e-ISSN: 2722-3558 Sriwijaya Journal of Surgery [SJS] https://sriwijayasurgery.
Mortality Predictors Spontaneous Intracerebral Hemorrhage:
External Validation of the ICH Score in the Indonesian Surgical Population Grady Christian1*.
Trijoso Permono2.
Ziske Maritska3 1Department of Surgery.
Faculty of Medicine.
Universitas Sriwijaya.
Palembang.
Indonesia 2Department of Neurosurgery.
Faculty of Medicine.
Universitas Sriwijaya.
Palembang.
Indonesia 3Department of Biology Medicine.
Faculty of Medicine.
Universitas Sriwijaya.
Palembang.
Indonesia
ARTICLE
ABSTRACT
INFO
Keywords:
External validation ICH score Intracerebral hemorrhage Mortality Neurosurgery *Corresponding author:
Grady Christian E-mail address:
grady_christian@yahoo.
All authors have reviewed and approved the Anal version of the manuscript.
https://doi.
org/10.
37275/sjs.
Introduction: Spontaneous intracerebral hemorrhage (ICH) is a major contributor to stroke-related mortality and long-term disability, particularly in Indonesia, which faces the highest age-standardized stroke mortality rate in Southeast Asia.
This study evaluates the predictive accuracy of the ICH Score for 30-day mortality among patients undergoing surgical intervention at a primary referral center in South Sumatra.
Methods: This analytical observational study utilized a retrospective cohort design, analyzing 81 patients with spontaneous ICH who underwent surgical evacuation at Dr.
Mohammad Hoesin Central General Hospital Palembang between July 2024 and June 2025.
Demographic, clinical, and radiological parameters were Accuracy was determined using Receiver Operating Characteristic (ROC) curve analysis to establish the Area Under the Curve (AUC), sensitivity, and specificity.
Results: The cohort was predominantly male .
8 percen.
and aged under 80 years .
4 percen.
Significant predictors of 30-day mortality included age 80 years or older .
< 0.
OR 26.
lower Glasgow Coma Scale (GCS) scores .
= 0.
, and the presence of intraventricular hemorrhage (IVH) .
< 0.
OR 15.
ROC analysis demonstrated an AUC of 0.
percent CI 0.
910Ae1.
An optimal ICH Score cut-off of 3 or higher yielded a sensitivity of 86.
2 percent and a specificity of 100 percent.
Conclusion: The ICH Score serves as an exceptionally accurate prognostic tool in the Indonesian surgical population.
An admission score of 3 or higher is a definitive predictor of mortality, facilitating risk stratification and informed clinical decision-making.
Introduction Spontaneous (ICH) represents a catastrophic neurosurgical emergency diagnosis and decisive intervention in emergency and remains one of the most devastating forms of In the Indonesian context, the epidemiological and stroke worldwide.
Characterized by the non-traumatic socioeconomic burden of stroke is particularly severe.
extravasation of blood into the brain parenchyma.
ICH National health data suggests that stroke is the accounts for approximately 10 percent to 15 percent primary cause of both death and long-term disability within the archipelago.
2 When compared to other prevalence compared to ischemic stroke.
ICH is nations in Southeast Asia.
Indonesia exhibits the associated with significantly higher rates of immediate highest age-standardized mortality rate for stroke, morbidity and Despite The clinical trajectory of 100,000 these patients is often precipitous, with nearly half of Furthermore, the impact on quality of life is profound, all deaths occurring within the first 24 hours post- with the country reporting 3,382.
2 Disability-Adjusted Life Years (DALYS) lost per 100,000 people.
Regional accurate early prognosis is vital for effective triaging, data from South Sumatra further illustrates this in 2018 alone, the province recorded 22,013 counseling to the families of afflicted patients.
decision-making, stroke cases.
At Dr.
Mohammad Hoesin General Historically, various prognostic models have been Hospital (RSMH) in Palembang, a major tertiary developed to assist clinicians in predicting mortality referral center, stroke admissions are frequent and and functional outcomes after ICH.
These models Between 2016 and 2017, the hospital treated generally incorporate a combination of neurological 1,303 stroke patients, of which 26.
2 percent were status, laboratory parameters, and neuroimaging identified as the hemorrhagic subtype.
