Guidelines for Neuroprognostication in Critically Ill Adults with Intracerebral Hemorrhage
Neurocritical Care Society · 2023 · USA
Source and licence
- Authors
- David Y Hwang, Keri S Kim, Susanne Muehlschlegel et al.
- Title
- Guidelines for Neuroprognostication in Critically Ill Adults with Intracerebral Hemorrhage
- Journal
- Neurocritical Care, 2023
- Licence
- CC BY 4.0
- Changes
- Verbatim excerpts; formatting adapted
Full text retrieved 2026-10-27 from Europe PMC · PMC10959839
Licence statement of the original publication
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Recommendations
Verbatim, with grade of recommendation or strength of consensus where given.
Outcome: Poor Functional Outcome at 3 Months or Later
- Question: When counseling patients with ICH or their surrogates, should age alone be considered a reliable predictor of poor functional outcome assessed at 3 months or later? Description of the predictor: Older age may be a surrogate for baseline infirmity, comorbidities, and/or and diminished cerebral reserve [144]. There are few ICH prognostication studies examining age as the primary predictor of interest [21–28], but it is a ubiquitous covariate in studies of nearly all potential predictors, as well as a component variable incorporated in nearly every ICH clinical grading scale. Most ICH studies incorporate age as a continuous variable. Those that either dichotomize or stratify it do not use standardized categorical cutoffs. Recommendation: When counseling patients with ICH or their surrogates, we suggest the patient’s age alone not be considered a reliable predictor of poor functional outcome assessed at 3 months or later (weak recommendation; very low quality evidence). Rationale: Older age was independently associated with poor ICH outcome in the majority of the reviewed studies of other predictors, and the panel acknowledged that age is likely factored into many clinicians’ subjective assessments of predicted functional outcomes for their patients with ICH. However, the quality of evidence for focusing on age alone as a potentially reliable predictor of functional outcome was downgraded over multiple concerns from the panel. These concerns included (1) risk of bias from self-fulfilling prophecies regarding limitations of life-sustaining therapy decisions made within study cohorts; (2) inconsistency regarding reported effect sizes, or the magnitude of associations of age with poor functional outcome; and (3) possible imprecision. A decision to suggest age alone as not reliable was also influenced by lack of consensus over the optimal cutoff values for defining “older” age groups and significant uncertainty regarding a consensus definition of “poor functional outcome,” as perceived by patients with ICH and their surrogates with varying values and preferences. Furthermore, the stakes of an inaccurate prediction of functional outcome—i.e., potential limitation of life-sustaining therapy for a patient who could have eventually achieved a perceived favorable outcome—raised the threshold among panel members for suggesting age alone as having sufficiently precise evidence to be considered as potentially reliable for neuroprognostication discussions.
- Question: When counseling patients with ICH or their surrogates, should clinical examination on admission alone be considered a reliable predictor of poor functional outcome assessed at 3 months or later? Description of the predictor: The clinical examination on admission for patients with ICH is a marker of initial severity of injury [29]. Similar to age, the admission clinical examination is a ubiquitous covariate in studies of nearly all potential predictors of ICH outcome, as well as a component variable incorporated in nearly every clinical grading scale. Of note, the methodology for defining a patient’s clinical examination varies significantly in the ICH literature, with many studies using various stratifications of the Glasgow Coma Scale (GCS) and others using various categorizations based on the National Institutes of Health Stroke Scale (NIHSS) [9]. Recommendation: When counseling patients with ICH or their surrogates, we suggest the patient’s clinical examination on admission alone not be considered a reliable predictor of poor functional outcome assessed at 3 months or later (weak recommendation; low quality evidence). Rationale: Similar to older age, a poor clinical examination on admission was independently associated, to some extent, with poor ICH outcome in the majority of the reviewed studies of other predictors. We acknowledge that clinical examination is likely factored into many clinicians’ early subjective assessments of predicted functional outcomes for their patients with ICH. However, the quality of evidence for focusing on admission clinical examination alone as a potentially reliable predictor of functional outcome was downgraded over (1) risk of bias from self-fulfilling prophecies and (2) possible imprecision. Furthermore, (1) varying methods used in studies to score the clinical examination, (2) lack of consensus over the optimal cutoff values for categorizing these scores, and (3) significant uncertainty regarding a consensus definition of “poor functional outcome,” as perceived by patients with ICH and their surrogates, all contributed to this recommendation. Once again, the stakes of an inaccurate prediction of functional outcome and premature limitation of life-sustaining therapy raised the threshold for comfort in suggesting admission clinical examination as having sufficiently precise evidence to be considered as potentially reliable for neuroprognostication discussions, by itself.
