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Factors beyond those in commonly used prognostic scores for intracerebral hemorrhage (ICH) were linked to early outcomes in an analysis of the large ERICH study cohort.

The study validated the usefulness of the commonly used and baseline severity scores in predicting survival with no worse than moderate disability as reflected in a 90-day modified Rankin Scale (mRS) score of 3 or less.

However, a more robust multivariable model adding in factors like white matter lesion burden on the initial CT scan boosted prognostication, reported Daniel Woo, MD, of the University of Cincinnati College of Medicine, and colleagues in .

That model had a significantly higher area under the receiver operating characteristics curve compared with the ICH score alone (C=0.88 vs 0.76, P<0.001).

Having yet another incrementally better score to add to the some 60 that have been published over the past 2 decades for post-ICH outcomes isn't much to be excited about, said J. Claude Hemphill III, MD, MAS, of the University of California San Francisco, and Wendy Ziai, MD, MPH, of Johns Hopkins University in Baltimore, in an .

Even the ICH score was never developed to precisely prognosticate outcomes in individual patients, although this has "shifted toward the desire, and even expectation, of precisely prognosticating patient outcome from a simple scale assessed at ICH onset," the editorialists pointed out. "It is not that simple, and the study by Woo et al reminds us of this."

They pointed to the study's identification of some post-baseline targets for intervention among the factors significant to prognosis as "reassuring that the die is not cast at ICH onset."

For example, presence of infection (OR 1.85, 95% CI 1.42-2.41) independently predicted a 90-day mRS score of 3 or less.

"Strikingly, the development of any infection (e.g., urinary tract, pneumonia) had a similar association with outcomes as hematoma expansion or requiring treatment for increased intracranial pressure," Woo and colleagues noted.

Other factors associated with 90-day good neurologic outcome in the logistic regression model included (all P<0.001):

• Larger log ICH volume (OR 2.74, 95% CI 2.36-3.19)
• Older age (OR 1.04 per year, 95% CI 1.02-1.05)
• Pre-ICH mRS score (OR 1.62, 95% CI 1.41-1.87)
• Lobar location (OR 0.22, 95% CI 0.16-0.30)

The ERICH (Ethnic/Racial Variations of Intracerebral Hemorrhage) study analyzed data from a prospectively recruited group of 1,000 patients each from non-Hispanic White, non-Hispanic Black, and Hispanic ethnicity who had spontaneous ICH. Among them, 2,568 patients (mean age 62.4 years, 41.6% women) had 3-month outcomes available.

Excluding patients for whom care was withdrawn didn't change the results. A smaller validation cohort generally confirmed the findings, although some were no longer statistically significant with lower power.

"In addition to the factors previously described, we found several simple measures on the initial CT, including white matter lesion burden, Graeb score, and atrophy, to be associated with disability at 3 months," Woo's group wrote. "Further evaluation is needed to determine which levels of each may contribute to redefining a future score."

The researchers didn't suggest that their scoring system should replace existing ones, which the editorialists praised.

"We also need to resist the urge to provide precise outcome prognosis at onset, or probably even early after ICH," Hemphill and Ziai wrote. "We need to hold ICH prognostication to the same standards that we do for our weather forecast or travel times on navigation apps: uncertainty is inherent, but a framework for possible outcomes is still useful."

"Furthermore, future efforts at prognosing outcome should bring in additional relevant parameters, such as postacute rehabilitation care and advanced assessment of cerebral functional integrity and capacity for recovery," they concluded. "The purpose of providing a prognosis for ICH outcomes should be the same as the purpose of a clinical trial: trying to identify treatments that can help patients. We believe that we are just getting started."

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