This high 7 Among these, the ICH Score, established by volume of cases at a regional hub necessitates a robust Hemphill in 2001, has emerged as the most widely clinical framework for risk stratification and resource recognized and utilized clinical tool for predicting 30- day mortality.
The score is elegantly simple, utilizing The economic ramifications of ICH in Indonesia are five easily obtainable components: the Glasgow Coma equally staggering.
Data from the Social Security Scale (GCS) score, age, hematoma volume, location of Administering Body for Health (BPJS Kesehata.
the hemorrhage .
upratentorial vs.
, and indicated that the cost of stroke care rose from 1.
trillion rupiah in 2016 to 2.
57 trillion rupiah by 2018.
hemorrhage (IVH).
These figures reflect not only the direct costs of acute The GCS score is given the highest weight in this hospital care and surgical intervention but also the model due to its powerful correlation with survival.
long-term expenses associated with chronic disability original validation cohorts, patients with an ICH Score and the loss of household productivity.
of 0 had a 0 percent mortality rate, while those with a The pathophysiology of ICH is complex and follows a dual-phase injury mechanism that complicates Intermediate scores of 1, 2, 3, and 4 were associated The primary injury phase is with 30-day mortality rates of 13 percent, 26 percent, initiated by the sudden, mechanical disruption of the 72 percent, and 97 percent, respectively.
While the brain parenchyma as the hematoma expands.
This ICH Score has been validated across diverse global expanding mass effect leads to a rapid increase in populations, its specific accuracy within surgical intracranial pressure (ICP), which can cause midline cohorts remains a subject of active investigation.
shift and life-threatening brain herniation.
This is Surgical intervention, such as hematoma evacuation immediately followed by a secondary injury phase, through craniotomy or craniectomy, fundamentally which is often more prolonged and biologically alters the natural history of the disease by reducing This phase is driven by neurotoxicity the primary mass effect and potentially limiting the resulting from blood breakdown productsAispecifically source of secondary neurotoxins.
There are ongoing thrombin and heminAiwhich activate microglia and concerns regarding whether the standard ICH Score trigger a profound inflammatory response.
This remains an accurate predictor when the clinical cascade leads to the development of perihematomal course is modified by neurosurgical intervention, edema, oxidative stress, and the breakdown of the particularly in settings where access to neuroimaging, blood-brain barrier.
Edema typically begins within 24 intensive care, and specialized surgical teams may hours, peaks around the fifth or sixth day, and can 9 Furthermore, some researchers have raised the persist for up to two weeks, further compromising issue of a self-fulfilling prophecy, suggesting that high initial scores may lead clinicians toward more progression from primary mechanical damage to conservative management or the withdrawal of life- sustaining treatment, thereby artificially confirming Because the poor prognosis predicted by the score.
progression and clinical outcomes of patients who had Indonesia, the application of the ICH Score in surgical already received treatment, the researchers could settings requires local validation to ensure it remains identify significant correlations between admission a reliable guide for the specific patient populations parameters and 30-day survival without interfering treated at tertiary centers like RSMH.
While some with active clinical management.
international studies suggest that the accuracy of the The study was conducted at Dr.
Mohammad score may decrease in patients undergoing surgery.
Hoesin General Hospital (RSMH) in Palembang.
South others maintain Sumatra, which serves as a major tertiary referral stratification tool.
Evaluating the performance of this center for the region.
Ethical integrity was a primary score in a local surgical population is essential for consideration throughout the research process.
The refining clinical protocols and ensuring that surgical protocol received formal approval from the Research candidates are selected based on objective, validated Ethics Committee of Dr.
Mohammad Hoesin General Hospital its utility Palembang.
This study aims to evaluate the accuracy of the ICH DP.
03/D.
XVi.
08/ETIK/014/2026.
The study Score as a predictive factor of 30-day mortality, was conducted in strict adherence to the ethical specifically for patients with spontaneous ICH who principles outlined in the Declaration of Helsinki and undergo surgical evacuation at Dr.
Mohammad Hoesin referred to the 2016 CIOMS Guidelines.
Furthermore.
General the research protocol satisfied the seven WHO 2011 relationship between individual score components and standards, including social value, scientific validity, actual clinical outcomes, this research seeks to determine the optimal prognostic threshold for this Because the study utilized existing specific population.
