CT estimation of hematoma volume as a predictor of morbidity and mortality in patients with intracerebral hemorrhage Poster No.: C-2276 Congress: ECR 2015 Type: Scientific Exhibit Authors: A. Z. Aracki-Trenkic, D. A. Stojanov, S. Lukic, S. Stankovic; Nis/RS Keywords: CNS, CT, Diagnostic procedure, Hemorrhage DOI: 10.1594/ecr2015/C-2276 Any information contained in this pdf file is automatically generated from digital material submitted to EPOS by third parties in the form of scientific presentations. References to any names, marks, products, or services of third parties or hypertext links to thirdparty sites or information are provided solely as a convenience to you and do not in any way constitute or imply ECR's endorsement, sponsorship or recommendation of the third party, information, product or service. ECR is not responsible for the content of these pages and does not make any representations regarding the content or accuracy of material in this file. As per copyright regulations, any unauthorised use of the material or parts thereof as well as commercial reproduction or multiple distribution by any traditional or electronically based reproduction/publication method ist strictly prohibited. You agree to defend, indemnify, and hold ECR harmless from and against any and all claims, damages, costs, and expenses, including attorneys' fees, arising from or related to your use of these pages. Please note: Links to movies, ppt slideshows and any other multimedia files are not available in the pdf version of presentations. www.myesr.org Page 1 of 12
Aims and objectives CT is the imaging technique of choice to detect early intracerebral hemorrhage (ICH) with potential to provide quantitative hematoma data and implications for use as a predictor of clinical outcome. ICH is a non-traumatic hemorrhage from parenchymal blood vessels of the brain, which can spread to the ventricles (intraventricular haemorrhage, IVH) and subarachnoid space (subarachnoid hemorrhage, SAH). It represents the second most common form of stroke, occurring in 10-30% of all stroke insults and it is one of the major causes of morbidity and mortality, whereas in survivors it leads to significant disability. About 30-50% of patients with ICH die within 30 days of haemorrhage onset, about half of these deaths occur within the first 48 hours. The most common conditions that lead to the occurrence of ICH are arterial hypertension and cerebral amyloid angiopathy (CAA). These hematomas are primary ICH. Secondary hematomas occur as a consequence of vascular malformations, tumors, etc. On the basis of localization, intracerebral hemorrhages are categorized as deep, lobar, cerebellar and pontine (Fig.1). The most important predictors of outcome after an ICH include ICH volume, Glasgow Coma Scale Score (GCSS), preasence of IVH, and age. We aimed to evaluate the significance of hematoma volume, location, ventricular extension and clinical findings in prediction of morbidity and mortality in patients with acute ICH. Images for this section: Page 2 of 12
Fig. 1: ICH localization: a)deep, b)lobar, c)cerebellar, d)pontine Page 3 of 12
Methods and materials A single center retrospective study included 40 patients, mean age 77.5 years, 22 (55%) female and 18 (45%) male, with ICH. Patients with traumatic ICH, hemorrhage caused by tumors, SAH as well as hemorrhagic transformation of cerebral infarction were excluded from the study. In all patients, the period from the onset of symptoms to the initial CT scan was less than 24 hours. All patients underwent unenhanced CT scan at the Center for Radiology, Clinical Center of Nis, on MSCT performed by General Electric Bright speed scanner with a slice thickness of 5 mm in supratentorial regions and 2.5 mm in the infratentorial fossa and Toshiba Aquilion with a slice thickness of 3 mm of the hole brains. We analyzed hematoma volume, location and ventricular extension. The hematoma volume was estimated by the elliptical approximation method ABC/2, where A is defined as the largest axial diameter evident in any slice, B as the largest axial diameter perpendicular to A, and C represents the vertical diameter (the product of slice thickness and the number of slices in which the hemorrhage is visible) (Fig.2). Then, we did a comparison with clinical and laboratory parameters, obtained by reviewing the medical history of the patients. Neurological function at presentation was assessed by GCSS. Test results were statistically processed and analyzed using Wald test of maximum likelihood (Wald test) and linear regression analysis. The values for p <0.05 were considered statistically significant. Images for this section: Page 4 of 12
