Skip to main content
SpringerLink
Log in

Risk of Long-Term Mortality for Complex Chronic Patients with Intracerebral Hemorrhage: A Population-Based e-Cohort Observational Study

  • Original Research
  • Published:
Advances in Therapy Aims and scope Submit manuscript

Abstract

Introduction

Over recent years there has been growing evidence of increased risk of mortality associated with hemorrhagic stroke among older patients. The main objective of this study is to propose and validate a prognostic life table for complex chronic patients after an intracerebral hemorrhage (ICH) episode in primary care settings.

Methods

This was a multicenter and retrospective study (April 1, 2006–December 31, 2016) of a cohort from the general population presenting an episode of ICH from which a predictive model of mortality was obtained using a Cox proportional hazards regression model. In addition, Kaplan–Meier survival curves, the log-rank test, receiver operating characteristic (ROC) curves, and area under the ROC curve (AUC) were used to evaluate the ability to stratify patients according to vital prognosis. We proceeded to external validation of the model through prospective monitoring (January 1, 2013–December 31, 2017) of the population of complex chronic patients with an episode of ICH.

Results

A total of 3594 people aged ≥ 65 years were identified as complex chronic patients (women 55.9%; mean age, 86.1 ± 8.4 years) of whom 161 suffered hemorrhagic stroke during the study period (January 1, 2013–December 31, 2017). The primary outcome was death from any cause within 5 years of follow-up after an ICH episode. The independent prognostic factors of mortality were age > 80 years (HR 1.048, 95% CI 1.021–1.076, p < 0.001) and HAS-BLED score (HR 1.369, 95% CI 1.057–1.774, p = 0.017). Compared to the general population, the incidence density/1000 person per year (15 vs 0.22) was significantly higher with a significantly lower annual lethality rate (17% vs 49.2%); and both the prognostic factors and the risk of stratified mortality showed different epidemiological patterns. The internal validation of the model was optimal (log-rank < 0.0001) in the general population, but its external validation was not significant in the complex chronic patient population (log-rank p = 0.104).

Conclusions

The ICH-AP is a clinical scale that can improve the prognostic prediction of mortality in primary care after an episode of ICH in the general population, but it was not significant in its external validation in a population of complex chronic patients.

Trial Registration

ClinicalTrials.gov ID: NCT03247049.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Fig. 1
Fig. 2

Similar content being viewed by others

References

  1. González-Henares MA, et al. Incidencia y evitabilidad de los ictus hemorrágicos. Resultados del registro Ebrictus. Rev Neurol. 2016;62:385–95.

    PubMed  Google Scholar 

  2. Gonzalez-Henares M, et al. Relationship between hemorrhagic stroke and mortality in chronic complex outpatients: results from a community cohort of patients. J Aging Sci. 2017;5:180.

    Google Scholar 

  3. van Asch CJJ, et al. 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.

    PubMed  Google Scholar 

  4. Clua-Espuny JL, et al. Atrial fibrillation and cognitive impairment: a growing association: occurrence of death among chronic complex outpatients. EC Cardiol. 2016;2:226–39.

    Google Scholar 

  5. González-Henares MA, et al. Falls risk and mortality among chronic complex outpatients: results of community-based prospective study. Gerontol Geriatr Res. 2016;2:1024.

    Google Scholar 

  6. Clua-Espuny JL, González-Henares MA, Queralt-Tomas MLL, Gil-Guillen VF. Polypharmacy and mortality among chronic complex outpatients: results of community-based prospective study. Int J Med Res Pharm Sci. 2016;3:59–74.

    Google Scholar 

  7. Pla de Salut 2011–2015. PPAC 2012 [cited November 2016]. Projecte de programa d’atenció al pacient crònic complex. Barcelona: Generalitat de Catalunya Departament de Salut; 2012. http://salutweb.gencat.cat/web/.content/home/ambits_tematics/linies_dactuacio/model_assistencial/atencio_al_malalt_cronic/documents/arxius/562conceptual.pdf. Accessed Jan 10, 2017.

