Spontaneous supratentorial intracerebral hemorrhage. Criteria for short-term functional outcome prediction

Background and Purpose: To identify the significant prognostic factors, upon admission, and construct a set of criteria to predict short-term functional outcome of patients with intracerebral hemorrhage (ICH). Methods: The records as well as the radiological findings, of 184 consecutive cases of spontaneous supratentorial intracerebral hemorrhage, that were treated medically, were reviewed. The hemorrhage was graded according to size, mass effect and intraventricular extension. Outcome upon discharge was scored using the modified Rankin Scale. A score of four or more was considered a poor outcome. Multivariate analysis was used to identify the factors associated with a poor outcome. Results: Six significant and independent prognostic variables were identified: decreased level of consciousness, severe hemiparesis, age older than sixty, large hematoma size, midline shift and intraventricular extension on CT. These variables were scored systematically to produce the ICH criteria. The sum of these criteria yields a figure between zero and six termed ICH score. Patient grouping according to ICH score identified four distinctive, prognostic groups: I – score of zero to one, II – score of two, III – score of three and IV – score of four to six in which 82 %, 53.7 %, 23.3 % and 0 % achieved a good outcome respectively (P < 0.05 for all groups). Conclusions: The present study identified six independent admission criteria predicting the short-term functional outcome of ICH patients. Their sum may serve to predict the short-term functional outcome upon admission of medically-treated patients with spontaneous supratentorial intracerebral hemorrhage. Received: 29 January 2002, Received in revised form: 18 April 2002, Accepted: 2 July 2002 Correspondence to Chen Hallevy, MD     

Early surgical treatment for supratentorial intracerebral hemorrhage: a randomized feasibility study.

BACKGROUND AND PURPOSE: The safety and the effectiveness of the surgical treatment of spontaneous intracerebral hemorrhage (ICH) remain controversial. To investigate the feasibility of urgent surgical evacuation of ICH, we conducted a small, randomized feasibility study of early surgical treatment versus current nonoperative management in patients with spontaneous supratentorial ICH. METHODS: Patients with spontaneous supratentorial ICH who presented to 1 university and 2 community hospitals were randomized to surgical treatment or best medical treatment. Principal eligibility criteria were ICH volume >10 cm(3) on baseline CT scan with a focal neurological deficit, Glasgow Coma Scale score >4 at the time of enrollment, randomization and therapy within 24 hours of symptom onset, surgery within 3 hours of randomization, and no evidence for ruptured aneurysm or arteriovenous malformation. The primary end point was the 3-month Glasgow Outcome Scale (GOS). A good outcome was defined as a 3-month GOS score >3. RESULTS: Twenty patients were randomized over 24 months, 9 to surgical intervention and 11 to medical treatment. The median time from onset of symptoms to presentation at the treating hospitals was 3 hours and 17 minutes, the time from randomization to surgery was 1 hour and 20 minutes, and the time from onset of symptoms to surgery was 8 hours and 35 minutes. The likelihood of a good outcome (primary outcome measure: GOS score >3) for the surgical treatment group (56%) did not differ significantly from the medical treatment group (36%). There was no significant difference in mortality at 3 months. Analysis of the secondary 3-month outcome measures showed a nonsignificant trend toward a better outcome in the surgical treatment group versus the medical treatment group for the median GOS, Barthel Index, and Rankin Scale and a significant difference in the National Institutes of Health Stroke Scale score (4 versus 14; P=0.04). CONCLUSIONS: Very early surgical treatment for acute ICH is difficult to achieve but feasible at academic medical centers and community hospitals. The trend toward less 3-month morbidity with surgical intervention in patients with spontaneous supratentorial ICH warrants further investigation of very early clot removal in larger randomized clinical trials.     

Spontaneous intracerebral hemorrhage

Spontaneous intracerebral hemorrhage (sICH) is defined as bleeding within the brain parenchyma, and occurs twice as commonly as subarachnoid hemorrhage, but is equally as deadly. Risk factors for sICH include hypertension, advanced age, leukoaraiosis, prior ICH, renal failure, use of anticoagulant drugs, and cerebral amyloid angiopathy. When a patient is clinically suspected of having sICH, head computed tomography scan is the standard diagnostic tool. However, newer magnetic resonance neuroimaging techniques may aid in determining the underlying pathology and aid in prognosis. Supportive care and blood pressure management are important in the care of patients with sICH. Ongoing research is aimed at determining a safe blood pressure goal that may also prevent expansion of hemorrhage. Hemostatic medications and neuroprotectants have thus far not shown clinical improvement. Although several neurosurgical trials have failed to demonstrate benefit for surgical evacuation of sICH, multiple research trials are ongoing investigating acute blood pressure control, deep or basal ganglionic hemorrhage evacuation via minimally invasive approach (MISTIE; http://mistietrial.com/default.aspx), lobar ICH evacuation (STICH; II http://research.ncl.ac.uk/stich/), and intraventricular thrombolysis with tissue plasminogen activator (tPA) (CLEAR III; http://biosgroup-johnshopkinsmedicine.health.officelive.com/default.aspx).     

