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Early Therapy Intensity Level (TIL) Predicts Mortality in Spontaneous Intracerebral Hemorrhage

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Abstract

Background

Outcome from spontaneous intracerebral hemorrhage (sICH) may depend on patient-care variability. We developed as ICH-specific therapy intensity level (TIL) metric using evidence-based elements in a high severity sICH cohort.

Methods

This is a cohort study of 170 patients with sICH and any intraventricular hemorrhage treated in 2 academic neuroICUs. Pre-defined quality indicators were identified based on current guidelines, scientific evidence, and likelihood of care documentation in first 72 h of hospital admission. We assessed performance on each indicator and association with discharge mortality. Significant indicators were aggregated to develop a TIL score. The predictive validity of the best fit TIL score was tested with threefold cross-validation of multivariate logistic regression models of in-hospital survival and good outcome (modified Rankin score 0–3).

Results

Median ICH score was 3; discharge mortality was 51.2 %. Five/19 tested variables were significantly associated with lower discharge mortality: no DNR/withdrawal of treatment within 24 h of admission, target glucose within 4 h of high glucose, no recurrent hyperpyrexia, clinical reversal of herniation/intracranial pressure >20 mmHg within 60 min of detection, and reversal of INR (<1.4) within 2 h of first elevation. One point was given for each or if not applicable. Median TIL score was significantly higher in survivors versus non-survivors (5[1] vs. 3[1]; P < 0.001). A 4-point aggregated TIL score was most predictive of discharge survival (area under receiving operating characteristic curve 0.85, 95 % CI 0.80–0.90) and good outcome (AUC 0.84) and was an independent predictor of both (survival: OR 7.10; 95 % CI 3.57–14.11; P < 0.001; good outcome: OR 3.10; 95 % CI 1.06–8.79; P < 0.001).

Conclusion

A simplified TIL score using evidenced-based patient-care parameters within first 3 days of admission after sICH was significantly associated with early mortality and good outcome. The next step is prospective validation of the simplified TIL score in a large clinical trial.

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Conflict of interest

Wendy Ziai, Aazim Siddiqui, Natalie Ullman, Daniel Herrick, Gayane Yenokyan, Nichol McBee, Karen Lane, and Daniel Hanley declare that they have no conflict of interest.

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Authors and Affiliations

  1. Division of Neurosciences Critical Care, Departments of Neurology, Anesthesiology/Critical Care Medicine, Johns Hopkins Hospital, Johns Hopkins University School of Medicine, 600 Wolf Street/Phipps 455, Baltimore, MD, 21287, USA

    Wendy C. Ziai

  2. Division of Brain Injury Outcomes, Johns Hopkins University School of Medicine, Baltimore, MD, USA

    Aazim A. Siddiqui, Natalie Ullman, Daniel B. Herrick, Nichol McBee, Karen Lane & Daniel F. Hanley

  3. The Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA

    Gayane Yenokyan

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  1. Wendy C. Ziai
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Correspondence to Wendy C. Ziai.

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Ziai, W.C., Siddiqui, A.A., Ullman, N. et al. Early Therapy Intensity Level (TIL) Predicts Mortality in Spontaneous Intracerebral Hemorrhage. Neurocrit Care 23, 188–197 (2015). https://doi.org/10.1007/s12028-015-0150-9

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