External Validation of the Secondary Intracerebral Hemorrhage Score in The Netherlands

Abstract

N ontraumatic intracerebral hemorrhage (ICH) is the subtype of stroke with the highest case fatality.1 Approximately 15% to 20% of patients with nontraumatic ICH have an underlying macrovascular abnormality cause, such as an arteriovenous malformation, a dural arteriovenous fistula, or an aneurysm. Early identification of these lesions has important therapeutic and prognostic consequences. 2,3 Computed tomography (CT) angiography enables assessment of vascular pathology in the emergency setting, but it is unclear which patients with ICH should undergo angiographic examinations. 4 The secondary ICH (SICH) score was developed and validated in the United States to identify patients with a high risk of an underlying macrovascular cause on the basis of patient and hemorrhage characteristics (Table I in the online-only Data Supplement). 5 The same investigators performed an external validation study in another US hospital, which indicated that the SICH score is an accurate tool in US settings. 6 The discriminative power of the SICH score, however, may depend on population differences and local variation in which patients with ICH undergo angiographic studies to find a macrovascular cause. We, therefore, sought to validate externally the SICH score in a setting outside the United States and to assess the effect of the separate items of the SICH score on the probability of harboring an underlying vascular cause. Materials and Methods Study PopulationFrom a prospectively collected database of patients with stroke admitted to the University Medical Center Utrecht, the Netherlands, we included patients admitted between February 2003 and May 2011 who met the following inclusion criteria: (1) nontraumatic ICH on noncontrast CT (NCCT); (2) ≥18 years; and (3) ≥1 angiographic study (CT angiography, MR angiography, or digital subtraction angiography), or pathological examination. PredictorsAge, sex, and history of hypertension or impaired coagulation were retrieved.5 NCCTs were reviewed independently by 2 observers blinded to clinical data and final diagnosis. Each NCCT was assessed by a neurology (C.J.J.v.A.) or radiology (P.J.v.L.) resident, and a neurology (C.J.M.K.) or radiology (B.K.V.) staff member. NCCTs were classified as high probability of finding an underlying macrovascular cause when enlarged vessels or calcifications were present Background and Purpose-We aimed to validate externally in a setting outside the United States the secondary intracerebral hemorrhage (ICH) score that was developed to predict the probability of macrovascular causes in patients with nontraumatic ICH. along the ICH margins, or visible hyperattenuation within a dural venous sinus or cortical vein. In low-probability NCCTs, none of these were present and the hematoma was located in basal ganglia or brain stem. Indeterminate probability NCCTs fulfilled neither high-nor low-probability criteria. 5 Differences in reader interpretations were resolved in consensus meetings. OutcomeThe outcome measure was a macrovascular cause of the ICH identified ...

Predicting the presence of macrovascular causes in non-traumatic intracerebral haemorrhage: the DIAGRAM prediction score

“…The model was based on patient characteristics and NCCT characteristics, which included enlarged vessels or calcifications along ICH margins and hyperattenuation within a dural venous sinus or cortical vein. Independent validation in the USA showed good performance of the model,19 performance was moderate in an external validation study in the Netherlands 3. NCCT categorisation was a strong predictor for macrovascular causes, but characteristics were not always easy to recognise on NCCT,3 which may limit easy application of the model in clinical practice.…”

“…Independent validation in the USA showed good performance of the model,19 performance was moderate in an external validation study in the Netherlands 3. NCCT categorisation was a strong predictor for macrovascular causes, but characteristics were not always easy to recognise on NCCT,3 which may limit easy application of the model in clinical practice. The DIAGRAM prediction score is the first model developed in a prospective cohort, excluding patients in whom yield of angiographic imaging has been shown to be very low (patients older than 45 years with a history of hypertension and a deep or posterior fossa bleed) 13.…”

The Cost-Utility of CT Angiography and Conventional Angiography for People Presenting with Intracerebral Hemorrhage

“…The large majority of patients demonstrated indeterminate (421; 68%) scans, while low risk scans constituted the remaining 29%. More recent studies confirm frequencies of high, intermediate and low risk scans of 2–11%, 42–61% and 32–36% respectively [23]–[25]. Acknowledging the need to further investigate patients with indeterminate risk and confirm NCCT suspicion in the high risk group, up to 90% of the ICH population would still require further angiographic imaging with this stratification approach.…”

Developing an algorithm to identify patients with intracerebral haemorrhage secondary to a macrovascular cause

“…[7][8][9] A scoring system incorporating pre-ICH hypertension and age (among other factors) to identify patients at risk of a macrovascular cause has been previously validated, but did not include imaging markers of SVD and only had moderate discrimination outside of the United States. 10,11 SVD can be directly identified on brain imaging by leukoaraoisis and lacunar infarction, even on plain CT. We therefore hypothesised that, in acute ICH patients, visualisation of SVD will predict a low yield of a macrovascular cause; furthermore, we aimed to develop and internally validate an algorithm to help clinicians identify patients at high risk of having a macrovascular cause underlying acute spontaneous ICH.…”