Outcome of Primary Intracerebral Hemorrhage: Study in a Tertiary Care Center in Western Nepal

To the Editor: Hemphill et al1 present an analysis of 161 patients carried out to determine a reliable grading score for the prediction of 30-day mortality in patients following a spontaneous intracerebral hemorrhage (ICH). Factors independently associated with 30-day mortality were Glasgow Coma Score, age >80 years, ICH volume, ICH of infratentorial position, and presence of intraventricular hemorrhage. A score based on these variables was assigned to each patient. All patients within their dataset with an ICH score of 0 survived, and all patients with a score of 5 (highest score assigned) died. Hemphill et al restricted the testing of the scoring system to the data that produced it. We were interested in whether this scoring system could be of similar predictive value in patients treated in our unit. From 1994 to date, all patients admitted following a spontaneous supratentorial ICH have been recorded on a prospective database and followed up to 6 months after ictus. Although we do not have specific mortality at 30 days, we have recorded outcome at neurosurgical discharge, which was on average 2 to 4 weeks after ictus. Up to August 1999, 440 …

BackgroundDue to the high morbidity and mortality of primary intracerebral hemorrhage (ICH), several non-contrast computed tomography (NCCT) imaging markers were proposed to determine the prognosis of affected patients. We prospectively evaluated the predictive accuracy of certain imaging features and established a predictive model composed of highly relevant imaging and clinical features to identify the 3-month functional outcome in primary ICH patientsMethodsPatients admitted for primary ICH to a tertiary care center (Al-Zahra Hospital, Isfahan, Iran) were prospectively included from September 2021 to October 2023. Inclusion criteria were defined as: Patients aged ≥18 years with primary or spontaneous ICH confirmed on NCCT at the time of admission. The baseline NCCT was conducted in the early stage of ICH (within 6 hours from symptom onset). The initial NCCT images were obtained within 6 hours from symptom onset. After 3 months, functional outcome of patients was assessed using the modified Rankin Scale (mRS); with mRS ≥3 as poor prognosis and mRS ≤2 as favorable prognosis. The Chi-squared and Logistic regression tests were used for determining the association between clinical and imaging features in differentiating patients’ prognosis. Machine learning algorithm [support vector machine (SVM)] was also used to determine the importance rate of each relevant imaging sign in predicting prognosis.ResultsA total of 203 primary ICH patients were included, among which 119 patients (58.6%) had unfavorable prognosis at 3 months. Age, diastolic blood pressure, and Glasgow Coma Scale (GCS) score at admission were significantly associated with prognosis. Among imaging features, hemorrhage volume [95% confidence interval (CI): 0.972–0.991, P<0.001], the presence of midline shift (95% CI: 2.038–7.911, P<0.001), blend sign (95% CI: 1.081–3.760, P=0.026), satellite sign (95% CI: 1.451–4.764, P=0.001), and black hole sign (95% CI: 2.262–12.714, P<0.001) were significantly different among 2 groups. SVM algorithm showed hemorrhage volume the most important prognostic imaging feature (importance rate: 100%), along with black hole (63.1%), midline shift (54%), satellite (20.4%), and blend sign (15.6%); with decreasing order of importance.ConclusionsUsing certain radiological and clinical features, we established a model with considerable prognostication in management of patients with primary ICH in emergency departments.

Introduction: Spontaneous intracerebral hemorrhage (ICH) comprises 10-15% of all strokes. Aim: To assess the relationship between the haematoma volume and early surgical outcome of patients with spontaneous primary supratentorial intracerebral hemorrhage by Glasgow Outcome Scale at the 30th post ictus day. Methods: This prospective study was done from April 2014 to March 2016 in Department of Neurosurgery, Combined Military Hospital (CMH), Dhaka. Forty seven cases were selected by set down criteria. Glasgow Coma Scale (GCS) score was recorded on admission, haematoma volume was calculated from the CT scan immediately after admission by Modified Ellipsoid Method and the surgical outcome of ICH patients was determined by Glasgow Outcome Scale (GOS) by face to face interview or by structured interview over phone at their 30th post ictus day. Correlation between the haematoma volume and the surgical outcome of ICH was done by Chi-square test. Again the correlations of three variables (haematoma volume, admission GCS and ICH score) with GOS was compared by Spearman’s correlation coefficient test. Results: Patients with haematoma volume of 30cc or more were found to have worst outcome. Conclusion: Relationship between haematoma volume and surgical outcome was found statistically very significant. Risk stratification of the patients with spontaneous primary supratentorial intracerebral hematomas basing on hematoma volume may be used to improve standardization of treatment protocols and clinical research studies. JAFMC Bangladesh. Vol 15, No 1 (June) 2020: 46-49

