Validation of the Intracerebral Hemorrhage Score Using Computed Tomography in Spontaneous Intracerebral Hemorrhage at a Tertiary Hospital in Kumasi Ghana A Prospective Cohort Study

Validation of the Intracerebral Hemorrhage Score Using Computed Tomography in Spontaneous Intracerebral Hemorrhage at a Tertiary Hospital in Kumasi Ghana A Prospective Cohort Study | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Validation of the Intracerebral Hemorrhage Score Using Computed Tomography in Spontaneous Intracerebral Hemorrhage at a Tertiary Hospital in Kumasi Ghana A Prospective Cohort Study Mansa Amamoo, Stephen Sarfo, Augustina Badu Peprah, Adu Tutu Amankwa, and 6 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-9301864/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 7 You are reading this latest preprint version Abstract Background Haemorrhagic stroke, particularly spontaneous intracerebral haemorrhage (ICH), represents a critical public health challenge worldwide, contributing significantly to premature mortality and long-term disability. Unlike ischaemic stroke, where therapeutic avenues such as thrombolysis and thrombectomy have revolutionised care, ICH lacks a definitive curative intervention of proven benefit, necessitating supportive care and precise prognostication. In sub-Saharan Africa, the burden of ICH is amplified by an epidemiological transition characterised by a rising prevalence of undiagnosed and uncontrolled hypertension. Given the high mortality rates and resource limitations in settings like Ghana, accurate risk stratification is essential for guiding clinical decision-making and optimising resource allocation. While the ICH score is validated in high‑income settings, its performance in sub‑Saharan Africa, where patients are younger, the hypertension burden is higher, and neurocritical care resources are limited, remains unknown. This study evaluates both the discriminative ability and calibration of the ICH score in a Ghanaian cohort with CT‑confirmed spontaneous ICH at the Komfo Anokye Teaching Hospital (KATH) in Kumasi. Methods The cross-sectional study was conducted over eight months at the Radiology Directorate of KATH. The study recruited 146 adult patients (≥ 18 years) presenting with acute neurological deficits and Computed Tomography (CT) confirmed ICH. Seven patients were lost to follow-up, leaving 139 for analysis. Socio-demographic and clinical data were obtained from patient interviews and the Lightwave Health Information Management System (LHIMS). Non‑enhanced CT scans were reviewed by two radiologists to determine haematoma location, volume, and intraventricular extension (IVH). Confirmatory vascular imaging (CT angiography or DSA) was not routinely available; therefore, a small proportion of cases may represent underlying vascular malformations, a limitation acknowledged in the analysis. The ICH score and Glasgow Coma Scale (GCS) were calculated on admission. The primary outcome was 30-day functional status and mortality, assessed using the modified Rankin Scale (mRS). Results The median age of the cohort was 53 years, with a peak prevalence in the 40–59 age group (59.0%). A male predominance was observed (69.1%). Hypertension was the dominant risk factor, present in 95.7% of patients on admission. The overall 30-day mortality rate was 61.8%. A GCS score of 3–4 was associated with a more than six-fold increase in mortality risk compared to a GCS score of 5–12 (p 30 mL) and the presence of IVH were independent predictors of poor outcomes. The ICH score demonstrated a strong positive correlation with 30-day mortality. Conclusion The ICH score demonstrates strong prognostic utility in this Ghanaian cohort, but absolute mortality for a given ICH score is significantly higher than reported in high‑income settings (e.g., ICH score 2: 75% vs. 26% originally). The study highlights a younger age of onset compared to global averages and a heavy burden of hypertension. These findings highlight the urgent need for enhanced hypertensive control programs and the establishment of dedicated stroke units to mitigate the high mortality associated with this condition. Primary Intracerebral Haemorrhage ICH Score Prognostication Stroke Hypertension Kumasi Ghana Computed Tomography Modified Rankin Scale Figures Figure 1 Figure 2 Figure 3 Figure 4 Figure 5 Figure 6 Figure 7 Figure 8 Figure 9 INTRODUCTION Stroke constitutes a worldwide health crisis of increasing magnitude, currently ranking as the second leading cause of death and a primary contributor to long-term disability worldwide [ 1 ]. The epidemiological landscape of stroke is undergoing a profound shift; while incidence rates have stabilised or declined in many high-income countries (HICs) due to effective preventative strategies and advanced acute care, the burden is accelerating in low- and middle-income countries (LMICs) [ 2 ]. Sub-Saharan Africa, in particular, finds itself at the epicentre of this transition, grappling with a "double burden" of disease where persistent infectious challenges overlap with a surging prevalence of non-communicable diseases (NCDs) such as hypertension and diabetes. Among the subtypes of stroke, primary intracerebral haemorrhage (ICH), defined as spontaneous bleeding into the brain parenchyma unrelated to trauma or underlying structural lesions, is particularly devastating. Although ICH accounts for a smaller proportion of all strokes globally compared to ischaemic stroke (approximately 10–20% in HICs), its incidence is notably higher in African populations, accounting for up to 34% of stroke cases [ 3 , 4 ]. This disparity is clinically significant because haemorrhagic stroke carries a higher risk of early mortality and severe functional impairment. The 30-day mortality rate for ICH can exceed 40%, with less than half of survivors achieving functional independence at one year [ 5 ]. The pathophysiology of ICH in the African context is inextricably linked to hypertension. Chronic, uncontrolled elevation in blood pressure induces lipohyalinosis and fibrinoid necrosis in the small perforating arteries of the brain, predisposing them to rupture [ 6 ]. The Stroke Investigative Research and Educational Network (SIREN) study identified hypertension as the single most potent modifiable risk factor for stroke in West Africa, with a population-attributable risk far exceeding that observed in other regions [ 7 ]. This biological vulnerability is compounded by systemic challenges, including limited access to neuroimaging, delayed presentation to hospitals, and a scarcity of neuro-critical care facilities. The clinical management of ICH is fraught with uncertainty. Unlike ischaemic stroke, where reperfusion therapies such as thrombolysis and mechanical thrombectomy have transformed outcomes, ICH lacks a definitive, universally proven medical or surgical treatment [ 8 ]. In this therapeutic vacuum, accurate prognostication becomes a cornerstone of management. To address the need for reliable risk stratification, several clinical grading scales have been developed. The most widely adopted is the Intracerebral Haemorrhage (ICH) score, introduced by Hemphill et al. in 2001 [ 9 ]. This simple, validated tool integrates five key clinical and radiological variables, Glasgow Coma Scale (GCS) score, age, haematoma volume, intraventricular haemorrhage (IVH), and infratentorial origin, to predict 30-day mortality. While the ICH score has demonstrated robust predictive validity in diverse populations across North America, Europe, and Asia, its performance in sub-Saharan Africa remains insufficiently characterised. The application of prognostic models derived from Western cohorts to African populations poses inherent risks. The derivation cohorts for the ICH score were predominantly elderly and Caucasian. In contrast, stroke patients in Ghana typically present two decades younger, often in their economically productive prime [ 10 ]. However, in the context of this study, we aim at measuring how an established score performs in a population with a different age structure, aetiology, and healthcare capacity. Relying on unvalidated scores could lead to the "self-fulfilling prophecy" of poor outcomes, where patients predicted to do poorly are potentially denied aggressive care [ 11 ]. Validating the ICH score at the Komfo Anokye Teaching Hospital (KATH) is a crucial step toward evidence-based stroke care in Ghana. KATH serves as a major referral hub for the northern sector of the country, managing a high volume of complex stroke cases. Patients in Ghana typically present at a much younger age, often in their prime economic years, and face a healthcare landscape constrained by limited neuro-critical care resources. There is a critical paucity of published data regarding the performance of the ICH score in the Ghanaian setting, particularly at the Komfo Anokye Teaching Hospital (KATH) in Kumasi. Without local validation, there is a risk that the score may inaccurately predict outcomes, either overestimating mortality, leading to a self-fulfilling prophecy of withdrawal of care, or underestimating severity, resulting in the futile utilisation of limited resources. Establishing the accuracy of the ICH score in this setting will empower clinicians to: (1) rationalize the allocation of scarce critical care resources (such as ICU beds and ventilators) to patients most likely to benefit, (2) provide families with realistic, data-driven expectations regarding survival and recovery, fostering trust and informed consent for palliative or aggressive pathways, and (3) use risk-adjusted mortality rates to monitor and improve the quality of stroke care within the institution. METHODOLOGY STUDY DESIGN The study utilised a hospital-based, cross-sectional design, conducted over a period of eight months from June 2024 to January 2025. STUDY SITE KATH is the second-largest tertiary healthcare facility in Ghana, with a bed capacity of approximately 1,200 [ 12 ]. Geographically, it is strategically located in Kumasi, the administrative and commercial capital of the Ashanti Region. Due to Kumasi's central location and extensive road networks, KATH serves as the apex referral centre for a vast catchment area that includes 13 of Ghana’s 16 administrative regions. It receives referrals not only from the Ashanti Region (population ~ 5.4 million) but also from the Bono, Bono East, Ahafo, Western North, and the entire northern belt of the country (Northern, North East, Savannah, Upper East, and Upper West regions), covering a catchment population of over 10 million people [ 12 ]. This immense catchment area ensures a diverse patient population, representative of the middle and northern sectors of Ghana. The specific locus of data collection was the Radiology Directorate at KATH. This directorate is critical to acute stroke management, providing 24-hour diagnostic imaging services. The directorate operates multiple CT scanners, but the primary machine utilised for emergency stroke imaging during the study period was the Siemens Somatom Perspective, a 128-slice multi-detector CT scanner located at the Accident and Emergency Centre. The Accident and Emergency unit at KATH is one of the busiest in West Africa, often managing complex medical emergencies that have bypassed lower-level district hospitals due to the lack of imaging facilities in peripheral areas The radiology department performs an average of 867 CT scans per month, with head CT scans constituting approximately 40% of this workload [ 12 ]. This high volume provided a dynamic stream of potential participants for the study. The operational setup at KATH involves a collaborative workflow where patients suspected of stroke are triaged at the "Red" (emergency) zone, stabilised, and then transported to the adjacent CT suite for urgent neuroimaging. This proximity was vital for recruiting patients within the acute phase of the ictus. Figure 2 Komfo Anokye Teaching Hospital Source KATH, (2024) STUDY DURATION AND POPULATION The study was conducted over eight months from June 2024 to January 2025. The study population comprised all adult patients (aged 18 years and above) who presented to the Accident and Emergency Department or the Polyclinic with clinical features suggestive of acute stroke and were subsequently referred for non-enhanced head CT scans. INCLUSION AND EXCLUSION CRITERIA Inclusion Criteria : Patients aged ≥ 18 years. Confirmation of primary intracerebral haemorrhage on non-enhanced head CT. Presentation for imaging within 72 hours of symptom onset (to ensure accurate characterisation of acute haematoma volume). Informed consent provided by the patient or a legally authorised representative (next of kin). Exclusion Criteria : Haemorrhage associated with head trauma, intracranial tumours, or haemorrhagic transformation of an ischaemic infarct on non‑contrast CT. Vascular malformations (e.g., arteriovenous malformations, aneurysms) cannot be reliably excluded using non‑contrast CT alone; therefore, we cannot claim that our cohort consists purely of primary ICH. Instead, they are “spontaneous ICH on NCCT.” These aetiologies were excluded when evident on NCCT (e.g., calcified AVM, visible aneurysm) because their pathophysiology and prognosis differ significantly from hypertensive ICH. Patients with purely subdural or epidural haematomas. Patients for whom critical admission variables (e.g., GCS, BP) were missing or who could not be contacted for the 30-day follow-up. DATA COLLECTION PROCEDURES Patient selection A purposive non-random sampling technique was employed. All patients with a clinical presentation of first-onset stroke who had been referred to the Radiology department of KATH for head CT scans and whose results showed CT-proven intracerebral haemorrhage were evaluated to ascertain their compliance with the inclusion criteria. Patients with head CT findings of haemorrhagic transformation of an ischaemic stroke, haemorrhagic tumours and intracranial haemorrhage with extra-axial haematomas, as well as patients with traumatic aetiology of the intracerebral haemorrhage, were excluded from the study. Eligible participants were approached in the waiting area of the Radiology department or followed up on the