Spontaneous intracerebral hemorrhage

To determine the prognostic value of etiology and localization in spontaneous intracerebral hemorrhage, 896 patients with spontaneous intracerebral hemorrhage, as proven by CT, operation or autopsy, were retrospectively studied using univariate data analysis. Etiologies were hypertension in 63.5%, cerebrovascular malformations in 8.5% and abnormal hemostasis in 15% of the patients. In 23% no etiology was determined. Main localizations were cerebral lobes in 49.2%, basal ganglia in 34.4%, brain stem in 6.9%, cerebellum in 6.7% and primary intraventricular in 2.3% of the patients. Ventricular extension was present in 47.0%. A higher case fatality correlated with: 1) ventricular extension ( P <0.00001), 2) increasing age ( P =0.00005), 3) surgical treatment ( P =0.00010), 4) localization in basal ganglia ( P =0.0108) and 5) hypertension as only etiology ( P =0.01471). A lower case fatality was found in patients with cerebrovascular malformations ( P =0.00006) and when the hemorrhage was localized to the cerebral lobes ( P =0.0050). We conclude that etiology and localization are of prognostic value in spontaneous intracerebral hemorrhage.     

Seizures after spontaneous supratentorial intracerebral hemorrhage

PURPOSE: To characterize seizures after intracerebral hemorrhage (ICH), evaluating the risk of occurrence and relapse, predisposing factors, and prognostic significance, and to assess the utility of antiepileptic drug (AED) therapy as used in clinical practice. METHODS: The study sample consisted of 761 patients with spontaneous, nonaneurysmal, supratentorial ICH. Seizures were classified as immediate (within 24 h of ICH) and early (within 30 days of ICH). Baseline variables and clinical events were compared in the seizure and nonseizure group by using a multivariate regression model of failure time data. RESULTS: Fifty-seven patients had one or more seizures. The 30-day actuarial risk of a post-ICH seizure was 8.1%. Lobar location and small volume of ICH were independent predictors of immediate seizures. Early seizures were associated with lobar location and neurologic complications, mainly rebleeding. In patients with lobar ICH, the risk of early seizures was reduced by prophylactic AED therapy. Among seizure patients, history of alcohol abuse increased the risk of status epilepticus. Immediate and early seizures were not independent predictors of in-hospital mortality. CONCLUSIONS: Patients with ICH are exposed to a substantial risk of seizures; however, short-term mortality was not affected, and the risk of epilepsy was lower than previously thought. The likelihood of immediate seizures is influenced by factors that are inherent characteristics of ICH, whereas the chance of developing early seizures is influenced not only by certain characteristics of ICH, but also by unpredictable events. A brief period of therapy soon after ICH onset may reduce the risk of early seizures in patients with lobar hemorrhage.     

Surgery for patients with severe supratentorial intracerebral hemorrhage

Introduction  Little information is available on the efficacy of aggressive treatment such as surgery in improving the outcome of severely affected patients after supratentorial intracerebral hemorrhage (ICH). Our objective was to assess the effect of hematoma removal and ventricular drainage on the mortality of patients with severe primary supratentorial ICH. Methods  We studied 103 consecutive patients who were admitted to the intensive care unit and diagnosed with primary supratentorial ICH. The impacts of clinical factors on 30-day mortality were assessed, including surgery, Glasgow Coma Scale (GCS) score and pupillary abnormality at admission, hematoma volume, and other related factors. Results  The 30-day mortality rate was 42%, and the median time between admission and death was 3 days (range: 1 to 27 days). Hematoma removal and ventricular drainage, within the first 24 hours of admission, were performed on 11 and 17 patients, respectively. Two patients who were treated with removal and four with drainage died. A logistic regression model for predicting 30-day mortality was performed. After controlling for GCS score, pupillary abnormality, hydrocephalus, and hematoma volume, hematoma removal was identified as an independent predictor of survival (odds ratio [OR], 0.12; 95% confidence interval [CI], 0.02 to 0.92). Ventricular drainage also tended to decrease mortality rate greatly (OR, 0.31; 95% CI, 0.06 to 1.76). Patients with GCS scores of 3 or 4 were 4.01 times more likely to die (95% CI, 1.13 to 14.26) than those with GCS of at least 5. Conclusions  Hematoma removal may reduce the mortality rate of patients with severe supratentorial ICH.     