The novelty of this research lies in medical records, the data were anonymized to ensure its dedicated focus on a surgical cohort within a major that no identifying information was included in the Indonesian regional referral center, providing essential local validation of a global prognostic tool.
Unlike standards of medical ethics and patient protection.
general stroke studies, this investigation specifically The target population for this investigation consisted examines the performance of the ICH Score when its of patients diagnosed with spontaneous intracerebral variables are influenced by neurosurgical intervention.
By establishing a precise prognostic cut-off tailored to underwent surgical intervention at RSMH Palembang.
the Indonesian surgical context, this study contributes The temporal scope of the data collection spanned a to the development of more accurate, evidence-based one-year period, specifically from July 2024 to June management strategies, ultimately aiming to improve During this period, an initial cohort of 92 neurosurgical outcomes and patient counseling in patients was identified as having undergone surgical Southeast Asia.
evacuation for ICH.
Hospital Palembang.
(ICH)
To ensure the homogeneity of the sample and the Methods validity of the results, strict inclusion and exclusion The methodological framework of this study was criteria were applied.
Inclusion was limited to patients constructed as an analytical observational research aged 18 years or older with a diagnosis of spontaneous project utilizing a retrospective cohort design.
This ICH design was specifically chosen to evaluate the Tomography (CT) scans.
Additionally, all subjects historical clinical data of patients over a defined period must have undergone a surgical procedure for to determine the predictive accuracy of established hematoma evacuation and possessed a complete medical record including admission GCS, radiological non-contrast Computed findings, and 30-day outcome status.
Significant 81 patients.
A simple random sampling technique was efforts were made to exclude cases of secondary ICH, utilized within this group to ensure that the sample as these represent distinct pathological entities with was representative of the broader patient population different prognostic trajectories.
Consequently, 11 treated at the facility and to satisfy the requirements cases were removed from the initial pool: 4 cases were for statistical significance.
The minimum required identified as secondary to brain tumors, 5 cases sample size was calculated at 80 subjects based on an resulted from underlying vascular malformations, and expected sensitivity of 75 percent and a research 2 cases were excluded due to incomplete or missing precision of 15 percent, making the final sample of 81 clinical data.
The final analytical sample consisted of patients statistically robust (Figure .
Figure 1.
STROBE flowchart of patient recruitment.
The independent variable for this research was the calculated for each patient by aggregating points total ICH Score calculated at the time of hospital This multi-component grading scale was Neurological status was assessed using the Glasgow Coma Scale (GCS), which was weighted most heavily Categorical variables were compared using in the scoring system.
Patients presenting with a GCS the Chi-Square test, while FisherAos Exact test was of 13 to 15 received 0 points, those with a GCS of 5 to applied in cases where the expected frequency in any 12 received 1 point, and those in a deep coma with a cell was less than five.
The strength of the associations GCS of 3 to 4 received 2 points.
The radiological was expressed using Odds Ratios (OR) with 95 percent assessment involved measuring the volume of the Confidence Intervals (CI).
To determine the overall hematoma using the ABC/2 method on the initial CT prognostic accuracy of the ICH Score, a Receiver In this formula, 'A' represents the largest Operating diameter of the hematoma on an axial slice, 'B' is the The Area Under the Curve (AUC) was diameter perpendicular to 'A', and 'C' is the number of slices showing the hematoma multiplied by the slice discriminate between survivors and non-survivors.
A volume of 30 cubic centimeters or more with an AUC closer to 1.
0 representing a higher level was assigned 1 point, while a volume less than 30 of accuracy.
Furthermore, the Youden Index was utilized to identify the optimal cut-off point for the Additional Characteristic (ROC) score, maximizing both sensitivity and specificity for intraventricular hemorrhage (IVH), where 1 point was assigned if blood was present within the ventricles and Sensitivity, specificity, positive predictive 0 points if absent.
The location of the hemorrhage was value (PPV), and negative predictive value (NPV) were also categorized.
infratentorial ICH .
riginating in the calculated for the identified cut-off to provide a pons or cerebellu.
received 1 point, whereas comprehensive assessment of the score's clinical supratentorial locations received 0 points.
Finally, the Differences in mean scores between the living patient's age was dichotomized, with those 80 years or and deceased groups were analyzed using the Mann- older receiving 1 point and those under 80 receiving 0 Whitney U test, given the non-parametric nature of the The aggregate score ranged from 0 to 6.