- Question: When counseling patients with ICH or their surrogates, should ICH volume on admission alone be considered a reliable predictor of poor functional outcome assessed at 3 months or later? Description of the predictor: ICH volume on admission is an intuitive radiographic measurement of severity of injury [30, 31]. Similar to age and clinical examination, ICH volume is also a ubiquitous covariate in studies of nearly all potential predictors of ICH outcome. Studies that report ICH volume use various cutoffs for categorization, with some having different cutoffs within the same study for patients with different ICH locations (e.g., supratentorial vs. infratentorial) [9]. Recommendation: When counseling patients with ICH or their surrogates, we suggest the patient’s ICH volume on admission alone not be considered a reliable predictor of poor functional outcome assessed at 3 months or later (weak recommendation; low quality evidence). Rationale: Similar to age and admission clinical examination, a large ICH volume on admission was independently associated to some extent with poor ICH outcome in many reviewed studies of other predictors. Those studies with larger cutoff volumes for defining their “large” categories were able to demonstrate strong associations with poor functional outcome. We acknowledge that ICH volume, like age and clinical examination, is likely factored into many clinicians’ early subjective assessments of predicted functional outcomes for their patients with ICH. However, similar to aforementioned variables, the quality of evidence for focusing on ICH volume alone as a potentially reliable predictor of functional outcome was downgraded over (1) risk of bias from self-fulfilling prophecies and (2) possible imprecision. The varying cutoff values among reviewed studies for categorizing small versus large volume hemorrhages, the influence of location on the impact of the volume of an ICH, and significant uncertainty regarding a consensus definition of “poor functional outcome,” as perceived by patients with ICH and their surrogates, were all factored into recommendation development. Similar to age and admission clinical examination, the stakes of an inaccurate prediction of functional outcome and premature limitation of life-sustaining therapy raised the panel’s threshold for comfort in suggesting admission ICH volume alone as having sufficiently precise evidence to be considered as potentially reliable for neuroprognostication discussions.
- Question: When counseling patients with ICH or their surrogates, should an infratentorial location alone be considered a reliable predictor of poor functional outcome assessed at 3 months or later? Description of the predictor: Because of the critical functions of the brainstem in maintaining a patient’s independent functional status, as well as the threat to the brainstem that a cerebellar ICH with sufficient size and/or accompanying cerebral edema can pose, an ICH located inferior to the cerebellar tentorium can often be of particular concern in discussions of prognosis. Most studies of ICH prognostic factors do not define ICH location in more detail aside from this supratentorial versus infratentorial distinction [9]. Recommendation: When counseling patients with ICH or their surrogates, we suggest that an infratentorial location alone of the patient’s ICH not be considered a reliable predictor of poor functional outcome assessed at 3 months or later (weak recommendation; low quality evidence). Rationale: Similar to previously discussed variables, infratentorial ICH location was independently associated with poor ICH outcome in a number of studies. However, the quality of evidence for focusing on infratentorial ICH location alone as a potentially reliable predictor of functional outcome was downgraded over (1) risk of bias from self-fulfilling prophecies and (2) possible imprecision, with wide confidence intervals reported among studies regarding the degree of association between infratentorial location and poor outcome. Also, varying functional neuroanatomy among specific infratentorial locations (e.g., reticular activating system vs. cerebellar hemisphere), the influence of ICH volume on the impact of ICH location, and the recurring uncertainty regarding a consensus definition of poor outcome itself factored into recommendation writing. With regards to a balance of desirable and undesirable consequences, the concern for premature limitation of life-sustaining therapy once again raised the panel’s threshold for suggesting infratentorial ICH volume as having sufficiently precise evidence to be considered as potentially reliable for neuroprognostication discussions, by itself.
- Question: When counseling patients with ICH or their surrogates, should the presence of intraventricular hemorrhage (IVH) on admission alone be considered a reliable predictor of poor functional outcome assessed at 3 months or later? Description of the predictor: IVH, either on its own or in conjunction with ICH, can disrupt normal cerebrospinal fluid (CSF) dynamics and lead to hydrocephalus. Hydrocephalus that is not sufficiently treated may result in mass effect on critical brain structures. Hydrocephalus that is treated with attempted CSF diversion and potentially intraventricular tissue plasminogen activator via an extraventricular drain may still lead to future morbidity and mortality and/or require permanent intracranial shunt placement by neurosurgical teams [145]. Despite the impact of the volume and location of IVH on the degree of CSF flow disruption, IVH is simply reported as present or absent in many studies of ICH prognosis [9]. Recommendation: When counseling patients with ICH or their surrogates, we suggest that the presence of IVH on admission alone not be considered a reliable predictor of poor functional outcome assessed at 3 months or later (weak recommendation; low quality evidence). Rationale: Historically, the presence of IVH, reported as a purely binary variable, has been independently associated with poor ICH outcome [33–41]. The panel downgraded the quality of evidence for focusing on the presence of IVH alone as a potentially reliable predictor of functional outcome due to (1) risk of bias from self-fulfilling prophecies and (2) possible imprecision. Concerns were expressed regarding the lack of information in many studies regarding the degree of IVH among their cohorts, lack of information in the reviewed studies regarding the aggressiveness of treatment of IVH, recurring uncertainty regarding a consensus definition of poor outcome itself, and the stakes that the threat of even occasional premature limitation of life-sustaining therapy raise.