ward. The background and purpose of the study were carefully explained to them or their next of kin (in the event the patient has an altered mental status or is unable to communicate) by the principal investigator or a trained research assistant in English or Twi, the dominant languages spoken in the Ashanti region. In the event the patient or next of kin was unable to communicate in either of these languages, an interpreter was sought to explain the details in their preferred language. The interaction sought to establish that participation in the study was entirely voluntary, without coercion, without reward, and in no way affected the degree of care the patient received at any point in the hospital, should they have decided to opt out at any point in time. Participants were required to provide their signature or thumbprint on the informed consent form after agreeing to participate in the study. Patient demographics, admission neurological parameters and risk factor assessment A data collection sheet was used by the principal investigator or the research assistant to obtain information on patient age, sex and phone numbers. The GCS (recorded between 3–15 out of 15) and admission BP were recorded on a data collection form as determined by the attending emergency physician who saw the patient on arrival. Risk factors were evaluated as follows: hypertension status was deemed positive based on patient self -report, a known history, or history of antihypertensive medication. Diabetes mellitus status was based on a previous history of the condition, self-report or a history of taking antidiabetic agents. For patients with hypertension or diabetes, their compliance with prescription medication was recorded with a binary answer, yes or no; yes to indicate compliance or no to indicate non- compliance. Patient was deemed to be compliant with their medication if they took the prescribed antihypertensive or antidiabetic drug consistently at the prescribed time. If the patient had failed to take their prescribed medication for a week, frequently skipped doses or had resorted to herbal medication, they were deemed non-compliant. Alcohol was considered a risk factor for patients whose intake was more than or equal to 30drinks /month (1 drink or 1 U of alcohol=8g of alcohol. One unit of alcohol was equivalent to 12 ounces of beer with 5% alcohol, 8 ounces of malt liquor with 7% alcohol, 5 ounces of wine with 12% alcohol and a shot or 1.5 ounces of liquor or distilled spirits, e.g. brandy, gin, rum, tequila, vodka, and whiskey (40% alcohol). Current cigarette smoking status was recorded on a data collection sheet [ 13 ]. Technique of CT Scan Imaging and Interpretation The CT images used were obtained from a 128-slice Siemens CT machine (Siemens Somatom Perspective, Year of manufacture November 2013 and Refurbished in July 2020) currently at the Accident and Emergency building of the Komfo Anokye Teaching hospital. Before having the CT scan taken, patients had the procedure briefly explained to them or their relatives. All Metallic objects such as earrings, which could produce artefacts, were removed. Patients were then placed in the supine position, head first, with their arms by their sides. A tube voltage of 120kVP was used, and an axial scout image was obtained. Non-enhanced axial images from the calvarium to the skull base with head tilt or angled gantry were then obtained in a craniocaudal fashion at 3 mm section thickness with coronal and sagittal reformatted images from axial images. All images were reviewed digitally via a Syngo/Siemens workstation, ensuring that optimal width and window levels were used. No CT angiography or digital subtraction angiography was performed as part of this study. Therefore, underlying vascular malformations (AVMs, aneurysms) could not be definitively ruled out. Intracerebral haemorrhage was described as a hyperdense lesion (+ 30-60HU) with or without perilesional oedema in the brain parenchyma. Laterality of the hematoma (whether left or right) and location of the haemorrhage were recorded. For areas where haematomas occurred in more than one location on the same side of the tentorium, the haematoma location was accorded for the one which occupied a larger area. Intraventricular extension of haemorrhage was seen as hyperdensity within the ventricular system. Mass effect was recorded if ventricular compression, midline shift, cerebral or uncal herniation were present. For this study, hydrocephalus was grouped under mass effect. Ventricular compression was recorded if there was direct compression of the ventricle by the adjacent haematoma. Midline shift was calculated in millimetres as the perpendicular distance between a midline structure and a designated midline. Cerebral referred to diffuse sulcal effacement. Hydrocephalus refers to the dilation of the ventricular system. ICH SCORE The ICH score was obtained by summing individual scores for age, GCS, location of hematoma, volume of haemorrhage and intraventricular extension of haematoma and recorded out of a total of 6 points. Age of 80years or more was scored 1 point, while age less than 80years scored no (0) points. A GCS score of 3–4 was assigned a score of 2, GCS of 5–12 was scored a single point (1), while a score of 0 was given for GCS while a GCS of haematoma volume of more than 30mls scored 1 point on the ICH score while a haematoma volume of less than 30mls was given no point (0). A score of 0 was assigned for supratentorial location of the haematoma if the haemorrhage was noted in the cerebral lobes (frontal, parietal, temporal or occipital), basal ganglia or thalamus and a score of 1 was assigned for haemorrhage in the cerebellum or midbrain, pons or medulla. Extension of haemorrhage into the ventricular system was accorded a score of 1, while the absence of intraventricular haemorrhage was given no score (0). The total ICH score was recorded on the data collection sheet. ASSESSMENT OF OUTCOME Patient outcome was assessed using the modified Rankin scale via a phone call or from information extracted from the LHIMS database at 30 days post the day of admission by the principal investigator. A score of 0 was accorded to a patient who had no stroke symptoms at all at the end of the 30 days and had no limitations to their Activities of Daily Living (ADLs). A score of 1 was given to a patient who had no significant disability but had symptoms of stroke present. A person had a score of two if they had a minor handicap and were unable to perform the typical social duties they had before the illness, such as working, taking care of others, or engaging in social and recreational activities, but they were still able to perform ADLs independently. A score of 3 was accorded if the person had moderate disability requiring assistance with some instrumental ADL such as preparing meals, using the phone, cleaning the home, or getting around either by driving or public transportation but not basic ADLs. 4 was the score given if the patient had moderately severe disability and needed assistance with some basic ADL such as eating and using the bathroom or walking but did not need constant care. A patient with severe disability requiring constant care was given a score of 5. A score of 6 was given if the patient had died within the period leading to the follow-up. DATA MANAGEMENT AND ANALYSIS Every day, data gathered from the facility was transferred to a cloud server that was password-protected to keep unauthorised users out. Only the principal investigator had the password and could access the cloud server. Data was then exported to Microsoft Excel (Redmond, Washington). All analyses were carried out using STATA version 14 (College Station, Texas) statistical software. The study employed both descriptive and inferential statistics in analysing the data. For categorical variables, the results were displayed as frequency counts and proportions; for continuous variables, the median (inter-quartile range [IQR]) was used. The Shapiro-Wilk test was used to confirm visually observed skewed distributions of continuous data. Sociodemographic factors (sex, age), risk factors (diabetes, hypertension, alcohol consumption (> 30 drinks per month), current cigarette smoking, GCS (score 3–15/15), CT variables (location haemorrhage, intracerebral haemorrhage volume, intraventricular extension), ICH score (score/6), and outcome (assessed using the modified Rankin scale: 30- days after the initial day of admission: 0-no symptoms, 1-no substantial disability, 2-slight disability, 3-moderate disability, 4-moderately severe disability, 5-severe disability, 6-death. To test for the hypothesis, a chi-square test was employed at a 95% level of significance in addition to Fisher's exact test. Bivariate and multivariate analyses were conducted between demographic variables and risk factors. All analyses in this report were narrowed to cases reported at the Radiology Directorate of KATH during the study period. Statistical significance for all testing was set at a p-value of 0.05 with a 95% confidence interval. ETHICAL CONSIDERATIONS The study protocol was reviewed and approved by the Committee on Human Research, Publications and Ethics (CHRPE) of the School of Medical Sciences, Kwame Nkrumah University of Science and Technology (KNUST), and the KATH Institutional Review Board (Ref: KATH-IRB/AP/138/23). All methods were performed in accordance with the ethical standards of the CHRPE and KATHIRB and with the principles of the Declaration of Helsinki. RESULTS DEMOGRAPHIC CHARACTERISTICS A total of 146 patients were initially recruited for the study. During the follow-up period, 7 participants were lost to follow-up, resulting in a final cohort of 139 individuals eligible for analysis. This cohort represents consecutive adults with spontaneous ICH confirmed on non‑contrast CT; confirmatory vascular imaging was not available, so we refer to the cohort as “spontaneous ICH” rather than “primary ICH.” Among these participants, 86 experienced mortalities related to their conditions, while 53 successfully survived through the 30-day follow-up period. This outcome highlights the significant challenges faced by the patient population under study. The demographic profile, as shown in Table 1 , revealed a significantly younger age of onset compared to populations typically seen in high-income countries. The median age of the study participants was 53 years (Interquartile Range: 45–62 years). The age distribution was heavily skewed towards the working-age population. The modal age group was 40–59 years, which accounted for 59.0% (n = 82) of all cases. Younger adults (20–39 years) comprised 9.4% (n = 13) of the cohort, while the elderly population (≥ 80 years) represented a small minority at 2.9% (n = 4). This indicates that the burden of ICH in this setting falls disproportionately on individuals in their prime economic years. In terms of gender distribution, there was a marked male predominance. Males constituted 69.1% (n = 96) of the study population, while females accounted for 30.9% (n = 43). This resulted in a male-to-female ratio of approximately 2.2:1. Table 1 Demographic Characteristics of Patients with ICH Characteristic Category Frequency (n = 139) Percentage (%) Age Group < 20 years 13 9.4 20–39 years 13 9.4 40–59 years 82 59.0 60–79 years 40 28.7 ≥ 80 years 4 2.9 Gender Male 96 69.1 Female 43 30.9 Median Age 53 years (IQR: 45–62) RISK FACTOR PROFILE Hypertension was the single most pervasive risk factor identified in the cohort. A known history of hypertension was reported in 67.6% (n = 94) of patients. However, objective measurements taken on admission painted a more severe picture: 95.7% (n = 133) of patients presented with elevated blood pressure (> 140/90 mmHg). This discrepancy suggests a significant burden of undiagnosed or uncontrolled hypertension in the population. Among those with a known history, medication non-compliance was alarmingly high, with 76.6% (n = 72) of diagnosed hypertensives reporting poor adherence to their treatment regimens. Other risk factors showed distinct patterns. Diabetes mellitus was present in 5.8% (n = 8) of the population. Lifestyle risk factors displayed significant gender disparities. Alcohol consumption (defined as > 30 drinks/month) was reported by 15.8% (n = 22) of the total population. However, this was almost exclusively a male phenomenon; 20.8% of men reported significant alcohol use compared to only 4.6% of women (p = 0.022). Current cigarette smoking was relatively rare, identified in only 2.9% (n = 4) of the participants. Table 2 Frequency of Risk Factors Risk Factor Category Frequency (n = 139) Percentage (%) Hypertension History Yes 94 67.6 No 45 32.4 Admission BP (> 140/90) Yes 133 95.7 No 6 4.3 Antihypertensive Compliance Non-Compliant 72 76.6 Compliant 17 18.1 Diabetes History Yes 8 5.8 No 131 94.2 Alcohol Use (> 30 units/mo) Yes 22 15.8 No 117 84.2 Current Smoking Yes 4 2.9 No 135 97.1 CLINICAL ASSESSMENT (GLASGOW COMA SCALE) The neurological status at presentation was a strong indicator of disease severity. Upon admission, more than half of the patients (51.1%) presented with moderate neurological impairment, defined as a GCS score of 5–12. Severe impairment (GCS 3–4) was observed in 14.4% of patients, while 34.5% retained relatively preserved consciousness (GCS 13–15). There was a profound, statistically significant association between admission GCS and 30-day mortality (p < 0.001). Patients presenting with a GCS of 3–4 had a mortality rate of 100% (20/20) in this study. In stark contrast, those presenting with GCS 13–15 had a survival rate of 90.7%. The odds of death for patients with a GCS of 3–4 were more than six times higher compared to those with a GCS of 5–12. Table 3 Association between GCS and 30-Day Outcome GCS Score Alive (n = 53) Dead (n = 86) Mortality Rate within Group p-value 3–4 0 (0.0%) 20 (100%) 100.0% < 0.001 5–12 13 (24.5%) 58 (67.4%) 81.7% 13–15 40 (75.5%) 8 (9.3%) 16.7% RADIOLOGICAL FINDINGS Haematoma Location and Laterality Analysis of the CT scans revealed that the majority of haemorrhages (81.3%, n = 113) were located in the supratentorial compartment. Infratentorial haemorrhages accounted for 18.0% (n = 25) of