Predicting Prognosis of Intracerebral Hemorrhage (ICH): Performance of ICH Score Is Not Improved by Adding Oral Anticoagulant Use

Abstract

BackgroundThe intracerebral hemorrhage (ICH) score is a commonly used prognostic model for 30-day mortality in ICH, based on five independent predictors (ICH volume, location, Glasgow Coma Scale, age, and intraventricular extension). Use of oral anticoagulants (OAC) is also associated with mortality but was not considered in the ICH score. We investigated (a) whether the predictive performance of ICH score is similar in OAC-ICH and non-OAC-ICH and (b) whether addition of OAC use to the ICH score increases the prognostic performance of the score.MethodsWe retrospectively selected all consecutive adult non-traumatic ICH cases (three hospitals, region South-Limburg, the Netherlands 2004–2009). Mortality at 30 days was recorded. Using univariable and multivariable logistic regression, association between OAC use and 30-day mortality was tested. Then (a) we computed receiver operating characteristic (ROC) curves for ICH score and determined the area under the curve (AUC) in OAC-ICH and non-OAC-ICH. Then (b) we created a New ICH score by adding OAC use to the ICH score. We calculated correlation between 30-day mortality and ICH score, respectively, New ICH score using Spearman correlation test. We computed ROC curves and calculated the AUC.ResultsWe analyzed 1,232 cases, 282 (22.9%) were OAC related ICH. Overall, 30-day mortality was 39.3%. OAC use was independently associated with 30-day mortality (OR 2.09, 95% CI, 1.48–2.95; p < 0.001), corrected for the five predictors of the ICH score. The ICH score performed slightly better in non-OAC-ICH (AUC 0.840) than in OAC-ICH (AUC 0.816), but this difference was not significant (p = 0.39). The ICH score and the New ICH score were both significantly correlated with 30-day mortality (rho 0.58, p < 0.001 and 0.59, p < 0.001, respectively). The AUC for the ICH score was 0.837, for New ICH score 0.840. This difference was not significant.ConclusionThe ICH score is a useful tool for predicting 30-day mortality both in patient who use and patients who do not use OAC. Although OAC use is an independent predictor of 30-day mortality, addition of OAC use to the existing ICH score does not increase the prognostic performance of this score.

Reliability of the intracerebral hemorrhage score for predicting outcome in patients with intracerebral hemorrhage using oral anticoagulants

“…In our cohort of almost 1800 patients, the difference in baseline characteristics was significant for almost all of the variables. The overall mortality in OAC‐ICH is twice as high as in OAC‐naive ICH, similar to the literature [2,3,5]. One of the main reasons for a higher mortality in OAC‐ICH could be secondary hematoma growth.…”

“…For the MUMC cohort, the ethical committee of MUMC had given its approval in the study performed by Houben et al . [5].…”

“…Several prognostic models have been developed to aid in decision making in the acute setting [4–8]. The ICH score is the most widely used and validated prognostic model for estimating the 30‐day mortality rate [6].…”

“…The ICH score (0–6) is the sum of individual points assigned to five different variables: Glasgow Coma Scale (GCS) score 3–4 (2 points) or 5–12 (1 point); age ≥ 80 years (1 point); infratentorial origin (1 point); ICH volume ≥ 30 mL (1 point); and intraventricular hemorrhage (1 point). However, a recent study has shown that the ICH score might underestimate the mortality rates for lower scores (≤3) in patients using OAC [5]. The original score was developed and validated in a more general population of patients with ICH and not for patients using OAC.…”

Key Points to Consider When Evaluating Andexxa for Formulary Addition

“…Excluding very low GCS will also lead to a group that by design can be expected to have lower ICH score. Given the very sharp change in expected mortality rates between ICH scores of 0, 1, 2, and 3, data for ICH score would shed light on the reported mortality despite the fact that the ICH score has been validated in ICH secondary to vitamin K antagonist and not specifically for NOACs [16]. A very large registry from the American Heart Association/American Stroke Association Get With The Guidelines-Stroke found a median National Institutes of Health Stroke Scale/Score (NIHSS) score of 8 and over one-third of NOAC-related bleedings with NIHSS > 14 [17].…”