Song Li, Shirui Wang, Qiang Shao, Wenzheng Li, Fuchao Yu, Xiaowen Zhang, Dianwei Liu, Wei Li
The admission IBIL/TBIL ratio is linearly and independently associated with 3-month functional outcome in sICH patients following surgical evacuation. As an inexpensive and routinely available biomarker, it may serve as an adjunctive prognostic indicator, but it should not be interpreted as a standalone replacement for established clinical severity measures.
BACKGROUND: Serum bilirubin levels are associated with the prognosis of spontaneous intracerebral hemorrhage (sICH). However, the specific predictive value of the indirect-to-total bilirubin (IBIL/TBIL) ratio in patients undergoing surgical hematoma evacuation remains unclear. This study aimed to investigate the association between the admission IBIL/TBIL ratio and 3-month functional outcomes.
METHODS: We retrospectively analyzed 168 sICH patients who underwent surgical intervention between January 2024 and December 2025. The primary predictor was the admission IBIL/TBIL ratio. The primary outcome was the 3-month functional outcome, evaluated using the utility-weighted modified Rankin Scale (uw-mRS). Multivariable linear regression and restricted cubic spline (RCS) models were utilized to assess the independent and non-linear associations. Receiver operating characteristic (ROC) curves were generated to compare predictive performances.
RESULTS: Multivariable regression analysis demonstrated that a higher IBIL/TBIL ratio was independently associated with improved functional outcomes [ln(uw-mRS + 1)] after adjusting for age, admission NIHSS score, initial hematoma volume, brain herniation, and secondary intraventricular hemorrhage (overall model p < 0.001). The RCS analysis showed an approximately linear relationship between the IBIL/TBIL ratio and functional recovery (P non-linearity = 0.568). The IBIL/TBIL ratio showed modest discrimination for 3-month poor functional outcome (mRS 4-6; AUC = 0.655), higher than TBIL alone (AUC = 0.504) but lower than the admission NIHSS score (AUC = 0.784).
CONCLUSION: The admission IBIL/TBIL ratio is linearly and independently associated with 3-month functional outcome in sICH patients following surgical evacuation. As an inexpensive and routinely available biomarker, it may serve as an adjunctive prognostic indicator, but it should not be interpreted as a standalone replacement for established clinical severity measures.