cases. One patient presented with simultaneous bleeding in both compartments. Regarding laterality, left-sided haemorrhages were slightly more common (55.4%) than right-sided ones (44.6%). Supratentorial Sites: The basal ganglia were the most frequent site of haemorrhage, accounting for 52.2% (n = 59) of supratentorial cases. This was followed by the thalamus at 39.8% (n = 45). Lobar haemorrhages were relatively rare, constituting only 6.2% (n = 7) of supratentorial bleeds. Infratentorial Sites Within the posterior fossa, the brainstem was the predominant site of pathology, accounting for 73.1% (n = 19) of infratentorial cases, with cerebellar haemorrhages making up the remaining 26.9% (n = 7). HAEMATOMA VOLUME AND COMPLICATIONS: The majority of patients (72.7%, n = 101) presented with haematoma volumes of ≤ 30 mL. Large haematomas (> 30 mL) were observed in 27.3% (n = 38) of the cohort. Intraventricular Haemorrhage (IVH), resulting in Extension of blood into the ventricular system, was a common complication, observed in 59.7% (n = 83) of patients. Evidence of mass effect (midline shift, ventricular effacement, or herniation) was present in 80.0% of scans. The most common descriptors were ventricular compression (46.9%) and subfalcine herniation (31.5%). Table 4 Radiological Characteristics Feature Category Frequency (n = 139) Percentage (%) Location Supratentorial 113 81.3 Infratentorial 25 18.0 Specific Site Basal Ganglia 59 52.2 (of Supra) Thalamus 45 39.8 (of Supra) Brainstem 19 73.1 (of Infra) Volume ≤ 30 mL 101 72.7 > 30 mL 38 27.3 IVH Present 83 59.7 Absent 56 40.3 OUTCOMES AND CORRELATIONS The overall 30-day mortality rate for the study population was 61.8% (86/139). Only 38.2% of patients survived to the 30-day mark. Predictors of Mortality: Patients with haematoma volumes > 30 mL were significantly more likely to die (Adjusted Odds Ratio: 8.5, 95% CI: 2.29–31.78, p = 0.001) compared to those with smaller volumes. The presence of IVH was a catastrophic prognostic marker. The mortality rate in the Intraventricular Haemorrhage ( IVH) group was 79.1%, compared to 20.9% in the non-IVH group. Patients with IVH had nearly an eight-fold increased risk of death (aOR: 7.9, 95% CI: 3.43–18.24, p < 0.001). ICH SCORE CORRELATION The study demonstrated a strong positive correlation between the total ICH score and the 30-day mRS score (Spearman's rho = 0.8, p < 0.001). Mortality rates increased progressively with higher ICH scores: ICH Score 1 : 32.3% mortality. ICH Score 2 : 75.0% mortality. ICH Score 3 : 100.0% mortality. ICH Score 4: 100.0% mortality. No patients with an ICH score of 5 or 6 were recorded in the study. DISCUSSION RISK FACTORS AND EPIDEMIOLOGY The demographic profile of ICH in this study aligns with the distinct "African phenotype" of stroke described in recent literature [ 3 , 7 ]. The median age of 53 years is strikingly lower than the average age of ~ 73 years seen in Western cohorts such as the original Hemphill study [ 9 ]. This two‑decade disparity is not merely descriptive; it represents a major novel finding for the ICH score literature: the score’s age component (≥ 80 years) contributes almost nothing to risk stratification in this population, suggesting that recalibration with a lower age cutoff (e.g., ≥ 60 years) may be needed for African cohorts. The male predominance (69.1%) observed here mirrors findings from other West African studies and global datasets [ 2 ]. This gender gap may be partly explained by the higher prevalence of lifestyle risk factors among men in this setting, such as alcohol consumption, which was significantly higher in males in our cohort (20.8% vs 4.6%). Alcohol is a known dose-dependent risk factor for haemorrhagic stroke, potentially exacerbating hypertension and interfering with platelet function [ 14 ]. Hypertension emerged as the ubiquitous driver of ICH in this population, present in nearly 96% of patients. This is consistent with the INTERSTROKE study, which found that the population-attributable risk of hypertension for haemorrhagic stroke is greater than for ischaemic stroke [ 15 ]. The high rate of medication non-compliance (76.6%) is a critical finding. It reflects systemic barriers, including the cost of medication, lack of patient education regarding the "silent" nature of hypertension, and perhaps cultural beliefs favouring herbal remedies [ 16 ]. Addressing these implementation challenges in hypertension control is arguably the single most effective strategy to reduce the burden of ICH in Ghana. NEUROLOGICAL PREDICTORS (GCS) The Glasgow Coma Scale remains the most powerful single clinical predictor of mortality. Our finding that GCS scores of 3–4 predicted 100% mortality is consistent with Hemphill's original validation and subsequent studies in Nigeria and Uganda [ 17 , 18 ]. The GCS reflects the global impact of the haemorrhage, capturing both the direct destruction of brain tissue and the secondary effects of raised intracranial pressure (ICP). In the resource-constrained setting of KATH, where mechanical ventilation and ICP monitoring are not universally available, a low GCS score serves as a grim prognosticator. However, it is crucial to note that "self-fulfilling prophecies" can occur; patients with low GCS may receive less aggressive care (e.g., Do Not Resuscitate orders or withholding of intubation), which directly contributes to the high mortality observed [ 11 ]. RADIOLOGICAL DETERMINANTS The anatomical distribution of haematomas in this study strongly supports hypertensive vasculopathy as the primary aetiology. Over 90% of supratentorial bleeds were located in the basal ganglia or thalamus, classic sites for rupture of Charcot-Bouchard microaneurysms induced by chronic hypertension [ 6 ]. This contrasts with elderly Western cohorts, where lobar haemorrhages secondary to cerebral amyloid angiopathy (CAA) are more common. The rarity of lobar bleeds (6.2%) in our study is consistent with the younger age structure, as CAA is a disease of advanced ageing. The presence of intraventricular haemorrhage (IVH) was a significant independent predictor of death, increasing mortality risk by nearly eightfold. IVH contributes to mortality through the development of acute obstructive hydrocephalus and direct toxicity of blood products to the periventricular structures [ 19 ]. While external ventricular drains (EVDs) can mitigate this risk, their availability is variable in many African centres, potentially contributing to the high mortality associated with IVH in this cohort. Haematoma volume \(\:>\) 30 mL was associated with \(\:>\) 90% mortality. This validates the volume cutoff used in the original ICH score. Larger volumes exert a greater mass effect, leading to herniation and compression of the brainstem. VALIDITY OF THE ICH SCORE IN GHANA This study successfully validated the ICH score as a robust predictor of mortality in a tertiary hospital setting in Ghana. The clear stepwise increase in mortality with increasing scores confirms the tool's discriminative ability. However, the absolute mortality rates observed for each score category were higher than those reported in the original Hemphill study. For example, patients with an ICH score of 2 in our study had a mortality of 75%, compared to 26% in Hemphill's cohort [ 9 ]. This “mortality gap” is a central finding of our study. It demonstrates that while the ICH score’s discriminative ability (c‑statistic) may travel well across populations, its calibration, the absolute risk for a given score, does not. This has direct clinical utility: in KATH, an ICH score of 3 or 4 predicts 100% mortality, whereas in high‑income settings, such scores are associated with 50‑70% mortality [ 20 ]. Therefore, the same score carries different prognostic weight depending on the availability of neurocritical care resources. Furthermore, the age component of the ICH score ( \(\:\ge\:\) 80 years) contributes little to risk stratification in this population, as < 3% of patients met this criterion. Some researchers have suggested lowering the age cutoff to 60 or 65 years for African populations to improve the score's sensitivity, given the lower life expectancy and earlier onset of vascular ageing [ 17 ]. Despite these calibration differences, the ICH score remains a highly useful clinical tool. It helps clinicians identify the "futility threshold"; in our data, scores of 3 and 4 were uniformly fatal. This knowledge empowers clinicians to initiate compassionate end-of-life discussions early, avoiding financial ruin for families pursuing futile aggressive care, while focusing maximum effort on patients with lower scores who have a salvageable chance of survival. CONCLUSION The ICH score is an effective and valid tool for predicting 30‑day mortality in Ghanaian patients with spontaneous ICH, though absolute mortality rates for each score are higher than in high‑income settings. While the biological drivers of outcome (GCS, volume, IVH) are universal, the threshold for mortality is lower in this setting compared to HICs, likely due to health system constraints. This study provides novel, context‑specific calibration data that can inform bedside decision‑making: ICH scores of 3–4 are uniformly fatal in our setting, whereas scores of 1–2 offer a realistic chance of survival. The age component of the original ICH score (≥ 80 years) has little relevance here; future studies should explore lowering the age cutoff to ≥ 60 years for African populations. The study confirms that spontaneous ICH in Ghana is a disease of the young and hypertensive, carrying a grave prognosis. LIMITATIONS The study was single‑centred, limiting generalizability to rural settings. The exclusion of patients who died before imaging or could not afford a CT scan may have introduced selection bias. The 30‑day outcome endpoint does not capture the long‑term burden of disability in survivors, which is substantial. A key methodological limitation is the absence of confirmatory vascular imaging (CT angiography or digital subtraction angiography). Non‑contrast CT cannot reliably exclude underlying arteriovenous malformations or aneurysms. Therefore, while we excluded overt cases of vascular malformations visible on NCCT (e.g., calcified AVM), a small proportion of our “spontaneous ICH” cohort may have unrecognised secondary causes. However, the anatomical distribution of haematomas (predominantly basal ganglia and thalamus) is typical of hypertensive vasculopathy, and the proportion of misclassified cases is expected to be low. Future research should focus on long‑term functional outcomes and the validation of modified scores (e.g., using a lower age cutoff), as well as prospective studies incorporating CTA to define true primary ICH cohorts in African settings. Declarations Clinical Trial Number Not applicable Consent to participate Written informed consent was obtained from all conscious participants. For patients with altered consciousness or aphasia, consent was obtained from the legal next of kin. Strict confidentiality was maintained by de-identifying all data during extraction and analysis. Consent for publication Informed consent was obtained from all the individual participants/patients for publication. Funding Authors receive no source of funding. Author Contribution MA: data curation, methodology, review and editing, SF: write-up and editing. ABP: write-up and editing. ATA: write-up and editing. RMKD: write-up and editing. IAK: review and editing. OO: write-up and editing. AA: methodology, review, and editing. KT: write up, methodology, YAA: write-up and editing. JBY-Data Analysis, all authors approved the version to be published and agreed to be accountable for all aspects of the work. Acknowledgement We acknowledge the participants who took part in the study. Data Availability All data supporting the findings of this study are available within the paper References Feigin VL, Stark BA, Johnson CO, et al. Global, regional, and national burden of stroke and its risk factors, 1990–2019: a systematic analysis for the Global Burden of Disease Study 2019. Lancet Neurol. 2021;20:795–820. Owolabi MO, Sarfo F, Akinyemi R, et al. Dominant modifiable risk factors for stroke in Ghana and Nigeria (SIREN): a case-control study. Lancet Glob Health. 2018;6:e436–46. Akinyemi RO, Ovbiagele B, Adeniji OA, et al. Stroke in Africa: profile, progress, prospects and priorities. Nat Rev Neurol. 2021;17:634–56. Donkor ES. Stroke in the 21st Century: A Snapshot of the Burden, Epidemiology, and Quality of Life. Stroke Res Treat. 2018;20:138–65. Witsch J, Siegerink B, Nolte CH, et al. Prognostication after intracerebral haemorrhage: a review. Neurol Res Pract. 2021;3:22. Pasi M, Viswanathan A. Pathophysiology of Primary Intracerebral Hemorrhage: Insights into Cerebral Small Vessel Disease. In: Lee S-H, editor Stroke Revisited: Hemorrhagic Stroke . Singapore: Springer Singapore, pp. 27–46. Sarfo FS, Ovbiagele B, Gebregziabher M, et al. Unraveling the risk factors for spontaneous intracerebral hemorrhage among West Africans. Neurology. 2020;94:e998–1012. Greenberg SM, Ziai WC, Cordonnier C, et al. 2022 Guideline for the Management of Patients With Spontaneous Intracerebral Hemorrhage: A Guideline From the American Heart Association/American Stroke Association. Stroke. 2022;53:e282–361. Hemphill JC, Bonovich DC, Besmertis L, et al. The ICH score: a simple, reliable grading scale for intracerebral hemorrhage. Stroke. 2001;32:891–7. Agyemang C, Attah-Adjepong G, Owusu-Dabo E, et al. Stroke in Ashanti region of Ghana. Ghana Med J. 2012;46:12–7. Sembill JA, Gerner ST, Volbers B, et al. Severity assessment in maximally treated ICH patients: The max-ICH score. Neurology. 2017;89:423–31. KATH, Home-About. Komfo Anokye Teaching Hospital , https://kath.gov.gh / (2024, accessed 3 October 2025). Alcohol. units. nhs.uk , https://www.nhs.uk/live-well/alcohol-advice/calculating-alcohol-units/ (2022, accessed 23 October 2026). Fowobaje KR, Okekunle AP, Akinyemi J, et al. Dominant Risk Factors For Stroke Among Africans: A Systematic Review And Meta-Analysis. Afr J Biomedical Res. 2024;27:7094–118. O’Donnell MJ, Chin SL, Rangarajan S, et al. Global and regional effects of potentially modifiable risk factors associated with acute stroke in 32 countries (INTERSTROKE): a case-control study. Lancet. 