JR-ZQSI-NICHE: A Digital Neurosurgical Decision Support System for Spontaneous Intracerebral Hemorrhage

BACKGROUND: Neurosurgical decision support systems, which integrate evidence with patient-specific factors into transparent and reproducible decision pathways, represent a promising approach to standardize the delivery of evidence-based care and improve outcomes in spontaneous intracerebral hemorrhage (ICH). Here, we developed JR-ZQSI-NICHE (Jose Reyes-Zeenat Qureshi Stroke Institute-Neurology and Neurosurgery Intracerebral Hemorrhage Evaluation), a web-based algorithm-driven application designed to support the identification of ICH patients who may benefit from neurosurgical intervention. AIMS: To evaluate the clinical effectiveness of JR-ZQSI-NICHE by comparing mortality and functional outcomes before and after implementation. METHODS: This retrospective before-after cohort study included consecutive adult patients admitted with spontaneous ICH at the Philippine National Specialty Center for Brain and Spine Care between January 2019 and December 2024. Data were extracted from a prospectively maintained institutional stroke registry. JR-ZQSI-NICHE was implemented on January 1, 2022, defining the pre- and post-implementation study periods. The primary outcome was all-cause in-hospital mortality. Secondary outcomes were 90- and 180-day functional status, assessed using the modified Rankin Scale (mRS). RESULTS: A total of 1551 patients were included (767 pre-implementation; 784 post-implementation). JR-ZQSI-NICHE implementation was independently associated with lower odds of all-cause in-hospital mortality (adjusted OR 0.16, 95% CI 0.09-0.30). Functional outcomes were improved at Day 90 (adjusted ordinal OR 0.39, 95% CI 0.32-0.47); however, this association did not persist in sensitivity analyses. At Day 180, implementation was independently associated with better functional outcomes (adjusted ordinal OR 0.42, 95% CI 0.35-0.52). CONCLUSIONS: JR-ZQSI-NICHE implementation was associated with lower in-hospital mortality and improved functional outcomes at 180 days in patients with spontaneous ICH. These findings provide preliminary, hypothesis-generating evidence supporting the potential clinical benefit of algorithm-based clinical decision support systems for neurosurgical decision-making in ICH. Prospective randomized trials are warranted to confirm these findings.