Intraventricular Extension Research Articles

Comparing Outcomes of Patients With Idiopathic Subarachnoid Hemorrhage by Stratifying Perimesencephalic Bleeding Patterns

Background: To determine the clinical outcomes of perimesencephalic subarachnoid hemorrhages based on the computed tomography (CT) bleeding patterns. Methods: This retrospective cohort study included: (1) patients (≥18 years) admitted to a comprehensive stroke center (January 2015-May 2018), (2) with angiography-negative, nontraumatic subarachnoid hemorrhage in a perimesencephalic or diffuse bleeding pattern, and (3) had CT imaging performed in ≤ 72 hours of symptom onset. Patients were stratified by location of bleeding on CT: Peri-1: focal prepontine hemorrhage; Peri-2: prepontine with suprasellar cistern +/− intraventricular extension; and diffuse. Results: Of the 39 patients included, 13 were Peri-1, 11 were Peri-2, and 15 were diffuse. The majority were male (n = 26), with a mean (standard deviation) age of 55.3 (11.3) years, who often presented with headache (n = 37) and nausea (n = 28). Overall, patients in Peri-1 were significantly less likely to have hydrocephalus compared to Peri-2 and dSAH (P= .003), and 4 patients required an external ventricular drain. Five patients developed symptomatic vasospasm. Patients in Peri-1, compared to Peri-2 and diffuse, had a significantly shorter median neuro critical care unit length of stay (LOS) and hospital LOS. Most patients (n = 35) had a discharge modified Rankin Score between 0 and 2 with no significant differences found between groups. Conclusion: These data suggest that patients with the best clinical course were those in Peri-1, followed by Peri-2, and then diffuse. Because these patients often present with similar clinical signs, stratifying by hemorrhage pattern may help clinicians predict which patients with perimesencephalic subarachnoid hemorrhage develop complications.

Use of CT-Scan for Predicting Mortality of Acute Intracerebral Haemorrhagic Stroke within 7 and 28 Days

Background: Recognition of factors affecting morbidity and mortality of a disease helps in the proper management of a disease. CT scan of Brain is an essential investigation for all stroke patients. Identifying different characteristics of the CT findings of stroke patients which affect morbidity and mortality will help in the specific management of stroke patients. Thus this study was done to identify such factors from CT scan of Brain which will help in the proper management of stroke patients.
 Objectives: The aim of this present study was to determine the 7th and 28th days’ mortality rate of acute intracerebral hemorrhagic stroke and to determine the predictors of mortality.
 Methodology: Consecutive CT scan proven stroke patients following ICH were studied in the department of Radiology & Imaging at Rajshahi Medical College, Rajshahi, Bangladesh in collaboration with the Department of Neurology of Rajshahi Medical College, Rajshahi from January 2012 to December 2013. Site, size and volume of haematoma, midline shift, pineal gland displacement, hydrocephalus and intraventricular extension of haemorrhage were correlated with the mortality within 7th and 28th days of acute stroke. Risk factors like hypertension, smoking, diabetes and alcoholism were also recorded.
 Result: Ninety-nine consecutive CT scan proven stroke patients following ICH were studied. The 28-day mortality of intracerebral hemorrhage was 44.44% and it was 29.30% within the first 7 days of onset. Maximum number of death occurred in brainstem haemorrhage (75%), initial haematoma volume 61 to 80 ml (89.47%), >80 ml (91.7%), pineal gland displacement >3mm (79.5%), septum pellucidum displacement >5 mm (72.4%), ventricular extension (88.57%), and hydrocephalus (76.74%).
 Conclusion: The present study shows that deaths within 7th and 28th day of acute haemorrhagic stroke are correlated with the initial CT findings which could be regarded as a good predictor of mortality.
 Journal of National Institute of Neurosciences Bangladesh, 2019;5(1): 42-46

Primary Thalamic Haemorrhage – Clinical Profile and Prognostic Predictors from a Series of 117 Cases

