Role of APACHE II scoring system in the prediction of severity and outcome of acute intracerebral hemorrhage

Purpose: Acute intracerebral hemorrhage (ICH) is prone to multiple organ dysfunction and has high disability and mortality. This study was to determine the role of acute physiology and chronic health evaluation II (APACHE II) scoring system in the prediction of severity and outcome of acute ICH. Methods: A total of 546 ICH patients were prospectively recruited between 1 January 2013 and 31 December 2014. Patients were divided into three groups according to the APACHE II scores: low score group (5–16), moderate score group (17–28) and high score group (≥29). The ICH volume and location, National Institutes of Health Stroke Scale (NIHSS) scores, Glasgow Coma Score and modified Rankin Scale (mRS) scores were used to assess the severity of acute ICH. Global outcome at three months was evaluated with the mRS. Results: Of 479 patients, the average age was 56.4 ± 3.4 years, 287 (59.9%) survived and 192 (40.1%) died. Results showed that the higher the APACHE II score, the higher the mortality was; the average hospital stay, ICH volume, NIHSS scores, mRS scores and survival rate were significantly different among three APACHE II groups (p < 0.05). APACHE II scores were able to predict the mortality and correlated positively with actual mortality (r = 0.84, p < 0.01). Conclusions: APACHE II scoring system can be used to predict the severity and outcome of acute ICH.     

Prior use of statins and outcome in patients with intracerebral haemorrhage

Background:  Pre-treatment with cholesterol lowering drugs of the statin family may exert protective effects in patients with ischaemic stroke and subarachnoid haemorrhage but their effects are not clear in patients with intracerebral haemorrhage (ICH).
Methods:  We recruited patients admitted to our University Hospital with an acute ICH and analysed pre-admission demographic variables, pre-morbid therapy, clinical and radiological prognostic markers and outcome variables including 90-day modified Rankin score and NIH stroke scale score (NIHSS).
Results:  We recruited 399 patients with ICH of which 101 (25%) were using statins. Statin users more often had vascular risk factors, had significantly lower haematoma volumes ( P  = 0.04) and had lower mortality rates compared with non-users (45.6% vs. 56.1%; P  = 0.11). However, statin treatment did not have a statistically significant impact on mortality or functional outcome on multiple logistic regression analysis.
Conclusions:  Treatment with statins prior to ICH failed to show a significant impact on outcome in this analysis despite lower haematoma volumes.     

Decompressive craniectomy with clot evacuation in large hemispheric hypertensive intracerebral hemorrhage

Introduction: Decompressive hemicraniectomy in large hemispheric infarctions has been reported to lower mortality and improve the unfavorable outcomes. Hematoma volume is a powerful predictor of 30-day mortality in patients with intracerebral hemorrhage (ICH). Hematoma volume adds to intracranial volume and may lead to life-threatening elevation of intracranial pressure. Methods: Records of 12 consecutive patients with hypertensive ICH treated with decompressive hemicraniectomy were reviewed. The data collected included Glasgow Coma Scale (GCS) score at admission and before surgery, ICH volume, ICH score, and a clinical grading scale for ICH that accurately risk-stratifies patients regarding 30-day mortality. Outcome was assessed as immediate mortality and modified Rankin Score (mRS) at the last follow-up. Results: Of the 12 patients with decompressive hemicraniectomy, 11 (92%) survived to discharge; of those 11, 6 (54.5%) had good functional outcome, defined as a mRS of 0 to 3 (mean follow-up: 17.13 months; range: 2–39 months). The mean age was 49.8 years (range: 19–76 years). Three of the 7 patients with pupillary abnormalities made a good recovery; of the 11 patients with intraventricular extensions (IVEs), 7 made a good recovery. The clinical finding (which was present in all 3 patients with mRS equal to 5 and which was not present in patients with mRS less than 5) was abnormal occulocephalic reflex. Of the 10 patients with an ICH score of 3,9 (90%) survived to discharge, 4 (44%) had good functional outcome (mRS: 1–3). Hematoma volume was 60 cm³ or greater in eight patients, four (50%) of whom had good functional outcome (mRS: 0–3). Conclusion: Decompressive hemicraniectomy with hematoma evacuation is life-saving and improves unfavorable outcomes in a select group of young patients with large right hemispherical ICH.     