2016;388:761–75. Adidja NM, Agbor VN, Aminde JA, et al. Non-adherence to antihypertensive pharmacotherapy in Buea, Cameroon: a cross-sectional community-based study. BMC Cardiovasc Disord. 2018;18:150. Abdallah A, Chang JL, O’Carroll CB, et al. Validation of the Intracerebral Hemorrhage Score in Uganda. Stroke. 2018;49:3063–6. Adeleye AO, Osazuwa UA, Ogbole GI. The Clinical Epidemiology of Spontaneous ICH in a Sub-Sahara African Country in the CT Scan Era: A Neurosurgical In-Hospital Cross-Sectional Survey. Front Neurol. 2015;6:169. Li Q, Li R, Zhao L-B, et al. Intraventricular Hemorrhage Growth: Definition, Prevalence and Association with Hematoma Expansion and Prognosis. Neurocrit Care. 2020;33:732–9. Baatiema L, de-Graft Aikins A, Sav A, et al. Barriers to evidence-based acute stroke care in Ghana: a qualitative study on the perspectives of stroke care professionals. BMJ Open. 2017;7:e015385. Additional Declarations No competing interests reported. Cite Share Download PDF Status: Under Review Version 1 posted Reviews received at journal 10 May, 2026 Reviewers agreed at journal 01 May, 2026 Reviewers invited by journal 01 May, 2026 Editor assigned by journal 01 May, 2026 Editor invited by journal 22 Apr, 2026 Submission checks completed at journal 12 Apr, 2026 First submitted to journal 12 Apr, 2026 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-9301864","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":633589921,"identity":"30df0300-3451-4e2e-be1a-a57a24b6dd70","order_by":0,"name":"Mansa 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10:25:26","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-9301864/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-9301864/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":109118291,"identity":"5ca1b770-1fb1-4863-bb5b-a9c5c13ac8b6","added_by":"auto","created_at":"2026-05-12 16:52:03","extension":"jpg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":69171,"visible":true,"origin":"","legend":"\u003cp\u003eMap of Ghana showing KATH\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eSource:\u003c/strong\u003e KATH, (2024)\u003c/p\u003e","description":"","filename":"1.jpg","url":"https://assets-eu.researchsquare.com/files/rs-9301864/v1/0d80138334307810b8550e64.jpg"},{"id":109204861,"identity":"7e0c229a-1679-426b-8edd-f37e71d9dea6","added_by":"auto","created_at":"2026-05-13 15:02:38","extension":"jpg","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":129762,"visible":true,"origin":"","legend":"\u003cp\u003eKomfo Anokye Teaching Hospital\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eSource:\u003c/strong\u003e KATH, (2024)\u003c/p\u003e","description":"","filename":"2.jpg","url":"https://assets-eu.researchsquare.com/files/rs-9301864/v1/fbdb43146130be9cf9870542.jpg"},{"id":109204847,"identity":"69a1cbee-d888-4fb5-8d10-47e15335ef01","added_by":"auto","created_at":"2026-05-13 15:02:35","extension":"jpg","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":127959,"visible":true,"origin":"","legend":"\u003cp\u003eMulti-slice Siemens Somatom Perspective CT scan machine\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eSource:\u003c/strong\u003e Radiology Directorate, KATH\u003c/p\u003e","description":"","filename":"3.jpg","url":"https://assets-eu.researchsquare.com/files/rs-9301864/v1/cf185732b721a1635f60aa46.jpg"},{"id":109204921,"identity":"fb1c9543-a308-4e40-92a0-66bbc5ee98c3","added_by":"auto","created_at":"2026-05-13 15:02:51","extension":"jpg","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":140322,"visible":true,"origin":"","legend":"\u003cp\u003e68-year-old male with acute right temporoparietal (lobar) haemorrhage with 0.7cm contralateral midline shift\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eSource: \u003c/strong\u003eRadiology Directorate, KATH\u003c/p\u003e","description":"","filename":"4.jpg","url":"https://assets-eu.researchsquare.com/files/rs-9301864/v1/e30455c491d788dc9831b062.jpg"},{"id":109118294,"identity":"65799e55-742d-429c-9527-f1793a589c9b","added_by":"auto","created_at":"2026-05-12 16:52:03","extension":"jpg","order_by":5,"title":"Figure 5","display":"","copyAsset":false,"role":"figure","size":110187,"visible":true,"origin":"","legend":"\u003cp\u003e50-year-old female with acute left paramedian pontine haemorrhage with intraventricular extension\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eSource:\u003c/strong\u003e Radiology Directorate, KATH\u003c/p\u003e","description":"","filename":"5.jpg","url":"https://assets-eu.researchsquare.com/files/rs-9301864/v1/7a0422cafc667fbec2676efc.jpg"},{"id":109204931,"identity":"e2860a6b-00fc-4fdd-8aa0-4486b6463bf0","added_by":"auto","created_at":"2026-05-13 15:02:54","extension":"jpg","order_by":6,"title":"Figure 6","display":"","copyAsset":false,"role":"figure","size":159669,"visible":true,"origin":"","legend":"\u003cp\u003e45-year-old male with acute left basal ganglia haemorrhage and left lateral ventricular extension\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eSource: \u003c/strong\u003eRadiology Directorate, KATH\u003c/p\u003e","description":"","filename":"6.jpg","url":"https://assets-eu.researchsquare.com/files/rs-9301864/v1/2391125018a04f804d2704c7.jpg"},{"id":109204825,"identity":"e8af5365-4766-4dac-9bec-f302212ac9c7","added_by":"auto","created_at":"2026-05-13 15:02:28","extension":"jpg","order_by":7,"title":"Figure 7","display":"","copyAsset":false,"role":"figure","size":140474,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eCalculation of haematoma volume: \u003c/strong\u003ethe haematoma volume was calculated as 8.1x3.6x5.4 /2= 78.7mls. For the ICH score, this volume scores 1; under volume, as it is \u0026gt;30mls. The presence of intraventricular extension scores another 1 point. The left basal ganglia location, which is supratentorial, scores 0 under haematoma location.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eSource: \u003c/strong\u003eRadiology Directorate, KATH\u003c/p\u003e","description":"","filename":"7.jpg","url":"https://assets-eu.researchsquare.com/files/rs-9301864/v1/312bb69321d9436b70432e78.jpg"},{"id":109204727,"identity":"ec13fab1-a43a-4eb2-b382-f1f81d4389c8","added_by":"auto","created_at":"2026-05-13 15:01:55","extension":"jpg","order_by":8,"title":"Figure 8","display":"","copyAsset":false,"role":"figure","size":81323,"visible":true,"origin":"","legend":"\u003cp\u003eFlow chart of patient recruitment\u003c/p\u003e","description":"","filename":"8.jpg","url":"https://assets-eu.researchsquare.com/files/rs-9301864/v1/2093208148ae6fdf4f1fe554.jpg"},{"id":109204785,"identity":"920dd36e-e58f-40e7-9c1c-e7df7023ccae","added_by":"auto","created_at":"2026-05-13 15:02:14","extension":"jpg","order_by":9,"title":"Figure 9","display":"","copyAsset":false,"role":"figure","size":56615,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eCorrelation of the ICH score with a 30-day outcome using the modified Rankin scale score\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"9.jpg","url":"https://assets-eu.researchsquare.com/files/rs-9301864/v1/c0f1bf34b1352a344659150a.jpg"},{"id":109206681,"identity":"a456e6b6-76a1-4140-8331-9c29954f6b73","added_by":"auto","created_at":"2026-05-13 15:15:16","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1306095,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-9301864/v1/87d25fe7-f189-4669-8a83-84f9172e48a8.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Validation of the Intracerebral Hemorrhage Score Using Computed Tomography in Spontaneous Intracerebral Hemorrhage at a Tertiary Hospital in Kumasi Ghana A Prospective Cohort Study","fulltext":[{"header":"INTRODUCTION","content":"\u003cp\u003eStroke constitutes a worldwide health crisis of increasing magnitude, currently ranking as the second leading cause of death and a primary contributor to long-term disability worldwide [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. The epidemiological landscape of stroke is undergoing a profound shift; while incidence rates have stabilised or declined in many high-income countries (HICs) due to effective preventative strategies and advanced acute care, the burden is accelerating in low- and middle-income countries (LMICs) [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. Sub-Saharan Africa, in particular, finds itself at the epicentre of this transition, grappling with a \"double burden\" of disease where persistent infectious challenges overlap with a surging prevalence of non-communicable diseases (NCDs) such as hypertension and diabetes.\u003c/p\u003e \u003cp\u003eAmong the subtypes of stroke, primary intracerebral haemorrhage (ICH), defined as spontaneous bleeding into the brain parenchyma unrelated to trauma or underlying structural lesions, is particularly devastating. Although ICH accounts for a smaller proportion of all strokes globally compared to ischaemic stroke (approximately 10\u0026ndash;20% in HICs), its incidence is notably higher in African populations, accounting for up to 34% of stroke cases [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. This disparity is clinically significant because haemorrhagic stroke carries a higher risk of early mortality and severe functional impairment. The 30-day mortality rate for ICH can exceed 40%, with less than half of survivors achieving functional independence at one year [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThe pathophysiology of ICH in the African context is inextricably linked to hypertension. Chronic, uncontrolled elevation in blood pressure induces lipohyalinosis and fibrinoid necrosis in the small perforating arteries of the brain, predisposing them to rupture [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. The Stroke Investigative Research and Educational Network (SIREN) study identified hypertension as the single most potent modifiable risk factor for stroke in West Africa, with a population-attributable risk far exceeding that observed in other regions [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. This biological vulnerability is compounded by systemic challenges, including limited access to neuroimaging, delayed presentation to hospitals, and a scarcity of neuro-critical care facilities.\u003c/p\u003e \u003cp\u003eThe clinical management of ICH is fraught with uncertainty. Unlike ischaemic stroke, where reperfusion therapies such as thrombolysis and mechanical thrombectomy have transformed outcomes, ICH lacks a definitive, universally proven medical or surgical treatment [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. In this therapeutic vacuum, accurate prognostication becomes a cornerstone of management.\u003c/p\u003e \u003cp\u003eTo address the need for reliable risk stratification, several clinical grading scales have been developed. The most widely adopted is the Intracerebral Haemorrhage (ICH) score, introduced by Hemphill et al. in 2001 [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. This simple, validated tool integrates five key clinical and radiological variables, Glasgow Coma Scale (GCS) score, age, haematoma volume, intraventricular haemorrhage (IVH), and infratentorial origin, to predict 30-day mortality. While the ICH score has demonstrated robust predictive validity in diverse populations across North America, Europe, and Asia, its performance in sub-Saharan Africa remains insufficiently characterised.\u003c/p\u003e \u003cp\u003eThe application of prognostic models derived from Western cohorts to African populations poses inherent risks. The derivation cohorts for the ICH score were predominantly elderly and Caucasian. In contrast, stroke patients in Ghana typically present two decades younger, often in their economically productive prime [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. However, in the context of this study, we aim at measuring how an established score performs in a population with a different age structure, aetiology, and healthcare capacity. Relying on unvalidated scores could lead to the \"self-fulfilling prophecy\" of poor outcomes, where patients predicted to do poorly are potentially denied aggressive care [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e].\u003c/p\u003e \u003cp\u003e Validating the ICH score at the Komfo Anokye Teaching Hospital (KATH) is a crucial step toward evidence-based stroke care in Ghana. KATH serves as a major referral hub for the northern sector of the country, managing a high volume of complex stroke cases. Patients in Ghana typically present at a much younger age, often in their prime economic years, and face a healthcare landscape constrained by limited neuro-critical care resources. There is a critical paucity of published data regarding the performance of the ICH score in the Ghanaian setting, particularly at the Komfo Anokye Teaching Hospital (KATH) in Kumasi. Without local validation, there is a risk that the score may inaccurately predict outcomes, either overestimating mortality, leading to a self-fulfilling prophecy of withdrawal of care, or underestimating severity, resulting in the futile utilisation of limited resources.\u003c/p\u003e \u003cp\u003eEstablishing the accuracy of the ICH score in this setting will empower clinicians to: (1) rationalize the allocation of scarce critical care resources (such as ICU beds and ventilators) to patients most likely to benefit, (2) provide families with realistic, data-driven expectations regarding survival and recovery, fostering trust and informed consent for palliative or aggressive pathways, and (3) use risk-adjusted mortality rates to monitor and improve the quality of stroke care within the institution.\u003c/p\u003e"},{"header":"METHODOLOGY","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eSTUDY DESIGN\u003c/h2\u003e \u003cp\u003eThe study utilised a hospital-based, cross-sectional design, conducted over a period of eight months from June 2024 to January 2025.