The score distribution.
A p-value of less than 0.
05 was primary dependent variable was 30-day mortality, defined as the survival status of the patient exactly one month after the surgical procedure.
This status was recorded as either living or deceased based on hospital records and follow-up data.
Results The study included 81 subjects.
Demographic data All clinical and radiological data were meticulously revealed that 46 .
8 percen.
were male and 35 .
entered into a digital database and processed using percen.
were female.
Age distribution showed that 70 the Statistical Product and Service Solutions (SPSS) patients .
4 percen.
were under 80 years old, while The 11 .
6 percen.
were 80 years or older.
In terms of .
population, including frequency distributions and presented with a GCS of 5Ae12.
Radiological findings indicated that 56 patients .
1 percen.
had a The normality of the data was tested using hematoma volume of 30 cc or more.
Intraventricular either the Kolmogorov-Smirnov or Shapiro-Wilk tests hemorrhage was present in 17 patients .
, to determine the appropriate subsequent statistical and 5 patients .
2 percen.
had infratentorial ICH.
Bivariate analysis was performed to evaluate The overall 30-day mortality rate was 35.
8 percent .
the relationship between each individual component of ICH Score 30-day Figure 2 delineates the predictive power of The IVH individual clinical and radiological components of the exacerbated the risk of death, elevating the mortality ICH rate to 82.
4% relative to 23.
4% in patients without Score 30-day surgically treated patients.
Bivariate analysis reveals that advanced age, depressed neurological status, and Interestingly, while a hematoma volume of 30 cc or the presence of intraventricular hemorrhage (IVH) greater and an infratentorial hemorrhage location serve as the most potent independent predictors of a indicated higher mortality trendsAiyielding odds ratios fatal outcome.
Specifically, patients aged 80 years or 00 and 8.
16, respectivelyAithese variables did not older exhibited a critically high mortality rate of 90.
achieve statistical significance within this specific compared to just 27.
1% in younger cohorts (OR 26.
surgical cohort .
= 0.
078 and p = 0.
Finally, p < 0.
Similarly, admission Glasgow Coma Scale gender demonstrated no significant association with (GCS) scores demonstrated a definitive prognostic all patients presenting with a severe GCS of 3 to 4 succumbed to their injuries .
% mortalit.
, hemorrhage rather than demographic characteristics whereas those with a mild GCS of 13 to 15 uniformly primarily drives postoperative clinical outcomes.
(OR
Figure 2.
Predictive power of ICH score components on 30-day mortality.
Table 2 elucidates the distribution of 30-day However, a definitive physiological tipping point is Intracerebral Hemorrhage (ICH) Score among the 81 unequivocally established at an ICH Score of 3.
For surgically treated patients.
The overarching mortality patients presenting with scores of 3 or 4, aggressive rate for the cohort was 35.
8 percent, representing 29 surgical intervention failed to avert fatal outcomes.
A granular examination of the data reveals a culminating in a 100 percent mortality rate across stark, nonlinear prognostic gradient inextricably both subgroups .
deaths and 4 deaths, respectivel.
Patients Consequently, no individual with a score of 3 or higher presenting with an admission score of 0 or 1 survived the 30-day postoperative observation period.
demonstrated a uniformly favorable survival profile.
This precipitous escalation from an 11.
1 percent to a with a 0 percent mortality rate observed across all 20 100 percent mortality rate emphasizes the profound individuals in these categories.
As the clinical and radiological severity increased to an ICH Score of 2, the Ultimately, the data substantiates that an ICH Score mortality rate experienced a modest elevation to 11.
of 3 or greater constitutes a critical prognostic percent, encompassing 4 deaths out of 36 patients.
threshold, providing neurosurgeons with an objective This relatively attenuated fatality rate within the moderate-risk tier highlights the potential therapeutic comprehensive family counseling.
ICH
secondary neurotoxicity and relieving mass effect.
Score.
efficacy of surgical hematoma evacuation in mitigating Figure Operating ICH Score of 3 or higher as the definitive cut-off point.
Characteristic (ROC) curve analysis, comprehensively At this specific threshold, the scoring system achieved a sensitivity of 86.
