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Front. Neurol. | doi: 10.3389/fneur.2018.00100

Predicting prognosis of intracerebral hemorrhage: performance of ICH score is not improved by adding oral anticoagulant use

 Rik Houben1*, Floris Schreuder2, Kim Bekelaar1, Danny Claessens1, Robert van Oostenbrugge1, 3 and  Julie Staals1, 3
  • 1Neurology, Maastricht University Medical Centre, Netherlands
  • 2Neurology, Medical Center, Radboud University Nijmegen, Netherlands
  • 3Cardiovascular Research Institute Maastricht, Maastricht University Medical Centre, Netherlands

Background – The ICH score is a commonly used prognostic model for 30-day mortality in intracerebral hemorrhage (ICH), based on five independent predictors (ICH volume, location, Glasgow Coma Scale, age, intraventricular extension). Use of oral anticoagulants (OAC) is also associated with mortality but was not considered in the ICH score. We investigated a) whether the predictive performance of ICH score is similar in OAC-ICH and non-OAC-ICH, and b) whether addition of OAC use to the ICH score increases the prognostic performance of the score.
Methods – We retrospectively selected all consecutive adult non-traumatic ICH cases (3 hospitals, region South-Limburg, the Netherlands 2004–2009). Mortality at 30 days was recorded. Using univariable and multivariable logistic regression, association between OAC use and 30-day mortality was tested. Then a) we computed receiver operating characteristic (ROC) curves for ICH score and determined the area under the curve (AUC) in OAC-ICH and non-OAC-ICH. Then b) we created a New ICH score by adding OAC use to the ICH score. We calculated correlation between 30-day mortality and ICH score respectively New ICH score using Spearman correlation test. We computed ROC curves and calculated the AUC.
Results – We analysed 1232 cases, 282 (22.9%) were OAC related ICH. Overall, 30-day mortality was 39.3%. OAC use was independently associated with 30-day mortality (OR 2.09, 95%-CI 1.48–2.95; p<0.001), corrected for the 5 predictors of the ICH score. The ICH score performed slightly better in non-OAC-ICH (AUC 0.840) than in OAC-ICH (AUC 0.816), but this difference was not significant (p=0.39).The ICH Score and the New ICH Score were both significantly correlated with 30-day mortality (rho 0.58, p<0.001 and 0.59, p<0.001 respectively). The AUC for the ICH Score was 0.837, for New ICH Score 0.840. This difference was not significant.
Conclusion – The ICH score is a useful tool for predicting 30-day mortality both in patient who use and patients who don’t use OAC. Although OAC use is an independent predictor of 30-day mortality, addition of OAC use to the existing ICH score does not increase the prognostic performance of this score.

Keywords: Mortality, intracerebral hemorrhage, Oral anticoagulants, ICH score, prognosis

Received: 25 Oct 2017; Accepted: 12 Feb 2018.

Edited by:

Barak Bar, Loyola University Medical Center, United States

Reviewed by:

Torrey A. Boland, Rush University, United States
M. Kamran Athar, Thomas Jefferson university hospital, United States  

Copyright: © 2018 Houben, Schreuder, Bekelaar, Claessens, van Oostenbrugge and Staals. This is an open-access article distributed under the terms of the Creative Commons Attribution License (CC BY). The use, distribution or reproduction in other forums is permitted, provided the original author(s) and the copyright owner are credited and that the original publication in this journal is cited, in accordance with accepted academic practice. No use, distribution or reproduction is permitted which does not comply with these terms.

* Correspondence: MD. Rik Houben, Maastricht University Medical Centre, Neurology, P. Debyelaan 25, Maastricht, 6229 HX, Limburg, Netherlands,