Impact of white matter hypodensities on outcome after intracerebral hemorrhage

ObjectivesWhite matter hypodensities (WMH), a surrogate of small vessel disease, associate with cognitive decline and stroke risk. The impact of WMH on functional outcome after intracerebral hemorrhage (ICH) has differed between studies. We aimed to examine factors associated with the severity of WMH in ICH, and whether there is an independent association between the extent of WMH and outcome.Materials and methodsThis was a prospective study of consented patients with non-traumatic primary ICH, admitted to the Helsinki University Hospital between May 2014 and December 2018. To evaluate the extent of the WMH, modified van Swieten score of the side contralateral to the ICH was obtained. Patients were grouped into 3 categories of the scores. We performed univariate and multivariable analyses to find out factors associated with the severity of WMH, and whether WMH associate with functional outcome and mortality up to 12 months, adjusted for the known major outcome predictors.ResultsIn our cohort of 417 ICH patients, WMH severity associated with older age, female sex, admission National Institutes of Health Stroke Scale (NIHSS) points, and signs of previous ischemic stroke on CT. We found an independent association between WMH severity and poor functional outcome at 3 months (OR 1.72, 95% CI 1.27-2.33), and 1 year (OR 2.16, 95% CI 1.57-2.95), and mortality at 1 year (OR 1.91, 95% CI 1.29-2.85).ConclusionsIn our ICH patients, vascular comorbidities and older age associated with the presence of WMH, which, in turn, strongly associated with poor functional outcome.     

Combination of high-sensitivity C-reactive protein and homocysteine predicts the short-term outcomes of Chinese patients with acute ischemic stroke

Abstract

Background: Ischemic stroke is one of the most common causes of death worldwide. Early and accurate prediction of outcome in acute ischemic stroke (AIS) is important and influences risk-optimized therapeutic strategies. We investigated the changes in high-sensitivity C-reactive protein (Hs-CRP) and homocysteine (HCY) levels, two of the risk factors, during the acute period of AIS and evaluated the relationship between these levels and short-term prognosis.

Methods: We prospectively studied 189 patients with AIS who were admitted within 24 hours after the onset of symptoms. Serum Hs-CRP, HCY levels, and National Institutes of Health Stroke Scale (NIHSS) were measured at the time of admission. Short-term functional outcome was measured by the modified Rankin scale (mRS), 90 days after admission.

Results: The median serum Hs-CRP and HCY levels were significantly higher in AIS patients as compared to normal controls (P < 0·0001, respectively). High-sensitivity C-reactive protein and HCY were independent prognostic markers of functional outcome and death (adjusted for age and the NIHSS) in patients with AIS. In receiver operating characteristic curve analysis, the prognostic accuracy of the combined model (HCY and Hs-CRP) was higher compared to all measured biomarkers individually and the NIHSS score.

Conclusion: High-sensitivity C-reactive protein and HCY are independent predictors of short-term outcome and mortality after AIS. The combined model may provide additional general prognostic information.     

Evaluation of stroke prognostication using age and NIH Stroke Scale index (SPAN-100 index) in delayed intravenous thrombolysis patients (beyond 4.5 hours)

