ICH-GRAEB COMBINATION SCORE IMPROVES OUTCOME PREDICTION IN SPONTANEOUS INTRACEREBRAL HEMORRHAGE
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ICH-GRAEB COMBINATION SCORE IMPROVES OUTCOME PREDICTION IN SPONTANEOUS INTRACEREBRAL HEMORRHAGE
- 1. COMBINATION ICH-GRAEB SCORE IMPROVES PREDICTION OF OUTCOME IN SPONTANEOUS INTRACEREBRALHEMORRHAGE Saputra A/ Niryana W Department of Surgery/ Faculty of Medicine Udayana University/ Sanglah General Hospital, Bali
- 2. Spontaneous Intracerebral Hemorrhage (ICH) 10-15% Morbidity & Mortality IVH secondary to ICH → 𝟑𝟐% 𝐝𝐞𝐚𝐭𝐡 43% poor functional outcome DECISION OF SURGERY ? • Do I need to operate? • When should to operate? Prognostic score model ANATOMICAL & PHYSIOLOGICAL
- 3. Caplan L.R. 2009. Caplan’s stroke a clinical approach 4th ed. Saunders. Elsevier
- 4. − Initial ICH volume of 60cc or greater - Severe Hydrocephalus - GCS score of 8 or less - Age 70 years and older Were INDEPENDENT OUTCOME PREDICTORS.
- 5. - Intraventricular hemorrhage (IVH) occurs in nearly half of patients with spontaneous intracerebral hemorrhage (ICH) - Patients with IVH were twice as likely to have a poor outcome
- 6. - Elderly patients - IVH volume - Acute Hydrocephalus - Poor initial level of consciousness SIGNIFICANTLY associated unfavourable prognosis in IVH group (Graeb score ≥ 𝟔)
- 7. - Removal of cloth include limitation of inflammation, edema, and cell death as well as restoration of CSF flow
- 8. IVH is an independent predictor of poor outcome in ICH Larger IVH volume and increasing number of affected ventricles have been associated with worse prognosis Little is known about the prognostic value of blood volume in the different parts of the ventricular system There is correlation of IVH volume in with outcome in patients with ICH
- 9. Prognosis Physiologic: • Age • GCS Anatomic: Based on CT scan ICH Score Graeb Score COMBINATION ? Improved outcome?
- 11. IIIrd IVth R Lat L Lat
- 12. Data prospective observational 88 patients - Age - GCS - ICH Volume - Outcome (modified Rankin Scale in 30 days) - Graeb Score, blood in lateral, third and fourth ventricle was estimated from Head CT scan: 1-4 MILD 5-8 MODERATE 9-12 SEVERE Analyzed using SPSS 17.0
- 13. Characteristic Mean Age, y 56.215.2 GCS 8.63.6 Volume ICH (ml) 45.137.9 Graeb Score 4.64.2 Male 41 59% Female 29 41% Gender
- 14. Supra Tentori al 20 23%Infra Tentori al 68 77% Location of ICH 45 20 11 4 15 BASAL GANGLIA THALAMUS LOBAR PONTINE CEREBELLAR Site of ICH
- 15. With IVH 59 67% Without IVH 29 33% Presence of IVH
- 20. 1.8 69 73.3 70.4 1.7 77.6 53.3 69.3 1.9 82.8 50 71.6 0 10 20 30 40 50 60 70 80 90 ICH Score Graeb Score Combination RR Sensitivity CI 95% Specificity (%) NPP NPN Accuracy (%) (%) (%) ICH score 1.8 69 73.3 83.3 55 70.4 Graeb score 1.7 77.6 53.3 76.3 55.2 69.3 Combination ICH-Graeb If Conservative If Surgical 1.9 82.8 76.9 84.4 50 77.8 38.1 76.2 83.3 74.5 60 70 53.3 71.6 RESULT
- 21. Prognosis → Based on decision maker of management Scoring → 1. to translate the severity of injury into a score 2. allows quantification of severity of injury 3. to predict outcome
- 22. END POINT: COMBINATION of anatomical – physiological create higher sensitivity and greater validity in outcome prediction
- 23. Used in Screening tools of unfavourable outcome ICH score ≥ 𝟑 Graeb score ≥ 𝟏 Easy implication on Triage setting (Accurate, Simple, Applicable and Reliable)
- 24. THANK YOU
Editor's Notes
- Spontaneous ICH is 10% to 15% of strokes and related mortality and morbidity world wide IVH secondary to spontaneous ICH results in: 32% death, 43% poor functional outcome How about the decision of surgery??? Decision of sugery must be individualized based on patient’s neurologic condition, SIZE & LOCATION of hematoma, Age, & patients’s expressed preference (e.c by living will) and the family wishes. With prognostic score model based on anatomical and physiological will answer this big question.
