Skip to main content

Factors Considered by Clinicians when Prognosticating Intracerebral Hemorrhage Outcomes

Abstract

Background

The early subjective clinical judgment of clinicians outperforms formal prognostic scales for accurate determination of outcome after intracerebral hemorrhage (ICH), with the judgment of physicians and nurses having equivalent accuracy. This study assessed specific decisional factors that physicians and nurses incorporate into early predictions of functional outcome.

Methods

This prospective observational study enrolled 121 ICH patients at five US centers. Within 24 h of each patient’s admission, one physician and one nurse on the clinical team were each surveyed to predict the patient’s modified Rankin Scale (mRS) at 3 months and to list up to 10 subjective factors used in prognostication. Factors were coded and compared between (1) physician and nurse and (2) accurate and inaccurate surveys, with accuracy defined as an exact prediction of mRS.

Results

Aside from factors that are components of the ICH or FUNC scores, surveys reported pre-existing comorbidities (40.0%), other clinical or radiographic factors not in clinical scales (43.0%), and non-clinical/radiographic factors (21.9%) as important. Compared to physicians, nurses more frequently listed neurologic examination components (Glasgow Coma Scale motor, 27.3 vs. 5.8%, p < 0.0001; GCS verbal, 12.4 vs. 0.0%, p < 0.0001) and non-clinical/radiographic factors (31.4 vs. 12.4%, p = 0.0005). Physicians more frequently listed neuroimaging factors (ICH location, 33.9 vs. 7.4%, p < 0.0001; intraventricular hemorrhage, 13.2 vs. 2.5%, p = 0.003). There was no difference in listed factors between accurate versus inaccurate surveys.

Conclusions

Clinicians frequently utilize factors outside of the components of clinical scales for prognostication, with physician and nurses focusing on different factors despite having similar accuracy.

This is a preview of subscription content, access via your institution.

Fig. 1

References

  1. Go AS, Mozaffarian D, Roger VL, et al. Heart disease and stroke statistics–2014 update: a report from the American heart association. Circulation. 2014;129:e28–292.

    Article  PubMed  Google Scholar 

  2. Zahuranec DB, Lisabeth LD, Sanchez BN, et al. Intracerebral hemorrhage mortality is not changing despite declining incidence. Neurology. 2014;82:2180–6.

    Article  PubMed  PubMed Central  Google Scholar 

  3. van Asch CJ, Luitse MJ, Rinkel GJ, van der Tweel I, Algra A, Klijn CJ. Incidence, case fatality, and functional outcome of intracerebral haemorrhage over time, according to age, sex, and ethnic origin: a systematic review and meta-analysis. Lancet Neurol. 2010;9:167–76.

    Article  PubMed  Google Scholar 

  4. Diringer MN, Edwards DF, Aiyagari V, Hollingsworth H. Factors associated with withdrawal of mechanical ventilation in a neurology/neurosurgery intensive care unit. Crit Care Med. 2001;29:1792–7.

    CAS  Article  PubMed  Google Scholar 

  5. Zurasky JA, Aiyagari V, Zazulia AR, Shackelford A, Diringer MN. Early mortality following spontaneous intracerebral hemorrhage. Neurology. 2005;64:725–7.

    CAS  Article  PubMed  Google Scholar 

  6. Becker KJ, Baxter AB, Cohen WA, et al. Withdrawal of support in intracerebral hemorrhage may lead to self-fulfilling prophecies. Neurology. 2001;56:766–72.

    CAS  Article  PubMed  Google Scholar 

  7. Hemphill JC, Newman J, Zhao S, Johnston SC. Hospital usage of early do-not-resuscitate orders and outcome after intracerebral hemorrhage. Stroke. 2004;35:1130–4.

    Article  PubMed  Google Scholar 

  8. Holloway RG, Gramling R, Kelly AG. Estimating and communicating prognosis in advanced neurologic disease. Neurology. 2013;80:764–72.