Predicting 30-Day Case Fatality of Primary Inoperable Intracerebral Hemorrhage Based on Findings at the Emergency Department

Introduction: Sporadic brain arteriovenous malformations (BAVMs) are rare vascular lesions that are a major cause of intracerebral hemorrhage (ICH) in younger persons. Genetic risk factors for ICH in BAVM have not been firmly established. Late-onset primary ICH is more common, with several candidate loci reported. It is not known whether genetic variants associated with primary ICH are also associated with BAVM ICH. Methods: We performed a case-control study including 138 Caucasian cases with BAVM ICH and 504 healthy Caucasian controls. We tested 8 candidate variants reported for primary ICH in or near 7 genes ( ACE , APOE , COL4A2 , MTHFR , PMF1 , SLC25A44 , and TRHDE) . Genotypes were extracted from existing Affymetrix genome-wide array data or from PCR-based assays for 3 variants. Logistic regression was used to determine whether candidate variants (or, when unavailable, proxy variants in high linkage disequilibrium) were associated with BAVM ICH, assuming an additive genetic model and adjusting for age and sex. We considered variants statistically significant if P&lt;0.05 and in the same direction of association (risk allele) as reported for primary ICH. Results: No statistically significant associations were observed between BAVM ICH and genetic variants implicated in primary ICH. The strongest finding was for rs9521733 in COL4A2 (OR=1.26, P=0.13). Further evaluation of the COL4A2 +/- 5kb locus revealed nine variants associated with BAVM ICH; the strongest association was with rs9521692 (OR=0.49, P=0.001). Conclusions: Specific candidate variants implicated in primary ICH were not significantly associated with BAVM ICH, suggesting that genetic risk factors may differ between primary and BAVM ICH. The COL4A2 locus may contain additional variants associated with BAVM ICH but will require larger studies to validate findings.

The purpose of this community-based study was first to estimate the incidence rates of primary intracerebral hemorrhage (ICH) and aneurysmal subarachnoid hemorrhage (SAH) in Izumo City, Japan, and second to investigate whether there were seasonal and diurnal periodicities in their onset. During 1991 through 1996, 267 patients with primary ICH and 123 with aneurysmal SAH were treated in Izumo City. The crude and the age- and sex-adjusted annual incidence rates per 100,000 population for all ages were 52 and 48 for ICH and 24 and 23 for SAH, respectively. These incidence rates were higher than those previously published for any other geographical region. The incidence rates of both ICH and SAH increased almost linearly with age. For ICH, a significant seasonal pattern was observed in men and in patients younger than 65 years, with a peak in winter and a trough in summer. However, no significant seasonal fluctuation was found in women or in individuals aged 65 years or older. There was no significant seasonal periodicity for SAH, even when patients were analyzed according to sex and age. Diurnal variations in the onset of both ICH and SAH were significant (except in men with SAH), with a nadir between midnight and 6:00 a.m. The actual incidence rates of both primary ICH and aneurysmal SAH seem to be much higher than have been reported so far. In addition, the data indicate the existence of seasonal periodicity for men and younger patients with ICH, and that the risk of both ICH and SAH is lower during nighttime.