超早期幕上高血压脑出血的诊疗体会

我院1998年至2007年共收治53例高血压幕上脑出血患者，均经头颅CT证实，现报道如下：一、对象与方法1．一般资料：共纳入有高血压病史患者53例，男39例，女14例。年龄41～85岁，平均63．5岁。2．临床表现：意识：意识清楚2例，嗜睡5例，浅昏迷27例，中度昏迷17例，深昏迷2例，CCS评分：4～14分，平均7分，其中≥13分者5例，9～12分31例，4～8分17例。     

Spontaneous intracerebral hemorrhage in young adults

Few studies have addressed intracerebral hemorrhage (ICH) in younger adults. We studied spontaneous ICH in adults 相似文献   

Spontaneous intracerebral hemorrhage and liver dysfunction

We evaluated liver function and coagulation parameters in 117 patients with spontaneous intracerebral hemorrhage (68 men and 49 women) admitted to our clinic within 24 hours after onset. Liver dysfunction was more common among men than women due to differences in alcohol consumption. Number of thrombocytes and fibrinogen concentrations were lower, especially among men with elevated concentrations of glutamic oxaloacetic transaminase or glutamic pyruvic transaminase and/or elevated gamma-globulin fraction. Five of the 78 patients undergoing stereotactic hematoma aspiration and one of the 39 treated nonsurgically rebled. All six of the patients who rebled were men, heavy alcohol consumers with liver dysfunction. Fibrinogen concentration was abnormally low in four of the six and at the lower end of the normal range in one. Two showed thrombocytopenia and one case showed prolonged prothrombin time. These facts suggest that liver disorders produce a state in which hemorrhage occurs more readily and that this hemorrhagic tendency may be one of the causal factors of spontaneous intracerebral hemorrhage.     

Early neurological change in patients with spontaneous supratentorial intracerebral hemorrhage

The frequency and causes of neurological change that occurs in patients within 24 hours after the onset of intracerebral hemorrhage (ICH), as well as their relationship to outcome, have seldom been reported. This study evaluated 184 patients with supratentorial ICH and neurological deterioration or improvement; measuring their level of consciousness (LOC) and motor skills the day after admission using the National Institutes of Health Stroke Scale. Nineteen patients (10%) deteriorated and 114 (62%) improved. Patient age, hematoma volume, and change in hematoma volume were independent predictors of early neurological improvement (p < 0.05). Independent predictors of 1-month functional outcome were age, LOC score at admission, motor score at admission, and change in motor score the day after admission (p < 0.05). Approximately 70% of the patients showed early neurological change. Observing early changes in hemiparesis was important for predicting functional outcome.     

脑室出血量对幕上自发性脑出血患者预后的影响

目的研究脑室出血（IVH）对幕上自发性脑出血（ICH）患者预后的影响。方法前瞻性收集幕上自发性ICH合并IVH患者105例,运用IVH评分系统量化IVH体积,采用多因素Logistic回归分析消除混杂因素的影响。结果发病后30 d,根据改良Rankin量表（mRS）评估患者预后,本组预后较好45例（42.9%;mRS 0-2分）,预后较差60例（57.1%;mRS 3-6分）。预后较差患者IVH体积[（26.5±14.1）ml]明显大于预后较好的患者[（5.1±5.3）ml;P〈0.01]。多因素Logistic回归分析显示,IVH体积是ICH患者预后不良的独立危险因素（OR=2.17;95%置信区间为1.39-3.92;P〈0.05）。结论IVH体积是幕上自发性ICH患者预后不良的独立危险因素;合并IVH体积越大,患者预后越差。     

Correlation of leukocytosis with early neurological deterioration following supratentorial intracerebral hemorrhage

Intracerebral hemorrhage (ICH) is a devastating and common admitting diagnosis to intensive care units in the USA. Despite advances in critical care, patients with ICH often experience early neurological deterioration (END) in the first 72 hours after admission due to a variety of factors, including hematoma and cerebral edema evolution. The purpose of this study was to determine factors associated with END after ICH. Using the Duke University Hospital Neuroscience Critical Care Unit Database, we retrospectively identified patients with an admitting diagnosis of supratentorial ICH from January to December 2010, verified by CT imaging. END was defined as a decrease in the Glasgow Coma Scale score of ?3 or death within the first 72 hours after hemorrhage. The chi-squared or t-test analysis was used to compare the groups, as appropriate. Multiple logistical regression modeling was performed to test for associations between likely predictors of END. Of the 89 subjects admitted with supratentorial ICH, we included 83 in the analysis based on complete datasets. Of these, 31 experienced END within 72 hours after onset of symptoms. ICH score, presence of midline shift on imaging, and white blood cell (WBC) count were used in a regression model for predicting END. WBC count demonstrated the greatest association with END. Patients with ICH are prone to END within the first few days after hemorrhage. Elevated WBC count appears predictive of deterioration. These data demonstrate that heightened inflammatory state after ICH may be related to early deterioration after injury.     