    Article  PubMed  PubMed Central  Google Scholar 

  9. Weimer JM, Nowacki AS, Frontera JA. Withdrawal of life-sustaining therapy in patients with intracranial hemorrhage: self-fulfilling prophecy or accurate prediction of outcome? Crit Care Med. 2016;44:1161–72.

    Article  PubMed  Google Scholar 

  10. Zahuranec DB, Brown DL, Lisabeth LD, et al. Early care limitations independently predict mortality after intracerebral hemorrhage. Neurology. 2007;68:1651–7.

    CAS  Article  PubMed  Google Scholar 

  11. Hemphill JC, Greenberg SM, Anderson CS, et al. Guidelines for the management of spontaneous intracerebral hemorrhage: a guideline for healthcare professionals from the American heart association/American stroke association. Stroke. 2015;46:2032–60.

    Article  PubMed  Google Scholar 

  12. Zahuranec DB, Fagerlin A, Sanchez BN, et al. Variability in physician prognosis and recommendations after intracerebral hemorrhage. Neurology. 2016;86:1864–71.

    Article  PubMed  PubMed Central  Google Scholar 

  13. Hemphill JC, Bonovich DC, Besmertis L, Manley GT, Johnston SC. The ICH score: a simple, reliable grading scale for intracerebral hemorrhage. Stroke. 2001;32:891–7.

    Article  PubMed  Google Scholar 

  14. Hemphill JC, Farrant M, Neill TA Jr. Prospective validation of the ICH Score for 12-month functional outcome. Neurology. 2009;73:1088–94.

    Article  PubMed  PubMed Central  Google Scholar 

  15. Rost NS, Smith EE, Chang Y, et al. Prediction of functional outcome in patients with primary intracerebral hemorrhage: the FUNC score. Stroke. 2008;39:2304–9.

    Article  PubMed  Google Scholar 

  16. Appelboom G, Bruce SS, Han J, et al. Functional outcome prediction following intracerebral hemorrhage. J Clin Neurosci. 2011;19:795–8.

    Article  Google Scholar 

  17. Chu SY, Hwang DY. Predicting outcome for intracerebral hemorrhage patients: current tools and their limitations. Semin Neurol. 2016;36:254–60.

    Article  PubMed  Google Scholar 

  18. Hwang DY, Dell CA, Sparks MJ, et al. Clinician judgment vs formal scales for predicting intracerebral hemorrhage outcomes. Neurology. 2016;86:126–33.

    Article  PubMed  PubMed Central  Google Scholar 

  19. Woo D, Rosand J, Kidwell C, et al. The ethnic/racial variations of intracerebral hemorrhage (ERICH) study protocol. Stroke. 2013;44:e120–5.

    Article  PubMed  Google Scholar 

  20. Bar B, Hemphill JC. Charlson comorbidity index adjustment in intracerebral hemorrhage. Stroke. 2011;42:2944–6.

    Article  PubMed  PubMed Central  Google Scholar 

  21. Urday S, Beslow LA, Dai F, et al. Rate of perihematomal edema expansion predicts outcome after intracerebral hemorrhage. Crit Care Med. 2016;44:790–7.

    Article  PubMed  PubMed Central  Google Scholar 

  22. Parry-Jones AR, Di Napoli M, Goldstein JN, et al. Reversal strategies for vitamin K antagonists in acute intracerebral hemorrhage. Ann Neurol. 2015;78:54–62.

    CAS  Article  PubMed  PubMed Central  Google Scholar 

  23. Roquer J, Rodriguez-Campello A, et al. Sex-related differences in primary intracerebral hemorrhage. Neurology. 2016;87:257–62.

    Article  PubMed  PubMed Central  Google Scholar 

  24. Hwang BY, Appelboom G, Kellner CP. Clinical grading scales in intracerebral hemorrhage. Neurocritical Care. 2010;13:141–51.

