Prognosis

Approximately half of all ich related mortality occurs within the first 24
hour after the initial hemorrhage. mortality approaches 50% at 30 days
factors associated with poor outcomes include large hematoma volume
(>30 ml), posterior fossa location , older age, mean arterial blood
pressure (MAP) >130 mmhg at admission and a score of below 4 on the
glasgow coma scale (GCS) on admission. the same factors are also the
most powerful predicators of mortality at 30 days. hematoma
expansion has also been shown to be an independent predictor of
diminished functional outcomes, neurological deterioration and
mortality. in a study by alvarez-sabin et al. (2004) increased levels of
matrix metalloproteinase (MMP)-9 and MMP-3 at 24 hour are associated
with increased peri-hematomal edema and mortality, respectively.

The ICH score and FUNC score are two clinical grading
scales used to prognosticate patients with hemorrhagic
stroke. all 26 patients with an ICH score of 0 survived and
all 6 patients with an ICH score of 5 died within the 30
days. The ICH score predicts 30 day mortality using
factors including age, ICH volume, GCS score and
presence of IVH (table 3). In a study by hemphill et all.
(2011) all 26 patients with an ICH score of 0 survived and
all 6 patients with an ICH score of 5 died within the 30
days. the limitation of the ICH score is that it is solely
used to prognosticate survival at 30 days without

Table 3. the ICH score predicts 30 days mortality using

factors including GCS score, ICH volume, presence of
intraventricular hemorrhage (IVH), and age. the scale
ranges from 0 to 6 points. in the original study all
patients with a score of 0 survived and all patients with a
score of 5 died within 30 days. the limitation of the ICH
score that is does not account for functional outcome.

Another prognostic tool is the FUNC (functional outcome risk

stratification) score. the patient is assessed for risk of functional
impairment at 90 days post stroke. the FUNC score range from zero
to eleven based on ICH volume, age, site of ICH, gcs score and pre
ICH cognitive impairment (table 4). a greater score is associated with
a greater chance of functional independence, defined as GCS 4 at
90 days. according to rost et all. (2008) no patient with a FUNC score
< 4 achieved functional independence and over 80 % of those with a
maximal FUNC score of 11 reached functional independence at 90
days. the limitation, however, is that only scores at the extreme ends
seem to be clinically useful as scores in the mid range heve little
predictive value.

Although these prognostic tool scores are importent in

the hospital setting, the AHA recommends prompt and
aggressive full care upon ICH onset with postponement
of new AND ("allow natural death") orders until at least
the second full day of hospitalization. this is because
there is evidence that a started poor prognosis can lead
to self - fullfilling prophecies of early death. withdrawal of
care is the strongest predictor of death after ICH and,
thus, in the emergency setting new AND orders or
withdrawal of care are not recommended.

table 4. the FUNC ( functional outcome risk stratification)

score assesses the patient for risk of functional
impairment at 90 days post stroke. the scores range from
0 to 11 based on ICH volume, age, ICH location, GCS
score, and pre ICH cognitive impairment. A greater score
is associated with a greater chance of functional
independence, defined as GCS > 4, at 90 days.
limitations include lack of predictive value for scores in
the mid range.