The TRACH score: Clinical and radiological predictors of tracheostomy in supratentorial spontaneous intracerebral hemorrhage

Background and Purpose: Spontaneous intracerebral hemorrhage (sICH) continues to have high morbidity and mortality. Patients with sICH and poor mental status are at high risk of airway compromise and frequently require intubation. The traditional ventilatory weaning parameters are not reliable in patients with brain pathology. The objective of this study is to identify clinical and radiological predictors for tracheostomy in mechanically ventilated patients with sICH and to develop a scale that will accurately predict the need for tracheostomy in these patients. Methods: Only patients with supratentorial sICH intubated on the field or on admission who survived the first 3 days were included. Univariate and multivariate logistic regression analysis of clinical and radiological variables was performed, and independent predictors were identified. A risk stratification scale (TRACH Score) was developed using these independent predictors. Results: Several independent factors were associated with early tracheostomy. The signficant clinical predictor was Glasgow Coma Scale (GCS) score (P < 0.003). Radiological predictors were presence of hydrocephalus (OR: 12.5; P < 0.002), septum pellucidum shift (OR: 9; P < 0.025), and location of sICH in the thalamus (OR: 9; P < 0.025). The TRACH score was defined by two variables radiological scale (RScale) and Glasgow Outcome Score (GOS). TRACH score = 3 + (1 × RScale) - (0.5× GCS). The RScale (L + H + S) was obtained by adding individual points assigned according presence of: sICH location in the thalamus (L) 2 points, hydrocephalus (H) 1.5 points, septum pellucidum shift (S) 3 points. The scale was very predictive of tracheostomy needs (OR: 2.57, P < 0.0001) with an ROC = 0.92, sensitivity of 94%, positive predictive value of 83%, and negative predictive value of 95%. Conclusions: The TRACH Score is a practical clinical grading scale that will allow physicians to identify patients who will be needing tracheostomy. Application of this scale could have significant impact on length of stay and cost of hospitalization.