\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eSTUDY SITE\u003c/h3\u003e\n\u003cp\u003eKATH is the second-largest tertiary healthcare facility in Ghana, with a bed capacity of approximately 1,200 [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. Geographically, it is strategically located in Kumasi, the administrative and commercial capital of the Ashanti Region. Due to Kumasi's central location and extensive road networks, KATH serves as the apex referral centre for a vast catchment area that includes 13 of Ghana\u0026rsquo;s 16 administrative regions. It receives referrals not only from the Ashanti Region (population\u0026thinsp;~\u0026thinsp;5.4\u0026nbsp;million) but also from the Bono, Bono East, Ahafo, Western North, and the entire northern belt of the country (Northern, North East, Savannah, Upper East, and Upper West regions), covering a catchment population of over 10\u0026nbsp;million people [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. This immense catchment area ensures a diverse patient population, representative of the middle and northern sectors of Ghana.\u003c/p\u003e \u003cp\u003eThe specific locus of data collection was the Radiology Directorate at KATH. This directorate is critical to acute stroke management, providing 24-hour diagnostic imaging services. The directorate operates multiple CT scanners, but the primary machine utilised for emergency stroke imaging during the study period was the Siemens Somatom Perspective, a 128-slice multi-detector CT scanner located at the Accident and Emergency Centre. The Accident and Emergency unit at KATH is one of the busiest in West Africa, often managing complex medical emergencies that have bypassed lower-level district hospitals due to the lack of imaging facilities in peripheral areas\u003c/p\u003e \u003cp\u003eThe radiology department performs an average of 867 CT scans per month, with head CT scans constituting approximately 40% of this workload [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. This high volume provided a dynamic stream of potential participants for the study. The operational setup at KATH involves a collaborative workflow where patients suspected of stroke are triaged at the \"Red\" (emergency) zone, stabilised, and then transported to the adjacent CT suite for urgent neuroimaging. This proximity was vital for recruiting patients within the acute phase of the ictus.\u003c/p\u003e \u003cp\u003e \u003cstrong\u003eFigure\u0026nbsp;2\u003c/strong\u003e \u003cp\u003eKomfo Anokye Teaching Hospital\u003c/p\u003e \u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e \u003cstrong\u003eSource\u003c/strong\u003e \u003cp\u003eKATH, (2024)\u003c/p\u003e \u003c/p\u003e\n\u003ch3\u003eSTUDY DURATION AND POPULATION\u003c/h3\u003e\n\u003cp\u003eThe study was conducted over eight months from June 2024 to January 2025. The study population comprised all adult patients (aged 18 years and above) who presented to the Accident and Emergency Department or the Polyclinic with clinical features suggestive of acute stroke and were subsequently referred for non-enhanced head CT scans.\u003c/p\u003e\n\u003ch3\u003eINCLUSION AND EXCLUSION CRITERIA\u003c/h3\u003e\n\u003cp\u003e \u003cb\u003eInclusion Criteria\u003c/b\u003e:\u003c/p\u003e \u003cp\u003e \u003col\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003ePatients aged\u0026thinsp;\u0026ge;\u0026thinsp;18 years.\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eConfirmation of primary intracerebral haemorrhage on non-enhanced head CT.\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003ePresentation for imaging within 72 hours of symptom onset (to ensure accurate characterisation of acute haematoma volume).\u003c/p\u003e \u003c/li\u003e\u003cli\u003e\u003cp\u003e Informed consent provided by the patient or a legally authorised representative (next of kin).\u003c/p\u003e\u003c/li\u003e \u003c/span\u003e \u003c/ol\u003e \u003c/p\u003e \u003cp\u003e \u003cstrong\u003e\u003c/strong\u003e \u003c/p\u003e \u003cp\u003e \u003cb\u003eExclusion Criteria\u003c/b\u003e:\u003c/p\u003e \u003cp\u003e \u003col\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eHaemorrhage associated with head trauma, intracranial tumours, or haemorrhagic transformation of an ischaemic infarct on non‑contrast CT. Vascular malformations (e.g., arteriovenous malformations, aneurysms) cannot be reliably excluded using non‑contrast CT alone; therefore, we cannot claim that our cohort consists purely of primary ICH. Instead, they are \u0026ldquo;spontaneous ICH on NCCT.\u0026rdquo; These aetiologies were excluded when evident on NCCT (e.g., calcified AVM, visible aneurysm) because their pathophysiology and prognosis differ significantly from hypertensive ICH.\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003ePatients with purely subdural or epidural haematomas.\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003ePatients for whom critical admission variables (e.g., GCS, BP) were missing or who could not be contacted for the 30-day follow-up.\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003c/ol\u003e \u003c/p\u003e\n\u003ch3\u003eDATA COLLECTION PROCEDURES\u003c/h3\u003e\n\u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003ePatient selection\u003c/h2\u003e \u003cp\u003eA purposive non-random sampling technique was employed. All patients with a clinical presentation of first-onset stroke who had been referred to the Radiology department of KATH for head CT scans and whose results showed CT-proven intracerebral haemorrhage were evaluated to ascertain their compliance with the inclusion criteria. Patients with head CT findings of haemorrhagic transformation of an ischaemic stroke, haemorrhagic tumours and intracranial haemorrhage with extra-axial haematomas, as well as patients with traumatic aetiology of the intracerebral haemorrhage, were excluded from the study.\u003c/p\u003e \u003cp\u003eEligible participants were approached in the waiting area of the Radiology department or followed up on the ward. The background and purpose of the study were carefully explained to them or their next of kin (in the event the patient has an altered mental status or is unable to communicate) by the principal investigator or a trained research assistant in English or Twi, the dominant languages spoken in the Ashanti region. In the event the patient or next of kin\u003c/p\u003e \u003cp\u003ewas unable to communicate in either of these languages, an interpreter was sought to explain the details in their preferred language. The interaction sought to establish that participation in the study was entirely voluntary, without coercion, without reward, and in no way affected the degree of care the patient received at any point in the hospital, should they have decided to opt out at any point in time.\u003c/p\u003e \u003cp\u003e Participants were required to provide their signature or thumbprint on the informed consent form after agreeing to participate in the study.\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003ePatient demographics, admission neurological parameters and risk factor assessment\u003c/h3\u003e\n\u003cp\u003eA data collection sheet was used by the principal investigator or the research assistant to obtain information on patient age, sex and phone numbers. The GCS (recorded between 3\u0026ndash;15 out of 15) and admission BP were recorded on a data collection form as determined by the attending emergency physician who saw the patient on arrival. Risk factors were evaluated as follows: hypertension status was deemed positive based on patient self -report, a known history, or history of antihypertensive medication. Diabetes mellitus status was based on a previous history of the condition, self-report or a history of taking antidiabetic agents. For patients with hypertension or diabetes, their compliance with prescription medication was recorded with a binary answer, yes or no; yes to indicate compliance or no to indicate non- compliance. Patient was deemed to be compliant with their medication if they took the prescribed antihypertensive or antidiabetic drug consistently at the prescribed time. If the patient had failed to take their prescribed medication for a week, frequently skipped doses or had resorted to herbal medication, they were deemed non-compliant. Alcohol was considered a risk factor for patients whose intake was more than or equal to 30drinks /month (1 drink or 1 U of alcohol=8g of alcohol. One unit of alcohol was equivalent to 12 ounces of beer with 5% alcohol, 8 ounces of malt liquor with 7% alcohol, 5 ounces of wine with 12% alcohol and a shot or 1.5 ounces of liquor or distilled spirits, e.g. brandy, gin, rum, tequila, vodka, and whiskey (40% alcohol). Current cigarette smoking status was recorded on a data collection sheet [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e].\u003c/p\u003e\n\u003ch3\u003eTechnique of CT Scan Imaging and Interpretation\u003c/h3\u003e\n\u003cp\u003eThe CT images used were obtained from a 128-slice Siemens CT machine (Siemens Somatom Perspective, Year of manufacture November 2013 and Refurbished in July 2020) currently at the Accident and Emergency building of the Komfo Anokye Teaching hospital. Before having the CT scan taken, patients had the procedure briefly explained to them or their relatives. All\u003c/p\u003e \u003cp\u003eMetallic objects such as earrings, which could produce artefacts, were removed. Patients were then placed in the supine position, head first, with their arms by their sides. A tube voltage of 120kVP was used, and an axial scout image was obtained. Non-enhanced axial images from the calvarium to the skull base with head tilt or angled gantry were then obtained in a craniocaudal fashion at 3 mm section thickness with coronal and sagittal reformatted images from axial images.\u003c/p\u003e \u003cp\u003eAll images were reviewed digitally via a Syngo/Siemens workstation, ensuring that optimal width and window levels were used. No CT angiography or digital subtraction angiography was performed as part of this study. Therefore, underlying vascular malformations (AVMs, aneurysms) could not be definitively ruled out.\u003c/p\u003e \u003cp\u003eIntracerebral haemorrhage was described as a hyperdense lesion (+\u0026thinsp;30-60HU) with or without perilesional oedema in the brain parenchyma. Laterality of the hematoma (whether left or right) and location of the haemorrhage were recorded. For areas where haematomas occurred in more than one location on the same side of the tentorium, the haematoma location was accorded for the one which occupied a larger area.\u003c/p\u003e \u003cp\u003eIntraventricular extension of haemorrhage was seen as hyperdensity within the ventricular system.\u003c/p\u003e \u003cp\u003eMass effect was recorded if ventricular compression, midline shift, cerebral or uncal herniation were present. For this study, hydrocephalus was grouped under mass effect.\u003c/p\u003e \u003cp\u003eVentricular compression was recorded if there was direct compression of the ventricle by the adjacent haematoma.\u003c/p\u003e \u003cp\u003eMidline shift was calculated in millimetres as the perpendicular distance between a midline structure and a designated midline.\u003c/p\u003e \u003cp\u003eCerebral referred to diffuse sulcal effacement.\u003c/p\u003e \u003cp\u003eHydrocephalus refers to the dilation of the ventricular system.\u003c/p\u003e \u003cdiv id=\"Sec11\" class=\"Section2\"\u003e \u003ch2\u003eICH SCORE\u003c/h2\u003e \u003cp\u003eThe ICH score was obtained by summing individual scores for age, GCS, location of hematoma, volume of haemorrhage and intraventricular extension of haematoma and recorded out of a total of 6 points.\u003c/p\u003e \u003cp\u003eAge of 80years or more was scored 1 point, while age less than 80years scored no (0) points. A GCS score of 3\u0026ndash;4 was assigned a score of 2, GCS of 5\u0026ndash;12 was scored a single point (1), while a score of 0 was given for GCS while a GCS of haematoma volume of more than 30mls scored 1 point on the ICH score while a haematoma volume of less than 30mls was given no point (0). A score of 0 was assigned for supratentorial location of the haematoma if the haemorrhage was noted in the cerebral lobes (frontal, parietal, temporal or occipital), basal ganglia or thalamus and a score of 1 was assigned for haemorrhage in the cerebellum or midbrain, pons or medulla. Extension of haemorrhage into the ventricular system was accorded a score of 1, while the absence of intraventricular haemorrhage was given no score (0). The total ICH score was recorded on the data collection sheet.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec12\" class=\"Section2\"\u003e \u003ch2\u003eASSESSMENT OF OUTCOME\u003c/h2\u003e \u003cp\u003ePatient outcome was assessed using the modified Rankin scale via a phone call or from information extracted from the LHIMS database at 30 days post the day of admission by the principal investigator. A score of 0 was accorded to a patient who had no stroke symptoms at all at the end of the 30 days and had no limitations to their Activities of Daily Living (ADLs). A score of 1 was given to a patient who had no significant disability but had symptoms of stroke present. A person had a score of two if they had a minor handicap and were unable to perform the typical social duties they had before the illness, such as working, taking care of others, or engaging in social and recreational activities, but they were still able to perform ADLs independently. A score of 3 was accorded if the person had moderate disability requiring assistance with some instrumental ADL such as preparing meals, using the phone, cleaning the home, or getting around either by driving or public transportation but not basic ADLs. 4 was the score given if the patient had moderately severe disability and needed assistance with some basic ADL such as eating and using the bathroom or walking but did not need constant care. A patient with severe disability requiring constant care was given a score of 5. A score of 6 was given if the patient had died within the period leading to the follow-up.