Vignan Yogendrakumar1, Eric E Smith2, Andrew M Demchuk2, Richard I Aviv3, David Rodriguez-Luna4, Carlos A Molina4, Yolanda Silva Blas5, Imanuel Dzialowski6, Adam Kobayashi7,8, Jean-Martin Boulanger9, Cheemun Lum10, Gord Gubitz11, Vasantha Padma12, Jayanta Roy13, Carlos S Kase14, Rohit Bhatia12, Myzoon Ali15, Patrick Lyden16, Michael D Hill2, Dar Dowlatshahi1. 1. Division of Neurology, Department of Medicine, University of Ottawa and Ottawa Hospital Research Institute, Ottawa, ON, Canada. 2. Calgary Stroke Program, Department of Clinical Neurosciences, Department of Radiology, Hotchkiss Brain Institute, University of Calgary, Calgary, AB, Canada. 3. Division of Neuroradiology and Department of Medical Imaging, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON, Canada. 4. Department of Neurology, Hospital Universitari Vall d'Hebron, Barcelona, Spain. 5. Department of Neurology, Dr. Josep Trueta University Hospital, Institut d'Investigació Biomèdica Girona (IDIBGi) Foundation, Girona, Spain. 6. Department of Neurology, Elblandklinikum Meissen Academic Teaching Hospital of the Technische University, Dresden, Germany. 7. 2nd Department of Neurology, Institute of Psychiatry and Neurology, Warsaw, Poland. 8. Department of Experimental and Clinical Pharmacology, Institute of Psychiatry and Neurology, Warsaw, Poland. 9. Department of Medicine, Charles LeMoyne Hospital, University of Sherbrooke, Montreal, QC, Canada. 10. Department of Diagnostic Imaging, Neuroradiology Section, University of Ottawa, Ottawa Hospital Research Institute, Ottawa, ON, Canada. 11. Department of Neurology, Dalhousie University, Halifax, NS, Canada. 12. Department of Neurology, All India Institute of Medical Sciences, New Delhi, India. 13. Department of Neuromedicine, Apollo Gleneagles Hospitals, Kolkata, India. 14. Department of Neurology, Boston Medical Center, Boston, MA. 15. Institutes of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, United Kingdom. 16. Department of Neurology, Cedars-Sinai Medical Center, Los Angeles, CA.
Abstract
OBJECTIVES: There are limited data as to what degree of early neurologic change best relates to outcome in acute intracerebral hemorrhage. We aimed to derive and validate a threshold for early postintracerebral hemorrhage change that best predicts 90-day outcomes. DESIGN: Derivation: retrospective analysis of collated clinical stroke trial data (Virtual International Stroke Trials Archive). VALIDATION: retrospective analysis of a prospective multicenter cohort study (Prediction of haematoma growth and outcome in patients with intracerebral haemorrhage using the CT-angiography spot sign [PREDICT]). SETTING: Neurocritical and ICUs. PATIENTS: Patients with acute intracerebral hemorrhage presenting less than 6 hours. Derivation: 552 patients; validation: 275 patients. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: We generated a receiver operating characteristic curve for the association between 24-hour National Institutes of Health Stroke Scale change and clinical outcome. The primary outcome was a modified Rankin Scale score of 4-6 at 90 days; secondary outcomes were other modified Rankin Scale score ranges (modified Rankin Scale, 2-6, 3-6, 5-6, 6). We employed Youden's J Index to select optimal cut points and calculated sensitivity, specificity, and predictive values. We determined independent predictors via multivariable logistic regression. The derived definitions were validated in the PREDICT cohort. Twenty-four-hour National Institutes of Health Stroke Scale change was strongly associated with 90-day outcome with an area under the receiver operating characteristic curve of 0.75. Youden's method showed an optimum cut point at -0.5, corresponding to National Institutes of Health Stroke Scale change of greater than or equal to 0 (a lack of clinical improvement), which was seen in 46%. Early neurologic change accurately predicted poor outcome when defined as greater than or equal to 0 (sensitivity, 65%; specificity, 73%; positive predictive value, 70%; adjusted odds ratio, 5.05 [CI, 3.25-7.85]) or greater than or equal to 4 (sensitivity, 19%; specificity, 98%; positive predictive value, 91%; adjusted odds ratio, 12.24 [CI, 4.08-36.66]). All definitions reproduced well in the validation cohort. CONCLUSIONS: Lack of clinical improvement at 24 hours robustly predicted poor outcome and showed good discrimination for individual patients who would do poorly. These findings are useful for prognostication and may also present as a potential early surrogate outcome for future intracerebral hemorrhage treatment trials.
OBJECTIVES: There are limited data as to what degree of early neurologic change best relates to outcome in acute intracerebral hemorrhage. We aimed to derive and validate a threshold for early postintracerebral hemorrhage change that best predicts 90-day outcomes. DESIGN: Derivation: retrospective analysis of collated clinical stroke trial data (Virtual International Stroke Trials Archive). VALIDATION: retrospective analysis of a prospective multicenter cohort study (Prediction of haematoma growth and outcome in patients with intracerebral haemorrhage using the CT-angiography spot sign [PREDICT]). SETTING: Neurocritical and ICUs. PATIENTS: Patients with acute intracerebral hemorrhage presenting less than 6 hours. Derivation: 552 patients; validation: 275 patients. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: We generated a receiver operating characteristic curve for the association between 24-hour National Institutes of Health Stroke Scale change and clinical outcome. The primary outcome was a modified Rankin Scale score of 4-6 at 90 days; secondary outcomes were other modified Rankin Scale score ranges (modified Rankin Scale, 2-6, 3-6, 5-6, 6). We employed Youden's J Index to select optimal cut points and calculated sensitivity, specificity, and predictive values. We determined independent predictors via multivariable logistic regression. The derived definitions were validated in the PREDICT cohort. Twenty-four-hour National Institutes of Health Stroke Scale change was strongly associated with 90-day outcome with an area under the receiver operating characteristic curve of 0.75. Youden's method showed an optimum cut point at -0.5, corresponding to National Institutes of Health Stroke Scale change of greater than or equal to 0 (a lack of clinical improvement), which was seen in 46%. Early neurologic change accurately predicted poor outcome when defined as greater than or equal to 0 (sensitivity, 65%; specificity, 73%; positive predictive value, 70%; adjusted odds ratio, 5.05 [CI, 3.25-7.85]) or greater than or equal to 4 (sensitivity, 19%; specificity, 98%; positive predictive value, 91%; adjusted odds ratio, 12.24 [CI, 4.08-36.66]). All definitions reproduced well in the validation cohort. CONCLUSIONS: Lack of clinical improvement at 24 hours robustly predicted poor outcome and showed good discrimination for individual patients who would do poorly. These findings are useful for prognostication and may also present as a potential early surrogate outcome for future intracerebral hemorrhage treatment trials.
Authors: Katja E Wartenberg; David Y Hwang; Karl Georg Haeusler; Susanne Muehlschlegel; Oliver W Sakowitz; Dominik Madžar; Hajo M Hamer; Alejandro A Rabinstein; David M Greer; J Claude Hemphill; Juergen Meixensberger; Panayiotis N Varelas Journal: Neurocrit Care Date: 2019-10 Impact factor: 3.210