External Validation of Hematoma Expansion Scores in Spontaneous Intracerebral Hemorrhage in an Asian Patient Cohort

• Published in: Neurocritical care 2019-04, Vol.30 (2), p.394-404
• Main Authors: Lim, Jia Xu, Han, Julian Xinguang, See, Angela An Qi, Lew, Voon Hao, Chock, Wan Ting, Ban, Vin Fei, Pothiawala, Sohil, Lim, Winston Eng Hoe, McAdory, Louis Elliot, James, Michael Lucas, King, Nicolas Kon Kam
• Format: Article
• Language: English
• Subjects: Aged; Aged, 80 and over; Blood pressure; Cerebral Hemorrhage - complications; Cerebral Hemorrhage - diagnosis; Cerebral Hemorrhage - diagnostic imaging; Cohort analysis; Critical Care Medicine; Ethnicity; Female; Glasgow Coma Scale; Hematoma; Hematoma - diagnosis; Hematoma - diagnostic imaging; Hematoma - etiology; Hemorrhage; Hospitals; Humans; Intensive; Internal Medicine; Male; Medical imaging; Medicine; Medicine & Public Health; Middle Aged; Models, Neurological; Mortality; Neurology; Original Article; Patients; Population; Prognosis; Prospective Studies; Risk Assessment; Singapore; Stroke; Tomography
• ISSN: 1541-6933; 1556-0961
• DOI: 10.1007/s12028-018-0631-8

Background Hematoma expansion (HE) occurs in approximately one-third of patients with intracerebral hemorrhage (ICH) and is known to be a strong predictor of neurological deterioration as well as poor functional outcome. This study aims to externally validate three risk prediction models of HE (PREDICT, 9-point, and BRAIN scores) in an Asian population. Methods A prospective cohort of 123 spontaneous ICH patients admitted to a tertiary hospital (certified stroke center) in Singapore was recruited. Logistic recalibrations were performed to obtain updated calibration slopes and intercepts for all models. The discrimination (c-statistic), calibration (Hosmer–Lemeshow test, le Cessie–van Houwelingen–Copas–Hosmer test, Akaike information criterion), overall performance (Brier score, R 2 ), and clinical usefulness (decision curve analysis) of the risk prediction models were examined. Results Overall, the recalibrated PREDICT performed best among the three models in our study cohort based on the novel matrix comprising of Akaike information criterion and c-statistic. The PREDICT model had the highest R 2 (0.26) and lowest Brier score (0.14). Decision curve analyses showed that recalibrated PREDICT was more clinically useful than 9-point and BRAIN models over the greatest range of threshold probabilities. The two scores (PREDICT and 9-point) which incorporated computed tomography (CT) angiography spot sign outperformed the one without (BRAIN). Conclusions To our knowledge, this is the first study to validate HE scores, namely PREDICT, 9-Point and BRAIN, in a multi-ethnic Asian ICH patient population. The PREDICT score was the best performing model in our study cohort, based on the performance metrics employed in this study. Our findings also showed support for CT angiography spot sign as a predictor of outcome after ICH. Although the models assessed are sufficient for risk stratification, the discrimination and calibration are at best moderate and could be improved.