Our study collected clinical information of 1,564 patients with CI in ICU (1315 survivals and 249 deaths) with cerebral infarction from MIMIC-IV database. This nomogram did great performance for both the primary and validation cohort as assessed by the lasso curves analysis, the calibration curves analysis, the decision curve analysis, the nomogram table and ROC curves. So, our nomogram could be greatly applied to clinical practice. Nomograms predict one’s probability of a clinical event using individual information and variables, they have become a usual prognostic model in oncology14. This study provided an easy-to-use prognostic nomogram for the first time with 4 clinical factors, which is collected on the first-day admission for critically ill patients with CI, the nomogram could meliorate one’s risk stratification and prevent death of critically ill patients with CI in time.
Cerebral infarction is a major disease that endangers modern people's health. Patients with cerebral infarction are likely to have sequelae if the treatment is not appropriate, with high incidence and mortality, which result in economic and health loads to our country and people. Substantial critically ill patients with CI are admitted to ICU8. While not all CI patients benefit from ICU care. In order to do risk stratification to make more efficient decisions for CI patients, we used the nomograms through integrating individual risk factors with performance status to forecast the clinical events. We hypothesized that a nomogram on account of a multivariable Cox regression model in a primary cohort, can also be applicable to CI patients’ risk stratification in ICU.
Age is one of the most essential risk factors in cerebrovascular diseases 15–16, such as cerebral infarction17, transient ischemic attack (TIA)18, Intracerebral hemorrhage (ICH)19, and intracranial aneurysm20. Our study also found age was an independent predict factors for the prognosis of cerebral infarction patients in intensive care units. Generally, serum aniongap (AG) rising resulted in over accumulation of organic acid or excessive loss of anions21. The excessive generation of lactate and pyruvate in serum result to common reason for AG cumulation 22–23. Serum AG count could be applied as a prognostic indicator to have evaluation for patients with CI in a short-term, higher AG on the first-day-admission was related to increased risk of all-cause mortality, a few patients who were in ICU had higher AG count24. WBC count is an important risk factor and is related with delayed cerebral ischemia25. High WBC count is also referred to mortality and pneumonia after acute ischemic stroke, which might be induced by stress and inflammatory response, it is reported that higher WBC is associated with mortality after acute stroke26. SOFA score is a sequential organ failure assessment score system, and applies to data collected in 24 hours of intensive care units’ admission. The SOFA score evaluation contents include respiratory, cardiovascular (BP, vasoactive drug use), renal, hepatic, neurological and haematological (platelet number) systems27–28. Totally, in our study those 4 factors are reliable prognostic factors for mortality of critically ill CI patients in the ICU, and these 4 factors also could contribute to clinical work.
Besides, we assessed the nomogram with properties and clinical benefits to prove its accuracy and utility. The nomogram was applied to clinical practice easily and identified high-risk patients and guided decision-making. Timely prognostic assessment is essential because of CI’s treatment time window is narrow. It’s especially essential to discriminate high-risk patients as early as possible to carry on further active intervention measures for a better prognosis. Currently, bio-markers catch much attention. Higher AG counting was related to increased incidence of all-cause mortality, which guided to monitor cerebral infarction and the formulation of secondary prevention strategies24.
While there are still some several problems to be solved. First, some previously reported risk factors (transient ischemic attack, atrial fibrillation, smoking and alcohol use, blood lipid, blood glucose, blood homocysteine) of CI27,29−30, were not proven to be related to the death in hospital in our study. So, the prognostic value of these factors for CI should be reconfirmed in future studies. National Institute of Health stroke scale (NIHSS) score and Modified Rankin Scale (MRS) score were not be contained in present study due to the complexity of their score and difficult to obtain in MIMIC-IV database. Thus, future studies can compare our nomogram with the two scoring models. Last, the nomogram model still needed extra more samples to confirm application and reliability, more external cohort would further solid the reliability and significance of the nomogram model.