  8. Catalunya. Departament de Salut, Termcat, Centre de Terminologia. Terminologia de la cronicitat [en línia]. Barcelona: Termcat, Centre de Terminologia, cop; 2013 (diccionaris en línia). http://www.termcat.cat/ca/Diccionaris_En_Linia/160/. (http://salutweb.gencat.cat/web/.content/home/ambits_tematics/linies_dactuacio/model_assistencial/atencio_al_malalt_cronic/documents/arxius/562conceptual.pdf. Accessed Jan 14, 2017.

  9. Sloma A, Backlund LG, Strender L-E, Skånér Y. Knowledge of stroke risk factors among primary care patients with previous stroke or TIA: a questionnaire study. BMC Fam Pract. 2010;11:47.

    PubMed  PubMed Central  Google Scholar 

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

    CAS  PubMed  Google Scholar 

  11. Zahuranec DB, et al. Variability in physician prognosis and recommendations after intracerebral hemorrhage. Neurology. 2016;86:1864–71.

    PubMed  PubMed Central  Google Scholar 

  12. Weimar C, Benemann J, Diener HC. Development and validation of the Essen intracerebral haemorrhage score. J Neurol Neurosurg Psychiatry. 2006;77:601–5.

    CAS  PubMed  Google Scholar 

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

    PubMed  Google Scholar 

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

    PubMed  PubMed Central  Google Scholar 

  15. Vermeer SE, Algra A, Franke CL, Koudstaal PJ, Rinkel GJE. Long-term prognosis after recovery from primary intracerebral hemorrhage. Neurology. 2002;59:205–9.

    CAS  PubMed  Google Scholar 

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

    PubMed  Google Scholar 

  17. Cheung RTF, Zou L-Y. Use of the original, modified, or new intracerebral hemorrhage score to predict mortality and morbidity after intracerebral hemorrhage. Stroke. 2003;34:1717–22.

    PubMed  Google Scholar 

  18. Tuhrim S, et al. Intracerebral hemorrhage: external validation and extension of a model for prediction of 30-day survival. Ann Neurol. 1991;29:658–63.

    CAS  PubMed  Google Scholar 

  19. Smith EE, et al. A risk score for in-hospital death in patients admitted with ischemic or hemorrhagic stroke. J Am Heart Assoc. 2013;2:e005207.

    PubMed  PubMed Central  Google Scholar 

  20. Maas MB, et al. Refining prognosis for intracerebral hemorrhage by early reassessment. Cerebrovasc Dis. 2017;43:110–6.

    PubMed  PubMed Central  Google Scholar 

  21. Hwang BY, et al. Clinical grading scales in intracerebral hemorrhage. Neurocrit Care. 2010;13:141–51.

    PubMed  Google Scholar 

  22. Hansen BM, et al. Intraventricular extension of supratentorial intracerebral hemorrhage: the modified Graeb scale improves outcome prediction in Lund stroke register. Neuroepidemiology. 2016;46:43–50.

    PubMed  Google Scholar 

  23. Ji R, et al. A novel risk score to predict 1-year functional outcome after intracerebral hemorrhage and comparison with existing scores. Crit Care. 2013;17:R275.

    PubMed  PubMed Central  Google Scholar 

  24. Lantigua H, et al. Subarachnoid hemorrhage: who dies, and why? Crit Care. 2015;19:309.

    PubMed  PubMed Central  Google Scholar 

  25. Oliveira AMP, Paiva WS, Figueiredo EGD, Oliveira HA, Teixeira MJ. Fisher revised scale for assessment of prognosis in patients with subarachnoid hemorrhage. Arq Neuropsiquiatr. 2011;69:910–3.