Background: Studies on isolated primary thalamic hematomas are limited. This study analyses 117 patients with primary thalamic hematomas and attempts to identify the various prognostic factors influencing the outcome. Materials and Methods: A retrospective analysis of the case records was carried out to analyse the following prognostic parameters - GCS on admission, comorbidities like systemic hypertension and diabetes mellitus, side and site of hematoma, volume of the clot, presence of intraventricular haemorrhage (IVH), development of hydrocephalus, and the role of surgical intervention. A Chi-square test was used to compare categorical variables, and Student t-test and Mann Whitney test were applied to calculate the P-value for continuous variables for univariate statistics. Binary Logistic regression was used for multivariate analysis. Results and Discussion: This study group comprised 67 men and 50 women with a mean age of 62.05±11.71years. The mean GCS on admission in the study group was 11.56±3.28. The mean clot volume was 13±9.5ml and majority (89.74%) of the patients had clots with a volume of less than 20 ml. An intraventricular extension was noted in 98 patients. Craniotomy and surgical evacuation were performed in only two patients while external ventricular drainage with urokinase instillation was performed in 23 patients. Of the 117 patients, 3 had anterior thalamic clots, 19 had posterior thalamic clots, 13 had medial clots, 53 had lateral thalamic bleeds and 29 had global clots. The overall three-month mortality with thalamic bleeds was 28.2%. At the end of three months, 59 patients (50.42%) had a favourable outcome (mRS < 4). On univariate analysis, male sex, dominant side bleed, preoperative GCS of less than 8 (p < 0.001), presence of hydrocephalus (p< 0.004) and a need for EVD (p<0.012) were found to be significantly associated with mortality and poor outcome. Similarly, clot volume less than 20 ml, right-sided bleed and surgical evacuation were associated with a favourable outcome (p < 0.001). On multiple logistic regression, age, volume of hematoma and GCS on admission were predictors for mortality and volume of hematoma was a significant predictor of poor outcome. Conclusion: Thalamic hematomas include a spectrum of clots of varying dimensions at different locations and the outcomes need not be uniformly poor. Isolated thalamic hemorrhages are generally small in volume preferentially located in the lateral thalamus. Patients with right-sided bleeds and small clot volume perform well. Male sex, poor GCS on admission, clot volume above 20 ml, intraventricular extension and a need for external ventricular drainage adversely influence the outcome.

Surgical management for large hypertensive basal ganglionic hemorrhage: single center experience

PurposeWe aim to summarize the role of surgical treatment of spontaneous basal ganglionic hemorrhage based on prospective analysis of our patients and determine the factors that favor the outcome.MethodsA prospective analysis was done of 66 patients from January 2014 to June 2017. Inclusion criteria for the patients in this study were as follows: patients aged between 15 and 60 years; CT scan showed basal ganglionic hematoma with or without intraventricular extension within 24 h post ictus; hematoma volume was Glasgow Coma Scale (GCS) scores ≥ 5, and stable vital signs. Surgical techniques are open craniotomy.ResultsA total of 66 patients underwent surgical intervention consisting of 47 (71.2%) men and 19 (28.8%) women. Their age varies from 15 to 60 with mean age ± SD (range) 46.53 ± 13.24 (18.0–60.0). According to GCS, patients were categorized into three groups: GCS 5–8, 21 (31.8%) patients; GCS 9–12, 30 (45.5%) patients; and GCS 13–15, 15 (22.7%) patients. The favorable outcome group was slightly younger (p value 0.050*). Also, the volume and extension of hematoma into the ventricular system, hydrocephalic dilatation, and midline shift greater than 5 mm had a significantly worse outcome with statistically significant difference.ConclusionThe early surgical management with removal of the hematoma led to dramatic reduction of ICP and improved the prognosis. Patients with signs of brain herniation, a midline shift > 5 mm, hydrocephalic dilatation, ventricular hemorrhage, and a depressed level of consciousness have a poor prognosis.Trial registration17300234 registered 9/2018

Infratentorial Intracerebral Hemorrhage.

Background and Purpose- Infratentorial intracerebral hemorrhage (ICH) has a poor outcome but is rarely analyzed by cerebellar versus brain stem location. We evaluated this relationship and clinical outcomes among participants of the INTERACT 1 and 2 (Intensive Blood Pressure Reduction in Acute Cerebral Hemorrhage Trials). Methods- Participants with brain stem and cerebellar ICH were compared. Logistic regression models were used to compare outcomes of death or major disability and quality of life. Results- Of 195 included patients, 92 (47%) and 103 (53%) had brain stem and cerebellar ICH, respectively. Patients with brain stem ICH were younger (mean [SD] age, 59±13 versus 70±11 years), less female (28.3% versus 50.5%), with higher admission National Institutes of Health Stroke Scale scores (median [interquartile range], 6 [4-10) versus 3 [2-8]), less prior ICH (3% versus 17%), smaller ICH volumes (1.6 mL [1.0-2.8 mL] versus 5.1 mL [2.6-10.7 mL]), and less intraventricular extension (3% versus 39%) than those with cerebellar ICH. Brain stem ICH had higher mortality (odds ratio, 37.1; 95% CI, 1.99-692.27) and worse scores in the European Quality of Life Scale (EQ-5D) pain domain (odds ratio, 3.36; 95% CI, 1.38-8.20). Conclusions- Cerebellar and brain stem ICH differ in their clinical characteristics and prognosis, with the latter being associated with higher case fatality and worse EQ-5D scores in the pain domain. Clinical Trial Registration- URL: https://www.clinicaltrials.gov . Unique identifiers: NCT00226096 and NCT00716079.

