Lack of early improvement predicts poor outcome following acute intracerebral haemorrhage

V Yogendrakumar , E Smith, A Demchuk, R Aviv, D Rodriguez-Luna, C Molina, YS Blas, I Dzialowski , A Kobayashi , J-M Boulanger , C Lum , G Gubitz , V Padma , J Roy , C Kase , R Bhatia , Myzoon Ali, Patrick Lyden, Michael Hill, D Dowlatshahi

Research output: Contribution to journalArticle

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.
Original languageEnglish
Pages (from-to)e310–e317
Number of pages8
JournalCritical Care Medicine
Volume46
Issue number4
DOIs
Publication statusPublished - 1 Apr 2018

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Cerebral Hemorrhage
Stroke
National Institutes of Health (U.S.)
ROC Curve
Nervous System
Odds Ratio
Hematoma
Multicenter Studies
Cohort Studies
Logistic Models
Clinical Trials
Hemorrhage
Sensitivity and Specificity
Growth

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Yogendrakumar , V., Smith, E., Demchuk, A., Aviv, R., Rodriguez-Luna, D., Molina, C., ... Dowlatshahi , D. (2018). Lack of early improvement predicts poor outcome following acute intracerebral haemorrhage. Critical Care Medicine, 46(4), e310–e317. https://doi.org/10.1097/CCM.0000000000002962
Yogendrakumar , V ; Smith, E ; Demchuk, A ; Aviv, R ; Rodriguez-Luna, D ; Molina, C ; Blas, YS ; Dzialowski , I ; Kobayashi , A ; Boulanger , J-M ; Lum , C ; Gubitz , G ; Padma , V ; Roy , J ; Kase , C ; Bhatia , R ; Ali, Myzoon ; Lyden, Patrick ; Hill, Michael ; Dowlatshahi , D. / Lack of early improvement predicts poor outcome following acute intracerebral haemorrhage. In: Critical Care Medicine. 2018 ; Vol. 46, No. 4. pp. e310–e317.
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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.",
author = "V Yogendrakumar and E Smith and A Demchuk and R Aviv and D Rodriguez-Luna and C Molina and YS Blas and I Dzialowski and A Kobayashi and J-M Boulanger and C Lum and G Gubitz and V Padma and J Roy and C Kase and R Bhatia and Myzoon Ali and Patrick Lyden and Michael Hill and D Dowlatshahi",
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Yogendrakumar , V, Smith, E, Demchuk, A, Aviv, R, Rodriguez-Luna, D, Molina, C, Blas, YS, Dzialowski , I, Kobayashi , A, Boulanger , J-M, Lum , C, Gubitz , G, Padma , V, Roy , J, Kase , C, Bhatia , R, Ali, M, Lyden, P, Hill, M & Dowlatshahi , D 2018, 'Lack of early improvement predicts poor outcome following acute intracerebral haemorrhage', Critical Care Medicine, vol. 46, no. 4, pp. e310–e317. https://doi.org/10.1097/CCM.0000000000002962

Lack of early improvement predicts poor outcome following acute intracerebral haemorrhage. / Yogendrakumar , V; Smith, E; Demchuk, A; Aviv, R; Rodriguez-Luna, D; Molina, C; Blas, YS; Dzialowski , I; Kobayashi , A; Boulanger , J-M; Lum , C; Gubitz , G; Padma , V; Roy , J; Kase , C; Bhatia , R; Ali, Myzoon; Lyden, Patrick ; Hill, Michael; Dowlatshahi , D.

In: Critical Care Medicine, Vol. 46, No. 4, 01.04.2018, p. e310–e317.

Research output: Contribution to journalArticle

TY - JOUR

T1 - Lack of early improvement predicts poor outcome following acute intracerebral haemorrhage

AU - Yogendrakumar , V

AU - Smith, E

AU - Demchuk, A

AU - Aviv, R

AU - Rodriguez-Luna, D

AU - Molina, C

AU - Blas, YS

AU - Dzialowski , I

AU - Kobayashi , A

AU - Boulanger , J-M

AU - Lum , C

AU - Gubitz , G

AU - Padma , V

AU - Roy , J

AU - Kase , C

AU - Bhatia , R

AU - Ali, Myzoon

AU - Lyden, Patrick

AU - Hill, Michael

AU - Dowlatshahi , D

N1 - Acceptance email and AAM req'd 14/11/19 DC; chaser sent 26/11/19 ET ^Author notes this is not linked to GCU but part of Glasgow Uni work. Tbc if eligible for REF submission for GCU. ET 18/11/19

PY - 2018/4/1

Y1 - 2018/4/1

N2 - 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.

AB - 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.

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Yogendrakumar V, Smith E, Demchuk A, Aviv R, Rodriguez-Luna D, Molina C et al. Lack of early improvement predicts poor outcome following acute intracerebral haemorrhage. Critical Care Medicine. 2018 Apr 1;46(4):e310–e317. https://doi.org/10.1097/CCM.0000000000002962