Background: Patient admitted with hemorrhagic stroke, particularly primary intracerebral hemorrhage (ICH) may develop different form of complications during their hospital stay. Objective: The objectives of the study were to find out the different complications of primary intracerebral hemorrhage among admitted patient and their effect on hospital stay and outcome. Methodology: This was a hospital based observational follow up study conducted at National Institute of Neurosciences and Hospital, Dhaka, Bangladesh in a period of 18 months (from February 2021 to August 2022). Total 570 (504 finally analyzed) primary intracerebral hemorrhage patient who admitted within 48 hours of onset of stroke were enrolled consecutively by purposive sampling method. Routine biochemical, hematological tests and computed tomography scan were done to all participants. All patients were followed up every day during hospital stay and any complication developed were noted. Patients’ outcome (discharge / death) was recorded. Results: This study revealed that mean (SD) age of participants were 59.1 (±13.4) years with majority male 262(52.0%). Electrolyte imbalance (hyponatremia) was the commonest complication found in 212 (42.1%) of patient followed by hematoma expansion 22.6%, hydrocephalus 15.5%, aspiration pneumonia 11.1%, convulsive seizure 10.0%, urinary tract infection and pressure sore both are 3.6%. Deep vein thrombosis was found in1.2%. Hypertension was the commonest risk factor (93.0%) followed by Diabetes mellitus (28.1%). Older (&gt;50 years) age (OR: 0.53; 95% CI: 0.36-0.80; p = 0.002), urban dwellers (OR: 1.56; 95% CI: 1.04-2.27; p =0.013) and poor (&lt;9.0) admission Glasgow Coma Scale (GCS) were associated with higher rate of complications (p = 0.001). Presence of Hydrocephalus (OR:0.66; 95% CI: 0.48-0.90; p = 0.001), Aspiration pneumonia (OR:0.53; 95% CI:0.99-0.73; p=0.0001), and convulsive seizure (OR: 0.63; 95% CI: 0.44-0.89; p=0.015) were associated with higher mortality. During hospital stay different form of complications developed in 338(67.0%) of patients and 356(70.6%) of patient discharged to home successfully. Different form of complication leads to longer hospital stay (p = 0.001) and higher mortality rate (p = 0.001) compared to those who developed no complication. Conclusion: Hyponatremia is the most common complication followed by hematoma expansion and hydrocephalus. Longer hospital stays and higher incidence of mortality was observed in patients who developed in-hospital complication after the stroke event. Journal of National Institute of Neurosciences Bangladesh, July 2024;10(2):87-93

Background: Many patients with acute intracerebral hemorrhage (ICH) clinically deteriorate between the time of paramedic assessment in the field and Emergency Department (ED) arrival. Cohort studies have used decline in the Glasgow Coma Scale (GCS) score from prehospital assessment to ED assessment to identify patients with early clinical deterioration (ECD), but the degree of GCS decline that best correlates with poor final functional outcome has not been delineated. Methods: Consecutive cases with primary ICH on initial imaging were identified from the Field Administration of Stroke Therapy-Magnesium (FAST-MAG) phase 3 clinical trial of intravenous magnesium vs. placebo. All subjects underwent GCS evaluation in the field by paramedics within 2 hours from symptom onset, and again in the ED by study research coordinators. Poor outcome was defined as a modified Rankin Scale of 4 to 6 at 3-months. Deteriorations in GCS from one point through 10 points were evaluated in relation to poor final functional outcome through receiver operating characteristic (ROC) and area under curve (AUC). Results: Among the 369 (22%) patients with primary ICH, mean [SD] age was 65 [13] years, 34% were women, 79% White race, 34% Hispanic ethnicity, 80% had pre-existing hypertension, 20% diabetes, 18% smokers. Paramedic on scene time was a median [IQR] of 23 [15-40] minutes from last known well and time of GCS assessment in the ED was a median of 140 [119-175] minutes after last known well. Glasgow Coma Scale scores were mean 14.4 (SD 1.5) and median 15 [15-15] in the field and mean 12.1 (SD 4.5) and median 15 [10-15] in the ED, and 59% had a poor outcome at 3 months. Frequency of deteriorations on the GCS included: ≥1 point - 38%, ≥2points - 31%, ≥3 points - 27%, ≥5 points - 21%, and ≥10 points - 13%. The best performing cutpoints on the the ROC for predicting poor final outcome were ECD definitions of GCS decline of &gt;=1: sensitivity 54% and specificity 85%; and GCS decline of &gt;=2: sensitivity 46% and specificity 91%. The c statistic for ECD defined as a 1 point GCS decline as a predictor of poor final outcome was 0.71 (95%CI 0.66, 0.76). Conclusions: Early clinical deterioration of GCS is common and its presence may be helpful in predicting poor outcome.

