Abstract
Background and Purpose: Intracerebral hemorrhage (ICH) requires rapid decision making to decrease morbidity and mortality although time frame and optimal therapy are still ill defined. Ideally, specialized neurologists, neurosurgeons, and (neuro-) radiologists who know the patient's clinical status and their cerebral computed tomography imaging (cCT) make a joint decision on the clinical management. However, in telestroke networks, a shift toward cCT imaging criteria used for decision making can be observed for practical reasons. Here we investigated the “reverse correlation” from cCT imaging to the actual clinical presentation as evaluated by the Glasgow Coma Scale (GCS) and the National Institutes of Health Stroke Scale (NIHSS).Methods: CCT images and basic information (age, sex, and time of onset) of 50 patients with hypertensive and lobar ICH were presented to 14 experienced neurologists and 15 neurosurgeons. Based on this information, the NIHSS and GCS scores were estimated for each patient. The differences between the actual GCS and NIHSS scores and the cCT-imaging-based estimated scores were plotted in a bland-Altman plot.Results: The average estimated GCS score mainly based on cCT imaging was 12. 4 ± 2.8 (actual value: 13.0 ± 2.5; p = 0.100), the estimated NIHSS score was 13.9 ± 9.1 (actual value: 10.8 ± 7.3; p < 0.001). Thus, in cCT-imaging-based evaluation, the neurological status of patients especially employing the NIHSS was estimated poorer, particularly in patients with lobar ICH. “Reverse clinical” evaluation based on cCT-imaging alone may increase the rate of intubation and secondary transferal and neurosurgical treatment. Telestroke networks should consider both, videoassessment of the actual clinical picture and cCT-imaging findings to make appropriate acute treatment decisions.
Highlights
Spontaneous intracerebral hemorrhage (ICH) accounts for 10 to 15% of all strokes in Western populations, and the case fatality ranges between 40 and 55% [1]
Plotting the difference between the actual Glasgow Coma Scale (GCS) and National Institutes of Health Stroke Scale (NIHSS) scores and the imaging-based estimated scores, we found that— on average—the GCS score was estimated lower than the actual GCS score which was not statistically significant
The NIHSS score estimated on the basis of the cerebral computed tomography imaging (cCT)-imaging findings correlated better with the actual values in patients with hypertensive ICH than in patients with lobar ICH (Figure 1)
Summary
Spontaneous intracerebral hemorrhage (ICH) accounts for 10 to 15% of all strokes in Western populations, and the case fatality ranges between 40 and 55% [1]. Non-specialized neurological examinations are increasingly followed by reading a patient’s cerebral computed tomography imaging(cCT) via teleradiology consultation. In the case of ischemic stroke, the decision to conduct thrombolysis or even endovascular treatment basically relies on the NIHSS score, a cCT scan excluding ICH, an appropriate time window and, the status of the arteries leading to the brain [2]. In acute stroke therapy telemedicine is established in Germany in networks like the TeleMedical Project for integrative Stroke Care (TEMPiS) in Bavaria, Germany, since 15 years and has significantly increased the rate of treated strokes and transient ischemic attacks as well as decreased the onset-to-treatment and door-to-needle time in clinically underserved areas [5]. Intracerebral hemorrhage (ICH) requires rapid decision making to decrease morbidity and mortality time frame and optimal therapy are still ill defined. We investigated the “reverse correlation” from cCT imaging to the actual clinical presentation as evaluated by the Glasgow Coma Scale (GCS) and the National Institutes of Health Stroke Scale (NIHSS)
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