2 percent, accurately capturing the performance of the Intracerebral Hemorrhage (ICH) vast majority of non-survivors, paired with an Score in predicting 30-day mortality among the 81 impeccable specificity of 100 percent.
By maximizing Receiver The both sensitivity and specificity, this cut-off effectively The capability, underscored by an Area Under the Curve specificity corresponds to a zero percent false-positive (AUC) of 0.
percent confidence interval: 0.
rate for mortality prediction.
unequivocally, every In the paradigm of clinical biostatistics, an patient within this cohort who presented with a score
AUC
of 3 or greater succumbed within the 30-day discriminatory power, confirming that the ICH Score Consequently, remains a highly robust tool even when the natural progression of the hemorrhage is structurally modified observation that an ICH Score of 3 represents a critical by neurosurgical evacuation.
physiological juncture in the Indonesian referral ROC To ascertain the maximum clinical utility, the context, providing an indispensable, evidence-based Youden Index was applied to the curve coordinates to metric for neurosurgical triaging, risk stratification, determine the optimal prognostic threshold.
This and guiding complex intensive care management.
mathematical optimization identified an admission Figure 3.
Receiver operating characteristic (ROC) curve analysis.
Discussion The The results of this investigation conclusively system consists of a delicate network of interconnected demonstrate that advanced age, specifically being 80 anatomical chambers through which cerebrospinal When intraventricular hemorrhage, serve as the most potent, intraparenchymal hematoma ruptures through the independent predictors of early mortality following ependymal lining and dissects into this system, the extravasated blood rapidly coagulates.
These dense From a rigorous pathophysiological standpoint, advanced age is inextricably linked with a anatomical choke points, particularly the cerebral profound reduction in cerebral physiological reserve aqueduct connecting the third and fourth ventricles, and an exponential increase in cerebrovascular or the lateral foramina of Luschka and the median foramen of Magendie.
As the human brain ages, the cerebral microvasculature undergoes extensive degenerative However, the pathogenesis of intraventricular Chronic exposure to hemodynamic stress hemorrhage extends far beyond simple mechanical leads to lipohyalinosis, a process characterized by the The introduction of whole blood into the deposition of hyaline material and lipid accumulation cerebrospinal fluid initiates a severe, cascading within the walls of small penetrating arteries.
This architectural degradation frequently results in the As erythrocytes undergo lysis within the Charcot-Bouchard which are highly susceptible to rupture under sudden hemoglobin, which subsequently degrades into highly hypertensive spikes.
toxic hemin and free iron.
These breakdown products Furthermore, are profoundly noxious to the ependymal cells and the significantly higher prevalence of cerebral amyloid angiopathy, wherein amyloid-beta proteins precipitate The impairs the specialized transport mechanisms of the choroid plexus, culminating in a dramatic, acute elevation in global intracranial pressure.
This creates octogenarian, the compromised vascular network fails a critical clinical dilemma: while a neurosurgeon may to effectively initiate hemostasis, leading to more successfully perform a craniotomy to evacuate the expansive and devastating primary mass lesions.
primary parenchymal clot, this intervention does not Beyond the mechanical injury, the aging brain exhibits Without the concurrent placement of an external Senescent microglia, existing in a primed ventricular drain to artificially divert the contaminated state, react excessively to the extravasation of blood.
This exaggerated immune response accelerates the hypertension will inevitably lead to fatal global breakdown of the blood-brain barrier, exacerbating cerebral ischemia.
rendering them exceptionally brittle.
13 Consequently, perihematomal edema and precipitating secondary Interestingly, while the original iteration of the neuronal apoptosis at a rate far exceeding that Intracerebral Hemorrhage Score assigns substantial observed in younger cohorts.
prognostic weight to a hematoma volume of 30 cubic The centimeters or greater, our specifically surgical cohort significantly compounds the clinical severity and demonstrated a compelling divergence from this serves as a catastrophic prognostic marker due to its traditional paradigm.
In our analysis, large hematoma direct role in the genesis of acute obstructive and volume did not independently predict mortality with the same statistical magnitude as advanced age or factorsAiwhich predominantly includes a deep state of intraventricular extension.
This observation suggests a profound modification of the natural history of the physiological odds.
18 From a clinical perspective, an ageAiface admission score of 3 represents a physiological point of no return.
At this juncture, the profound loss of management, a large volume of clotted blood acts as a brainstem reflexes, combined with the global ischemic persistent nidus for both expansive mass effect and sustained chemical neurotoxicity.