Objectivesthe efficacy of delayed intravenous tissue plasminogen activator (tPA), beyond the 4.5 h window, is evolving. Advanced age and high admission National Institutes of Health Stroke Scale (NIHSS) score are proposed to adversely affect the outcome of delayed thrombolysis and limit the inclusion criteria. The summation of patient age and admission NIHSS score was introduced as the SPAN-100 index as a tool of prediction of the clinical outcome after acute ischemic stroke (AIS). We aimed to assess the SPAN-100 index in AIS thrombolysed patients after 4.5 h.Materials and MethodsThe SPAN-100 index was applied to AIS patients receiving delayed IV thrombolysis (IVT) after 4.5 h. Patients demographics, risk factors, clinical, laboratory and radiological data, mismatch evidence, treatment onset and modality, NIHSS score at baseline and at discharge, and 3 months follow-up modified Rankin Scale (mRS) were reviewed. SPAN-100 score ≥ 100 is classified as SPAN-100 positive while score < 100 is SPAN-100 negative. Clinical outcomes, death and intracerebral hemorrhage (ICH) incidences were compared between SPAN-100 positive and negative groups.ResultsSPAN-100-positive delayed IVT-patients (11/136) had a 6-fold increased risk for unfavorable outcome compared to SPAN-negative patients (OR 6.34; 95% CI 1.59–25.24 p=0.004), however there was no relation between the SPAN-100 positivity and mortality or ICH.ConclusionSPAN-100-positive patients are more likely to achieve non-favorable outcome with delayed IVT in comparison to the SPAN-100-negative patients. SPAN-100 index may influence the eligibility criteria of delayed thrombolysis.     

Decompressive hemicraniectomy improves outcome in patients with failed arterial recanalization after acute carotid artery occlusion

Abstract

Background and objectives: Decompressive hemicraniectomy reduces morbidity and mortality in patients with large hemispheric stroke. However, its role in patients that underwent failed endovascular reperfusion remains unknown.

Methods: Patients with acute stroke secondary to internal carotid artery occlusion who underwent endovascular multimodal reperfusion therapy were evaluated. Patients with failed revascularization who were referred for decompressive hemicraniectomy were compared with patients with failed reperfusion who did not undergo decompressive hemicraniectomy. Functional outcome was assessed with the modified Rankin Score (mRS) and neurological disability with the NIH Stroke Scale Score (NIHSS) at 90 days from stroke onset.

Results: Six decompressive hemicraniectomy-treated patients were included (four females, mean age: 36.7 years, mean NIHSS: 24.5). None of the decompressive hemicraniectomy-treated patients died compared to six of seven patients with failed multi-modal reperfusion therapy that did not undergo decompressive hemicraniectomy. All decompressive hemicraniectomy-treated patients were discharged to a rehabilitation facility whereas the only surviving non-decompressive hemicraniectomy-treated patient was discharged to a nursing facility. Five of the six decompressive hemicraniectomy-treated (84%) and none of the non-decompressive hemicraniectomy-treated patients had an mRS ≤3 at 90 days post-stroke.

Discussion: Decompressive hemicraniectomy can significantly improve functional outcome in patients with large carotid artery strokes that failed to recanalize following multi-modal reperfusion therapy. These results imply that decompressive hemicraniectomy should be planned in patients who undergo multi-modal reperfusion therapy for large carotid artery stroke.     

Underlying intracranial atherosclerotic disease is associated with worse outcomes in acute large vessel occlusion undergoing endovascular thrombectomy

BackgroundData on large vessel occlusion (LVO) management due to intracranial atherosclerotic disease (ICAD) are scarce.ObjectiveTo compare clinical outcomes between patients with ICAD and those without ICAD following mechanical thrombectomy (MT).MethodsWe performed a retrospective analysis of consecutive patients who underwent MT for LVO in a large academic comprehensive stroke center, and compared in-hospital mortality, 90-day mortality, favorable functional outcome at 90 days, and symptomatic intracranial hemorrhage (ICH) using chi-squared tests and multivariate logistic regression analyses. We defined ICAD as observable plaque at occlusion site post-thrombectomy.ResultsAmong 215 patients (mean age 67.1 ± 16.0 years; 60.5% female; 83.6% Black, median NIHSS score 16), ICAD was present in 38 patients (17.7%). Diabetes and dyslipidemia were more common in those with ICAD (57.9% vs. 38.4%, p = 0.027 and 29.0% vs. 14.7%, p = 0.035, respectively). Substantial reperfusion (TICI ≥2b) was achieved less often (84.2% vs. 94.4%, p = 0.031) but symptomatic ICH was also less common in ICAD patients (0% vs. 9.0%, p = 0.081). In-hospital and 90-day mortality were more common (36.8% vs. 15.8%, p = 0.003 and 52.6% vs. 26.6%, p = 0.002, respectively) and favorable functional outcome (mRS 0-2) at 90 days was less common (7.9% vs. 33.9%, p = 0.001) in ICAD patients. After adjusting for prognostic variables, ICAD was independently associated with in-hospital mortality (OR=4.1, 95% CI 1.7-9.7), 90-day mortality (OR=3.7, 95% CI 1.6-8.6), and poor functional outcome at 90 days (OR=5.5, 95% CI 1.6-19.4).ConclusionSymptomatic ICAD in a predominantly African American cohort is associated with increased odds of mortality and poor functional outcome at 90 days in patients with LVO undergoing MT.     