Fig. 2: Measurement of ICH volume Page 5 of 12
Results Twelve (30%) patients died within the first 3 days after admission. The volume of hematoma was significantly higher in deceased patients [49.7 (10.08-104.16) vs. 9.65 (4.65-27.23) cm 3 ; p<0.05]. There was a statistically significant correlation between mortality and hematoma volume # 30 cm 3 (p<0.05) (Tab.1). The risk of a lethal outcome is 6.75 times higher for patients with a GCSS of 3-8 (Fig.3), and 4.6 times for patients with IVH (Tab.2). The results also show that the values of arterial pressure cannot be considered as significant predictors of patients' outcome (Fig.4). Considering the localization, the largest number of patients with a lethal outcome had a lobar hemorrhage (58.3%), whereas in a slightly smaller number of patients there was a deep localization of hemorrhage (Tab.2). There was no statistically significant correlation between age and a lethal outcome (Fig.5), as well as between sex and a lethal outcome, although the odds ratio for the occurrence of a possible lethal outcome is 2.16 times higher in men (Fig.6). The volume of hematoma (p<0.05), presence of IVH (p<0.05), and initial GCSS (p<0.05) were significant predictors of mortality, whereas age, sex, systolic blood pressure, and location of hemorrhage were not. Images for this section: Page 6 of 12
Table 1: Radiological features-volume: a statistically significant correlation between mortality and hematoma volume # 30 cm3; IQR-interquartile range Fig. 3: Values of GCSS in groups with a different outcome: the risk of a lethal outcome is 6.75 times higher for patients with a GCSS (3-8). Table 2: Radiological features-localization: the risk of a lethal outcome is 4.6 times higher for patients with IVH Page 7 of 12
Fig. 4: The values of arterial pressure (AP) parameters in groups with a different outcome. Page 8 of 12
Fig. 5: Age distribution of patients in groups with a different outcome Page 9 of 12
Fig. 6: Gender distribution of patients in groups with a different outcome Page 10 of 12
Conclusion Hematoma volume greater than 30 cm 3, a low GCSS (3-8) and the presence of IVH are significant predictors of a high mortality rate. CT measuring of hematoma volume is powerful and easy-to-use predictor of clinical outcome in patients with ICH. Personal information References 1. van Asch CJ, Luitse MJ, Rinkel GJ et al. Incidence, case fatality, and functional outcome of intracerebral haemorrhage over time, according to age, sex, and ethnic origin: a systematic review and meta-analysis. Lancet Neurol 2010; 9(2):167-176. 2. Luki# S, Cojbasi# Z, Peri# Z, Miloševi# Z, Spasi# M, Pavlovi# V, Milojevi# A. Artificial neural networks based early clinical prediction of mortality after spontaneous intracerebral hemorrhage.acta Neurol Belg 2012; 112(4):375-382. 3. Divani AA, Majidi S, Luo X, Souslian FG, Zhang J, Abosch A, Tummala RP. The ABCs of accurate volumetric measurement of cerebral hematoma. Stroke 2011; 42(6):1569-1574. 4. Narayan SK, Sivaprasad P, Sushma S, Sahoo RK, Dutta TK. Etiology and outcome determinants of intracerebral hemorrhage in a south Indian population, A hospital-based study. Ann Indian Acad Neurol 2012; 15(4): 263-266. 5. Kuramatsu JB, Sauer R, Mauer C, Lücking H, Kloska SP, Kiphuth IC, Staykov D, Köhrmann M, Huttner HB. Correlation of age and hematoma volume in patients with spontaneous lobar intracerebral hemorrhage. J Neurol Neurosurg Psychiatry 2011; 82(2):144-149. 6. Beslow LA, Ichord RN, Kasner SE, Mullen MT, Licht DJ, Smith SE, Storm PB, Jordan LC, Messé SR. ABC/XYZ estimates intracerebral hemorrhage volume as a percent of total brain volume in children. Stroke 2010; 41(4):691-694. 7. Sturgeon JD, Folsom AR, Longstreth WT Jr, Shahar E, Rosamond WD, Cushman M. Risk factors for intracerebral hemorrhage in a pooled prospective study. Stroke 2007; 38(10):2718-2725. Page 11 of 12
8. Ovesen C, Havsteen I, Rosenbaum S, Charistensen H. Prediction and observation of post-admission hematoma expansion in patients with intracerebral hemorrhage. Front Neurol 2014;5:186. 9. Poon MT, Fonville AF, Al-Shahi Salman R. Long-term prognosis after intracerebral haemorrhage: systematic review and meta-analysis. J Neurol Neurosurg Psychiatry 2014; 85(6):660-667. 10. LoPresti MA, Bruce SS, Camacho E, Kunchala S, Dubois BG, Bruce E, Appelboom G, Connolly ES Jr. Hematoma volume as the major determinant of outcomes after intracerebral hemorrhage. J Neurol Sci 2014;345(1-2):3-7. Page 12 of 12