ICH-FOS for evaluating surgical outcomes in supratentorial spontaneous ICH: Toward precision neurosurgical care

Identifying patients with supratentorial spontaneous intracerebral hemorrhage (sICH) who are most likely to benefit from neurosurgical intervention remains challenging. We aimed to assess the value of the Intracerebral Hemorrhage Functional Outcome Score (ICH-FOS) for stratifying baseline risk and evaluating outcomes across risk strata following neurosurgical intervention.

We analyzed two observational ICH cohorts from China: a prospective, multicenter cohort (cohort 1) enrolled from January 2014 to September 2016 and a retrospective, single-center cohort (cohort 2) enrolled from November 2023 to December 2024. Patients were stratified into low (0-4), moderate (5-8), and high (9-16) risk groups based on ICH-FOS. The primary outcome was 1-year favorable functional outcome, defined as a modified Rankin Scale (mRS) score of 0-3. Outcomes were assessed with logistic regression models, adjusting for covariates selected based on clinical relevance and baseline imbalances between groups.

Cohort 1 included 1057 patients with 203 (19.2 %) receiving neurosurgical intervention. Cohort 2 included 636 patients with 107 (16.8 %) undergoing surgery. In cohort 1, neurosurgical intervention was associated with better 1-year functional outcomes in high-risk patients (odds ratio [OR], 2.99; 95 % CI, 1.12-7.98), but worse outcomes in low- (OR, 0.24; 95 % CI, 0.09-0.62) and moderate-risk groups (OR, 0.39; 95 % CI, 0.18-0.87). Consistent patterns were observed at 3 months, with surgery associated with worse outcomes in low- (OR, 0.33; 95 % CI, 0.14-0.77) and moderate-risk groups (OR, 0.20; 95 % CI, 0.09-0.44), and no significant functional benefit in high-risk patients (OR, 1.02; 95 % CI, 0.30-3.49), but improved survival in this group. The results of cohort 2 were consistent with those of cohort 1.

Among patients with supratentorial sICH, those classified as low- to moderate-risk by the ICH-FOS derived greater benefit from conservative management, whereas high-risk patients experienced improved survival and potential long-term functional benefit with neurosurgical intervention. These findings highlight the value of ICH-FOS in stratifying baseline risk and evaluating potential outcomes across patient subgroups, supporting a precision-medicine perspective in sICH.