Initial experience with minimally invasive endoscopic evacuation of intracerebral hemorrhage in the setting of radiographic herniation

BackgroundSpontaneous intracerebral hemorrhage (ICH) can rapidly result in cerebral herniation, leading to poor neurologic outcomes or mortality. To date, neither decompressive hemicraniectomy (DH) nor hematoma evacuation have been conclusively shown to improve outcomes for comatose ICH patients presenting with cerebral herniation, with these patients largely excluded from clinical trials. Here we present the outcomes of a series of patients presenting with ICH and radiographic herniation who underwent emergent minimally invasive (MIS) ICH evacuation.MethodsWe reviewed our prospectively collected registry of patients undergoing MIS ICH evacuation at a single institution from 01/01/2017 to 10/01/2021. We selected all consecutive patients with Glasgow coma scale (GCS) ≤ 8 and radiographic herniation for this case series. Clinical and radiographic variables were collected, including admission GCS score, preoperative and postoperative hematoma volumes, National Institute of Health stroke scale (NIHSS) scores, and modified Rankin scale (mRS) scores at last follow-up.ResultsOf 176 patients with spontaneous supratentorial ICH who underwent minimally invasive endoscopic evacuation during the study time period, a total of 9 patients presented with GCS ≤ 8 and evidence of radiographic herniation. Among these patients, the mean age was 62 ± 12 years, the median GCS at presentation was 5 [IQR 4-6], the mean preoperative hematoma volume was 94 ± 44 mL, the mean time from ictus to evacuation was 12 ± 5 h, and the mean postoperative hematoma volume was 11 ± 16 mL, for a median evacuation percentage of 97% [83-99]. Three patients (33%) died, four (44%) survived with mRS 5 and two (22%) with mRS 4. Patients had a median NIHSS improvement of 5 compared to their initial NIHSS. Age was very strongly correlate to improvements in NIHSS (r² = 0.90).ConclusionData from this initial experience suggest emergent MIS hematoma evacuation in the setting of ICH with radiographic herniation is feasible and technically effective. Further randomized studies are required to determine if such an intervention offers overall benefits to patients and their families.     

Mechanical Thrombectomy in Patients Presenting with NIHSS Score <6: A Safety and Efficacy Analysis

Background and ObjectivesGroundbreaking trials have shown the tremendous efficacy of mechanical thrombectomy for large vessel occlusions. Currently, mechanical thrombectomy is limited to patients with NIHSS scores ≥6. We investigated the feasibility and safety of MT in patients presenting with NIHSS scores <6.Materials and MethodsA retrospective review of patient who presented with acute ischemic stroke due to large vessel occlusion with an NIHSS score <6 between 2015 – 2021. The patients were then divided into two groups: those who received mechanical thrombectomy and those who did not.ResultsAmong 83 patients, 41 received a mechanical thrombectomy while 42 received medical treatment only. The mean age in the mechanical thrombectomy group was 66 years versus 60 years in the medical group (p = 0.06). Risk factors for stroke did not differ significantly between both groups. 14 patients (34.1%) in the mechanical thrombectomy group and 20 (47.6%) in the medical group received tissue plasminogen activator. No significant difference in clinical improvement (NIHSS) at discharge (p=0.85) or the mRS score at 90 days (p = 0.15) was noted. Mechanical thrombectomy was associated with smaller infarct size (p=0.04) and decreased mortality (p=0.03).ConclusionsMechanical thrombectomy is safe and effective for patients who present with large vessel occlusions and low initial NIHSS scores. Therefore, the decision to offer the patient mechanical thrombectomy or not should not be decided by NIHSS score alone. Rather, the decision should be multifactorial with the aim of maximizing the patients’ outcomes.     