    PubMed  Google Scholar 

  26. Bhatia R, et al. A prospective study of in-hospital mortality and discharge outcome in spontaneous intracerebral hemorrhage. Neurol India. 2013;61:244–8.

    PubMed  Google Scholar 

  27. Godoy DA, Piñero G, Di Napoli M. Predicting mortality in spontaneous intracerebral hemorrhage: can modification to original score improve the prediction? Stroke. 2006;37:1038–44.

    PubMed  Google Scholar 

  28. Watson-Fargie T, Dai D, MacLeod MJ, Reid JM. Comparison of predictive scores of symptomatic intracerebral haemorrhage after stroke thrombolysis in a single centre. J R Coll Physicians Edinb. 2015;45:127–32.

    CAS  PubMed  Google Scholar 

  29. Tuhrim S, Horowitz DR, Sacher M, Godbold JH. Validation and comparison of models predicting survival following intracerebral hemorrhage. Crit Care Med. 1995;23:950–4.

    CAS  PubMed  Google Scholar 

  30. Sim J, Teece L, Dennis MS, Roffe C, SO2S Study Team. Validation and recalibration of two multivariable prognostic models for survival and independence in acute stroke. PLoS One. 2016;11:e0153527.

    PubMed  PubMed Central  Google Scholar 

  31. Satopää J, et al. Comparison of all 19 published prognostic scores for intracerebral hemorrhage. J Neurol Sci. 2017;15(379):103–8. https://doi.org/10.1016/j.jns.2017.05.034.

    Article  Google Scholar 

  32. Hwang DY, et al. Clinician judgment vs formal scales for predicting intracerebral hemorrhage outcomes. Neurology. 2016;86(2):126–33. https://doi.org/10.1212/WNL.0000000000002266.

    Article  PubMed  PubMed Central  Google Scholar 

  33. Ariesen MJ, Claus SP, Rinkel GJE, Algra A. Risk factors for intracerebral hemorrhage in the general population. Stroke. 2003;34:2060–5.

    CAS  PubMed  Google Scholar 

  34. Ruiz-Sandoval JL, Chiquete E, Romero-Vargas S, Padilla-Martínez JJ, González-Cornejo S. Grading scale for prediction of outcome in primary intracerebral hemorrhages. Stroke. 2007;38:1641–4.

    PubMed  Google Scholar 

  35. Melchor I, et al. La mortalidad evitable. ¿Cambios en el nuevo siglo? Gac Sanit. 2008;22:200–9.

    PubMed  Google Scholar 

  36. Fogelholm R, Murros K, Rissanen A, Avikainen S. Long term survival after primary intracerebral haemorrhage: a retrospective population based study. J Neurol Neurosurg Psychiatry. 2005;76:1534–8.

    CAS  PubMed  PubMed Central  Google Scholar 

  37. Hackam DG, et al. Statins and intracerebral hemorrhage: a retrospective cohort study. Arch Neurol. 2012;69:39–45.

    PubMed  Google Scholar 

  38. Ziff OJ, Banerjee G, Ambler G, Werring DJ. Statins and the risk of intracerebral haemorrhage in patients with stroke: systematic review and meta-analysis. J Neurol Neurosurg Psychiatry. 2018;90:75–83.

    PubMed  Google Scholar 

  39. Flint AC, et al. Effect of statin use during hospitalization for intracerebral hemorrhage on mortality and discharge disposition. JAMA Neurol. 2014;71:1364–71.

    PubMed  Google Scholar 

  40. Matchett SC, et al. Predicting mortality after intracerebral hemorrhage: comparison of scoring systems and influence of withdrawal of care. J Stroke Cerebrovasc Dis. 2006;15:144–50.

    PubMed  Google Scholar 

  41. Safatli D, et al. Predictors of 30-day mortality in patients with spontaneous primary intracerebral hemorrhage. Surg Neurol Int. 2016;7:S510–7.

