To our knowledge, the present study is the first to establish a scientific and reasonable nomogram model to predict a 6-month prognosis among young adults with ICH.In this consecutive series of young individuals with ICH, age,hematoma volume,bood glucose,infratentorial lesion,hemoglobin and the NIHSS were significant prognostic factors in the univariate logistic regression analysis and confirmed as an independent risk factor for functional prognosis.Based on those predicting parameters, we constructed a nomogram model for evaluating. We incorporated several common clinical factors and an easily overlooked blood indicator into our model.The performance of the present nomogram was strictly assessed and internally validated,and its net benefit was also explored by DCA and CIC, compared with other prognostic scores commonly used in clinical practice.In addition, our study demonstrates that clinical applicability of this nomogram is feasible for ICH in young adults.
Hemoglobin level is a part of automated blood analysis of blood cells at no additional cost, establishing an important link with the undesirable prognosis of stroke.19In recent years, several studies have found a positive correlation between anemia and higher mortality in stroke patients.12,20In 2018,a meta-analysis identified seven cohort studies with 7,328 ICH patients, including 1,546 patients with anemia,revealed that anemia was associated with an increased risk of poor outcome in patients with ICH (OR = 2.29 for 3-month outcome,95% CI 1.16 to 4.51; OR = 3.42 for 12-month outcome,95% CI 0.50 to 23.23).12Another recent study reported a large meta-analysis that pooled data from the ATACH-2, FAST, and ERICH studies,also found higher admission Hb levels were associated with better outcomes.20David J. Roh et al reported that such a result may occur because theses patient had a hematologic disorder that causes the hematoma,and eventually a poor prognosis.21Lower erythrocyte counts may result in less efficient radial transport of platelets toward the vessel wall, preventing the platelet endothelial interaction vital to hemostasis initiation. In addition, erythrocytes themselves may be implicated in hemostasis through their adhesion to the injured vessel wall in addition to their interaction withplatelets and fibrinogen leading to blood clot contraction.22David J. Roh et al also suggested hyperacute transfusion of pRBC can be considered in preventing the early occurrence of HE to improve outcomeBut the timing of red blood cell transfusions still needed more research to be clear.21
Previous studies suggested hyperglycemia was associated with mortality in ICH patients.23,24 A meta-analysis of 16 studies reinforced this view: high blood glucose was significantly associated with poor functional outcome in ICH patient.25previous animal studies identified an evident association between hyperglycemia and perihematomal neuronal apoptosis in rat models.26 In ICH models, hematoma with high blood glucose was found to lead to neurological injury and decreased autophagy.27 High blood glucose can increase superoxide production in ICH induced by tissue plasminogen activator.28
A 2013 study showed that age could affect the prognosis of intracerebral hemorrhage in young people, and the INTERACT-2 study also showed that age is a strong predictor of a poor prognosis for intracerebral hemorrhage, consistent with the results of this study.1110The reason for this may be that young people have better physical condition than the old. Their vascular atherosclerosis is mild, and they can establish collateral circulation in a short period of time, so that angioedema is relatively mild, neurological deficits are lighter, and young patients have a strong sense of health care and actively carry out secondary prevention.29
The GCS and NIHSS scores are commonly used in stroke scales, with GCS scores assessing a patient's state of consciousness, and NIHSS scores assessing not only the state of consciousness but also the patient's neurological deficits.A 2003 study found that the NIHSS score was superior to the GCS score in predicting the prognosis of patients with intracerebral hemorrhage, which was consistent with the results of the univariate analysis of this study that the NIHSS score and GCS score affected the prognosis at the time of univariate analysis, while the NIHSS score was independent of the influencing factors in the multivariate regression analysis.30
We found that certain outcomes were consistent with former studies. Using continuous variables,a nomogram cooperating hemoglobin with acceptable discrimination (C-index = 0.791) and calibration was established for predicting an unfavourable outcome, and it seems to possess more power efficiency than currently utilized prognostic tools.The decision curve suggested that when the probability ranges from 20–40%,the net benefits of the nomogram were higher than ICH-score and ICH-FOS. Moreover, the outcome was verified by a clinical impact curve.
In this study,the nomogram has novelity and certain advantages. Firstly, we integrated and internally validated a new nomogram model that combined clinical score and laboratory data. The nomogram can be employed to predict early functional prognosis with high accuracy (AUC 0.791). Secondly, the DCA and CIC were used to evaluate the clinical performance of the new model cretively. Finally, the data required for the nomogram model is readily available for clinical work,without adding additional workload.
However, there were still some limitations. Firstly,it was a retrospective study in a single center and not a randomized controlled trial (RCT).As a results, selection bias caused by single-center data may result in a lack of representation of results.And accuracy of clinical valuation may be attenuated by its retrospective nature.External validations in other institutions is warranted.Moreover,our model covered many types of clinical data variables, but the lacked detailed neuroimaging and therapeutic data that may lead to an unavoidable systemic bias to weaken its discriminative performance of the nomogram model.Finally,we have collected a limited number of cases and have a 30% loss-of-follow rate,that may affect the credibility of the results.Despite these limitations, we made a first attempt to establish and validate a nomogram model to predict a 6-month functional prognosis in young ICH patients.