Association of ICH Score with Withdrawal of Life-Sustaining Treatment: A Decade from the Florida Stroke Registry

Background and PurposeThe intracerebral hemorrhage (ICH) score was created as a tool improve communication and consistency among providers, and authors initially cautioned against its use as a predictor of outcomes. We aimed to investigate the association of ICH score with mortality and withdrawal of life-sustaining treatment (WLST). MethodsPatients with a diagnosis of ICH were identified using data from Florida Stroke Registry (FSR) hospitals participating in the American Heart Association (AHA) Get with the Guidelines-Stroke (GWTG-S) from 2013-2022. Outcomes of WLST and in-hospital mortality were collected. ICH score was stratified into three groups: ICH score 0-2; 3-4; 5-6. Importance plots were generated to identify the most predictive factors associated with WLST. AUC-ROC curves were generated for logistic regression (LR) and random forest (RF) models, adjusted for relevant confounders. Secondary outcome analyses were performed using stratified univariate logistic regression to assess changes between 2015-2018 and 2019-2022. ResultsA total of 12,426 (26%) patients had documented ICH scores (mean age 69, 55% male, 56% white). The most predictive factors associated with WLST were ICH score, age, state region, presenting level of consciousness, insurance status and race (RF AUC=.94, LR AUC=.82). Mortality was 6.6%, 41.5% and 66% for ICH score 0-2, 3-4 and 5-6. Decision to WLST occurred more for ICH scores 3-4 (OR 9.35, 95% CI: 8.5-10.3) and ICH scores 5-6 (15.43, 95% CI: 15.28-22.74). Early WLST (< 2 days) was more likely for ICH score 3-4 (OR 2.97, 95% CI: 2.48-3.55) and score 5-6 groups (OR 9.51, 95% CI: 7.33-12.35). ConclusionAmong ICH patients admitted across Florida, we noted a significant association between ICH score and likelihood of mortality, decision to WLST, and specifically WLST within two days of presentation. We identified the most predictive variable associated with WLST to be the ICH score. These findings suggest a continued influence of the self-fulfilling prophecy in ICH.