Scoring the unfavorable Odds A narrative review of Intracerebral Hemorrhage ICH scoring systems

Intracerebral hemorrhage (ICH) is a potentially fatal neurologic emergency that accounts for 10-27 percent of total strokes and entails significant disability-adjusted life years (DALY) loss, mortality and morbidity rates [1,2]. A clear-cut estimation of functional outcome is an indispensable tool to assist providers, patient and concerned family members attain the most comprehensive and interactive management strategy. However, several studies have accentuated the overestimation of ICH-mortality, as an independent risk factor of one-month mortality rate as a result of early care restriction, withdrawals and do not resuscitate orders [7-12].
To this day many scoring systems and independent prognostic factors have been suggested as outcome predictors of ICH based upon the patient’s demographics, initial history, physical examination, lab test and imaging to predict ICH mortality and functional outcome. Many scoring systems have been suggested as potential decision-making tools. There has been a debate on the superiority of prediction scores over clinicians’ judgement [13-15]. Nonetheless, many clinicians favor scoring systems for their consistency and compatibility to clinician’s level of expertise. American Heart Association/American Stroke Association guidelines identified withdrawal of medical support, do-not-resuscitate (DNR) orders, and comfort care as the most reprehensible limitation of scoring systems [33-35].
In this study we reviewed twelve of the most influential and widely used scoring systems. Volume of hemorrhage, Intraventricular spread, Infratentorial location, GCS, NIHSS, Pre-ICH cognitive status, Narrow pulse Pressure, presence of Hyperglycemia, Body Temperature, SBP≥200 mmHg, DBP≥ 130 mmHg, Mode of arrival and use of anticoagulants where the main independent predictive variables utilized by the scoring systems. Despite discrepancies in the ordinal classification of cut-offs, GCS, NIHSS and volume of hemorrhage were the most predictive variables.
Although there is no single gold standard in predicting ICH prognosis and outcome, optimization studies can focus on more itemized cut-off ranges, numerical decision-making models and scoring systems based on the patients underlying risk factor. Furthermore, scoring systems should be used as a collaborative – but not substitutive tool to a clinician’s judgement.