30-days’ outcome of haemorrhagic stroke: correlation between intracerebral hemorrhage score and modified Rankin score

Intracerebral hemorrhage (ICH) constitutes 10% to 15% of all strokes. Within 30 days reported mortality is 35-52% and only 20% is functionally independent in 6 months. Despite several existing outcome prediction models for ICH, modified Rankin scale is found to be best predictor of outcome in early and long term period. To find out 30-day mortality in ICH and predict outcome based on modified Rankin score. In this study, 48 patients presenting with acute ICH presenting to a tertiary hospital in Khulna were enrolled. The 30-day mortality and disability were recorded, and ICH score along with modified Rankin score at presentation were calculated. In this study, the 30-day mortality rate was 27.1%; regression analysis showed the correlation between the scores (as measured by modified Rankin scale) for patient disability, intraventricular hemorrhage, the Glasgow Coma score, and volume of hematoma (>30 ml vs <30 ml) were significantly correlated with corresponding ICH scores. The ICH scale is a simple clinical grading scale which can predict mortality as well as disability in haemorrhagic stroke within 30 days that can be helpful to physicians in prioritization of their patient management and forecasting about prognosis.

middle-income countries shows that, there is 42.0%decrease in high-income countries and a greater than 100% increase in lowand middle-income countries. 3Incidence in Bangladesh (2.6 per 1000 population) 4 is more than two times of that in the United Kingdom (1.0 per 1000 population) 5 and Bangladeshi people even after migration to United Kingdom, experience more stroke than the native people.
In Japan, the country with the longest life Mediscope 2018;5(1):10-14 expectancy from birth, improvements in life expectancy are partially attributed to the large reduction in stroke mortality rates in the 1960s. 6Haemorrhagic stroke is defined as bleeding into brain parenchyma without accompanying trauma.It is responsible for 10.0-15.0% of all stroke and carries higher risk than ischaemic stroke and subarachnoid hemorrhage in terms of mortality and morbidity. 7,8[11][12] Within 30 days reported mortality is 35.0-52.0%and only 20.0% is functionally independent in 6 months. 135][16] On the other hand, modified Rankin scale is well validated scoring system to measure stroke disability. 17e aim of the present study was to find out 30-day mortality, and the correlation between ICH score and modified Rankin score.

Materials and Method
This prospective observational study was carried on admitted haemorrhagic stroke patients in Khulna Medical College Hospital, Khulna from November 2016 to April 2017.All samples purposively selected with voluntary consent from the patients or legal guardians were included in the study.The patients with recurrent stroke, traumatic brain injury and disable prior to stroke, require ventilatory support or surgical intervention were excluded from the study.Total 48 cases were recruited.
ICH score was calculated after obtaining computed tomography (CT) scan report (Table 1).The volume of haemorrhage was measured by 'ABC/2 x slice thickness' formula in which A is the greatest diameter on the largest hemorrhage slice, B is the diameter perpendicular to A, and C is the approximate number of axial slices with hemorrhage multiplied by the slice thickness.Other variables like history of hypertension,  diabetes mellitus, smoking, location of hematoma and clinical features were noted.All the patients were treated accordingly and followed up to 30 days, and modified Rankin scpre (Table 2) for disability was measured.
Ordinal regression analysis was conducted in different groups (according to ICH score) with disability to find out its correlation between modified Rankin score and ICH score.

Results
The gender and average age of the patients are shown in Table 3.The number of patients was 48 (23 males and 25 females).
The age (mean±SD) of the sample was 58.7±10.9years.Hypertension was present in 60.4% of the patients, and diabetes mellitus in 56.3% and 18.8% patients had both of the conditions.Most common site for intracerebral haemorrhage was basal ganglia (31.3%) followed by lobe (25.5%).Other sites were brainstem, thalamus and cerebellum.Intraventricular haemorrhage was present in 52.1% of the patients and hematoma below tentorium cerebelli in 29.2% of the patients.
Table 5 shows the correlation between modified ranking score and corresponding ICH score.Ordinal regression analysis showed the correlation between the scores (as measured by modified Rankin scale) for patient disability, intraventricular hemorrhage, Glasgow Coma Score (GCS), and volume of hematoma (>30 ml vs <30 ml) were significantly correlated with corresponding ICH scores.

Discussion
The aim of the present study was to evaluate 30-days' outcome in haemorrhagic stroke.The mortality within this period in our study was 27.1%, but other study reported a slightly higher mortality rate, 35-52%. 13 18 According to some studies, level of consciousness at hospital admission and hematoma volume are the most robust outcome predictors. 19We found that those presented with loss of consciousness and hematoma volume >30 ml had worst prognosis.Although, initial clinical presentation alone cannot always predict functional outcome, because ICH score is not a static phenomenon, expansion of hematoma detected by repeated CT was found in 27% of the cases. 20Mean age of our study patients was 58.7 years very close to a Malaysian study but another study from Italy showed higher mean age. 21,22The mean duration of hospital stay in the study was 5.2 days, lower than reported in an another study. 21Actually, hospital burden and socioeconomic backgrounds were the reasons of the short hospital stay in our study.
Hypertension is the most common significant and independent risk factor for ICH, contributing about 60-70% of all cases and treatment of hypertension results in reduction in stroke. 23,24The mean systolic blood pressure in our patients was found to be 175.7 mmHg, close to other study. 21History of diabetes mellitus but not hypertension was reported to be an independent predictor of early death in ICH patients. 25Our study showed opposite effect that history of hypertension but not diabetes had adverse effect on mortality.Smoking was reported as a risk factor for haemorrhagic stroke, 26 but it did not affect the outcome in our study.Neither age >65 years and gender affect the outcome of the patients as reported in a study. 27Hematoma volume >30 ml predicts poor outcome as already proved in other studies. 16,21Although site of hematoma was reported to affect outcome, 21 we did not found any correlation between the site and functional outcomes.Slight disability was found in 20.8% of the patients, well below from that found in a study of Cheung et al. 28 To the best of our knowledge, this is the first study to predict 30-days' outcome in haemorrhagic stroke based on ICH score comparing with modified Rankin score.As it is a singlecentered study involving small number of population, a generalized inference based on this study is not suitable to state.Therefore, a multi-centered study with a large sample is needed for further clarification.

Conclusion
Functional outcome in terms of modified Rankin score well correlated with ICH score which is easy to calculate, might serve as a rapid tool for predicting outcome of haemorrhagic stroke within 30 days that can be helpful to physicians in prioritization of their patient management and forecasting about prognosis.

Table 3 . Gender and average age of the patientsTable 4 . Clinical features of the patients
R, correlation coefficient.

Table 5 . Correlation between modified ranking score and corresponding ICH score study
of Mayer et al.