The prognostic value of systemic inflammatory indices in elderly patients with spontaneous intracerebral hemorrhage

Background: Very old patients represent the fastest-growing age subgroup among patients with intracerebral hemorrhage (ICH), which justifies studying age-specific prognostic behavior in this population. While systemic inflammatory indices are increasingly recognized for their prognostic potential in various conditions, their specific value in this rapidly expanding geriatric cohort remains unclear. This study aimed to evaluate whether specific indices, particularly the Monocyte-to-Albumin Ratio (MAR) and Systemic Inflammatory Response Index (SIRI), provide independent prognostic information for case-fatality in this population. Methods and findings: We conducted a retrospective observational cohort study of patients aged ≥65 years with spontaneous ICH admitted to a single tertiary emergency department between 2020 and 2025. Of 326 patients initially screened, 118 consecutive patients met inclusion criteria and constituted the cohort. Inflammatory indices were calculated from admission blood tests. Admission non-contrast cranial computed tomography scans were utilized to measure initial hematoma volume using the validated ABC/2 and ABC/2-derived compartmental methods. The primary outcome was 30-day all-cause case-fatality; secondary outcomes included 48-hour and 90-day case-fatality. Multivariable logistic and Cox regression models were adjusted for age, sex, hemorrhage type, and treatment type. Receiver operating characteristic (ROC) analysis was performed to assess predictive performance. Conclusions: In elderly patients with spontaneous ICH, admission MAR is independently associated with short- and medium-term case-fatality, whereas SIRI offers limited additional prognostic value. MAR may serve as a useful adjunctive marker for risk stratification, but its data-driven cut-offs and modest discrimination necessitate external validation and prospective assessment before clinical adoption.