Predicting long-term outcomes in acute intracerebral haemorrhage using delayed prognostication scores

Objective The concept of the‘self-fulfilling prophecy’is well established in intracerebral haemorrhage(ICH).The ability to improve prognostication and prediction of long-term outcomes during the first days of hospitalisation is important in guiding conversations around goals of care.We previously demonstrated that incorporating delayed imaging into various prognostication scores for ICH improves the predictive accuracy of 90-day mortality.However,delayed prognostication scores have not been used to predict long-term functional outcomes beyond 90 days.Design,setting and participants We analysed data from the ICH Deferoxamine trial to see if delaying the use of prognostication scores to 96 hours after ICH onset will improve performance to predict outcomes at 180 days.276 patients were included.Interventions and measurements We calculated the original ICH score(oICH),modified-ICH score(MICH),max-ICH score and the FUNC score on presentation(baseline),and on day 4(delayed).Outcomes assessed were mortality and poor functional outcome in survivors(defined as modified Rankin Scale of 4-5)at 180 days.We generated receiver operating characteristic curves,and measured the area under the curve values(AUC)for mortality and functional outcome.We compared baseline and delayed AUCs with non-parametric methods.Results At 180 days,21 of 276(7.6%)died.Out of the survivors,54 of 255 had poor functional outcome(21.2%).The oICH,MICH and max-ICH performed significantly better at predicting 180-day mortality when calculated 4 days later compared with their baseline equivalents((0.74 vs 0.83,p=0.005),(0.73 vs 0.80,p=0.036),(0.74 vs 0.83,p=0.008),respectively).The delayed calculation of these scores did not significantly improve our accuracy for predicting poor functional outcomes.Conclusion Delaying the calculation of prognostication scores in acute ICH until day 4 improved prediction of 6-month mortality but not functional outcomes.Trial registration number ClinicalTrials.gov Registry(NCT02175225).

Decline in subarachnoid haemorrhage volumes associated with the first wave of the COVID- 19 pandemic

Background During the COVID-19 pandemic,decreased volumes of stroke admissions and mechanical thrombectomy were reported.The study’s objective was to examine whether subarachnoid haemorrhage(SAH)hospitalisations and ruptured aneurysm coiling interventions demonstrated similar declines.Methods We conducted a cross-sectional,retrospective,observational study across 6 continents,37 countries and 140 comprehensive stroke centres.Patients with the diagnosis of SAH,aneurysmal SAH,ruptured aneurysm coiling interventions and COVID-19 were identified by prospective aneurysm databases or by International Classification of Diseases,10th Revision,codes.The 3-month cumulative volume,monthly volumes for SAH hospitalisations and ruptured aneurysm coiling procedures were compared for the period before(1 year and immediately before)and during the pandemic,defined as 1 March-31 May 2020.The prior 1-year control period(1 March-31 May 2019)was obtained to account for seasonal variation.Findings There was a significant decline in SAH hospitalisations,with 2044 admissions in the 3 months immediately before and 1585 admissions during the pandemic,representing a relative decline of 22.5%(95%CI−24.3%to−20.7%,p<0.0001).Embolisation of ruptured aneurysms declined with 1170-1035 procedures,respectively,representing an 11.5%(95%CI−13.5%to−9.8%,p=0.002)relative drop.Subgroup analysis was noted for aneurysmal SAH hospitalisation decline from 834 to 626 hospitalisations,a 24.9%relative decline(95%CI−28.0%to−22.1%,p<0.0001).A relative increase in ruptured aneurysm coiling was noted in low coiling volume hospitals of 41.1%(95%CI 32.3%to 50.6%,p=0.008)despite a decrease in SAH admissions in this tertile.Interpretation There was a relative decrease in the volume of SAH hospitalisations,aneurysmal SAH hospitalisations and ruptured aneurysm embolisations during the COVID-19 pandemic.These findings in SAH are consistent with a decrease in other emergencies,such as stroke and myocardial infarction.