- Question: When counseling patients with ICH or their surrogates, should anticoagulation at the time of the patient’s ICH onset alone be considered a reliable predictor of poor functional outcome assessed at 3 months or later? Description of the predictor: Anticoagulation at the time of ICH onset is a strong risk factor for ICH expansion and neurologic deterioration [42–54]. The mainstay of treatment for anticoagulated patients is to reverse the coagulopathy emergently. Even anticoagulated patients who are reversed emergently face additional clinical challenges, including assessment of continued adequate reversal and decisions involving risks and benefits of restarting anticoagulation, given their original indications for the patient requiring anticoagulation [146]. Recommendation: When counseling patients with ICH or their surrogates, we suggest that anticoagulation at the time of the patient’s ICH onset alone not be considered a reliable predictor of poor functional outcome assessed at 3 months or later (weak recommendation; low quality evidence). Rationale: While many studies have shown a strong independent association between anticoagulation at time of ICH onset and poor functional outcome, the panel downgraded the quality of evidence for focusing on the anticoagulation alone as a potentially reliable predictor. This decision was due to risk of bias from self-fulfilling prophecies; possible imprecision; general lack of information in reviewed studies regarding the speed, method, and success of ICH reversal; general lack of information regarding the types of initial anticoagulation that patients were receiving [46]; recurring uncertainty regarding a consensus definition of poor outcome itself; and, once again, the stakes raised by even the occasional threat of premature limitation of life-sustaining therapy.
Outcome: Functional Outcome
- Question: When counseling family members or surrogates of patients suffering from spontaneous intracerebral hemorrhage, should the “original” ICH score be considered a reliable predictor of functional outcome assessed at three months or later? Description of the prediction model: The original ICH score was initially developed from a bicentric cohort of 152 North American patients with nontraumatic ICH [12]. The original ICH score includes five characteristic factors determined to independent predictors of outcome easily and rapidly determined at time of ICH presentation. GCS score, most strongly associated with outcome, was divided in different groups: GCS score 13 – 15 = 0 points, GCS score 5 – 12 = 1 point, GCS score 3 – 4 = 2 points. Further components are ICH volume, cm3 (≥30; <30); intraventricular extension of hemorrhage (yes/no); infratentorial origin (yes/no); and age, years (≥80; <80). ICH volume ≥ 30 cm3, intraventricular extension of hemorrhage, infratentorial hemorrhage, and age ≥ 80 years are each assigned 1 point. Calculation of the original ICH score gives a sum of maximal 6 points. The validation for functional outcome (3, 6, and 12 months) was provided in a further prospective study of 243 patients with nontraumatic ICH demonstrating a higher likelihood of unfavorable outcome with increasing original ICH score [13]. Numerous studies have performed external validation of the original ICH score in prospective monocentric and multicentric cohorts [11, 110–130], including data analysis of good discrimination (area under the curve (AUC), range from 0.67–0.89) for mortality and unfavorable outcome up to 12-month follow-up. Recommendation: When counseling patients with ICH or their surrogates, we suggest that the patient’s “original” ICH score not be considered a reliable predictor of poor functional outcome at 3 months or later (weak recommendation; low quality evidence). Rationale: The body of evidence for the original ICH score as a predictor of functional outcome was downgraded over concerns regarding (1) possible risk of bias from the self-fulfilling prophecy; and (2) possible imprecision, given its derivation and prospective observational validation studies are mostly monocentric with variable sample sizes. Furthermore, one study has found that the “original” ICH score appears to be outperformed by the early subjective judgment of clinicians with regards to 3-month functional outcome prediction [148]. In addition, the decision to suggest this score as not reliable for real-world prognostication of patients was also influenced by uncertainty regarding values and preferences among individual patients with ICH and/or their surrogates with respect to acceptable outcome.