P104 Introduction: Several studies have shown the detrimental effect of fever on brain injury. Recently, the incidence and prognostic significance of fever after intracerebral hemorrhage (ICH) was reported. The underlying cause of fever remains speculative. We present data on fever after ICH, volume of ICH, 3rd ventricular shift, and patient outcome. Methods: Data from 61 patients with ICH were collected prospectively from August 1999 to April 2000 including age, admission Glasgow Coma Scale (GCS) score, ICH volume, 3rd ventricular shift, maximum temperature (Tmax) and fever (T >38.5 °C) at 24, 48, 72 and 96 hours. Patients were screened for common causes of fever. Outcome was determined by mortality at discharge and National Institute of Health Stroke Scale (NIHSS), modified Rankin Scale (mRS), and Barthel Index (BI) at 3 months. Spearman correlation coefficient, Mann-Whitney test, and logistic regression were used to assess relationships. No adjustment was made to significance criterion for multiple comparisons over time. Results: The average age was 65 ± 16 years. The mean admission GCS score was 8.8 ± 4.8. The mean ICH volume was 48.9 ± 52.4 cc. The mean 3rd ventricular shift was 3.6 ± 4.5 mm. The mean Tmax was 38.0 ± 0.9°C. There was a correlation between ICH volume and Tmax at 24 hours (p= 0.04) and at 72 hours (p= 0.03) and fever at 24 hours (p=0.039) and at 72 hours (p=0.036). Tmax at 72 hours correlated with 3rd ventricular shift (p= 0.01). Patients with 3rd ventricular shift > 1 mm were more likely to have a fever within the first 72 hours (p= 0.049). Multivariate logistic regression analysis showed no confounding effects from intubation status, presence of infection (positive blood, sputum, or urine culture/urinalysis), abnormal chest x-ray, or DVT. Fever at 72 hours was associated with a higher mortality at discharge (p=0.046). Fever within 72 hours was associated with a trend of a worse NIHSS score (p=0.06) at 3 months but no worse outcome by BI or mRS score at 3 months. Conclusion: Fever after ICH correlates with 3rd ventricular shift and ICH volume. The underlying mechanism may be hypothalamic dysfunction. Fever may be associated with a worse outcome but more studies are needed.

Surgical Evacuation of Intracerebral Hemorrhage: The Potential Importance of Timing.

Early mortality in spontaneous supratentorial intracerebral haemorrhage

P96 Introduction: The National Institutes of Health Stroke Scale (NIHSS) score has been correlated with outcome in ischemic strokes but not intracerebral hemorrhage (ICH). We sought to validate the use of NIHSS in ICH patients by comparing it to outcomes using the Glasgow Coma Scale (GCS) score and volume of ICH. Use of the NIHSS will allow clinicians to follow the outcome of more specific parameters which may be used in clinical trials. Methods: We prospectively followed 61 ICH patients admitted to the Cleveland Clinic within 24 hours of onset. Age, NIHSS, GSC, Barthel index (BI), modified Rankin scale (mRs) were obtained on admission, discharge and at 3 months. An ICH volume was calculated using the AxBxC/2 method from the admission CT scan. Correlation was assessed using the Spearman correlation coefficient (SCC) and 95% CI, with a worst score given to deaths. Patients with a history of ischemic stroke were excluded. The maximum NIHSS for coma was 35. Results: The average age of the patients was 66 years old with 35 females and 26 males. On admission, the average NIHSS was 21 for all patients, 28 for those who died at 3 months and 10 for 3-month survivors. The average NIHSS for 3- month survivors was 3. On admission, the average GCS score was 9 for all patients, 7 for those who died and 12 for 3-month survivors. The average GCS of 3-month survivors was 15. The average BI and mRs were 98 and 0 on admission and 86 and 1 at 3 months for survivors. On admission, the average ICH volume was 49 cc for all patients, 66 cc for those who died at 3 months and 24 cc for 3-month survivors. For admission NIHSS of 18 or greater the 3-month mortality was 82% vs 9% for those with NIHSS &lt; 18 (P&lt;0.001). Admission NIHSS correlated strongly with admission GCS (SCC=0.82, CI 0.68, 0.97) and the two scores correlated similarly with volume (SCC=0.45, CI 0.22, 0.68; GCS SCC=0.40,CI 0.16, 0.63). Impressively, admission NIHSS correlated with the 3 month NIHSS (SCC=0.72, CI 0.53, 0.91), 3-month BI (SCC=0.74, CI 0.55, 0.92), 3-month mRs (SCC=0.72, CI 0.53, 0.91) significantly better than did the GCS (SCC=0.57,0.57 and 0.59 for the NIHSS, BI, and mRs, respectively). Conclusion: The admission NIHSS predicts 3-month survival in ICH patients better than the GCS.

