Possibilities of verification of a short-term functional outcome prognosis in the acute period of spontaneous supratentorial intracerebral hemorrhage using modified variants of the Intracerebral Hemorrhage Scale

Materials and methods. A total of 122 conservatively treated patients (mean age was 64.7 ± 1.1 years old) in the acute period of SSICH were enrolled in a prospective study. Clinical and neuroimaging assessment of the patients’ condition severity was conducted on admission to hospital using the ICH Scale and its modified versions (mICH-A, mICH-B). The value >3 in accordance with the modified Rankin Scale on the 21st day of disease was considered as unfavourable functional outcome in SSICH. The ROC analysis was used for the comparative analysis of the scales’ informative value and for the criteria development.

The choice of optimal tactics for patient management with spontaneous supratentorial intracerebral hemorrhage (SSICH) is one of the most difficult and, unfortunately, still unsolved problems in modern neurology [1]. It is highly important from the medical and social point of view due to leading positions of this pathology in the cause-of-death and disability structure among the adult population in most countries of the world [2,3].
One of the most effective ways of solving the problem is to develop a differentiated approach to the optimal treatment strategy choice, taking into consideration an individual shortterm prognosis [1,4]. In this context, it is appropriate to use the tools of clinical neuroimaging assessment of the severity at the disease onset. The "gold standard" in this area is the original Intracerebral Hemorrhage (oICH) Scale, which demonstrated a high informative value when used to detect the risk for a lethal outcome of acute hemorrhagic stroke [5,6].
At the same time, the results of our previous study showed a significantly lower informative value of the oICH Scale when used to evaluate a short-term functional prognosis in this cohort of patients [7]. All of the above justifies the search for alternative tools for clinical neuroimaging scoring. In view of these facts, our attention was drawn to modified versions of the oICH Scale [8]. Available research literature did not reveal any information on the studies related to the development of criteria for the short-term functional outcome after SSICH in the acute period using modified oICH Scale variants.

The aim
The aim of the study was to analyze a diagnostic informative value of modified variants of the Intracerebral Hemorrhage Scale as techniques for detecting adverse functional outcome risk in the acute period of SSICH.

Materials and methods
The study included 122 patients with SSICH (65 men and 57 women, the mean age was 64.7 ± 1.1 years old) who were admitted to the Brain Circulation Disorders Department of the Municipal Institution "Zaporizhzhia City Clinical Hospital No 6" within the first 24 hours from the disease onset and underwent conservative therapy.
The diagnosis was confirmed by the results of a neuroimaging study, which was performed on admission with the use of a computed tomography scanner "Simens Somatom Spirit". The site and size of lesion, midline shift and a secondary intraventricular hemorrhage (SIVH) presence were assessed. The lesion size (ICH volume) was calculated based on ellipsoid formula: ICH volume (mL) = а*b*c, where а, b and c are linear sizes of lesion (mm). The severity of a SIVH was evaluated using the Graeb Scale.
Integral clinical and neuroimaging assessment of the patients' condition severity was conducted using the oICH score and its modified versions (mICH-A, mICH-B). The functional outcome of SSICH in the acute period was assessed using the modified Rankin Scale (mRS), thus mRS score >3 on the 21st day after admission was considered as unfavourable functional outcome of the disease.
Statistical analysis of the obtained data was conducted using Statistica 13.0 software (StatSoft Inc., USA, series number JPZ804I382130ARCN10-J) and MedCalc (version 16.4). Shapiro-Wilk criterion was used in order to assess the distribution normality. As the distribution of the majority of indexes differed from a normal one, descriptive statistics were presented as a median and interquartile range. The intergroup differences were compared based on the Mann-Whitney criterion. A ROC analysis was carried out to develop prognosis criteria and to evaluate their informative value. A P-value ˂ 0.05 was considered to be statistically significant.

