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(Stroke. 2003;34:6.)
© 2003 American Heart Association, Inc.

Letters to the Editor

The ICH Score: Predicting Mortality and Functional Outcome in an Asian Population

Roland Dominic G. Jamora, MD; Emilio M. Kishi-Generao, Jr, MD; Ester S. Bitanga, MD Robert N. Gan, MD

Department of Neurosciences and Diosdado Macapagal Stroke Center, University of the Philippines, Philippine General Hospital, Manila, Philippines

Natalie Emperatriz P. Apaga, MD Ma. Cristina Z. San Jose, MD

Institute for Neurosciences, St Luke’s Medical Center, Quezon City, Philippines

To the Editor:

We were impressed by the simplicity yet apparent accuracy of the ICH scoring system proposed by Hemphill and coworkers.¹ The score included factors that were found to be independent predictors of poor prognosis not only in their data set but in most other previously published studies as well. In response to their call for its validation in an independent cohort, Fernandes et al² tested the score on 393 patients admitted to their neurosurgical unit in the United Kingdom. While ICH score was predictive of mortality at neurosurgical discharge, they felt that it was not as useful in predicting independent recovery because of a high rate of unfavorable outcome (severe disability, death, or vegetative state) even at a score of 2.

We were interested to see whether the proposed ICH score will prove valid in predicting not only mortality but also eventual functional outcome in our Asian population. Our local data show that intracerebral hemorrhage accounts for approximately 21% of hospitalized stroke cases. For the year 2001, we prospectively collected data on 302 patients with spontaneous ICH consecutively admitted to two major medical centers in the Philippines: the Philippine General Hospital and St Luke’s Medical Center. Data on 30-day mortality and modified Rankin scale (MRS) were complete in only 243 patients.

Infratentorial hemorrhage accounted for 12% of our cohort. Yet none of our patients scored 6. Only 3 patients scored 5 (1%), 18 scored 4 (7%), 28 scored 3 (12%), 52 scored 2 (21%), 70 scored 1 (29%), and 72 scored 0 (30%).

Overall 30-day mortality in our study was only 23%. The relationship between ICH score and 30-day mortality is shown in Figure 1. We likewise found the score to be predictive of poor functional outcome (MRS 4) at discharge and even more so at 30 days after discharge (Figure 2). This is in contrast to the results of Fernandes and coworkers² who did not find the ICH score to be as helpful in this aspect maybe because they evaluated outcome too early at discharge without accounting for the eventual improvement in function over time.

View larger version (12K): [in this window] [in a new window]   Figure 1. The ICH score and 30-day mortality.

View larger version (37K): [in this window] [in a new window]   Figure 2. The ICH score and proportion of patients with modified Rankin score of 4 at discharge and one month after discharge.

Our results support the validity of the ICH score in predicting both mortality and eventual early functional outcome in our population. A subsequent analysis of functional outcome at a more meaningful time point, eg, 6 months, may be more revealing as suggested by Hemphill et al.³ As of the moment, however, one should observe caution in unintentionally using the ICH score in making treatment decisions. We propose that future investigations in the role of surgical interventions in intracerebral hemorrhage be stratified according to ICH score. Indeed, the results of such study will help standardize medical and surgical treatment protocols in intracerebral hemorrhage.

References

1. Hemphill JC III, Bonovich DC, Besmertis L, Manley GT, Johnston SC. The ICH score: a simple, reliable grading scale for intracerebral hemorrhage. Stroke. 2001; 32: 891–897.[Abstract/Free Full Text]
2. Fernandes H, Gregson BA, Siddigue MS, Mendelow AD. Testing the ICH score: letter to the editor. Stroke. 2002; 33: 1455–1456.[Free Full Text]
3. Hemphill JC III, Bonovich DC, Johnston SC, Manley GT. Testing the ICH score: response. Stroke. 2002; 33: 1455–1456.[Free Full Text]

J. Claude Hemphill, III, MD; David C. Bonovich, MD S. Claiborne Johnston, MD, PhD

Department of Neurology

Geoffrey T. Manley, MD, PhD

Department of Neurosurgery, University of California, San Francisco, San Francisco, Calif

Response

Jamora et al describe their study in which they undertook to validate the ICH score in their own population from two medical centers in the Philippines. Overall, they found that the ICH score accurately risk stratified patients with regard to 30-day mortality (the outcome measure used in our original description of the ICH score), and that this risk stratification may extend to functional outcome, at least at 30 days after ICH. This was true despite a different distribution of patient ICH scores and a different 30-day mortality rate between their cohort and the UCSF ICH cohort used for initial development of the ICH score.¹ We are pleased that Jamora and colleagues have subjected the ICH score to critical appraisal in their distinct population and believe that their study has several merits worthy of mention.

By prospectively gathering data, they avoided biases that might occur in retrospective record review from missing or incomplete data. Also, their Asian population likely represents a group of patients ethnically and culturally distinct from both the UCSF ICH cohort and that of Fernandes et al.² This suggests that specific culturally unique aspects related to patient or physician decision-making in ICH do not bias the applicability of the ICH score. Finally, they apply a different outcome measure, functional outcome on the modified Rankin Scale, in order to further test the ICH score.

Not mentioned in their study is whether they actually used the ICH score for clinical decision making during the period in which they were prospectively validating this scale. We agree with their comment in the final paragraph of their letter that caution should be exercised in utilizing the ICH score for making treatment decisions in individual patients and assume that this implies that they did not introduce this source of bias into their prospective validation study. Interestingly, although their Figure 2 suggests that the ICH score may risk stratify functional outcome at 30 days as well, it also affirms that 30 days after ICH is probably too early to detect the level of improvement that is best assessed by functional outcome scales such as the modified Rankin Scale.

We appreciate that Jamora and colleagues have done what we could not: validate the ICH score in a group of patients geographically remote and culturally distinct from that of our original UCSF ICH cohort. This type of international critical appraisal of clinical grading scales and diagnostic tests is an invaluable way to advance collaboration in stroke. Perhaps more than anything, we hope that this ongoing dialogue about the ICH score has raised awareness and engendered enthusiasm for the daunting task ahead: finding an effective treatment for intracerebral hemorrhage.

References

1. Hemphill JC III, Bonovich DC, Besmertis L, Manley GT, Johnston SC. The ICH score: a simple, reliable grading scale for intracerebral hemorrhage. Stroke. 2001; 32: 891–897.[Abstract/Free Full Text]
2. Fernandes H, Gregson BA, Siddique MS, Mendelow AD. Testing the ICH score: letter to the editor. Stroke. 2002; 33: 1455–1456.[Free Full Text]

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