- This table describe the incidence of risk factors in type of stroke in world wide There is cardiologic and metabolic comorbids.
- Stein et al in 2010 - Initial SICH volume of 60 cm3 or greater - Severe Hydrocephalus - GCS score of 8 or less - Age 70 years and older Were INDEPENDENT OUTCOME PREDICTORS.
- Hallevi in 2008 Intraventricular hemorrhage (IVH) occurs in nearly half of patients with spontaneous intracerebral hemorrhage (ICH) Patients with IVH were twice as likely to have a poor outcome
- Nishikawa et al in 2009 - Elderly patients IVH volume Acute Hydrocephalus Poor initial level of consciousness SIGNIFICANTLY associated unfavourable prognosis in IVH group (Graeb score ≥𝟔)
- Hanley in 2009 Removal of cloth include limitation of inflammation, edema, and cell death as well as restoration of CSF flow
- Determination of the prognosis of is important in management, unlike trauma case where stroke has many comorbid factors. Based on prognostic analysis in there are -Physiological factors: are Age and GCS which describe intracranial physiology. -Anatomical factors: Graeb divides degree of brain structural abnormality on IVH, based on CT abnormality No single scores is perfect, each has its own advantages and disadvantages. Single prognosis is good, and already widely used. Is Combination has an outcome of prediction value? Combination in the hope of improving the ability and minimize the limitation.
- Hemphill et al in 2001 Component of ICH Score are: GCS, Volume and origin of ICH, Presence of IVH, and age. What kind of presence? How many presence of IVH? Graeb score is the answer.
- Graeb score is a semi quantitative score ranging from 0 to 12 can be measure by reliable, simple, quick and clinical meaningful approximation with simple algebraic calculation.
- Unfavourable 0: No symptom No significant disability Slight disability Moderate disability Moderate severe Severe Dead
- Based on this ROC (Receiver Operating Characteristic) analysis to assess the ability of the prediction of ICH score in predicting outcomes, assessed based on the Area Under the Curve (AUC). a curve is formed above the diagonal line, which means that the lower the value of the parameter (a score of ICH) then the chances of getting a higher unfavourable outcomes Interpretation of the ROC curve, Formed diagonal line on these curves in the get AUC amounting to 0.7546, This means that a low ICH has a good ability to predict unfavourable outcomes. The best cut point is determined based on the coordinates of the line furthest from the diagonal and in the get ICH 𝐬𝐜𝐨𝐫𝐞≥𝟑
- formed diagonal line on these curves in the get AUC amounting to 0.6365, This means that a low IVH has a good ability to predict unfavourable outcomes. The best cut point is determined based on the coordinates of the line furthest from the diagonal and in the get Graeb score ≥𝟏
- Determine the screening in accurately reflected by sensitivity and specificity. -Ideal screening tools has high validity, shown from high sensitivity and specificity. -Sensitivity is probability detection (true positif) : How many relevant items are selected. -Specificity is (True negative): Proportion of actual negative that correctly identified. -NPV : kemampuan meramalkan , benar2 Fav -PPV: kemampuan meramalkan, benar2 unFav
- Screening can predict the unfavourable outcome, before sign and symptoms of complication appear. Early management and better outcome. Best screening should be: Accurate and reliable -Accurate: The extent to which result match reality -Reliable is standardized testing: If done repeatedly the result obtained are not much different. Good screening conditions: Accurate, simple, applicable and reliable Reference to clinical management Family education Allocation of resources and funds.