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec13\" class=\"Section2\"\u003e \u003ch2\u003eDATA MANAGEMENT AND ANALYSIS\u003c/h2\u003e \u003cp\u003eEvery day, data gathered from the facility was transferred to a cloud server that was password-protected to keep unauthorised users out. Only the principal investigator had the password and could access the cloud server. Data was then exported to Microsoft Excel (Redmond, Washington). All analyses were carried out using STATA version 14 (College Station, Texas) statistical software. The study employed both descriptive and inferential statistics in analysing the data. For categorical variables, the results were displayed as frequency counts and proportions; for continuous variables, the median (inter-quartile range [IQR]) was used. The Shapiro-Wilk test was used to confirm visually observed skewed distributions of continuous data.\u003c/p\u003e \u003cp\u003eSociodemographic factors (sex, age), risk factors (diabetes, hypertension, alcohol consumption (\u0026gt;\u0026thinsp;30 drinks per month), current cigarette smoking, GCS (score 3\u0026ndash;15/15), CT variables (location haemorrhage, intracerebral haemorrhage volume, intraventricular extension), ICH score (score/6), and outcome (assessed using the modified Rankin scale: 30- days after the initial day of admission: 0-no symptoms, 1-no substantial disability, 2-slight disability, 3-moderate disability, 4-moderately severe disability, 5-severe disability, 6-death. To test for the hypothesis, a chi-square test was employed at a 95% level of significance in addition to Fisher's exact test. Bivariate and multivariate analyses were conducted between demographic variables and risk factors. All analyses in this report were narrowed to cases reported at the Radiology Directorate of KATH during the study period. Statistical significance for all testing was set at a p-value of 0.05 with a 95% confidence interval.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec14\" class=\"Section2\"\u003e \u003ch2\u003eETHICAL CONSIDERATIONS\u003c/h2\u003e \u003cp\u003e The study protocol was reviewed and approved by the Committee on Human Research, Publications and Ethics (CHRPE) of the School of Medical Sciences, Kwame Nkrumah University of Science and Technology (KNUST), and the KATH Institutional Review Board (Ref: KATH-IRB/AP/138/23). All methods were performed in accordance with the ethical standards of the CHRPE and KATHIRB and with the principles of the Declaration of Helsinki.\u003c/p\u003e \u003c/div\u003e"},{"header":"RESULTS","content":"\u003cdiv id=\"Sec16\" class=\"Section2\"\u003e \u003ch2\u003eDEMOGRAPHIC CHARACTERISTICS\u003c/h2\u003e \u003cp\u003eA total of 146 patients were initially recruited for the study. During the follow-up period, 7 participants were lost to follow-up, resulting in a final cohort of 139 individuals eligible for analysis. This cohort represents consecutive adults with spontaneous ICH confirmed on non‑contrast CT; confirmatory vascular imaging was not available, so we refer to the cohort as \u0026ldquo;spontaneous ICH\u0026rdquo; rather than \u0026ldquo;primary ICH.\u0026rdquo; Among these participants, 86 experienced mortalities related to their conditions, while 53 successfully survived through the 30-day follow-up period. This outcome highlights the significant challenges faced by the patient population under study.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eThe demographic profile, as shown in Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e, revealed a significantly younger age of onset compared to populations typically seen in high-income countries. The median age of the study participants was 53 years (Interquartile Range: 45\u0026ndash;62 years).\u003c/p\u003e \u003cp\u003eThe age distribution was heavily skewed towards the working-age population. The modal age group was 40\u0026ndash;59 years, which accounted for 59.0% (n\u0026thinsp;=\u0026thinsp;82) of all cases. Younger adults (20\u0026ndash;39 years) comprised 9.4% (n\u0026thinsp;=\u0026thinsp;13) of the cohort, while the elderly population (\u0026ge;\u0026thinsp;80 years) represented a small minority at 2.9% (n\u0026thinsp;=\u0026thinsp;4). This indicates that the burden of ICH in this setting falls disproportionately on individuals in their prime economic years.\u003c/p\u003e \u003cp\u003eIn terms of gender distribution, there was a marked male predominance. Males constituted 69.1% (n\u0026thinsp;=\u0026thinsp;96) of the study population, while females accounted for 30.9% (n\u0026thinsp;=\u0026thinsp;43). This resulted in a male-to-female ratio of approximately 2.2:1.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eDemographic Characteristics of Patients with ICH\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCharacteristic\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eCategory\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eFrequency (n\u0026thinsp;=\u0026thinsp;139)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003ePercentage (%)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eAge Group\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;20 years\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e13\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e9.4\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e20\u0026ndash;39 years\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e13\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e9.4\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e40\u0026ndash;59 years\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e82\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e59.0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e60\u0026ndash;79 years\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e40\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e28.7\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026ge;\u0026thinsp;80 years\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2.9\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eGender\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e96\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e69.1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eFemale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e43\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e30.9\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eMedian Age\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c4\" namest=\"c2\"\u003e \u003cp\u003e53 years (IQR: 45\u0026ndash;62)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec17\" class=\"Section2\"\u003e \u003ch2\u003eRISK FACTOR PROFILE\u003c/h2\u003e \u003cp\u003eHypertension was the single most pervasive risk factor identified in the cohort. A known history of hypertension was reported in 67.6% (n\u0026thinsp;=\u0026thinsp;94) of patients. However, objective measurements taken on admission painted a more severe picture: 95.7% (n\u0026thinsp;=\u0026thinsp;133) of patients presented with elevated blood pressure (\u0026gt;\u0026thinsp;140/90 mmHg). This discrepancy suggests a significant burden of undiagnosed or uncontrolled hypertension in the population. Among those with a known history, medication non-compliance was alarmingly high, with 76.6% (n\u0026thinsp;=\u0026thinsp;72) of diagnosed hypertensives reporting poor adherence to their treatment regimens.\u003c/p\u003e \u003cp\u003eOther risk factors showed distinct patterns. Diabetes mellitus was present in 5.8% (n\u0026thinsp;=\u0026thinsp;8) of the population. Lifestyle risk factors displayed significant gender disparities. Alcohol consumption (defined as \u0026gt;\u0026thinsp;30 drinks/month) was reported by 15.8% (n\u0026thinsp;=\u0026thinsp;22) of the total population. However, this was almost exclusively a male phenomenon; 20.8% of men reported significant alcohol use compared to only 4.6% of women (p\u0026thinsp;=\u0026thinsp;0.022). Current cigarette smoking was relatively rare, identified in only 2.9% (n\u0026thinsp;=\u0026thinsp;4) of the participants.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eFrequency of Risk Factors\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRisk Factor\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eCategory\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eFrequency (n\u0026thinsp;=\u0026thinsp;139)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003ePercentage (%)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eHypertension History\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e94\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e67.6\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e45\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e32.4\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eAdmission BP (\u0026gt;\u0026thinsp;140/90)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e133\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e95.7\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e4.3\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eAntihypertensive Compliance\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNon-Compliant\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e72\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e76.6\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eCompliant\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e17\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e18.1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eDiabetes History\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e5.8\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e131\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e94.2\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eAlcohol Use (\u0026gt;\u0026thinsp;30 units/mo)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e22\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e15.8\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e117\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e84.2\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eCurrent Smoking\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2.9\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e135\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e97.1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec18\" class=\"Section2\"\u003e \u003ch2\u003eCLINICAL ASSESSMENT (GLASGOW COMA SCALE)\u003c/h2\u003e \u003cp\u003eThe neurological status at presentation was a strong indicator of disease severity. Upon admission, more than half of the patients (51.1%) presented with moderate neurological impairment, defined as a GCS score of 5\u0026ndash;12. Severe impairment (GCS 3\u0026ndash;4) was observed in 14.4% of patients, while 34.5% retained relatively preserved consciousness (GCS 13\u0026ndash;15).\u003c/p\u003e \u003cp\u003eThere was a profound, statistically significant association between admission GCS and 30-day mortality (p\u0026thinsp;\u0026lt;\u0026thinsp;0.001). Patients presenting with a GCS of 3\u0026ndash;4 had a mortality rate of 100% (20/20) in this study. In stark contrast, those presenting with GCS 13\u0026ndash;15 had a survival rate of 90.7%. The odds of death for patients with a GCS of 3\u0026ndash;4 were more than six times higher compared to those with a GCS of 5\u0026ndash;12.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eAssociation between GCS and 30-Day Outcome\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"5\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGCS Score\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAlive (n\u0026thinsp;=\u0026thinsp;53)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eDead (n\u0026thinsp;=\u0026thinsp;86)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eMortality Rate within Group\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003ep-value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003e3\u0026ndash;4\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0 (0.0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e20 (100%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e100.0%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003e5\u0026ndash;12\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e13 (24.5%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e58 (67.4%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e81.7%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003e13\u0026ndash;15\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e40 (75.5%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e8 (9.3%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e16.7%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec19\" class=\"Section2\"\u003e \u003ch2\u003eRADIOLOGICAL FINDINGS\u003c/h2\u003e \u003cdiv id=\"Sec20\" class=\"Section3\"\u003e \u003ch2\u003eHaematoma Location and Laterality\u003c/h2\u003e \u003cp\u003eAnalysis of the CT scans revealed that the majority of haemorrhages (81.3%, n\u0026thinsp;=\u0026thinsp;113) were located in the supratentorial compartment. Infratentorial haemorrhages accounted for 18.0% (n\u0026thinsp;=\u0026thinsp;25) of cases. One patient presented with simultaneous bleeding in both compartments. Regarding laterality, left-sided haemorrhages were slightly more common (55.4%) than right-sided ones (44.6%).\u003c/p\u003e \u003cp\u003eSupratentorial Sites: The basal ganglia were the most frequent site of haemorrhage, accounting for 52.2% (n\u0026thinsp;=\u0026thinsp;59) of supratentorial cases. This was followed by the thalamus at 39.8% (n\u0026thinsp;=\u0026thinsp;45). Lobar haemorrhages were relatively rare, constituting only 6.2% (n\u0026thinsp;=\u0026thinsp;7) of supratentorial bleeds.\u003c/p\u003e \u003cp\u003e \u003cstrong\u003eInfratentorial Sites\u003c/strong\u003e \u003cp\u003eWithin the posterior fossa, the brainstem was the predominant site of pathology, accounting for 73.1% (n\u0026thinsp;=\u0026thinsp;19) of infratentorial cases, with cerebellar haemorrhages making up the remaining 26.9% (n\u0026thinsp;=\u0026thinsp;7).\u003c/p\u003e \u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv id=\"Sec21\" class=\"Section2\"\u003e \u003ch2\u003eHAEMATOMA VOLUME AND COMPLICATIONS:\u003c/h2\u003e \u003cp\u003eThe majority of patients (72.7%, n\u0026thinsp;=\u0026thinsp;101) presented with haematoma volumes of \u0026le;\u0026thinsp;30 mL. Large haematomas (\u0026gt;\u0026thinsp;30 mL) were observed in 27.3% (n\u0026thinsp;=\u0026thinsp;38) of the cohort.\u003c/p\u003e \u003cp\u003eIntraventricular Haemorrhage (IVH), resulting in Extension of blood into the ventricular system, was a common complication, observed in 59.7% (n\u0026thinsp;=\u0026thinsp;83) of patients.