TITLE:
Predicting the Neurosurgical Indication at Admission for Stroke at Bouaké University Hospital (Côte d’Ivoire): Development and Internal Validation of a Nomogram, an Integer Score and a Decision Tree
AUTHORS:
Koffi Yves Soress Dongo, Faozo Stephane Landry Teti, Kouadio Jean-Baptiste Keke, Yao Bernard Fionko, Aderehime Haidara
KEYWORDS:
Stroke, Surgical Indication, Nomogram, Decision Tree, Predictive Model, Neurosurgery, Sub-Saharan Africa
JOURNAL NAME:
Open Journal of Modern Neurosurgery,
Vol.16 No.4,
October
28,
2026
ABSTRACT: Background: In resource-limited settings, the decision to operate on a stroke rests on individual experience, with no formal tool. Objective: To develop and internally validate a model estimating, at admission, the probability that a patient meets a neurosurgical indication. Patients and Methods: Prospective cohort of 250 consecutive patients admitted for imaging-confirmed stroke between January 2022 and December 2023. The target was the operative indication recorded in the chart. A logistic regression with backward selection was translated into a nomogram and an integer score. A classification and regression tree was built in parallel. Internal validation reproduced the whole process across 1000 bootstrap resamples. Results: An indication was recorded in 107 patients (42.8%). Four variables were independently associated with it: hydrocephalus (adjusted odds ratio: 4.15; 95% CI: 2.03 - 8.46), mass effect (2.42), intraventricular extension (2.31) and impaired consciousness (2.23). The apparent area under the curve was 0.77 (0.71 - 0.83), the optimism-corrected area was 0.73 (95% CI: 0.66 - 0.79), and the corrected calibration slope was 0.84 (95% CI: 0.65 - 1.03). The model outperformed existing scores (ICH score: 0.66; ≤0.60 for the others). The probability of indication rose from 15.7% to 95.0% across the integer score (0 - 5). Of 107 indications, only 45 were operated on, and none of the 15 aneurysmal indications were operated on. Conclusion: A four-variable bedside tool estimates the probability of a neurosurgical indication in stroke and outperforms prognostic scores repurposed to this end. It objectifies a 58% access gap. External multicentre validation remains necessary.