Response to Letter by Di Napoli and Godoy
We have read with great interest the comments by Di Napoli and Godoy concerning our recent article on the proposal of an intracerebral hemorrhage grading scale (ICH-GS).1 The difference between their results and ours highlights the need for a unified scale which is able to adapt to different clinical scenarios. In their external validation of the ICH-GS, Di Napoli and Godoy stressed that they were unable to confirm the superiority of our scale over the original ICH score (oICH score),2 and that their version of the scale, named mICH-B score,3 performed better than ours in predicting mortality and good functional outcome, in a “similar Latin American population.” Nevertheless, both proposals, ours and theirs, are dissimilar. First, the ICH-GS was originally designed to predict in-hospital and 30-day mortality, as well as 30-day good functional outcome, a more realistic scenario for most low-income countries, where early and pragmatic bedside decisions need to be taken. Second, our scale was developed based on patients managed completely in general wards, whereas the mICH-B score was designed on patients included in the Neurocritical Care Unit, which may be a great difference. Third, with the largest sample size to date, in the ICH-GS every component of the scale was obtained by multivariate analysis and not at discretional level, which enables a greater statistical discrimination.
With respect to the mICH-B score, we indeed recognize that adding a variable that in some manner quantifies the amount of blood in the ventricular system (ie, the Graeb score) is a more realistic approach to the estimation of the severity of the ICH, which in turn may improve prediction of outcome. However, the inclusion of variables of the APACHE score plus some other comorbidities need standardization, because some of these comorbidities included in the mICH-B score are actually more related to the ischemic stroke than to ICH. Moreover, we believe that the early recognition and tight management of any of these morbid conditions could favor the mICH-B score in the prognosis of a 6-month functional outcome, over the oICH score and the ICH-GS. Thus, as Di Napoli and Godoy pointed out, the mICH-B score needs external validation.
We currently see a great opportunity to fill the gap of knowledge on ICH, a forgotten form of the cerebrovascular disease, and agree with Di Napoli and Godoy in the need for a collaborative international network aimed to the development of a unified scale for mortality and functional outcome after ICH, which can be used in research protocols and everyday clinical practice.
Ruiz-Sandoval JL, Chiquete E, Romero-Vargas S, Padilla Martínez JJ, González-Cornejo S. Grading scale for prediction of outcome after primary intracerebral hemorrhages. Stroke. 2007; 38: 1641–1644.
Hemphill JC 3rd, Bonovich DC, Besmertis L, Manley GT, Johnston SC. The ICH score: a simple, reliable grading scale for intracerebral hemorrhage. Stroke. 2001; 32: 891–897.
Godoy DA, Pinero G, Di Napoli M. Predicting mortality in spontaneous intracerebral hemorrhage: can modification to original score improve the prediction? Stroke. 2006; 37: 1038–1044.