The purpose of this study was to assess the overall management and surgical outcome of primary intracerebral hemorrhage (ICH) and aneurysmal subarachnoid hemorrhage (SAH) among the 85,000 residents of Izumo City, Japan. During 1991 through 1996, 267 patients with ICH and 123 with SAH were treated in Izumo. Of the 267 patients with ICH, 25 underwent hematoma removal by open craniotomy or suboccipital craniectomy and 34 underwent stereotactic evacuation of the hematoma, whereas aneurysm clipping was performed in 71 of the 123 patients with SAH; operability rates were thus 22% for ICH and 58% for SAH (p < 0.0001). The overall 30-day survival rates were 86% for ICH and 66% for SAH (p < 0.0001) and the 2-year survival rates were 73% and 62% (p = 0.0207), respectively. In patients who underwent surgery, 30-day and 2-year survival rates were 93% for ICH and 100% for SAH (p = 0.0262), and 75% for ICH and 97% for SAH (p = 0.0002), respectively. In patients with ICH, the most important predictors of 30-day case-fatality rates were the volume of the hematoma, the Glasgow Coma Scale (GCS) score, rebleeding, and midline shifting, whereas those for 2-year survival were the GCS score, age, rebleeding, and hematoma volume. In patients with SAH, the most important determinants of 30-day case-fatality rates were the GCS score and age, whereas only the GCS score had a significant impact on 2-year survival. The overall survival rates for patients with ICH or SAH in Izumo were more favorable than those in previously published epidemiological studies. However, despite improved surgical results, the overall management of ICH and SAH still produced an unsatisfactory outcome, mainly because of primary brain damage.

Aim: Radiomics refers to automatic extraction of numerous quantitative features from medical images to supplement visual assessment. Machine-learning algorithms provide a suitable statistical methodology for devising predictive classifiers based on large radiomics datasets. We aimed to predict intracerebral hemorrhage (ICH) outcome by applying machine-learning classifiers to both clinical data and hematoma radiomics features. Methods: Patients enrolled in the Yale Longitudinal Study of ICH were included if they had (1) spontaneous supratentorial ICH, (2) baseline CT scan, (3) known admission Glasgow Coma Scale (GCS), and (4) 3-month modified Rankin Scale (mRS). A total of 1134 radiomics features related to the intensity, shape, texture, and waveform were extracted from manually segmented ICH lesions on baseline CT. Clinical variables were patients’ age, gender, GCS, presence of intraventricular hemorrhage, and thalamic ICH. We calculated the averaged receiver operating characteristics (ROC) area under curve (AUC) in outcome prediction among 100 repeats of 5-fold cross-validation (x500 iterations) for different combinations of feature selection and machine-learning algorithms. Results: A total of 119 ICH patients were included, of whom 60 had poor outcome (mRS ≥4). Among different combinations, lasso regression feature selection and partial least square (PLS) classification model yielded the highest accuracy in outcome prediction (Figure), with an averaged (95% confidence interval) ROC AUC of 0.86 (0.83 - 0.89) using clinical variables “only”, versus 0.92 (0.89 - 0.95) using combination of clinical variables and 54 radiomics features selected by lasso regression. Among radiomics features selected by lasso regression, ICH lesion flatness had the highest variable importance and was the only shape feature selected. Conclusion: Addition of ICH lesion radiomics to clinical variables using machine-learning models can improve outcome prediction.

Background and objectiveThe presence of active contrast extravasation during CT angiography, the spot sign, is a potent predictor of in-hospital mortality in patients with primary intracerebral hemorrhage (ICH). However, its...