By actively and secondary neuroinflammation, creates an irreversible cascade of neurological devastation.
The data starkly neurosurgeon directly eliminates the primary source reveal that aggressive surgical decompression, while catastrophic midline shift and uncal herniation that reversing the terminal trajectory of these patients.
Furthermore.
Conversely, the remarkably low mortality rate removing the clot substantially reduces the volume of observed in patients presenting with a score of 2 underscores the highly protective effect of early products, theoretically neurosurgical intervention for the moderate-risk inflammatory cascade.
This therapeutic mechanism In our cohort, patients with a score of 2 effectively neutralizes the mortality risk typically experienced an 11.
1 percent mortality rate.
This is a associated with a large initial hematoma volume, particularly in patients who maintain a moderate level compared to the foundational data published by of neurological function upon admission.
Hemphill The discriminative capability of the Intracerebral predominantly through medical means faced an Hemorrhage Score within this specific Indonesian approximate 26 percent mortality rate at the same score level.
This significant deviation highlights the demonstrated by an Area Under the Curve of 0.
tangible benefit of prompt craniotomy or craniectomy the realm of clinical biostatistics, a value exceeding in preserving neurological viability.
For patients who 90 is categorized as outstanding, indicating that the have suffered a significant hemorrhage but have not scoring system correctly classifies patient outcomes yet progressed to profound, irreversible brainstem compression, surgical evacuation effectively intercepts establishes that for patients who survive the initial the pathway to herniation, salvaging endangered but insult long enough to reach the operating theater, the still viable cortical tissue.
near-perfect This preoperative score remains an incredibly robust discriminator of ultimate survival.
While the findings of this investigation provide context-specific A critical, practice-changing insight derived from prognostic tool, the study is not without inherent this analysis is the establishment of an admission limitations that must be thoughtfully considered.
score of 3 or higher as a definitive threshold for 100 Foremost, the research utilizes a retrospective cohort percent mortality.
Within our cohort, every individual design restricted to a single tertiary referral center.
presenting with a cumulative score of 3 or 4 ultimately Retrospective analyses are inherently vulnerable to succumbed to their condition within thirty days, representing a positive predictive value of absolute documentation practices, although stringent inclusion criteria were implemented to mitigate these factors.
burdened with this specific combination of risk Additionally, because the study focused strictly on This patients deemed suitable for surgery, there is an Sumatra.
inherent survivorship bias.
patients who suffered hemorrhages so catastrophic that they died before consciousness as measured by the Glasgow Coma reaching the hospital, or were deemed too unstable for Scale, and the presence of intraventricular blood anesthesia, are naturally excluded from the data set.
extension are the most formidable clinical drivers of Furthermore, the statistical power regarding specific subcategoriesAinamely, identifies a cumulative admission score of 3 or higher infratentorial hemorrhages and those aged 80 years or as the definitive physiological threshold for critical olderAiwas constrained by the relatively small sample mortality risk, beyond which surgical intervention sizes inherent to these less common presentations.
yields no survival benefit.
This specific metric provides This limitation may affect the broad generalizability of the odds ratios calculated specifically for those statistically validated tool to optimize the rapid demographic subsets.
The Crucially.
Another vital limitation is the reliance on 30-day Furthermore, integrating this precise cut-off into mortality as the singular primary endpoint.
While routine clinical practice will fundamentally enhance mortality provides a definitive, unambiguous metric the quality of communication with patients' families, for surgical outcome, it fails to capture the profound allowing physicians to set realistic, compassionate nuances of In the context of severe expectations regarding prognosis.
Ultimately, the neurological injury, simply preserving life does not rigorous application of this validated scoring system equate to preserving human agency or quality of life.
will refine the ethical allocation of highly intensive.
Future prospective research protocols must prioritize limited neurocritical care resources, ensuring that longitudinal follow-up to assess the functional and aggressive surgical interventions are directed toward cognitive outcomes of survivors using standardized those moderate-risk patients who possess the greatest instruments such as the modified Rankin Scale.
physiological potential for meaningful survival.
Understanding the true burden of survival is essential, as surviving a devastating intracerebral hemorrhage often means transitioning into a state of severe.
References