Original Intracerebral Hemorrhage Score for the Prediction of Short-Term Mortality in Cerebral Hemorrhage: Systematic Review and Meta-Analysis.

OBJECTIVES: To systematically assess the discrimination and calibration of the Intracerebral Hemorrhage score for prediction of short-term mortality in intracerebral hemorrhage patients and to study its determinants using heterogeneity analysis. DATA SOURCES: PubMed, ISI Web of Knowledge, Scopus, and CENTRAL from inception to September 15, 2018. STUDY SELECTION: Adult studies validating the Intracerebral Hemorrhage score for mortality prediction in nontraumatic intracerebral hemorrhage at 1 month/discharge or sooner. DATA EXTRACTION: Data were collected on the following aspects of study design: population studied, level of care, timing of outcome measurement, mean study year, and mean cohort Intracerebral Hemorrhage score. The summary measures of interest were discrimination as assessed by the C-statistic and calibration as assessed by the standardized mortality ratio (observed:expected mortality ratio). Random effect models were used to pool both measures. Heterogeneity was measured using the I statistic and explored using subgroup analysis and meta-regression. DATA SYNTHESIS: Fifty-five studies provided data on discrimination, and 35 studies provided data on calibration. Overall, the Intracerebral Hemorrhage score discriminated well (pooled C-statistic 0.84; 95% CI, 0.82-0.85) but overestimated mortality (pooled observed:expected mortality ratio = 0.87; 95% CI, 0.78-0.97), with high heterogeneity for both estimates (I 80% and 84%, respectively). Discrimination was affected by study mean Intracerebral Hemorrhage score (ß = -0.05), and calibration was affected by disease severity, with the score overestimating mortality for patients with an Intracerebral Hemorrhage score greater than 3 (observed:expected mortality ratio = 0.84; 95% CI, 0.78-0.91). Mortality rates were reproducible across cohorts for patients with an Intracerebral Hemorrhage score 0-1 (I = 15%). CONCLUSIONS: The Intracerebral Hemorrhage score is a valid clinical prediction rule for short-term mortality in intracerebral hemorrhage patients but discriminated mortality worse in more severe cohorts. It also overestimated mortality in the highest Intracerebral Hemorrhage score patients, with significant inconsistency between cohorts. These results suggest that mortality for these patients is dependent on factors not included in the score. Further studies are needed to determine these factors.

Assessment and Comparison of the Four Most Extensively Validated Prognostic Scales for Intracerebral Hemorrhage: Systematic Review with Meta-analysis.

BACKGROUND/OBJECTIVE: Intracerebral hemorrhage (ICH) is a devastating disorder, responsible for 10% of all strokes. Several prognostic scores have been developed for this population to predict mortality and functional outcome. The aim of this study was to determine the four most frequently validated and most widely used scores, assess their discrimination for both outcomes by means of a systematic review with meta-analysis, and compare them using meta-regression. METHODS: PubMed, ISI Web of Knowledge, Scopus, and CENTRAL were searched for studies validating the ICH score, ICH-GS, modified ICH, and the FUNC score in ICH patients. C-statistic was chosen as the measure of discrimination. For each score and outcome, C-statistics were aggregated at four different time points using random effect models, and heterogeneity was evaluated using the I2 statistic. Score comparison was undertaken by pooling all C-statistics at different time points using robust variance estimation (RVE) and performing meta-regression, with the score used as the independent variable. RESULTS: Fifty-three studies were found validating the original ICH score, 14 studies were found validating the ICH-GS, eight studies were found validating the FUNC score, and five studies were found validating the modified ICH score. Most studies attempted outcome prediction at 3 months or earlier. Pooled C-statistics ranged from 0.76 for FUNC functional outcome prediction at discharge to 0.85 for ICH-GS mortality prediction at 3 months, but heterogeneity was high across studies. RVE showed the ICH score retained the highest discrimination for mortality (c = 0.84), whereas the modified ICH score retained the highest discrimination for functional outcome (c = 0.80), but these differences were not statistically significant. CONCLUSIONS: The ICH score is the most extensively validated score in ICH patients and, in the absence of superior prediction by other scores, should preferably be used. Further studies are needed to validate prognostic scores at longer follow-ups and assess the reasons for heterogeneity in discrimination.

Prognostic models for intracerebral hemorrhage: systematic review and meta-analysis.

BACKGROUND: Prognostic tools for intracerebral hemorrhage (ICH) patients are potentially useful for ascertaining prognosis and recommended in guidelines to facilitate streamline assessment and communication between providers. In this systematic review with meta-analysis we identified and characterized all existing prognostic tools for this population, performed a methodological evaluation of the conducting and reporting of such studies and compared different methods of prognostic tool derivation in terms of discrimination for mortality and functional outcome prediction. METHODS: PubMed, ISI, Scopus and CENTRAL were searched up to 15th September 2016, with additional studies identified using reference check. Two reviewers independently extracted data regarding the population studied, process of tool derivation, included predictors and discrimination (c statistic) using a predesignated spreadsheet based in the CHARMS checklist. Disagreements were solved by consensus. C statistics were pooled using robust variance estimation and meta-regression was applied for group comparisons using random effect models. RESULTS: Fifty nine studies were retrieved, including 48,133 patients and reporting on the derivation of 72 prognostic tools. Data on discrimination (c statistic) was available for 53 tools, 38 focusing on mortality and 15 focusing on functional outcome. Discrimination was high for both outcomes, with a pooled c statistic of 0.88 for mortality and 0.87 for functional outcome. Forty three tools were regression based and nine tools were derived using machine learning algorithms, with no differences found between the two methods in terms of discrimination (p = 0.490). Several methodological issues however were identified, relating to handling of missing data, low number of events per variable, insufficient length of follow-up, absence of blinding, infrequent use of internal validation, and underreporting of important model performance measures. CONCLUSIONS: Prognostic tools for ICH discriminated well for mortality and functional outcome in derivation studies but methodological issues require confirmation of these findings in validation studies. Logistic regression based risk scores are particularly promising given their good performance and ease of application.