anna; Terry, John B.

doi:10.1212/wnl.0000000000004195

Cited by 7 publications

(6 citation statements)

References 6 publications

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“…More than half of ICH patients that are unconscious on admission are dead at one year after the bleed, and even though our ability to accurately prognosticate recovery is dismal, the primary mode of death is withdrawal of life sustaining therapies 26 . Accurate prediction of functional outcomes is challenging in the acute setting and confounded by biases contributing to the self-fulfilling prophecy of poor outcomes 27,28 . In this study we show that lesions identified on MRIs obtained within one week of ICH not only correlate with level of consciousness at the time of MRI but, more importantly, are able to identify patients that will recover consciousness prior to ICU discharge and have better 3-month functional outcomes.…”

Section: Discussionmentioning

confidence: 99%

Deep structural brain lesions associated with consciousness impairment early after hemorrhagic stroke

Rohaut

Doyle

Reynolds

et al. 2019

Sci Rep

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The purpose of this study was to determine the significance of deep structural lesions for impairment of consciousness following hemorrhagic stroke and recovery at ICU discharge. Our study focused on deep lesions that previously were implicated in studies of disorders of consciousness. We analyzed MRI measures obtained within the first week of the bleed and command following throughout the ICU stay. A machine learning approach was applied to identify MRI findings that best predicted the level consciousness. From 158 intracerebral hemorrhage patients that underwent MRI, one third was unconscious at the time of MRI and half of these patients recovered consciousness by ICU discharge. Deep structural lesions predicted both, impairment and recovery of consciousness, together with established measures of mass effect. Lesions in the midbrain peduncle and pontine tegmentum alongside the caudate nucleus were implicated as critical structures. Unconscious patients predicted to recover consciousness by ICU discharge had better long-term functional outcomes than those predicted to remain unconscious.

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Section: Discussionmentioning

confidence: 99%

Deep structural brain lesions associated with consciousness impairment early after hemorrhagic stroke

Rohaut

Doyle

Reynolds

et al. 2019

Sci Rep

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“…More than half of ICH patients that are unconscious on admission are dead at one year after the bleed, and even though our ability to accurately prognosticate recovery is dismal, the primary mode of death is withdrawal of life sustaining therapies [24]. Accurate prediction of functional outcomes is challenging in the acute setting and confounded by biases contributing to the self-fulfilling prophecy of poor outcomes [25,26]. In this study we show that lesions identified on MRIs obtained within one week of ICH not only correlate with level of consciousness at the time of MRI but, more importantly, are able to identify patients that will recover consciousness prior to ICU discharge and have better 3-month functional outcomes.…”

Section: Discussionmentioning

confidence: 99%

Deep structural brain lesions associated with consciousness impairment early after haemorrhagic stroke

Rohaut

Doyle

Reynolds

et al. 2018

Preprint

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BackgroundThe significance of deep structural lesions on level of consciousness early after intracerebral haemorrhage (ICH) is largely unknown.MethodsWe studied a consecutive series of patients with spontaneous ICH that underwent MRI within 7 days of the bleed. We assessed consciousness by testing for command following from time of MRI to hospital discharge, and determined 3-months functional outcomes using the Glasgow Outcome Scale-Extended (GOS-E). ICH and oedema volumes, intraventricular haemorrhage (IVH), and midline shift (MLS) were quantified. Presence of blood and oedema in deep brain regions previously implicated in consciousness were assessed. A machine learning approach using logistic regression with elastic net regularization was applied to identify parameters that best predicted consciousness at discharge controlling for confounders.ResultsFrom 158 ICH patients that underwent MRI, 66% (N=105) were conscious and 34% (N=53) unconscious at the time of MRI. Almost half of unconscious patients (49%, N= 26) recovered consciousness by ICU discharge. Focal lesions within subcortical structures predicted persistent impairment of consciousness at discharge together with MLS, IVH, and ICH and oedema volumes (AUC 0.74; 95%-CI 0.73-0.75). Caudate nucleus, midbrain peduncle, and pontine tegmentum were implicated as critical structures. Unconscious patients predicted to recover consciousness had better 3-month functional outcomes than those predicted to remain unconscious (35% vs 0% GOS-E ≥4; p-value=0.02).ConclusionMRI lesions within key subcortical structures together with measures reflecting the mass effect of the haemorrhage (lesion volumes, IVH, MLS) obtained within one week of ICH can help predict early recovery of consciousness and 3-month functional outcome.

