Elizabeth M. Aradine, DO

Fallenius M, Skrifvars MB, Reinikainen M, Bendel S, Curtze S, Sibolt G, et al. Spontaneous Intracerebral Hemorrhage: Factors Predicting Long-Term Mortality After Intensive Care. Stroke. 2019;50:2336-2343.

High mortality from a large spontaneous intracerebral hemorrhage (ICH) is somewhat intuitive, but whether this holds true months after the event is not well known. The authors sought to better elucidate this in “Spontaneous Intracerebral Hemorrhage: Factors Predicting Long-Term Mortality After Intensive Care.” This multicenter retrospective study included all adults admitted to the ICU in Finland from 2003 to 2013 with spontaneous ICH. Demographics and clinical data including age, admission GCS, anticoagulation use, and chronic medical comorbidities were recorded. A CT scan was required to evaluate the hemorrhage location and were categorized as supratentorial superficial, supratentorial deep, brainstem, and cerebellum. The volume of hemorrhage was calculated using the ABC/2 formula, which incorporates length, width, and shape of hemorrhage, as well as CT slice thickness and number of slices where hemorrhage is present. Three models (clinical, radiographic, and combined clinical and radiographic) were used to evaluate the predictability of mortality from ICH. Patients were followed for 12 months.

972 patients were included, and mortality was 51%. 38% of deaths occurred in the ICU; 43% occurred within 12 months. Brainstem hemorrhage had the highest mortality (69%), and cerebellar hemorrhage had the lowest (36%). The combined clinical and radiographic data was better at predicting 12-month mortality in supratentorial ICH. However, clinical data alone was more accurate at predicting mortality in infratentorial ICH.

Radiographic scoring of intracerebral hemorrhage is intrinsically biased for supratentorial hemorrhage, as it relies on hemorrhage volume and number of CT slices where hemorrhage is seen. Because of this intrinsic limitation, the radiographic model will underestimate the severity of infratentorial hemorrhage, especially in the brainstem. This study highlights the importance of understanding that mortality from spontaneous ICH differs based on location, clinical variables, and radiographic data. A combined model of clinical and radiographic variables should be used when discussing the prognosis of a spontaneous supratentorial hemorrhage, while clinical variables should be used for infratentorial hemorrhage.