Neurocritical Care

, Volume 13, Issue 1, pp 40–46 | Cite as

The TRACH Score: Clinical and Radiological Predictors of Tracheostomy in Supratentorial Spontaneous Intracerebral Hemorrhage

  • Viktor Szeder
  • Santiago Ortega-Gutierrez
  • Wendy Ziai
  • Michel T. TorbeyEmail author
Original Article


Background and Purpose

Spontaneous intracerebral hemorrhage (sICH) continues to have high morbidity and mortality. Patients with sICH and poor mental status are at high risk of airway compromise and frequently require intubation. The traditional ventilatory weaning parameters are not reliable in patients with brain pathology. The objective of this study is to identify clinical and radiological predictors for tracheostomy in mechanically ventilated patients with sICH and to develop a scale that will accurately predict the need for tracheostomy in these patients.


Only patients with supratentorial sICH intubated on the field or on admission who survived the first 3 days were included. Univariate and multivariate logistic regression analysis of clinical and radiological variables was performed, and independent predictors were identified. A risk stratification scale (TRACH Score) was developed using these independent predictors.


Several independent factors were associated with early tracheostomy. The signficant clinical predictor was Glasgow Coma Scale (GCS) score (P < 0.003). Radiological predictors were presence of hydrocephalus (OR: 12.5; P < 0.002), septum pellucidum shift (OR: 9; P < 0.025), and location of sICH in the thalamus (OR: 9; P < 0.025). The TRACH score was defined by two variables radiological scale (RScale) and Glasgow Outcome Score (GOS). TRACH score = 3 + (1 × RScale) − (0.5× GCS). The RScale (L + H + S) was obtained by adding individual points assigned according presence of: sICH location in the thalamus (L) 2 points, hydrocephalus (H) 1.5 points, septum pellucidum shift (S) 3 points. The scale was very predictive of tracheostomy needs (OR: 2.57, P < 0.0001) with an ROC = 0.92, sensitivity of 94%, positive predictive value of 83%, and negative predictive value of 95%.


The TRACH Score is a practical clinical grading scale that will allow physicians to identify patients who will be needing tracheostomy. Application of this scale could have significant impact on length of stay and cost of hospitalization.


Intracerebral hemorrhage Tracheostomy Mechanically ventilated Predictor Outcome Prognosis 


