External Validation of Hematoma Expansion Scores in Spontaneous Intracerebral Hemorrhage in an Asian Patient Cohort
Hematoma expansion (HE) occurs in approximately one-third of patients with intracerebral hemorrhage (ICH) and is known to be a strong predictor of neurological deterioration as well as poor functional outcome. This study aims to externally validate three risk prediction models of HE (PREDICT, 9-point, and BRAIN scores) in an Asian population.
A prospective cohort of 123 spontaneous ICH patients admitted to a tertiary hospital (certified stroke center) in Singapore was recruited. Logistic recalibrations were performed to obtain updated calibration slopes and intercepts for all models. The discrimination (c-statistic), calibration (Hosmer–Lemeshow test, le Cessie–van Houwelingen–Copas–Hosmer test, Akaike information criterion), overall performance (Brier score, R2), and clinical usefulness (decision curve analysis) of the risk prediction models were examined.
Overall, the recalibrated PREDICT performed best among the three models in our study cohort based on the novel matrix comprising of Akaike information criterion and c-statistic. The PREDICT model had the highest R2 (0.26) and lowest Brier score (0.14). Decision curve analyses showed that recalibrated PREDICT was more clinically useful than 9-point and BRAIN models over the greatest range of threshold probabilities. The two scores (PREDICT and 9-point) which incorporated computed tomography (CT) angiography spot sign outperformed the one without (BRAIN).
To our knowledge, this is the first study to validate HE scores, namely PREDICT, 9-Point and BRAIN, in a multi-ethnic Asian ICH patient population. The PREDICT score was the best performing model in our study cohort, based on the performance metrics employed in this study. Our findings also showed support for CT angiography spot sign as a predictor of outcome after ICH. Although the models assessed are sufficient for risk stratification, the discrimination and calibration are at best moderate and could be improved.
KeywordsIntracerebral hemorrhage Hematoma expansion External validation Risk prediction
JXL contributed to protocol development, data collection and management, and manuscript writing and editing. JH contributed to protocol development, data analysis, and manuscript writing and editing. AAQS contributed to protocol development, data analysis, and manuscript writing and editing. VHL, WTC, and VFB contributed to data collection and management and manuscript approval. SP, LEM, and WEHL contributed to protocol development, data collection, and manuscript approval. MLJ contributed to protocol development and manuscript writing and editing. NKKK contributed to protocol development, data analysis, and manuscript writing and editing. MLJ is the Basic Science Editor for Neurocritical Care.
Sources of support
Compliance with Ethical Standards
Conflict of interest
Michael James is the Basic Science Editor for Neurocritical Care. The other authors declare that they have no conflict of interest.
Human and Animal Rights
This is a prospective study, needs statement of ethics approval and consent.
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