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Predicting Gastrostomy Tube Placement After Intracerebral Hemorrhage: External Validation of the GRAVo Score

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Abstract

Background

Dysphagia is a common consequence of intracerebral hemorrhages (ICH). It can lead to enduring impairments of dietary intake and the requirement for feeding via percutaneous gastrostomy (PEG) tubes. However, variabilities in the course of swallowing recovery after ICH make it difficult to anticipate the need for PEG placement in an individual patient. A new tool called the GRAVo score was recently developed to predict PEG tube placement after an ICH but has not been externally validated. Our study aims were to externally validate the GRAVo score in a multicenter cohort and reexamine the role of race in predicting PEG placement, given the uncertain biological plausibility for this relationship observed in the derivation cohort.

Methods

Patients for this analysis were selected from a previously completed multicenter, randomized, double-blind futility design clinical trial, the Intracerebral Hemorrhage Deferoxamine trial, and underwent a retrospective review of prospectively collected data. The GRAVo scores were computed by using previously established methods using the following variables: Glasgow Coma Scale ≤ 12 (2 points), race (1 point for Black), age > 50 years (2 points), and ICH volume > 30 mL (1 point). Association of GRAVo scores with PEG placement were examined by using logistic regression analysis after adjustment for exposure to deferoxamine. Model performance was estimated by using area under the receiving operating characteristic curve (AUROC). Subsequently, a second model was created by excluding scores for race, and the AUROC of both models were compared.

Results

A total of 291 patients with complete data points served as the study cohort; 38 (13%) underwent PEG placement. The median GRAVo score for patients in the PEG and non-PEG groups were 4 (interquartile range 3–4) versus 2 (interquartile range 2–3), respectively (p < 0.0001). External validation of the GRAVo score yielded an AUROC of 0.7008 (95% confidence interval 0.6036–0.78); the model obtained without assignment of scores for the variable race yielded an AUROC of 0.6958 (95% confidence interval 0.6124–0.7891). The receiver operating characteristic curves from both models demonstrated close overlap.

Conclusions

The results of our external validation demonstrate the validity of GRAVo scores for predicting PEG tube placement after an ICH. However, its performance was more modest compared with that of the derivation cohort. Inclusion of the race variable had no measurable effect on model performance. Differences in patient characteristics between these cohorts may have influenced our results. These findings should be taken into consideration when using the GRAVo score to assist clinical decision making on PEG placement after an ICH.

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Funding

The Intracerebral Hemorrhage Deferoxamine trial was funded by the National Institute of Neurological Disorders and Stroke (NINDS) (U01 NS074425) (Principal Investigator: MS).

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Authors and Affiliations

  1. Department of Neurology/Stroke Division, Beth Israel Deaconess Medical Center, Palmer 127, 185 Pilgrim Road, Boston, MA, 02215, USA

    David Lin, Michael Minyetty, Magdy Selim, Sarah Marchina, Filipa Carvalho, Elizabeth Heistand, Gogia Bhanu, Saad Hasan & Sandeep Kumar

  2. Harvard Medical School, Boston, MA, USA

    Magdy Selim, Sarah Marchina, Gogia Bhanu, Saad Hasan & Sandeep Kumar

Authors
  1. David Lin
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  2. Michael Minyetty
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  3. Magdy Selim
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  4. Sarah Marchina
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  5. Filipa Carvalho
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  6. Elizabeth Heistand
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  7. Gogia Bhanu
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  8. Saad Hasan
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  9. Sandeep Kumar
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Contributions

Substantial contribution to study conception: DL, MM, MS, and SK. Substantial contribution to data acquisition: DL and MM. Substantial contribution to data analysis: DL and SK. Substantial contribution to data interpretation: DL, MM, MS, SM, FC, EH, GB, SH, and SK. Substantial contribution to drafting the article: DL, MM, MS, and SK. Substantial contribution to critical revision of the article for intellectual content: DL, MM, MS, SM, FC, EH, GB, SH, and SK. The final manuscript was approved by all authors.

Corresponding author

Correspondence to Sandeep Kumar.

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Conflicts of interest

Dr. Selim received grant funding support from NINDS to conduct the Intracerebral Hemorrhage Deferoxamine trial as Principal Investigator and is a current recipient of National institutes of Health/NINDS funds. Dr. Kumar receives grant support from National institutes of Health/NINDS and foundation grant (Sparks Grant).

Ethical approval/informed consent

We have adhered to ethical guidelines in conduct of this research. This study was conducted under institutional review board approval.

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Lin, D., Minyetty, M., Selim, M. et al. Predicting Gastrostomy Tube Placement After Intracerebral Hemorrhage: External Validation of the GRAVo Score. Neurocrit Care 37, 506–513 (2022). https://doi.org/10.1007/s12028-022-01523-1

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  • DOI: https://doi.org/10.1007/s12028-022-01523-1

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