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“…This fact is especially true with regards to mortality as the outcome of interest. However, even with regards to predicting functional outcomes, attempts to develop grading scales based on cohorts excluding patients with care limitations are helpful but can raise questions of optimistic biases in their projections [ 150 ]. Studies of patient cohorts in which care limitations are simply not allowed are unethical.…”

Section: Future Directionsmentioning

confidence: 99%

“…Despite these barriers in identifying “reliable” predictors of ICH outcome as the word is strictly defined in this guideline, a number of different perspectives have nevertheless been offered in the literature with regards to research that might improve a multimodal approach to ICH prognostication [ 151 ], including: Additional external validation of existing major clinical grading scales [ 131 ], in particular those that have attempted to adjust for the self-fulfilling prophecy [ 150 ]; Comparisons of the accuracy of existing clinical grading scales against subjective clinician judgment [ 148 ]; Incorporation of frailty assessment [ 152 ] and/or newer imaging, fluid, or electrophysiology biomarkers [ 138 ] into novel grading scales; Incorporation of patient-reported outcome measures into novel grading scales [ 153 ]; Additional research regarding the optimal timing of prognostic assessment and the quality of post-acute rehabilitation services as a key predictor of interest [ 154 ]; Application of machine learning techniques for defining thresholds of interest for key clinical variables [ 155 ] and developing new predictive models [ 156 , 157 ]; Development of new clinical scales based on cohort of patients undergoing newer techniques for ICH evacuation [ 158 ]. …”

Section: Future Directionsmentioning

confidence: 99%

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Guidelines for Neuroprognostication in Critically Ill Adults with Intracerebral Hemorrhage

Hwang,

Kim,

Muehlschlegel

et al. 2023

Neurocrit Care

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Background The objective of this document is to provide recommendations on the formal reliability of major clinical predictors often associated with intracerebral hemorrhage (ICH) neuroprognostication. Methods A narrative systematic review was completed using the Grading of Recommendations Assessment, Development, and Evaluation methodology and the Population, Intervention, Comparator, Outcome, Timing, Setting questions. Predictors, which included both individual clinical variables and prediction models, were selected based on clinical relevance and attention in the literature. Following construction of the evidence profile and summary of findings, recommendations were based on Grading of Recommendations Assessment, Development, and Evaluation criteria. Good practice statements addressed essential principles of neuroprognostication that could not be framed in the Population, Intervention, Comparator, Outcome, Timing, Setting format. Results Six candidate clinical variables and two clinical grading scales (the original ICH score and maximally treated ICH score) were selected for recommendation creation. A total of 347 articles out of 10,751 articles screened met our eligibility criteria. Consensus statements of good practice included deferring neuroprognostication—aside from the most clinically devastated patients—for at least the first 48–72 h of intensive care unit admission; understanding what outcomes would have been most valued by the patient; and counseling of patients and surrogates whose ultimate neurological recovery may occur over a variable period of time. Although many clinical variables and grading scales are associated with ICH poor outcome, no clinical variable alone or sole clinical grading scale was suggested by the panel as currently being reliable by itself for use in counseling patients with ICH and their surrogates, regarding functional outcome at 3 months and beyond or 30-day mortality. Conclusions These guidelines provide recommendations on the formal reliability of predictors of poor outcome in the context of counseling patients with ICH and surrogates and suggest broad principles of neuroprognostication. Clinicians formulating their judgments of prognosis for patients with ICH should avoid anchoring bias based solely on any one clinical variable or published clinical grading scale.

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Max-ICH score

Cited by 7 publications

References 6 publications

Deep structural brain lesions associated with consciousness impairment early after hemorrhagic stroke

Deep structural brain lesions associated with consciousness impairment early after hemorrhagic stroke

Deep structural brain lesions associated with consciousness impairment early after haemorrhagic stroke

Guidelines for Neuroprognostication in Critically Ill Adults with Intracerebral Hemorrhage

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