From the Departments of Neurology (J.A.S., S.T.G., B.V., T.B., S.S., H.B.H., J.B.K.) and Neuroradiology (H.L., S.P.K.), University Hospital Erlangen, Germany.
Neurology. 2017 Aug 1;89(5):423-431. doi: 10.1212/WNL.0000000000004174. Epub 2017 Jul 5.
As common prognostication models in intracerebral hemorrhage (ICH) are developed variably including patients with early (<24 hours) care limitations (ECL), we investigated its interaction with prognostication in maximally treated patients and sought to provide a new unbiased severity assessment tool.
This observational cohort study analyzed consecutive ICH patients (n = 583) from a prospective registry over 5 years. We characterized the influence of ECL on overall outcome by propensity score matching and on conventional prognostication using receiver operating characteristic analyses. We established the max-ICH score based on independent predictors of 12-month functional outcome in maximally treated patients and compared it to existing models.
Prevalence of ECL was 19.2% (n = 112/583) and all of these patients died. Yet propensity score matching displayed that 50.7% (n = 35/69) theoretically could have survived, with 18.8% (n = 13/69) possibly reaching favorable outcome (modified Rankin Scale score 0-3). Conventional prognostication seemed to be confounded by ECL, documented by a decreased predictive validity (area under the curve [AUC] 0.67, confidence interval [CI] 0.61-0.73 vs AUC 0.80, CI 0.76-0.83; < 0.01), overestimating poor outcome (mortality by 44.8%, unfavorable outcome by 10.1%) in maximally treated patients. In these patients, the novel max-ICH score (0-10) integrates strength-adjusted predictors, i.e., NIH Stroke Scale score, age, intraventricular hemorrhage, anticoagulation, and ICH volume (lobar and nonlobar), demonstrating improved predictive accuracy for functional outcome (12 months: AUC 0.81, CI 0.77-0.85; < 0.01). The max-ICH score may more accurately delineate potentials of aggressive care, showing favorable outcome in 45.4% (n = 214/471) and a long-term mortality rate of only 30.1% (n = 142/471).
Care limitations significantly influenced the validity of common prognostication models resulting in overestimation of poor outcome. The max-ICH score demonstrated increased predictive validity with minimized confounding by care limitations, making it a useful tool for severity assessment in ICH patients.
由于脑出血（ICH）的常见预后模型各不相同，包括有早期（<24 小时）治疗限制（ECL）的患者，我们研究了它与最大治疗患者预后的相互作用，并试图提供一种新的无偏严重程度评估工具。
本观察性队列研究分析了来自前瞻性登记处的 5 年内连续的 ICH 患者（n=583）。我们通过倾向评分匹配来描述 ECL 对总体结局的影响，并通过接受者操作特征分析来描述 ECL 对常规预后的影响。我们根据最大治疗患者 12 个月功能结局的独立预测因素建立了 max-ICH 评分，并将其与现有模型进行了比较。
ECL 的患病率为 19.2%（n=112/583），所有这些患者均死亡。然而，倾向评分匹配显示，理论上有 50.7%（n=35/69）的患者可以存活，18.8%（n=13/69）的患者可能有良好的结局（改良 Rankin 量表评分 0-3）。常规预后似乎因 ECL 而受到干扰，这一点通过降低预测有效性（曲线下面积 [AUC] 0.67，置信区间 [CI] 0.61-0.73 与 AUC 0.80，CI 0.76-0.83；<0.01）得到证实，高估了最大治疗患者的不良结局（死亡率增加 44.8%，不良结局增加 10.1%）。在这些患者中，新型 max-ICH 评分（0-10）整合了强度调整的预测因素，即 NIH 卒中量表评分、年龄、脑室内出血、抗凝和 ICH 体积（脑叶和非脑叶），对功能结局的预测准确性更高（12 个月：AUC 0.81，CI 0.77-0.85；<0.01）。max-ICH 评分可能更准确地描绘出积极治疗的潜力，显示出 45.4%（n=214/471）的良好结局，长期死亡率仅为 30.1%（n=142/471）。
治疗限制显著影响了常见预后模型的有效性，导致对不良结局的高估。max-ICH 评分通过最小化治疗限制的混杂因素，显示出更高的预测有效性，是评估 ICH 患者严重程度的有用工具。