External validation of the ICH score

Introduction: The ICH score is a clinical grading scale that is composed of five components related to outcome after nontraumatic intracerebral hemorrhage (ICH): Glasgow Coma Scale score, ICH volume, presence of intraventricular hemorrhage, infratentorial origin, and age. The ICH score accurately risk-stratifies patients in the cohort from which it was developed, but it has not yet been fully externally validated. The purpose of this study was to determine whether the ICH score accurately risk-stratifies patients in an independent cohort. Methods: Records of all patients with acute ICH presenting to Stanford Medical Center and Santa Clara Valley Medical Center from 1998 through 2000 were reviewed. Outcome was assessed as mortality at 30 days.     

重组组织型纤溶酶原激活剂静脉治疗轻型缺血性卒中患者的疗效分析

目的 观察轻型缺血性卒中患者重组组织型纤溶酶原激活剂（recombinant tissue plasminogen activator,rt-PA）静脉溶栓治疗的疗效及安全性。      

Validation of ICH and ICH-GS Scores in an Indian Cohort: Impact of Medical and Surgical Management

ObjectivePrognostic scores help in predicting mortality and functional outcome post intracerebral hemorrhage (ICH). We aimed to validate the ICH and ICH-GS scores in a cohort of Indian patients with ICH and observe the impact of any surgical intervention on prognostication.MethodsThis was an ambispective observational study of primary ICH cases enrolled between January 2014 and April 2018. Observed mortality on ICH and ICH GS scores for the entire cohort and individually for the medically and surgically managed patients was compared to the published mortality in the original derivation cohorts.Results617 patients, (464 retrospective and 153 prospective) of ICH were included. In hospital mortality and 30-day mortality was 28.7% and 28.5% respectively. There was a significant association of increasing mortality with increasing ICH and ICH-GS scores. Area under receiver operating characteristic curve for 30-day mortality was 75.9% and 74.1% for ICH and ICH-GS scores respectively. However, mortality observed at individual scores was significantly less than previously reported. Among the surgically intervened patients (n = 265), both the expected mortality at baseline and discriminative ability of ICH and ICH-GS scores for 30-day mortality was significantly reduced following surgical intervention (ROC in surgically intervened groups: 59.9 (52.6-67.2) and 63(56-70) for ICH and ICH-GS scores respectively).ConclusionsAlthough ICH and ICH-GS scores are valid in Indian population, mortality at individual scores is lower than previously reported. Mortality prediction using ICH and ICH GS scores is significantly modified by surgical interventions. Thus, newer prognostic tools which incorporate surgical intervention need to be developed and validated in future.     

Development of a new non invasive prognostic stroke scale (NIPSS) including triage elements for sleep apnea and peripheral artery disease