Results
The unfavourable functional outcome in the acute period of SSICH was registered in 50 (41 %) patients. The frequency of the unfavourable outcome in the acute period of SSICH in patients with different values of the mICH-A Scale score and mICH-B Scale score is presented in Tables 1 and 2.
The gradations distribution of the mICH-A Scale and mICH-B Scale subtest values in comparison with the func-tional outcome in the acute period of SSICH is presented in Tables 3 and 4.
As the data shows, the presence and severity of SIVH (Pearson's chi-squared test statistic = 32.8 for the mICH-A Scale, P ˂ 0.0001; Pearson's chi-squared test statistic = 32.6 for the mICH-B Scale, P ˂ 0.0001), as well as the patient's age (Pearson's chi-squared test statistic = 17.0 for the mICH-A Scale, P = 0.0002; Pearson's chi-squared test statistic = 15.0 for the mICH-B Scale, P ˂ 0.0001) were associated with the functional outcome in the acute period of SSICH. At the same time, patients with different variants of the functional outcome of SSICH in the acute period were not only of different ages and the Graeb Scale score at the disease onset, but also they had different the Glasgow Coma Scale score and intracerebral hemorrhage volume ( Table 5).
It was determined that the mICH-A Scale score >2 and the mICH-B Scale score >1 were associated with the risk of an unfavourable functional outcome of SSICH in the acute period, multiplied by 3.6 (RR 95 % CI 3.1-4.1, P ˂ 0.0001) and 3.2, respectively, (RR 95 % CI 2.8-3.6, P ˂ 0.0001) ( Table 6).

Discussion
In the course of the study, it was determined that the modified versions of the oICH Scale were informative tools to detect an individual risk for an unfavourable functional      outcome of SSICH in the acute period. The AUC values of the specified scales (≥0.80) corresponded to the gradation "very good" in accordance with the International Expert Scale for the quality of binary classifiers assessment (1993) [9]. In our opinion, a high informative value of these scales was supported by the integral assessment of clinical and neuroimaging data, which were associated with the outcome of disease in the acute period. The obtained data are consistent with the results of meta-analysis, which proved the prognostic value of the patient's age, initial level of consciousness and intracerebral hemorrhage volume in patients with cerebral hemorrhagic hemispheric stroke [10]. Based on the ROC analysis, the mICH-A Scale score (>2) and the mICH-B Scale score (>1) were determined along with an optimal sensitivity and specificity ratio, being associated with the risk of the mRS score >3 on the 21 st day of the disease, multiplied by 3.6 (RR 95 % CI 3.1-4.1, P ˂ 0.0001) and 3.2, respectively, (RR 95 % CI 2.8-3.6, P ˂ 0.0001). The accuracy of functional prognosis verification for SSICH outcome in the acute period using these criteria exceeded 75.0 %, while there were no statistically significant differences in the AUC values between the mICH-A and mICH-B Scales (P = 0.2771). At the same time, these scales had a higher informative value in comparison with the oICH Scale with regard to detection of an individual risk for an unfavourable functional outcome of SSICH in the acute period, which, in our opinion, was attributed to a quantitative assessment of SIVH severity, unlike the oICH Scale. The interrelation between the Graeb Scale score and the functional outcome of SSICH in the acute period was revealed (Pearson's chi-squared test P ˂ 0.0001 for both scales), which proves the above-mentioned hypothesis. The obtained data are consistent with the results of other studies, which demonstrated the negative effect of SIVH severity on the SSICH outcome [11,12].
All of the above justifies the expediency of using the modified versions of the oICH Scale in order to make a short-term functional prognosis of SSICH outcome in the acute period. The perspective for the further scientific research is to assess the informative value of modified versions of the ICH Scale for a short-term vital prognosis determination in patients with SSICH.

Funding
The study is funded as a part of scientific research work at Zaporizhzhia State Medical University "Improving diagnosis and treatment of cerebral circulation disorders at different stages of the disease", number of state registration 0118U007145 (2018-2023).
Conflicts of interest: author has no conflict of interest to declare.   Оригинальные исследования