Intraventricular Extension of Supratentorial Intracerebral Hemorrhage: The Modified Graeb Scale Improves Outcome Prediction in Lund Stroke Register

Abstract

Background/Aims: The modified Graeb Scale (mGS) is a semi-quantitative method to assess the extension of intraventricular hemorrhage (IVH) in patients with intracerebral hemorrhage (ICH). The mGS has been shown to prognosticate outcome after ICH in cohorts derived from convenience samples. We evaluated the external validity of mGS in supratentorial ICH-patients from an unselected cohort. Methods: ICH-patients were included prospectively and consecutively in Lund Stroke Register. Follow-up survival status was obtained from the National Census Office; functional outcome was obtained from the Swedish Stroke Register or medical records. Using multivariate analyses, we examined if mGS was related to 30-day survival or poor functional outcome (modified Rankin Scale ≥4) at 90 days. Results: Of 198 supratentorial ICH-patients, 86 (43%) had IVH (median mGS 12, range 1-28). In multivariate regression analyses, the mGS independently predicted 30-day mortality (per point; OR 1.16; 95% CI 1.06-1.27; p = 0.002) and poor functional outcome (OR 1.11; 95% CI 1.02-1.20; p = 0.011) after ICH. In receiver-operator characteristic analysis, the addition of mGS tended to be associated with a higher prognostic accuracy for survival (area under curve 0.886 vs. not including mGS 0.812; p = 0.053). Conclusions: The mGS improves outcome prediction after supratentorial ICH beyond other previously established factors in an unselected population.

Applicability of Clinical Trials in an Unselected Cohort of Patients With Intracerebral Hemorrhage

“…Our well categorized consecutive hospital-based ICH-patient cohort from a setting with high hospitalization and CT rates for stroke-patients[4] provides validity to our findings. Eligibility might have been over-estimated because patients with missing data were included, and consent from all patients was assumed.…”

“…Registration of patients, baseline variables, and outcome follow-up, has been previously described. [4] The study was approved by the Regional Ethical Review Board.…”

“…Functional outcome (modified Rankin scale, mRS) was obtained from the Swedish Stroke Register, or review of medical records. [4] Poor outcome was defined as mRS≥4 at 90 days (range 50–150 days) or death <150 days after ICH, choosing the outcome closest to 90 days.…”

Thrombolytic removal of intraventricular haemorrhage in treatment of severe stroke: results of the randomised, multicentre, multiregion, placebo-controlled CLEAR III trial

“…The survival and good functional outcomes observed in the CLEAR III controls was greater than in our previous study 6 or in the expected levels from the general population (where low frequencies of extraventricular drain use are coupled with very high reliance on medical care as the sole supportive intervention for intraventricular haemorrhage). 2,3,6,7,9 Only convenience sample data exists for outcomes of medically managed patients; thus, our knowledge about risk and benefit for the intervention in the general population is restricted. Another possible limitation is that the CLEAR III sample might not represent a true general intraventricular haemorrhage population, rather a milder or more severe population.…”

“…They show full population estimates of mortality (40–60%) and low good functional outcome (10–30%) suggesting less intense therapies might not produce as many benefits. 2,5 Finally, the main outcome measure: mRS 0–3 versus mRS 4–6 proportion is only one measure of disability. Further research will be needed to clarify the divergent picture within the more severe disability segments of mRS and eGOS.…”