    Article  PubMed  Google Scholar 

  25. Hemphill JC, White DB. Clinical nihilism in neuroemergencies. Emerg Med Clin North Am. 2009;27:27–37.

    Article  PubMed  PubMed Central  Google Scholar 

  26. Morgenstern LB, Zahuranec DB, Sanchez BN, et al. Full medical support for intracerebral hemorrhage. Neurology. 2015;84:1739–44.

    Article  PubMed  PubMed Central  Google Scholar 

Download references

Acknowledgements

We thank Christian Ramos, Division of Neurocritical Care and Emergency Neurology, Department of Neurology, Yale School of Medicine, for his assistance with cleaning the data. The Wake Forest School of Medicine Center for Public Health Genomics provided computational support. Supported by: American Heart Association (Clinical Research Training Award 11CRP5480009 to K.N.S.) and National Institute of Neurological Disorders and Stroke (R01NS059727 to J.R. and U01NS069763 to D.W.). The sources of funding had no role in study design, data collection, analyses, interpretations, and decision to submit the article for publication.

Author Contribution’s

All authors contributed to the study design and data analysis and approved the final version of the manuscript. In addition: D.Y.H. monitored data collection for all sites; cleaned, analyzed, and interpreted the data; and drafted the paper. S.Y.C. analyzed and interpreted the data and drafted the paper. C.A.D., M.J.S., and T.D.W. recruited subjects and collected data for their local site and monitored data collection for all sites. C.D.L. and M.E.C. contributed to study conception and statistical analysis. T.W.K.B., M.L.P., J.M., and J.L.O. each recruited subjects and collected data at respective sites. J.R., S.K., M.L.J., D.W., S.J.K., and K.N.S. each contributed to study conception and supervised data collection at respective sites. K.N.S., the principal investigator, initiated the study, designed data collection tools, had access to all the data, and takes responsibility for the data, accuracy of the data analysis, and the conduct of the research. D.W. and K.N.S. obtained funding for the study.

Author information

Authors and Affiliations

Authors

Corresponding author

Correspondence to David Y. Hwang.

Ethics declarations

Conflicts of interest

This study was sponsored by the American Heart Association (Dr. Sheth) and the National Institute of Neurological Disorders and Stroke (Dr. Rosand and Dr. Woo). Dr. Hwang has received recent funding from the American Brain Foundation, the Apple Pickers Foundation (Westerly, RI), the Neurocritical Care Society, and the National Institute on Aging (for Loan Repayment). He has also received recent speaking fees from Pennsylvania State University, Mayo Clinic, and the Society of Critical Care Medicine and modest book royalties from Oxford University Press and the Neurocritical Care Society. Dr. Chu reports no relevant disclosures. Mr. Dell reports no relevant disclosures. Ms. Sparks reports no relevant disclosures. Ms. Watson reports no relevant disclosures. Dr. Langefeld reports no relevant disclosures. Ms. Comeau reports no relevant disclosures. Dr. Rosand reports no further relevant disclosures. Mr. Battey reports no relevant disclosures. Dr. Koch reports no relevant disclosures. Dr. Perez reports no relevant disclosures. Dr. James reports no relevant disclosures. Dr. McFarlin reports no relevant disclosures. Ms. Osborne reports no relevant disclosures. Dr. Woo reports no further relevant disclosures. Dr. Kittner reports no relevant disclosures. Dr. Sheth reports no further relevant disclosures.

Ethical approval

All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki Declaration and its later amendments or comparable ethical standards.

Electronic supplementary material

Below is the link to the electronic supplementary material.

Supplementary material 1 (DOCX 13 kb)

Rights and permissions

Reprints and Permissions

About this article

Verify currency and authenticity via CrossMark

Cite this article

Hwang, D.Y., Chu, S.Y., Dell, C.A. et al. Factors Considered by Clinicians when Prognosticating Intracerebral Hemorrhage Outcomes. Neurocrit Care 27, 316–325 (2017). https://doi.org/10.1007/s12028-017-0430-7

Download citation

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s12028-017-0430-7

Keywords

  • Intracerebral hemorrhage
  • Prognosis
  • Cohort studies
  • Outcome research
  • Critical care