BackgroundAlthough sleep apnea and peripheral artery disease are prognostic factors for stroke, their added benefit in the acute stage to further prognosticate strokes has not been evaluated.ObjectivesWe tested the accuracy in the acute stroke stage of a novel score called the Non-Invasive Prognostic Stroke Scale (NIPSS).Patients and methodsProspective cohort with imaging-confirmed ischemic stroke. Clinical data, sleep apnea risk score (STOPBANG) and blood pressure measures were collected at baseline. Primary outcome was the 90-day modified Rankin Scale (mRS), with poor outcome defined as mRS 3-6. Area under the ROC curve (AUC) was calculated for NIPSS and compared to six other stroke prognostic scores in our cohort: SPAN-100 index, S-SMART, SOAR, ASTRAL, THRIVE, and Dutch Stroke scores.ResultsWe enrolled 386 participants. After 90 days, there were 56% with poor outcome, more frequently older, female predominant and with higher admission National Institute of Health Stroke Scale (NIHSS). Four variables remained significantly associated with primary endpoint in the multivariable model: age (OR 1.87), NIHSS (OR 7.08), STOPBANG category (OR 1.61), and ankle-braquial index (OR 2.11). NIPSS AUC was 0.86 (0.82–0.89); 0.83 (0.79-0.87) with bootstrapping. When compared to the other scores, NIPSS, ASTRAL, S-SMART and DUTCH scores had good abilities in predicting poor outcome, with AUC of 0.86, 0.86, 0.83 and 0.82, respectively. THRIVE, SOAR and SPAN-100 scores were fairly predictive.Discussion and conclusionsNon-invasive and easily acquired emergency room data can predict clinical outcome after stroke. NIPSS performed equal to or better than other prognostic stroke scales.     

National Institutes of Health Stroke Scale in patients with primary intracerebral hemorrhage

Background

The National Institutes of Health Stroke Scale (NIHSS) is able to predict mortality and functional outcome in patients with ischemic stroke. Its role in primary intracerebral hemorrhage (ICH) is not clear. The objective of our study was to investigate whether NIHSS is a reliable instrument of clinical monitoring and correlates with mortality and functional outcome in ICH.

Methods

One hundred fifty-six consecutive subjects with primary ICH were included. We evaluated NIHSS at admission. The functional state after a 30-day and a 3-month-long follow-up was assessed by the modified Rankin Scale (mRS). Spearman’s rank correlation coefficient analysis was used for statistics. Sensitivity, specificity, positive predictive value, negative predictive value, global accuracy, and ROC curve were computed using the median score 7 as NIHSS cutoff and the score 4 as mRS cutoff.

Results

Median NIHSS score at admission was 7 (16–4); the mean (± SD) was 10.82 (±?8.27). Thirty-two patients (20.5%) died within 30 days and other 22 (14.1%) within 3 months. The median mRS score at 3 months was 4 (6–1); the mean (± SD) was 3.38 (±?2.42). We found a statistically significant correlation between initial NIHSS score and mRS score after 30 days (0.74) and 3 months (0.66, p?<?0.01). Sensitivity was 93.5 and 92.2%, specificity 82.3 and 69.6%, and GA 87.8 and 80.8%, respectively, at 1 and 3 months. The 1- and 3-month ROC curves comparing initial NIHSS and mRS showed a fitted area as 0.914 and 0.833, respectively.

Conclusions

NIHSS is a reliable tool of clinical monitoring and correlates with 30-day and 3-month mortality and functional outcome in subjects with ICH.

     

Hemicraniectomy for Supratentorial Primary Intracerebral Hemorrhage: A Retrospective,Propensity Score Matched Study

Background and Purpose: Spontaneous supratentorial intracerebral hemorrhage (ICH) contributes disproportionately to stroke mortality, and randomized trials of surgical treatments for ICH have not shown benefit. Decompressive hemicraniectomy (DHC) improves functional outcome in patients with malignant middle cerebral artery ischemic stroke, but data in ICH patients is limited. We hypothesized that DHC would reduce in-hospital mortality and poor functional status (defined as modified Rankin scale ≥5) among survivors at 3 months, without increased complications. Methods: We performed a retrospective, case-control, propensity score matched study to determine whether hemicraniectomy affected outcome in patients with spontaneous supratentorial ICH. The propensity score consisted of variables associated with outcome or predictors of hemicraniectomy. Forty-three surgical patients were matched to 43 medically managed patients on ICH location, sex, and nearest neighbor matching. Three-month functional outcomes, in-hospital mortality, and in-hospital complications were measured. Results: In the medical management group, 72.1% of patients had poor outcome at 3 months compared with 37.2% who underwent hemicraniectomy (odds ratio 4.8, confidence interval 1.6-14). In-hospital mortality was 51.2% for medically managed patients and 16.3% for hemicraniectomy patients (odds ratio 8.5, confidence interval 2.0-36.8). There were no statistically significant differences in the occurrence of in-hospital complications. Conclusions: In our retrospective study of selected patients with spontaneous supratentorial ICH, DHC resulted in lower rate of in-hospital mortality and better 3-month functional status compared with medically managed patients. A randomized trial is necessary to evaluate DHC as a treatment for certain patients with spontaneous supratentorial ICH.     

