UMEM Educational Pearls

Category: Neurology

Title: Prognostication in intracerebral hemorrhage - A self-fulfilling prophecy?

Keywords: Intracerebral hemorrhage, ICH score, prognostication, early decisions to limit medical treatment (PubMed Search)

Posted: 4/8/2015 by WanTsu Wendy Chang, MD (Updated: 10/14/2015)
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Prognostication in intracerebral hemorrhage - A self-fulfilling prophecy?

The ICH Score is a validated outcome prediction model for intracerebral hemorrhage (ICH) developed from clinical and neuroimaging characteristics on presentation.

While predictive models are often used in clinical care for prognostication, is it a self-fulfilling prophecy to make early decisions to limit medical treatments based on these models?

Morgenstern et al. conducted an observational study across 5 hospitals looking at 30-day mortality of patients with ICH with initial GCS <12 who received full medical care for at least 5-days following symptom onset.

417/972 (42.9%) of patients had GCS < 12
148/417 (35.5%) of patients were made DNR by family or physician before day 5
109/417 (26.1%) of patients were included in the study
Overall observed 30-day mortality was 20.2%, which was 29.8% less than the ICH Score-predicted mortality
Each increase in the ICH Score was associated with both an increase in predicted and observed 30-day mortality

Take Home Point: The ICH Score is a useful tool for stratifying patient severity, but one should be cautious in using the model to provide specific numerical values as outcome predictions.

References

Hemphill JC, Bonovich DC, Besmertis L, Manley GT, Johnston SC. The ICH Score. A simple, reliable grading scale for intracerebral hemorrhage. Stroke 2001;32:891-897.

Morgenstern LB, Zahuranec DB, Sanchez, BN, et al. Full medical support for intracerebral hemorrhage. Neurology 2015;84:1-6.

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