    PubMed  PubMed Central  Google Scholar 

  42. Appelboom G, et al. Functional outcome prediction following intracerebral hemorrhage. J Clin Neurosci. 2012;19:795–8.

    PubMed  Google Scholar 

  43. Cheung CM, et al. Using the National Institutes of Health Stroke Scale (NIHSS) to predict the mortality and outcome of patients with intracerebral haemorrhage. Hong Kong Med J. 2008;14:367–70.

    CAS  PubMed  Google Scholar 

  44. Servei d’Informació i Estudis. La mortalitat evitable a Catalunya i regions sanitàries. Actualització de les dades 2005–2011. Barcelona: Departament de Salut, Generalitat de Catalunya; 2013. Accessed Feb 20, 2017.

  45. Abumuaileq RRY, et al. Comparison between 3 bleeding scoring systems in nonvalvular atrial fibrillation patients. What can the new ORBIT score provide? Rev Esp Cardiol (Engl Ed). 2016;69:1112–4.

    Google Scholar 

  46. Kirchhof P, et al. 2016 ESC Guidelines for the management of atrial fibrillation developed in collaboration with EACTS: the task force for the management of atrial fibrillation of the European Society of Cardiology (ESC) developed with the special contribution of the European Heart Rhythm Association (EHRA) of the ESC endorsed by the European Stroke Organisation (ESO). Eur Heart J. 2016;37:2893–962.

    Google Scholar 

  47. Lip GYH. Assessing bleeding risk with the HAS-BLED score: balancing simplicity, practicality, and predictive value in bleeding-risk assessment. Clin Cardiol. 2015;38:562–4.

    PubMed  PubMed Central  Google Scholar 

  48. Naval NS, Mirski MA, Carhuapoma JR. Impact of statins on validation of ICH mortality prediction models. Neurol Res. 2009;31:425–9.

    PubMed  Google Scholar 

  49. Bustamante A, Montaner J. Statin therapy should not be discontinued in patients with intracerebral hemorrhage. Stroke. 2013;44:2060–1.

    PubMed  Google Scholar 

  50. Crandall KM, Rost NS, Sheth KN. Prognosis in intracerebral hemorrhage. Rev Neurol Dis. 2011;8:23–9.

    PubMed  Google Scholar 

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

    CAS  PubMed  Google Scholar 

Download references

Acknowledgements

The authors wish to thank the research group Ebrictus for providing assistance and support to this manuscript; as well as Jesus Carot Domenech for his technical support from Information and Communication Technology.

Funding

No funding or sponsorship was received for this study or publication of this article. The Rapid Service Fee was funded by the authors.

Authorship

All named authors meet the International Committee of Medical Journal Editors (ICMJE) criteria for authorship for this article, take responsibility for the integrity of the work as a whole, and have given their approval for.

Disclosures

Maria Antonia González-Henares, Jose Luis Clua-Espuny, Blanca Lorman-Carbo, Jose Fernández-Saez, Lluisa Queralt-Tomas, Eulalia Muria-Subirats, Juan Ballesta-Ors and Jose Vincente Gil-Guillen have nothing to disclose.

Compliance with Ethics Guidelines

Ethics approval was granted by the Ethics Committee at the Research Institute of Primary Care Jordi Gol i Gurina (IDIAP), Health Department, Generalitat de Cataluña, code P16/087 and complies with the Helsinki Declaration and the local ethics committee requirements for clinical research. Registry information was collected from the government-run healthcare provider responsible for all inpatient care in the county without contact with participants in order to gather data from the study. Records of inpatient care after baseline assessment with International Classification of Diseases (10th version; ICD-10) code prefixes I60, I61, I63, I64 and H34, I67, and G45 were compiled for all participants. All other diagnoses were based on information from assessments conducted during home visits and records from hospitals, general practitioners, and institutional care facilities. Given each study site belongs to Catalonian Health Institute–Public Health Govern, an ethical approval was not obtained from each one.

