Possibilities of clinical neuroimaging assessment scales using for patient severity in the onset of cerebral hemorrhagic supratentorial stroke to predict the outcome of the disease acute period

Materials and methods. A prospective, cohort, complex clinical and paraclinical study was conducted in 124 patients (72 men and 52 women, mean age 64.7 ± 1.1 years) with CHSS. This study included clinical assessment using National Institute of Health Stroke Scale and Glasgow Coma Scale, visualization of cerebral structures and integrated assessment of health state severity using the Hemphill-ICH Scale and ICH-GS. The functional outcome of the acute period was determined by the modified Rankin Scale.


Introduction
Cerebral hemorrhagic stroke (CHS) is at leading positions as for the structure of death and disability causes in young and middle-aged people in most countries of the world [2,6,12]. The most common focus of intracerebral haemorrhages is the supratentorial localization [13,15].
One of the ways to improve the effectiveness of treatment activities in this contingent of patients is a differentiated definition of optimal therapeutic tactics with regard to individual vital and functional prognosis of the disease acute period outcome [4,5,10].
Numerous studies have convincingly proved the connexion between the initial neurological deficiency level, structural changes in brain substance and the outcome of cerebral hemorrhagic supratentorial stroke (CHSS), which justifies the advisability of complex clinical-neuroimaging scales using in assessment of patient severity for verifying the prognosis [3,7,8,11,14]. In accordance with the results of the meta-analysis, the Hemphill Intracerebral Hemorrhage (Hemphill-ICH) Scale and ICH-Grading Scale (ICH-GS) are the most informative for the prediction of patient survival during the first half of the year after CHS [9].
However, unified criteria for the CHSS acute period outcome prediction along with the optimal sensitivity (Se) and specificity (Sp) ratio, which would take into account the results of the assessment on the indicated scales, are currently unavailable.
The aforesaid served a thematic justification of this study.

Purpose
The main purpose of the study was to determine the criteria for the vital and functional prognosis of the acute period outcome of cerebral hemorrhagic supratentorial stroke based on the Hemphill-ICH Scale and ICH-GS in the onset of the disease.

Materials and methods
To achieve the goal, a prospective, cohort, complex clinical and paraclinical study was conducted in 124 patients (72 men and 52 women, mean age 64.7 ± 1.1 years) with CHSS. They were treated at Cerebrovascular Accident Department of the Municipal Institution "Zaporizhzhia City Clinical Hospital No. 6".
Inclusion criteria were: 1) spontaneous supratentorial intracerebral hemorrhage confirmed by the clinical computed tomography study; 2) hospitalization within the first 24 hours since the onset of the disease; 3) a signed informed consent form for the participation in the study; Exclusion criteria were: 1) presence of acute disorders of cerebral circulation in the anamnesis; 2) primary subarachnoid and / or intramuscular hemorrhage; 3) ≥2 lesions; 4) the presence of indications for surgical treatment upon the examination held by a neurosurgeon; 5) the presence of oncologic pathology in the medical history; 6) decompensated stage of somatic pathology; 7) extracerebral cause of death in accordance with the autopsy results.
All patients underwent clinical neurological examination along with the initial levels of neurologic deficits assessment in accordance with the National Institute of Health Stroke Scale and cerebral syndrome assessment in accordance with the Glasgow Coma Scale. The functional outcome of the acute period was determined by the modified Rankin Scale. The value of 4-5 points were considered as unfavourable functional outcome of CHSS acute period, and ≤3 points on the 21 st day of the disease were considered as favourable.
The visualization of cerebral structures was carried out with the help of Computed Tomography Scanner «Siemens Somatom Spirit» within the first 24 hours since the onset of the disease, taking into consideration the lesion size (LS), the severity of dislocation syndrome due to the median brain structures displacement, the presence of blood breakthrough into the ventricular system of the brain. The LS was calculated in accordance with the ellipsoid formula: LS (ml) = a * b * c/2, where a, b, c are linear dimensions of the lesion (cm).
The Hemphill-ICH Scale and ICH-GS were used for the integrated assessment of health state severity in patients with cerebral hemorrhagic supratentorial stroke. They take Оригинальные исследования into account different age gradations, the severity of brain syndrome in accordance with the Glasgow Coma Scale upon hospitalization LS and localization and the presence of blood breakthrough into the ventricular system of the brain.
All patients underwent conservative therapy in accordance with the Unified Clinical Protocol for the provision of medical care to patients with cerebral hemorrhagic stroke, approved by the order of the Ministry of Health of Ukraine No. 275, dated April 17, 2014 [1]. The statistical data processing was carried out with the help of Statistica 6.0 software (Stat-Soft Inc., USA, series number AXXR712D833214FAN5) and MedCalc software (version 16.4). Descriptive statistics were presented in the form of the mean value and the standard error of the mean value (M ± m). Receiver operating characteristic (ROC) analysis and relative risk (RR) calculation were used for the determination of predictive criteria.