- Question: When counseling family members or surrogates of patients suffering from spontaneous intracerebral hemorrhage, should the max-ICH score be considered a reliable predictor of functional outcome assessed at three months or later? Description of the prediction model: The max-ICH score was developed to provide severity assessment for functional long-term outcome with minimized confounding by care limitations among 583 patients from a prospective monocentric German registry [55]. The cohort included 112 patients with ICH with early care limitations and 471 with maximal treatment. The max-ICH score focuses on six components which sum up to a maximum of 10 points. Included variables are NIHSS at hospital admission (0–6 = 0 points, 7–13 = 1 point, 14–20 = 2 points, ≥ 21: 3 points); age, years (≥ 69 = 0 points, 70–74 = 1 point, 75–79 = 2 points, ≥80: 3 points); IVH (yes = 1 point); oral anticoagulation (yes = 1 point); lobar ICH volume, cm3 (≥ 30 = 1 point); and nonlobar ICH volume, cm3 (≥ 10 = 1 point). All imaging components indicate measures on initial computed tomography examinations. External validation has been completed in several cohorts [56, 110, 132], with good discrimination and calibration for functional outcome demonstrated. Recommendation: When counseling patients with ICH or their surrogates, we suggest that the patient’s max-ICH score not be considered a reliable predictor of poor functional outcome at 3 months or later (weak recommendation; low quality evidence). Rationale: Quality of evidence for the max-ICH score was downgraded over concerns regarding (1) possible risk of bias, in that analysis of only maximally treated patients with ICH may in turn bias outcomes positively; and (2) relatively limited worldwide validation at this point, in comparison to the original ICH score. Furthermore, results of head-to-head comparisons of the discrimination of the max-ICH score to that the original ICH score for long-term functional outcome prediction at this point have been mixed [110]. No studies have examined either the accuracy of the max-ICH score compared with subjective clinician judgment for 3-month functional outcome prediction. Also, the decision to suggest the max-ICH score as not reliable for real-world prognostication of patients with respect to functional outcome was once again also influenced by uncertainty regarding values and preferences among individual patients with ICH and/or their surrogates with respect to acceptable outcome.
Outcome: Mortality
- RecommendationWhen patients with ICH or their surrogates, we suggest that the patient’s “original” ICH score not be considered a reliable predictor of mortality at 30 daysweak recommendation; very low quality evidence
Abstract
Background: The objective of this document is to provide recommendations on the formal reliability of major clinical predictors often associated with intracerebral hemorrhage (ICH) neuroprognostication.
Methods: A narrative systematic review was completed using the Grading of Recommendations Assessment, Development, and Evaluation methodology and the Population, Intervention, Comparator, Outcome, Timing, Setting questions. Predictors, which included both individual clinical variables and prediction models, were selected based on clinical relevance and attention in the literature. Following construction of the evidence profile and summary of findings, recommendations were based on Grading of Recommendations Assessment, Development, and Evaluation criteria. Good practice statements addressed essential principles of neuroprognostication that could not be framed in the Population, Intervention, Comparator, Outcome, Timing, Setting format.
Results: Six candidate clinical variables and two clinical grading scales (the original ICH score and maximally treated ICH score) were selected for recommendation creation. A total of 347 articles out of 10,751 articles screened met our eligibility criteria. Consensus statements of good practice included deferring neuroprognostication—aside from the most clinically devastated patients—for at least the first 48–72 h of intensive care unit admission; understanding what outcomes would have been most valued by the patient; and counseling of patients and surrogates whose ultimate neurological recovery may occur over a variable period of time. Although many clinical variables and grading scales are associated with ICH poor outcome, no clinical variable alone or sole clinical grading scale was suggested by the panel as currently being reliable by itself for use in counseling patients with ICH and their surrogates, regarding functional outcome at 3 months and beyond or 30-day mortality.
Conclusions: These guidelines provide recommendations on the formal reliability of predictors of poor outcome in the context of counseling patients with ICH and surrogates and suggest broad principles of neuroprognostication. Clinicians formulating their judgments of prognosis for patients with ICH should avoid anchoring bias based solely on any one clinical variable or published clinical grading scale.
Supplementary Information: The online version contains supplementary material available at 10.1007/s12028-023-01854-7.
Contents of the original publication
The section headings of the original.
- Introduction
- Scope, Purpose, and Target Audience
- How to Use These Guidelines
- Methods
- Selection of Predictors
- Selection of Outcomes
- Systematic Review Methodology
- Evidence to Recommendation Criteria
- Good Practice Statements
- Good Practice Statement #1
- Rationale
- Good Practice Statement #2
- Rationale
- Good Practice Statement #3
- Rationale
- Good Practice Statement #4
- Rationale
- Recommendations: Clinical Variables as Predictors
- Outcome: Poor Functional Outcome at 3 Months or Later
- Outcome: Mortality
- Recommendations: Clinical Grading Scales
- Outcome: Functional Outcome
- Outcome: Mortality
- Future Directions
- Conclusions
- Endorsements
- Source of Support
- Ethical Approval/Informed Consent
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