Management of lobar intracerebral hemorrhage: medical or surgical

Two case histories of left parietal hemorrhage, with CTs, were evaluated by 88 board-certified neurologists and 114 board-certified neurosurgeons. Among the neurologists, 24% would have referred both patients for removal of the hemorrhage, 24% would have referred one of them, and 52% would have referred neither. Among the neurosurgeons, 47% would have operated on both patients, 25% on one of them, and 28% on neither. The lack of consensus probably results from an imperfect understanding of the natural history of these lesions. Controlled studies, or at least large retrospective studies, are needed to clarify this important therapeutic issue.     

神经内镜手术和显微手术治疗幕上高血压性脑出血疗效的Meta分析

目的 比较神经内镜手术与显微手术治疗幕上高血压性脑出血的疗效及安全性。方法 计算机检索PubMed、Medline、EMbase、Cochrane等英文数据库及CNKI、万方、维普等中文数据库,搜集1997年1月至2017年6月关于对比神经内镜手术与显微手术治疗幕上高血压性脑出血的研究,使用Rev Man 5.1软件进行Meta分析。结果 共纳入3篇随机对照研究和10篇病例对照研究,1 163例中神经内镜组570例,显微手术组593例。Meta分析结果显示,神经内镜手术治疗幕上高血压性脑出血血肿清除率高,手术时间及住院时间短,术中失血少,病死率及并发症发生率低（P<0.05）。结论 神经内镜手术治疗幕上高血压性脑出血的安全性及有效性均高于显微手术。     

Prediction of mortality after evacuation of supratentorial intracerebral hemorrhage using NSQIP data

Spontaneous intracerebral hemorrhage (sICH) is associated with high rates of morbidity and mortality. Neurosurgical clot evacuation is controversial but often a life saving maneuver in the setting of severe mass effect and cerebral herniation. Outcomes from large multicenter databases are sparsely reported. Patients who underwent craniotomy for evacuation of a supratentorial sICH between 2006 and 2017 were systematically extracted from the American College of Surgeons National Surgical Quality Improvement Program Participant Use Files. Our primary outcomes of interest were 30-day mortality, non-routine discharge disposition, and extended length of stay ([eLOS], defined as the top quartile for the cohort). Individual binary logistic regression models were constructed to query the associations between pre- and perioperative variables and each outcome. A total of 751 patients met the inclusion criteria. The 30-day mortality rate was 23.3% and increased from 2011 to 2017 (pooled OR 2.060 [95% CI 1.437 – 2.953]). Older age, morbid obesity, preoperative mechanical ventilation, preoperative systemic inflammatory response syndrome (SIRS) or septic shock, and thrombocytopenia were associated with mortality. Older age, race, and preoperative mechanical ventilation were associated with non-routine discharge. Patients who were mechanically ventilated or were insulin-dependent diabetics had greater odds of experiencing eLOS. A formula for estimating 30-day mortality was developed and found to have a strong linear association with actual mortality rates (R² = 0.777, p = 0.002). Preoperative mechanical ventilation is a consistent predictor of poor outcomes following surgery for supratentorial sICH. Mortality is also influenced by older age, body habitus, SIRS, septic shock, and thrombocytopenia.     

微创穿刺引流术治疗幕上自发性脑出血的临床效果分析

目的对比分析微创穿刺引流术与内科保守法在治疗幕上自发性脑出血疗效的差异。 方法回顾性分析北京市顺义区医院神经外科自2014年1月至2017年6月收治的幕上自发性脑出血患者173例（出血量20~40 mL）的临床资料,分为微创穿刺引流术组和内科保守治疗组,分别统计2组的入院时出血量、入院时GCS评分、7 d后残余血肿量、7 d后GCS评分及3个月后GOS评分。 结果2组均出现死亡病例,但短期死亡率差异无统计学意义;治疗7 d后微创穿刺引流术组较内科保守治疗组残余血肿量、GCS评分差异有统计学意义（P<0.05）,3个月后微创穿刺引流术组GOS评分较内科保守治疗组差异有统计学意义（P<0.05）。 结论微创穿刺引流术在治疗中等量幕上自发性脑出血中较保守治疗存在优势,可以改善患者的神经功能,改善患者预后。