\u003c/p\u003e \u003cp\u003eEvidence of mass effect (midline shift, ventricular effacement, or herniation) was present in 80.0% of scans. The most common descriptors were ventricular compression (46.9%) and subfalcine herniation (31.5%).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab4\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 4\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eRadiological Characteristics\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFeature\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eCategory\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eFrequency (n\u0026thinsp;=\u0026thinsp;139)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003ePercentage (%)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eLocation\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSupratentorial\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e113\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e81.3\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eInfratentorial\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e25\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e18.0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eSpecific Site\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eBasal Ganglia\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e59\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e52.2 (of Supra)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eThalamus\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e45\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e39.8 (of Supra)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eBrainstem\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e19\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e73.1 (of Infra)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eVolume\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026le;\u0026thinsp;30 mL\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e101\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e72.7\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026gt;\u0026thinsp;30 mL\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e38\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e27.3\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eIVH\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePresent\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e83\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e59.7\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAbsent\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e56\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e40.3\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec22\" class=\"Section2\"\u003e \u003ch2\u003eOUTCOMES AND CORRELATIONS\u003c/h2\u003e \u003cp\u003eThe overall 30-day mortality rate for the study population was 61.8% (86/139). Only 38.2% of patients survived to the 30-day mark.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cdiv id=\"Sec23\" class=\"Section3\"\u003e \u003ch2\u003ePredictors of Mortality:\u003c/h2\u003e \u003cp\u003ePatients with haematoma volumes\u0026thinsp;\u0026gt;\u0026thinsp;30 mL were significantly more likely to die (Adjusted Odds Ratio: 8.5, 95% CI: 2.29\u0026ndash;31.78, p\u0026thinsp;=\u0026thinsp;0.001) compared to those with smaller volumes.\u003c/p\u003e \u003cp\u003eThe presence of IVH was a catastrophic prognostic marker. The mortality rate in the Intraventricular Haemorrhage \u003cb\u003e(\u003c/b\u003eIVH) group was 79.1%, compared to 20.9% in the non-IVH group. Patients with IVH had nearly an eight-fold increased risk of death (aOR: 7.9, 95% CI: 3.43\u0026ndash;18.24, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001).\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv id=\"Sec24\" class=\"Section2\"\u003e \u003ch2\u003eICH SCORE CORRELATION\u003c/h2\u003e \u003cp\u003eThe study demonstrated a strong positive correlation between the total ICH score and the 30-day mRS score (Spearman's rho\u0026thinsp;=\u0026thinsp;0.8, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001). Mortality rates increased progressively with higher ICH scores:\u003c/p\u003e \u003cp\u003e \u003cul\u003e \u003cli\u003e \u003cp\u003e \u003cb\u003eICH Score 1\u003c/b\u003e: 32.3% mortality.\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003e \u003cb\u003eICH Score 2\u003c/b\u003e: 75.0% mortality.\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003e \u003cb\u003eICH Score 3\u003c/b\u003e: 100.0% mortality.\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eICH Score 4: 100.0% mortality.\u003c/p\u003e \u003c/li\u003e \u003c/ul\u003e \u003cdiv class=\"BlockQuote\"\u003e \u003cp\u003eNo patients with an ICH score of 5 or 6 were recorded in the study.\u003c/p\u003e \u003c/div\u003e \u003c/p\u003e \u003c/div\u003e"},{"header":"DISCUSSION","content":"\u003cdiv id=\"Sec26\" class=\"Section2\"\u003e \u003ch2\u003eRISK FACTORS AND EPIDEMIOLOGY\u003c/h2\u003e \u003cp\u003eThe demographic profile of ICH in this study aligns with the distinct \"African phenotype\" of stroke described in recent literature [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. The median age of 53 years is strikingly lower than the average age of ~\u0026thinsp;73 years seen in Western cohorts such as the original Hemphill study [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. This two‑decade disparity is not merely descriptive; it represents a major novel finding for the ICH score literature: the score\u0026rsquo;s age component (\u0026ge;\u0026thinsp;80 years) contributes almost nothing to risk stratification in this population, suggesting that recalibration with a lower age cutoff (e.g., \u0026ge;\u0026thinsp;60 years) may be needed for African cohorts.\u003c/p\u003e \u003cp\u003eThe male predominance (69.1%) observed here mirrors findings from other West African studies and global datasets [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. This gender gap may be partly explained by the higher prevalence of lifestyle risk factors among men in this setting, such as alcohol consumption, which was significantly higher in males in our cohort (20.8% vs 4.6%). Alcohol is a known dose-dependent risk factor for haemorrhagic stroke, potentially exacerbating hypertension and interfering with platelet function [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eHypertension emerged as the ubiquitous driver of ICH in this population, present in nearly 96% of patients. This is consistent with the INTERSTROKE study, which found that the population-attributable risk of hypertension for haemorrhagic stroke is greater than for ischaemic stroke [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]. The high rate of medication non-compliance (76.6%) is a critical finding. It reflects systemic barriers, including the cost of medication, lack of patient education regarding the \"silent\" nature of hypertension, and perhaps cultural beliefs favouring herbal remedies [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]. Addressing these implementation challenges in hypertension control is arguably the single most effective strategy to reduce the burden of ICH in Ghana.\u003c/p\u003e \u003cdiv id=\"Sec27\" class=\"Section3\"\u003e \u003ch2\u003eNEUROLOGICAL PREDICTORS (GCS)\u003c/h2\u003e \u003cp\u003eThe Glasgow Coma Scale remains the most powerful single clinical predictor of mortality. Our finding that GCS scores of 3\u0026ndash;4 predicted 100% mortality is consistent with Hemphill's original validation and subsequent studies in Nigeria and Uganda [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e, \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]. The GCS reflects the global impact of the haemorrhage, capturing both the direct destruction of brain tissue and the secondary effects of raised intracranial pressure (ICP).\u003c/p\u003e \u003cp\u003eIn the resource-constrained setting of KATH, where mechanical ventilation and ICP monitoring are not universally available, a low GCS score serves as a grim prognosticator. However, it is crucial to note that \"self-fulfilling prophecies\" can occur; patients with low GCS may receive less aggressive care (e.g., Do Not Resuscitate orders or withholding of intubation), which directly contributes to the high mortality observed [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e].\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv id=\"Sec28\" class=\"Section2\"\u003e \u003ch2\u003eRADIOLOGICAL DETERMINANTS\u003c/h2\u003e \u003cp\u003eThe anatomical distribution of haematomas in this study strongly supports hypertensive vasculopathy as the primary aetiology. Over 90% of supratentorial bleeds were located in the basal ganglia or thalamus, classic sites for rupture of Charcot-Bouchard microaneurysms induced by chronic hypertension [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. This contrasts with elderly Western cohorts, where lobar haemorrhages secondary to cerebral amyloid angiopathy (CAA) are more common. The rarity of lobar bleeds (6.2%) in our study is consistent with the younger age structure, as CAA is a disease of advanced ageing.\u003c/p\u003e \u003cp\u003eThe presence of intraventricular haemorrhage (IVH) was a significant independent predictor of death, increasing mortality risk by nearly eightfold. IVH contributes to mortality through the development of acute obstructive hydrocephalus and direct toxicity of blood products to the periventricular structures [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]. While external ventricular drains (EVDs) can mitigate this risk, their availability is variable in many African centres, potentially contributing to the high mortality associated with IVH in this cohort.\u003c/p\u003e \u003cp\u003eHaematoma volume \u003cspan class=\"InlineEquation\"\u003e\u003cspan class=\"mathinline\"\u003e\\(\\:\u0026gt;\\)\u003c/span\u003e\u003c/span\u003e 30 mL was associated with \u003cspan class=\"InlineEquation\"\u003e\u003cspan class=\"mathinline\"\u003e\\(\\:\u0026gt;\\)\u003c/span\u003e\u003c/span\u003e 90% mortality. This validates the volume cutoff used in the original ICH score. Larger volumes exert a greater mass effect, leading to herniation and compression of the brainstem.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec29\" class=\"Section2\"\u003e \u003ch2\u003eVALIDITY OF THE ICH SCORE IN GHANA\u003c/h2\u003e \u003cp\u003eThis study successfully validated the ICH score as a robust predictor of mortality in a tertiary hospital setting in Ghana. The clear stepwise increase in mortality with increasing scores confirms the tool's discriminative ability. However, the absolute mortality rates observed for each score category were higher than those reported in the original Hemphill study. For example, patients with an ICH score of 2 in our study had a mortality of 75%, compared to 26% in Hemphill's cohort [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThis \u0026ldquo;mortality gap\u0026rdquo; is a central finding of our study. It demonstrates that while the ICH score\u0026rsquo;s discriminative ability (c‑statistic) may travel well across populations, its calibration, the absolute risk for a given score, does not. This has direct clinical utility: in KATH, an ICH score of 3 or 4 predicts 100% mortality, whereas in high‑income settings, such scores are associated with 50‑70% mortality [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e]. Therefore, the same score carries different prognostic weight depending on the availability of neurocritical care resources.\u003c/p\u003e \u003cp\u003eFurthermore, the age component of the ICH score (\u003cspan class=\"InlineEquation\"\u003e\u003cspan class=\"mathinline\"\u003e\\(\\:\\ge\\:\\)\u003c/span\u003e\u003c/span\u003e 80 years) contributes little to risk stratification in this population, as \u0026lt;\u0026thinsp;3% of patients met this criterion. Some researchers have suggested lowering the age cutoff to 60 or 65 years for African populations to improve the score's sensitivity, given the lower life expectancy and earlier onset of vascular ageing [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eDespite these calibration differences, the ICH score remains a highly useful clinical tool. It helps clinicians identify the \"futility threshold\"; in our data, scores of 3 and 4 were uniformly fatal. This knowledge empowers clinicians to initiate compassionate end-of-life discussions early, avoiding financial ruin for families pursuing futile aggressive care, while focusing maximum effort on patients with lower scores who have a salvageable chance of survival.\u003c/p\u003e \u003c/div\u003e"},{"header":"CONCLUSION","content":"\u003cp\u003eThe ICH score is an effective and valid tool for predicting 30‑day mortality in Ghanaian patients with spontaneous ICH, though absolute mortality rates for each score are higher than in high‑income settings. While the biological drivers of outcome (GCS, volume, IVH) are universal, the threshold for mortality is lower in this setting compared to HICs, likely due to health system constraints. This study provides novel, context‑specific calibration data that can inform bedside decision‑making: ICH scores of 3\u0026ndash;4 are uniformly fatal in our setting, whereas scores of 1\u0026ndash;2 offer a realistic chance of survival. The age component of the original ICH score (\u0026ge;\u0026thinsp;80 years) has little relevance here; future studies should explore lowering the age cutoff to \u0026ge;\u0026thinsp;60 years for African populations. The study confirms that spontaneous ICH in Ghana is a disease of the young and hypertensive, carrying a grave prognosis.