A simple clinical and MRI scale to predict good outcome in t-PA patients

Abstract

Background and purpose: The frequency of good outcome at 3 months after tissue plasminogen activator (t-PA) therapy is ～35%. The present study aimed to devise a simple scale to predict good outcome using clinical factors and magnetic resonance imaging (MRI) findings before and immediately after t-PA infusion.

Methods: Consecutive patients with acute ischemic stroke treated with t-PA within 3 hours of stroke onset were studied prospectively. We assessed clinical factors independently associated with good outcome [modified Rankin scale (mRS): 0-1] at 3 months after t-PA therapy. We created a simple scale to predict good outcome in t-PA patients using factors selected by multivariate logistic regression analysis.

Results: Subjects comprised 105 patients (69 men; median age, 74 years). Multivariate logistic regression analysis revealed the following independent factors associated with good outcome: baseline National Institutes of Health Stroke Scale (NIHSS) <11 [odds ratio (OR), 13·64; 95% confidence interval (CI), 3·588-51·822; P = 0·0001], glucose <150 mg/dl (OR, 3·76; 95%CI, 1·014-13·963; P = 0·0475), and early recanalization within 1 hour after t-PA infusion (OR, 5·28; 95%CI, 1·179-23·656; P = 0·0296). Those three variables were selected for use in the good outcome scale, with NIHSS <11 as 2 points, glucose <150 mg/dl as 1 point, and early recanalization as 1 point. Frequencies of patients with good outcome for each score were as follows: score 0, 0·0%; score 1, 7·1%; score 2, 43·5%; score 3, 65·4%; and score 4, 71·4%. The C statistic for the score was 0·849 (95%CI, 0·776-0·922).

Conclusion: A simple clinical and MRI scale can predict good outcome in t-PA patients.     

Intensive Care Unit Admission for Patients in the INTERACT2 ICH Blood Pressure Treatment Trial: Characteristics,Predictors, and Outcomes

Background

Wide variation exists in criteria for accessing intensive care unit (ICU) facilities for managing patients with critical illnesses such as acute intracerebral hemorrhage (ICH). We aimed to determine the predictors of admission, length of stay, and outcome for ICU among participants of the main Intensive Blood Pressure Reduction in Acute Cerebral Hemorrhage Trial (INTERACT2).

Methods

INTERACT2 was an international, open, blinded endpoint, randomized controlled trial of 2839 ICH patients (<6 h) and elevated systolic blood pressure (SBP) allocated to receive intensive (target SBP <140 mmHg within 1 h) or guideline-recommended (target SBP <180 mmHg) BP-lowering treatment. The primary outcome was death or major disability, defined by modified Rankin scale scores 3–6 at 90 days. Logistic regression and propensity score analyses were used to determine independent associations.

Main Results

Predictors of ICU admission included younger age, recruitment in China, prior ischemic/undetermined stroke, high SBP, severe stroke [National Institute of Health stroke scale (NIHSS) score ≥15], large ICH volume (≥15 mL), intraventricular hemorrhage (IVH) extension, early neurological deterioration, intubation and surgery. Determinants of prolonged ICU stay (≥5 days) were prior antihypertensive use, NIHSS ≥15, large ICH volume, lobar ICH location, IVH, early neurological deterioration, intubation and surgery. ICU admission was associated with higher-risk major disability at 90-day assessment compared to those without ICU admission.

