Wednesday, December 21, 2005

Intracranial Cerebral hemorrhage Prognosis

The free article from the Journal of Neurology, Neurosurgery and Psychiatry on prognosis of ICH-type strokes provides a good tool for use in the ICU. The development and validation of the Essen ICH Score can be useful to neurologists and palliative medicine physicians dealing with this devastating illness.

Using a functional index of daily activities called the
Barthel Index (0-100, worst to best) to assess independence and functional recovery, the study followed 340 patients from stroke onset to 100 days post stroke. The Essen ICH Score is derived from 3 factors: Age, NIH-Stroke Scale (NIH-SS), and NIH-SS Level of Consciousness. The maximum Essen ICH Score is 10 with >7 indicating likely death, and <3>95 on the Barthel Index). They compared the sensitivity, specificity, Positive and Negative Predictive Value (PPV and NPV) for the Essen ICH Score, physician's prediction and the old standard prognosis scales the ICH Score and the Modified ICH score.

The major improvement with the Essen ICH Score is that it helps to predict functional recovery which the ICH score and modified ICH score never did. The PPV and NPV of the Essen ICH score to predict death is 88.7% and 81.0% and to predict functional recovery is 69.8% and 86.7%. Of note these scores are very similar to the physician's predictions. In fact, the prognosis of the physicians had a better PPV for death (93.3%) and for complete recovery (79.2%).
An interesting last line of the article:

In contrast, the even higher positive predictive value of the physicians´ prediction of death may hint at a self-fulfilling prophecy.
I will have to see what the three articles that were cited have to say on this matter. The self-fulfilling prophecy of prognosis and the classic physician's dilemma is one that has been written about by Christakis in a number of articles and in his book, Death Foretold.

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