summarizes the baseline and initial treatment characteristics for the entire cohort of 243 patients. The majority of ICH cases were presumed due to chronic hypertension, with coagulopathy being the second most common cause. Surgical hematoma evacuation was performed in only 14 cases: 5 cerebellar (23%), 8 lobar (12%), and 1 basal ganglia (1%). ICP monitoring via a ventricular catheter was performed in 24% of patients. Thirty-nine percent of patients died during the initial hospitalization; 78% of patients who died during initial hospitalization had withdrawal of support. Components of the ICH Score were widely distributed, with 20% of patients aged 80 or older, 38% of patients having an initial hematoma volume greater than or equal to 30 mL, 19% of patients with infratentorial origin, and IVH present in 57% of cases. GCS was 3–5 in 22%, 5–12 in 30%, and 13–15 in 47% of patients.
Table 1 Characteristics of intracerebral hemorrhage (ICH) cohort (n = 243)
As demonstrated in , the ICH Score accurately stratified patients with regard to 12-month functional outcome on the mRS. While the overall likelihood of a favorable outcome decreased as lower numbered mRS cutpoints were used to define favorable outcome, the ICH Score accurately stratified patients at each of these cutpoints (p < 0.05, test for trend) as well as across the entire mRS (p < 0.05, test for trend). This means that, in general, an increasing ICH Score was associated with a lower likelihood of favorable outcome regardless of the specific cutpoint used to define outcome. c-Statistics for the various mRS cutpoints were 0.80 for mRS ≤1, 0.81 for mRS ≤2, 0.80 for mRS ≤3, and 0.84 for mRS ≤4. Sensitivity analyses excluding those patients who were unavailable for 12-month follow-up, had medical records reviewed for 12-month timepoint assessment, underwent surgical hematoma evacuation, or had intracranial pressure monitoring did not affect the conclusions of the study. Of note, one patient with an ICH Score of 5 achieved a 12-month mRS of 2. This 49-year-old patient presented to the ED with a GCS of 12 and rapidly deteriorated to a GCS of 3; he was then taken for urgent head CT which demonstrated a 30 mL cerebellar hematoma that was immediately surgically evacuated.
Figure 1 Favorable 12-month outcome based on various dichotomized cutpoints
This same significant trend for ICH Score outcome stratification was present for these same mRS cutpoints even when functional outcome was measured at 30 days, 3 months, or 6 months post-ICH (data not shown). In order to determine if withdrawal of support affected the ability of the ICH Score to accurately stratify patients with regard to functional outcome, sensitivity analysis was done excluding patients who died during initial hospitalization. For each of the 4 mRS cutpoints in , the ICH Score accurately stratified surviving patients with regard to functional outcome at all measured timepoints, indicating that the ability of the ICH Score to accurately stratify long-term outcome is not affected by withdrawal of support (p < 0.05, test for trend). The ICH Score remained a significant predictor of mortality risk at 30 days (c = 0.86), as well as 3 (c = 0.88), 6 (c = 0.87), and 12 months (c = 0.87) post-ICH (p < 0.001 for all timepoints, test for trend).
describes the proportion of patients with various outcomes, as measured by the mRS, at various timepoints during the first year post-ICH, irrespective of ICH Score. The vast majority of patients who died did so early after ICH. Of the 16 patients who died between hospital discharge and 3 months, only 2 patients were known to die of causes not directly following from the initial ICH (1 cancer, 1 renal failure). Of the 6 patients who died after 3 months, none was known to clearly follow from the initial ICH (1 each with brain tumor, multiorgan dysfunction from sepsis, collagen vascular disease, and cardiovascular disease, 2 with cause not known).
Table 2 Modified Rankin Scale (mRS) score at various timepoints (n = 243)
Overall, 51 of the 148 (34%) patients who survived to hospital discharge improved in mRS score between hospital discharge and 12 months. Eleven of these patients (13% of hospital survivors) improved at least 2 points on the mRS. Thirty-two patients (22% of hospital survivors) worsened on the mRS between hospital discharge and 12 months, with 15 of these patients (10% of hospital survivors) worsening by 2 or more points. Of these 15 patients, 13 died after hospital discharge as described above, 1 patient deteriorated from a hospital discharge mRS of 3 to a 12-month mRS of 5, and 1 patient developed a new ICH between 3 and 6 months after initial ICH. Forty-four percent (n = 65) of hospital survivors did not change in mRS between hospital discharge and 12 months.
demonstrates the change in mRS for patients across different timepoints during the first year after ICH indicating that change in clinical status was common. For example, from , 31 patients (13%) had an mRS of 3 at hospital discharge and 31 patients (13%) had an mRS of 3 at 12 months. However, only 12 of these were the same patients, information not readily apparent from summary statistics such as in . In , arrow thickness is used to illustrate the proportion of patients with a specific mRS score who remain the same or change until the next assessment point, whereas arrow color is used to illustrate the absolute change in mRS scale points. As seen in panel A, most patients remain at the same mRS value from one timepoint to the next (gray shaded arrow). However, many patients demonstrate improvement and this improvement may occur throughout the first year post-ICH. This is especially notable during the first 3 months in severely impaired patients (mRS 4 or 5). Improvement in moderately affected patients (mRS ≤3) continued through 12 months, whereas improvement in more severely affected patients (mRS 4 or 5) was rare after 6 months. Panel B demonstrates that some patients do worsen throughout the year, but most of this is modest (1 point on the mRS) except for those patients who die from their initial ICH (usually within 3 months) or who develop a new unrelated medical problem resulting in death or disability.
Figure 2 Change in modified Rankin Scale (mRS) score during first year after intracerebral hemorrhage (ICH)