Predicting the presence of macrovascular causes in non-traumatic intracerebral haemorrhage: the DIAGRAM prediction score

J Neurol Neurosurg Psychiatry. 2018 Jul;89(7):674-679. doi: 10.1136/jnnp-2017-317262. Epub 2018 Jan 18.


Objective: A substantial part of non-traumatic intracerebral haemorrhages (ICH) arises from a macrovascular cause, but there is little guidance on selection of patients for additional diagnostic work-up. We aimed to develop and externally validate a model for predicting the probability of a macrovascular cause in patients with non-traumatic ICH.

Methods: The DIagnostic AngioGRAphy to find vascular Malformations (DIAGRAM) study (n=298; 69 macrovascular cause; 23%) is a prospective, multicentre study assessing yield and accuracy of CT angiography (CTA), MRI/ magnetic resonance angiography (MRA) and intra-arterial catheter angiography in diagnosing macrovascular causes in patients with non-traumatic ICH. We considered prespecified patient and ICH characteristics in multivariable logistic regression analyses as predictors for a macrovascular cause. We combined independent predictors in a model, which we validated in an external cohort of 173 patients with ICH (78 macrovascular cause, 45%).

Results: Independent predictors were younger age, lobar or posterior fossa (vs deep) location of ICH, and absence of small vessel disease (SVD). A model that combined these predictors showed good performance in the development data (c-statistic 0.83; 95% CI 0.78 to 0.88) and moderate performance in external validation (c-statistic 0.66; 95% CI 0.58 to 0.74). When CTA results were added, the c-statistic was excellent (0.91; 95% CI 0.88 to 0.94) and good after external validation (0.88; 95% CI 0.83 to 0.94). Predicted probabilities varied from 1% in patients aged 51-70 years with deep ICH and SVD, to more than 50% in patients aged 18-50 years with lobar or posterior fossa ICH without SVD.

Conclusion: The DIAGRAM scores help to predict the probability of a macrovascular cause in patients with non-traumatic ICH based on age, ICH location, SVD and CTA.

Keywords: CT angiography; arteriovenous malformation; digital subtraction angiography; intracerebral haemorrhage.

Publication types

  • Multicenter Study
  • Research Support, Non-U.S. Gov't

MeSH terms

  • Adolescent
  • Adult
  • Aged
  • Central Nervous System Vascular Malformations / complications*
  • Central Nervous System Vascular Malformations / diagnostic imaging*
  • Cerebral Angiography
  • Cerebral Hemorrhage / diagnostic imaging*
  • Cerebral Hemorrhage / etiology*
  • Computed Tomography Angiography
  • Female
  • Humans
  • Logistic Models
  • Magnetic Resonance Angiography
  • Male
  • Middle Aged
  • Netherlands
  • Predictive Value of Tests
  • Prospective Studies
  • Risk Factors
  • Young Adult