Acknowledgment and Funding



  1. 1.
    Burtin P, Bollaert PE, Feldmann L, et al. Prognosis of stroke patients undergoing mechanical ventilation. Intensive Care Med. 1994;20:32–6.CrossRefPubMedGoogle Scholar
  2. 2.
    Steiner T, Mendoza G, De Georgia M, Schellinger P, Holle R, Hacke W. Prognosis of stroke patients requiring mechanical ventilation in a neurological critical care unit. Stroke. 1997;28:711–5.PubMedGoogle Scholar
  3. 3.
    Wijdicks EF, Scott JP. Causes and outcome of mechanical ventilation in patients with hemispheric ischemic stroke. Mayo Clin Proc. 1997;72:210–3.CrossRefPubMedGoogle Scholar
  4. 4.
    Diringer MN, Edwards DF, Zazulia AR. Hydrocephalus: a previously unrecognized predictor of poor outcome from supratentorial intracerebral hemorrhage. Stroke. 1998;29:1352–7.PubMedGoogle Scholar
  5. 5.
    Garibi J, Bilbao G, Pomposo I, Hostalot C. Prognostic factors in a series of 185 consecutive spontaneous supratentorial intracerebral haematomas. Br J Neurosurg. 2002;16:355–61.CrossRefPubMedGoogle Scholar
  6. 6.
    Hemphill JC 3rd, Bonovich DC, Besmertis L, Manley GT, Johnston SC. The ICH score: a simple, reliable grading scale for intracerebral hemorrhage. Stroke. 2001;32:891–7.PubMedGoogle Scholar
  7. 7.
    Qureshi AI, Bliwise DL, Bliwise NG, Akbar MS, Uzen G, Frankel MR. Rate of 24-hour blood pressure decline and mortality after spontaneous intracerebral hemorrhage: a retrospective analysis with a random effects regression model. Crit Care Med. 1999;27:480–5.CrossRefPubMedGoogle Scholar
  8. 8.
    Tuhrim S, Horowitz DR, Sacher M, Godbold JH. Volume of ventricular blood is an important determinant of outcome in supratentorial intracerebral hemorrhage. Crit Care Med. 1999;27:617–21.CrossRefPubMedGoogle Scholar
  9. 9.
    Gujjar AR, Deibert E, Manno EM, Duff S, Diringer MN. Mechanical ventilation for ischemic stroke and intracerebral hemorrhage: indications, timing, and outcome. Neurology. 1998;51:447–51.PubMedGoogle Scholar
  10. 10.
    Chevron V, Menard JF, Richard JC, Girault C, Leroy J, Bonmarchand G. Unplanned extubation: risk factors of development and predictive criteria for reintubation. Crit Care Med. 1998;26:1049–53.CrossRefPubMedGoogle Scholar
  11. 11.
    Coplin WM, Pierson DJ, Cooley KD, Newell DW, Rubenfeld GD. Implications of extubation delay in brain-injured patients meeting standard weaning criteria. Am J Respir Crit Care Med. 2000;161:1530–6.PubMedGoogle Scholar
  12. 12.
    Nava S, Ambrosino N, Clini E, et al. Noninvasive mechanical ventilation in the weaning of patients with respiratory failure due to chronic obstructive pulmonary disease A randomized, controlled trial. Ann Intern Med. 1998;128:721–8.PubMedGoogle Scholar
  13. 13.
    Namen AM, Ely EW, Tatter SB, et al. Predictors of successful extubation in neurosurgical patients. Am J Respir Crit Care Med. 2001;163:658–64.PubMedGoogle Scholar
  14. 14.
    Huttner HB, Kohrmann M, Berger C, Georgiadis D, Schwab S. Predictive factors for tracheostomy in neurocritical care patients with spontaneous supratentorial hemorrhage. Cerebrovasc Dis. 2006;21:159–65.CrossRefPubMedGoogle Scholar
  15. 15.
    Qureshi AI, Suarez JI, Parekh PD, Bhardwaj A. Prediction and timing of tracheostomy in patients with infratentorial lesions requiring mechanical ventilatory support. Crit Care Med. 2000;28:1383–7.CrossRefPubMedGoogle Scholar
  16. 16.
    Broderick JP, Adams HP Jr, Barsan W, et al. Guidelines for the management of spontaneous intracerebral hemorrhage: a statement for healthcare professionals from a special writing group of the Stroke Council, American Heart Association. Stroke. 1999;30:905–15.PubMedGoogle Scholar
  17. 17.
    Kothari RU, Brott T, Broderick JP, et al. The ABCs of measuring intracerebral hemorrhage volumes. Stroke. 1996;27:1304–5.PubMedGoogle Scholar
  18. 18.
    Graeb DA, Robertson WD, Lapointe JS, Nugent RA, Harrison PB. Computed tomographic diagnosis of intraventricular hemorrhage. Etiology and prognosis. Radiology. 1982;143:91–6.PubMedGoogle Scholar
  19. 19.
    Morgan T, Awad I, Keyl P, Lane K, Hanley D. Preliminary report of the clot lysis evaluating accelerated resolution of intraventricular hemorrhage (CLEAR-IVH) clinical trial. Acta Neurochir Suppl. 2008;105:217–20.CrossRefPubMedGoogle Scholar
  20. 20.
    Juvela S. Risk factors for impaired outcome after spontaneous intracerebral hemorrhage. Arch Neurol. 1995;52:1193–200.PubMedGoogle Scholar
  21. 21.
    Lisk DR, Pasteur W, Rhoades H, Putnam RD, Grotta JC. Early presentation of hemispheric intracerebral hemorrhage: prediction of outcome and guidelines for treatment allocation. Neurology. 1994;44:133–9.PubMedGoogle Scholar
  22. 22.
    Tuhrim S, Dambrosia JM, Price TR, et al. Intracerebral hemorrhage: external validation and extension of a model for prediction of 30-day survival. Ann Neurol. 1991;29:658–63.CrossRefPubMedGoogle Scholar
  23. 23.
    Lanza DC, Parnes SM, Koltai PJ, Fortune JB. Early complications of airway management in head-injured patients. Laryngoscope. 1990;100:958–61.CrossRefPubMedGoogle Scholar
  24. 24.
    Nowak P, Cohn AM, Guidice MA. Airway complications in patients with closed-head injuries. Am J Otolaryngol. 1987;8:91–6.CrossRefPubMedGoogle Scholar
  25. 25.
    Whited RE. A prospective study of laryngotracheal sequelae in long-term intubation. Laryngoscope. 1984;94:367–77.CrossRefPubMedGoogle Scholar
  26. 26.
    Richard I, Giraud M, Perrouin-Verbe B, Hiance D, Mauduyt de la Greve I, Mathe JF. Laryngotracheal stenosis after intubation or tracheostomy in patients with neurological disease. Arch Phys Med Rehabil. 1996;77:493–6.CrossRefPubMedGoogle Scholar
  27. 27.
    Stauffer JL, Olson DE, Petty TL. Complications and consequences of endotracheal intubation and tracheotomy. A prospective study of 150 critically ill adult patients. Am J Med. 1981;70:65–76.CrossRefPubMedGoogle Scholar
  28. 28.
    Koh WY, Lew TW, Chin NM, Wong MF. Tracheostomy in a neuro-intensive care setting: indications and timing. Anaesth Intensive Care. 1997;25:365–8.PubMedGoogle Scholar
  29. 29.
    Kluger Y, Paul DB, Lucke J, et al. Early tracheostomy in trauma patients. Eur J Emerg Med. 1996;3:95–101.CrossRefPubMedGoogle Scholar
  30. 30.
    Rodriguez JL, Steinberg SM, Luchetti FA, Gibbons KJ, Taheri PA, Flint LM. Early tracheostomy for primary airway management in the surgical critical care setting. Surgery. 1990;108:655–9.PubMedGoogle Scholar

Copyright information

© Springer Science+Business Media, LLC 2010

Authors and Affiliations

  • Viktor Szeder
    • 1
  • Santiago Ortega-Gutierrez
    • 1
    • 2
  • Wendy Ziai
    • 4
  • Michel T. Torbey
    • 1
    • 3
    • 5
    Email author
  1. 1.Department of NeurologyMedical College of WisconsinMilwaukeeUSA
  2. 2.Department of MedicineMedical College of WisconsinMilwaukeeUSA
  3. 3.Department of NeurosurgeryMedical College of WisconsinMilwaukeeUSA
  4. 4.Department of NeurologyJohns Hopkins UniversityBaltimoreUSA
  5. 5.Neurocritical Care Program, Departments of Neurology and NeurosurgeryMedical College of WisconsinMilwaukeeUSA

Personalised recommendations