Results and discussion
Clinical and neuroimaging characteristics of examined patients in the onset of the disease are presented in the Table 1.
Lethal outcome (12.1 %), relatively unfavourable functional outcome in the form of 4-5 points on the Rankin Scale (37.9 %) and relatively favourable functional outcome in the form of ≤3 points on the aforementioned scale (50.0 %) were registered in the outcome structure in the acute period of the disease.
In accordance with the ROC analysis, it has been established that the predictors of disease acute period lethal outcome are the Hemphill-ICH Scale score ≥ 2 (Se = 77.3 %, Sp = 77.5 %) and ICH-GS score ≥8 (Se = 54.6 %, Sp = 86.3 %).
The frequency distribution of CHSS acute period lethal outcome in terms of the Hemphill-ICH Scale and ICH-GS is shown in the Table 2.
It has been determined that the Hemphill-ICH Scale is characterized by a higher informative value for the vital prognosis of CHSS acute period (AUC = 0.84) in comparison with the ICH-GS (AUC = 0.78, P < 0.05).
Criteria for prognosis of CHSS acute period outcome, based on the assessment of patients in the onset of the disease in accordance with the Hemphill-ICH scale and ICH-GS, are integrated in the Table 3.
It has been determined that the Hemphill-ICH Scale is inferior to ICH-GS as for the predictive value related to functional recovery degree determination upon the 21st day after CHSS (AUC 0.61 vs. 0.69, P < 0.05).
The comparative analysis of AUC values allows to state that the Hemphill-ICH Scale and ICH-GS are more informative for vital, rather than functional, prognosis of CHSS acute period outcome (AUC = 0.84 vs AUC = 0.61 for Hemphill-ICH Scale, P < 0.05; AUC = 0.78 vs AUC = 0.69 for ICH-GS, P < 0.05).
The results of the obtained criteria quality assessment for vital and functional prognosis of CHSS acute period outcome in accordance with M. H. Zweig, G. Campbell Scale (1993) [16], which takes into account the AUC value, are shown in the Table 4.
Thus, the study made it possible to develop informative criteria for the short-term vital and functional prognosis of CHSS acute period outcome with the optimal sensitivity and specificity ratio in accordance with the Hemphill-ICH scale and ICH-GS. At the same time, the results of the analysis of AUC indicators based on these scales justify the advisability of the more informative criteria elaboration for predicting vital and, in particular, functional outcome of CHSS acute period.    2. The Hemphill-ICH Scale score = 0 (Se = 79.6 %, Sp = 28.3 %) and the ICH-GS score = 5 (Se = 59.2 %, Sp = 71.7 %) are the criteria for the favourable functional outcome of CHSS acute period (mRS score ≤3 on the 21st day).
3. The Hemphill-ICH Scale is characterized by a higher informative value for CHSS acute period lethal outcome prediction (AUC = 0.84) in comparison with the ICH-GS (AUC = 0.78, P < 0.05).
4. The ICH-GS is characterized by a higher informative value for the functional prognosis of CHSS acute period outcome (AUC = 0.69) in comparison with the Hemphill-ICH Scale (AUC = 0.61, P < 0.05).
5. The informative value of the Hemphill-ICH Scale and ICH-GS is higher for the vital prognosis than for the verification of the functional prognosis of CHSS acute period outcome.
The perspective for the further scientific research is the elaboration of mathematical models for the CHSS acute period outcome prediction, which take into account complex results of clinical and neurovisual research at onset of disease.