Conclusions

This study presents prognostic variables for ICU management and outcome of ICH patients included in a large international cohort. These data may assist in the selection and counseling of patients and families concerning ICU admission.

     

Plasma Levels of miR-125b-5p and miR-206 in Acute Ischemic Stroke Patients After Recanalization Treatment: A Prospective Observational Study

Introduction: Multiple microRNAs (miRNAs) participate in the response to hypoxic/ischemic and ischemia-reperfusion events. However, the expression of these miRNAs in circulation from patients with acute ischemic stroke (AIS) receiving recanalization treatment has not been examined, and whether they are associated with the severity and outcome of stroke is still unknown. Materials and methods: In this prospective cohort study, plasma levels of miR-125b-5p, miR-15a-3p, miR-15a-5p, and miR-206 were measured at 24 hours after thrombolysis with or without endovascular treatment in 94 patients with AIS, as determined by qRT-PCR. Stroke severity was assessed based on National Institutes of Health Stroke Scale (NIHSS) score and infarct lesion. Intracranial haemorrhage (ICH) was recorded. An unfavorable outcome was defined as a modified Rankin Scale score greater than 2 at day 90 after stroke. Results: miR-125b-5p and miR-206 levels were correlated with NIHSS scores (P = .014 and P = .002) and cerebral infarction volumes (P = .025 and P = .030). miR-125b-5p levels were significantly higher in patients with an unfavorable outcome than in patients with a favorable outcome (P = .002) and showed good diagnostic accuracy in discriminating the presence of an unfavorable outcome (area under the curve .735, 95% confidence interval .623-.829, P < .001). No association was found between different miRNAs and ICH. Conclusions: In AIS patients after thrombolysis with or without endovascular treatment, miR-125b-5p is a novel prognostic biomarker highly associated with an unfavorable outcome. miR-125b-5p and miR-206 levels are associated with stroke severity.     

Machine Learning Models Prognosticate Functional Outcomes Better than Clinical Scores in Spontaneous Intracerebral Haemorrhage

ObjectiveThis study aims to develop and compare the use of deep neural networks (DNN) and support vector machines (SVM) to clinical prognostic scores for prognosticating 30-day mortality and 90-day poor functional outcome (PFO) in spontaneous intracerebral haemorrhage (SICH).Materials and methodsWe conducted a retrospective cohort study of 297 SICH patients between December 2014 and May 2016. Clinical data was collected from electronic medical records using standardized data collection forms. The machine learning workflow included imputation of missing data, dimensionality reduction, imbalanced-class correction, and evaluation using cross-validation and comparison of accuracy against clinical prognostic scores.Results32 (11%) patients had 30-day mortality while 177 (63%) patients had 90-day PFO. For prognosticating 30-day mortality, the class-balanced accuracies for DNN (0.875; 95% CI 0.800-0.950; McNemar's p-value 1.000) and SVM (0.848; 95% CI 0.767-0.930; McNemar's p-value 0.791) were comparable to that of the original ICH score (0.833; 95% CI 0.748-0.918). The c-statistics for DNN (0.895; DeLong's p-value 0.715), and SVM (0.900; DeLong's p-value 0.619), though greater than that of the original ICH score (0.862), were not significantly different. For prognosticating 90-day PFO, the class-balanced accuracies for DNN (0.853; 95% CI 0.772-0.934; McNemar's p-value 0.003) and SVM (0.860; 95% CI 0.781-0.939; McNemar's p-value 0.004) were better than that of the ICH-Grading Scale (0.706; 95% CI 0.600-0.812). The c-statistic for SVM (0.883; DeLong's p-value 0.022) was significantly greater than that of the ICH-Grading Scale (0.778), while the c-statistic for DNN was 0.864 (DeLong's p-value 0.055).ConclusionWe showed that the SVM model performs significantly better than clinical prognostic scores in predicting 90-day PFO in SICH.