Data Availability

Currently the datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request. All data generated or analyzed during this study will be shared in ClinicalTrials.gov ID: NCT03247049, Unique Protocol ID: IDIAP Jordi Gol code P16/087. Title: Prognosis in Intracerebral Hemorrhage. The ICH-AP Score in Primary Care. Official Title: Predicting Long Term Survival in Patients with Primary Intracerebral Hemorrhage. Development and Validation of the ICH-AP in Primary Care.

Author information

Authors and Affiliations

  1. EAP-Alcanar-St Carlos de la Rápita, Catalonian Health Institute, SAP Terres de l’Ebre, Health Department, Generalitat de Catalunya, CAP St Carles de la Rápita, 43540, Sant Carles de la Ràpita, Spain

    Maria Antonia González-Henares

  2. Department of Research, ICS Terres de l’Ebre, Research Institute University Primary Care (IDIAP) Jordi Gol, Barcelona, Spain

    Maria Antonia González-Henares & Jose Luis Clua-Espuny

  3. EAP-Tortosa 1-Est Catalonian Health Institute, SAP Terres de l’Ebre, Health Department, Generalitat de Catalunya, CAP Temple, Plaça Carrilet, s/núm, 43500, Tortosa, Spain

    Jose Luis Clua-Espuny

  4. UUDD Tortosa-Terres de l’Ebre, Catalonian Health Institute, SAP Terres de l’Ebre, Health Department, Generalitat de Catalunya, CAP Temple, 43500, Tortosa, Spain

    Blanca Lorman-Carbo, Eulalia Muria-Subirats & Juan Ballesta-Ors

  5. Unitat de Suport a la Recerca Terres de l’Ebre, Institut Universitari d’Investigació en Atenció Primària (IDIAP) Jordi Gol, Grupo de investigación de Salud Pública, Universidad de Alicante, Alicante, Spain

    Jose Fernández-Saez

  6. EAP-Tortosa-Oest, Catalonian Health Institute, SAP Terres de l’Ebre, Health Department, Generalitat de Catalunya, CAP Xerta, 43592, Xerta, Spain

    Lluisa Queralt-Tomas

  7. Universidad Miguel Hernández, Cátedra Medicina de Familia, Carretera Alicante-Elche s/num, 03202, Elche, Spain

    Jose Vicente Gil-Guillen

  8. Clinical Evidence Based Medicine and Emotional Department, Miguel Hernández University, Family and Community Specialty, Elche, Spain

    Jose Vicente Gil-Guillen

Authors
  1. Maria Antonia González-Henares
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Jose Luis Clua-Espuny
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Blanca Lorman-Carbo
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Jose Fernández-Saez
    View author publications

    You can also search for this author in PubMed Google Scholar

  5. Lluisa Queralt-Tomas
    View author publications

    You can also search for this author in PubMed Google Scholar

  6. Eulalia Muria-Subirats
    View author publications

    You can also search for this author in PubMed Google Scholar

  7. Juan Ballesta-Ors
    View author publications

    You can also search for this author in PubMed Google Scholar

  8. Jose Vicente Gil-Guillen
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Jose Luis Clua-Espuny.

Additional information

Enhanced Digital Features

To view enhanced digital features for this article go to https://doi.org/10.6084/m9.figshare.9792863.

Electronic supplementary material

Below is the link to the electronic supplementary material.

Supplementary material 1 (PDF 123 kb)

Rights and permissions

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

González-Henares, M.A., Clua-Espuny, J.L., Lorman-Carbo, B. et al. Risk of Long-Term Mortality for Complex Chronic Patients with Intracerebral Hemorrhage: A Population-Based e-Cohort Observational Study. Adv Ther 37, 833–846 (2020). https://doi.org/10.1007/s12325-019-01206-y

Download citation

  • Received:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s12325-019-01206-y

Keywords

Search

Navigation