\u003c/p\u003e \u003cdiv id=\"Sec31\" class=\"Section2\"\u003e \u003ch2\u003eLIMITATIONS\u003c/h2\u003e \u003cp\u003eThe study was single‑centred, limiting generalizability to rural settings. The exclusion of patients who died before imaging or could not afford a CT scan may have introduced selection bias. The 30‑day outcome endpoint does not capture the long‑term burden of disability in survivors, which is substantial. A key methodological limitation is the absence of confirmatory vascular imaging (CT angiography or digital subtraction angiography). Non‑contrast CT cannot reliably exclude underlying arteriovenous malformations or aneurysms. Therefore, while we excluded overt cases of vascular malformations visible on NCCT (e.g., calcified AVM), a small proportion of our \u0026ldquo;spontaneous ICH\u0026rdquo; cohort may have unrecognised secondary causes. However, the anatomical distribution of haematomas (predominantly basal ganglia and thalamus) is typical of hypertensive vasculopathy, and the proportion of misclassified cases is expected to be low. Future research should focus on long‑term functional outcomes and the validation of modified scores (e.g., using a lower age cutoff), as well as prospective studies incorporating CTA to define true primary ICH cohorts in African settings.\u003c/p\u003e \u003c/div\u003e "},{"header":"Declarations","content":"\u003cp\u003e \u003ch2\u003eClinical Trial Number\u003c/h2\u003e \u003cp\u003eNot applicable\u003c/p\u003e \u003c/p\u003e\u003cp\u003e \u003ch2\u003eConsent to participate\u003c/h2\u003e \u003cp\u003e Written informed consent was obtained from all conscious participants. For patients with altered consciousness or aphasia, consent was obtained from the legal next of kin. Strict confidentiality was maintained by de-identifying all data during extraction and analysis.\u003c/p\u003e \u003c/p\u003e \u003cp\u003e \u003cstrong\u003eConsent for publication\u003c/strong\u003e \u003cp\u003e Informed consent was obtained from all the individual participants/patients for publication.\u003c/p\u003e \u003c/p\u003e\u003ch2\u003eFunding\u003c/h2\u003e \u003cp\u003eAuthors receive no source of funding.\u003c/p\u003e\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003eMA: data curation, methodology, review and editing, SF: write-up and editing. ABP: write-up and editing. ATA: write-up and editing. RMKD: write-up and editing. IAK: review and editing. OO: write-up and editing. AA: methodology, review, and editing. KT: write up, methodology, YAA: write-up and editing. JBY-Data Analysis, all authors approved the version to be published and agreed to be accountable for all aspects of the work.\u003c/p\u003e\u003ch2\u003eAcknowledgement\u003c/h2\u003e\u003cp\u003eWe acknowledge the participants who took part in the study.\u003c/p\u003e\u003ch2\u003eData Availability\u003c/h2\u003e\u003cp\u003eAll data supporting the findings of this study are available within the paper\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eFeigin VL, Stark BA, Johnson CO, et al. Global, regional, and national burden of stroke and its risk factors, 1990\u0026ndash;2019: a systematic analysis for the Global Burden of Disease Study 2019. Lancet Neurol. 2021;20:795\u0026ndash;820.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eOwolabi MO, Sarfo F, Akinyemi R, et al. Dominant modifiable risk factors for stroke in Ghana and Nigeria (SIREN): a case-control study. Lancet Glob Health. 2018;6:e436\u0026ndash;46.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAkinyemi RO, Ovbiagele B, Adeniji OA, et al. Stroke in Africa: profile, progress, prospects and priorities. Nat Rev Neurol. 2021;17:634\u0026ndash;56.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDonkor ES. Stroke in the 21st Century: A Snapshot of the Burden, Epidemiology, and Quality of Life. Stroke Res Treat. 2018;20:138\u0026ndash;65.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWitsch J, Siegerink B, Nolte CH, et al. Prognostication after intracerebral haemorrhage: a review. Neurol Res Pract. 2021;3:22.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePasi M, Viswanathan A. Pathophysiology of Primary Intracerebral Hemorrhage: Insights into Cerebral Small Vessel Disease. In: Lee S-H, editor \u003cem\u003eStroke Revisited: Hemorrhagic Stroke\u003c/em\u003e. Singapore: Springer Singapore, pp. 27\u0026ndash;46.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSarfo FS, Ovbiagele B, Gebregziabher M, et al. Unraveling the risk factors for spontaneous intracerebral hemorrhage among West Africans. Neurology. 2020;94:e998\u0026ndash;1012.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGreenberg SM, Ziai WC, Cordonnier C, et al. 2022 Guideline for the Management of Patients With Spontaneous Intracerebral Hemorrhage: A Guideline From the American Heart Association/American Stroke Association. Stroke. 2022;53:e282\u0026ndash;361.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHemphill JC, Bonovich DC, Besmertis L, et al. The ICH score: a simple, reliable grading scale for intracerebral hemorrhage. Stroke. 2001;32:891\u0026ndash;7.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAgyemang C, Attah-Adjepong G, Owusu-Dabo E, et al. Stroke in Ashanti region of Ghana. Ghana Med J. 2012;46:12\u0026ndash;7.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSembill JA, Gerner ST, Volbers B, et al. Severity assessment in maximally treated ICH patients: The max-ICH score. Neurology. 2017;89:423\u0026ndash;31.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKATH, Home-About. \u003cem\u003eKomfo Anokye Teaching Hospital\u003c/em\u003e, \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://kath.gov.gh\u003c/span\u003e\u003cspan address=\"https://kath.gov.gh\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e/ (2024, accessed 3 October 2025).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAlcohol. units. \u003cem\u003enhs.uk\u003c/em\u003e, \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.nhs.uk/live-well/alcohol-advice/calculating-alcohol-units/\u003c/span\u003e\u003cspan address=\"https://www.nhs.uk/live-well/alcohol-advice/calculating-alcohol-units/\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e (2022, accessed 23 October 2026).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eFowobaje KR, Okekunle AP, Akinyemi J, et al. Dominant Risk Factors For Stroke Among Africans: A Systematic Review And Meta-Analysis. Afr J Biomedical Res. 2024;27:7094\u0026ndash;118.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eO\u0026rsquo;Donnell MJ, Chin SL, Rangarajan S, et al. Global and regional effects of potentially modifiable risk factors associated with acute stroke in 32 countries (INTERSTROKE): a case-control study. Lancet. 2016;388:761\u0026ndash;75.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAdidja NM, Agbor VN, Aminde JA, et al. Non-adherence to antihypertensive pharmacotherapy in Buea, Cameroon: a cross-sectional community-based study. BMC Cardiovasc Disord. 2018;18:150.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAbdallah A, Chang JL, O\u0026rsquo;Carroll CB, et al. Validation of the Intracerebral Hemorrhage Score in Uganda. Stroke. 2018;49:3063\u0026ndash;6.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAdeleye AO, Osazuwa UA, Ogbole GI. The Clinical Epidemiology of Spontaneous ICH in a Sub-Sahara African Country in the CT Scan Era: A Neurosurgical In-Hospital Cross-Sectional Survey. Front Neurol. 2015;6:169.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLi Q, Li R, Zhao L-B, et al. Intraventricular Hemorrhage Growth: Definition, Prevalence and Association with Hematoma Expansion and Prognosis. Neurocrit Care. 2020;33:732\u0026ndash;9.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBaatiema L, de-Graft Aikins A, Sav A, et al. Barriers to evidence-based acute stroke care in Ghana: a qualitative study on the perspectives of stroke care professionals. BMJ Open. 2017;7:e015385.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"discover-medicine","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"","sideBox":"Learn more about [Discover Medicine](https://link.springer.com/journal/44337)","snPcode":"44337","submissionUrl":"https://submission.springernature.com/new-submission/44337/3","title":"Discover Medicine","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Discover Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Primary Intracerebral Haemorrhage, ICH Score, Prognostication, Stroke, Hypertension, Kumasi, Ghana, Computed Tomography, Modified Rankin Scale","lastPublishedDoi":"10.21203/rs.3.rs-9301864/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-9301864/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003eHaemorrhagic stroke, particularly spontaneous intracerebral haemorrhage (ICH), represents a critical public health challenge worldwide, contributing significantly to premature mortality and long-term disability. Unlike ischaemic stroke, where therapeutic avenues such as thrombolysis and thrombectomy have revolutionised care, ICH lacks a definitive curative intervention of proven benefit, necessitating supportive care and precise prognostication. In sub-Saharan Africa, the burden of ICH is amplified by an epidemiological transition characterised by a rising prevalence of undiagnosed and uncontrolled hypertension. Given the high mortality rates and resource limitations in settings like Ghana, accurate risk stratification is essential for guiding clinical decision-making and optimising resource allocation. While the ICH score is validated in high‑income settings, its performance in sub‑Saharan Africa, where patients are younger, the hypertension burden is higher, and neurocritical care resources are limited, remains unknown. This study evaluates both the discriminative ability and calibration of the ICH score in a Ghanaian cohort with CT‑confirmed spontaneous ICH at the Komfo Anokye Teaching Hospital (KATH) in Kumasi.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eThe cross-sectional study was conducted over eight months at the Radiology Directorate of KATH. The study recruited 146 adult patients (\u0026ge;\u0026thinsp;18 years) presenting with acute neurological deficits and Computed Tomography (CT) confirmed ICH. Seven patients were lost to follow-up, leaving 139 for analysis. Socio-demographic and clinical data were obtained from patient interviews and the Lightwave Health Information Management System (LHIMS). Non‑enhanced CT scans were reviewed by two radiologists to determine haematoma location, volume, and intraventricular extension (IVH). Confirmatory vascular imaging (CT angiography or DSA) was not routinely available; therefore, a small proportion of cases may represent underlying vascular malformations, a limitation acknowledged in the analysis. The ICH score and Glasgow Coma Scale (GCS) were calculated on admission. The primary outcome was 30-day functional status and mortality, assessed using the modified Rankin Scale (mRS).\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eThe median age of the cohort was 53 years, with a peak prevalence in the 40\u0026ndash;59 age group (59.0%). A male predominance was observed (69.1%). Hypertension was the dominant risk factor, present in 95.7% of patients on admission. The overall 30-day mortality rate was 61.8%. A GCS score of 3\u0026ndash;4 was associated with a more than six-fold increase in mortality risk compared to a GCS score of 5\u0026ndash;12 (p\u0026thinsp;\u0026lt;\u0026thinsp;0.001). Radiologically, supratentorial haemorrhages were most common (81.3%), predominantly in the basal ganglia (52.2%) and thalamus (39.8%). Large haematoma volume (\u0026gt;\u0026thinsp;30 mL) and the presence of IVH were independent predictors of poor outcomes. The ICH score demonstrated a strong positive correlation with 30-day mortality.\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e \u003cp\u003eThe ICH score demonstrates strong prognostic utility in this Ghanaian cohort, but absolute mortality for a given ICH score is significantly higher than reported in high‑income settings (e.g., ICH score 2: 75% vs. 26% originally). The study highlights a younger age of onset compared to global averages and a heavy burden of hypertension. These findings highlight the urgent need for enhanced hypertensive control programs and the establishment of dedicated stroke units to mitigate the high mortality associated with this condition.\u003c/p\u003e","manuscriptTitle":"Validation of the Intracerebral Hemorrhage Score Using Computed Tomography in Spontaneous Intracerebral Hemorrhage at a Tertiary Hospital in Kumasi Ghana A Prospective Cohort Study","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-05-12 16:51:53","doi":"10.21203/rs.3.rs-9301864/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"editorInvitedReview","content":"","date":"2026-05-10T20:22:29+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"209377182071487615049481223439195935184","date":"2026-05-01T11:58:26+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2026-05-01T10:24:48+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2026-05-01T10:23:28+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2026-04-22T18:19:42+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2026-04-12T07:09:45+00:00","index":"","fulltext":""},{"type":"submitted","content":"Discover Medicine","date":"2026-04-12T07:06:15+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"discover-medicine","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"","sideBox":"Learn more about [Discover Medicine](https://link.springer.com/journal/44337)","snPcode":"44337","submissionUrl":"https://submission.springernature.com/new-submission/44337/3","title":"Discover Medicine","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Discover Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"09c8c66e-f784-4aed-ad4b-ffdc23c8bd69","owner":[],"postedDate":"May 12th, 2026","published":true,"recentEditorialEvents":[{"type":"editorInvitedReview","content":"","date":"2026-05-10T20:22:29+00:00","index":32,"fulltext":""},{"type":"reviewerAgreed","content":"209377182071487615049481223439195935184","date":"2026-05-01T11:58:26+00:00","index":28,"fulltext":""},{"type":"reviewersInvited","content":"8","date":"2026-05-01T10:24:48+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2026-05-01T10:23:28+00:00","index":"","fulltext":""}],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2026-05-12T16:51:58+00:00","versionOfRecord":[],"versionCreatedAt":"2026-05-12 16:51:53","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-9301864","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-9301864","identity":"rs-9301864","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}