Relationship Between Changes in Prehospital Blood Pressure and Early Neurological Deterioration in Spontaneous Intracerebral Hemorrhage.

The aim of this study was to explore the relationship between changes in prehospital blood pressure (BP) and the incidence of early neurological deterioration (END) after spontaneous intracerebral hemorrhage (SICH) in patients who arrive at the emergency department (ED) with a normal Glasgow Coma Scale (GCS) score. Records of consecutive adults with SICH transported by ambulance and treated in our ED from January 2015 to December 2017 were retrospectively reviewed. The study cohort included all patients with SICH occurring within the previous 6 hr who had a normal GCS score on ED arrival. Detailed information was retrieved from our hospital's intracerebral hemorrhage databank and then cross-checked in the medical and nursing charts to confirm completeness and accuracy. Early neurological deterioration was defined as a decrease of 2 or more points in the GCS score within 6 hr after ED arrival. The change in prehospital BP was defined as the BP on ED arrival minus the initial on-scene BP. An association between a change in prehospital BP and the occurrence of END was assessed by univariate and multivariate analyses (multiple logistic regression analysis). Of the 168 patients evaluated, 36 (21.4%) developed END. Factors associated with END on univariate analysis were regular antiplatelet agent use, shorter elapsed time, on-scene systolic blood pressure (SBP), prehospital SBP increase of 15 mmHg or more, intraventricular extension of the hematoma, and the presence of 3 or more noncontrast computed tomographic signs of hematoma expansion. After adjusting for other covariates, an increase in prehospital SBP of 15 mmHg or more was significantly associated with a higher risk of END. In patients with SICH who arrive at the ED with a normal GCS score, an increase in the prehospital SBP of more than 15 mmHg is associated with a higher incidence of END.

Combination Intracerebral Hemorrhage-Graeb Score Improves Prediction of Outcome in Spontaneous Intracerebral Hemorrhage

Intraventricular extension of intracerebral hemorrhage (IVH) is an poor independent outcome predictor in spontaneous intracerebral hemorrhage (ICH). IVH volume important in prediction of outcome and management; however, it is hard to measure routinely. Large IVH volume and increased number of affected ventricles have been associated with worse prognosis. Easy-to-use ICH scoring systems inform physicians of the severity and help to decide the course of management. ICH scoring system used to translate the severity into a score, allows quantification of severity, to predict outcome and clinical research. Graeb score can estimate the probability of survival in IVH volume. Purpose of this study is to combine original ICH score and Graeb score, to predict outcome in patients spontaneous ICH and determined the combination would improve the prediction.This prospective observational study of 88 patients who demonstrated spontaneous ICH with and without IVH on initial brain computed tomography (CT) were enrolled at Sanglah General Hospital Denpasar throughout 2017. Independent mortality or good outcome evaluation disability using modified Rankin Scale (mRS) at 30 days. Combination ICH-Graeb score was created by adding Graeb Score into original ICH. Mortality rate was 53.4%, and 34% has good outcome. Statistical result in terms of predictive power ICH score for in-hospital unfavourable outcome with cutoff point ³3 {Area Under Curve (AUC): 0.7546} risk ratio 1.8 (Confidence Interval/CI 95%: 1.29-2.67; p=0.0002). While predictive power Graeb score for in-hospital unfavourable outcome with cutoff point ³1 (AUC: 0.6365) risk ratio 1.7 (Confidence Interval/CI 95%: 1.11-2.61; p=0.0034). Combined ICH and Graeb score risk ratio 1.9 (Confidence Interval/CI 95%: 1.16-3.14; p=0.0012). The combination ICH-Graeb score better tools for prediction of unfavourable outcome. Combination of ICH and Graeb score improves the prediction of outcome in spontaneous ICH. Provides as accurate, simple, applicable and reliable screening tools.

Abstract TP534: Comparing the Outcomes of Patients With Idiopathic Subarachnoid Hemorrhage by Three Distinct Perimesencephalic Bleed Patterns

Introduction: Most studies on idiopathic subarachnoid hemorrhage (SAH) focus on comparing perimesencephalic bleeds (PSAHs) to aneurysmal SAHs. We divided PSAHs into three distinct bleed groups and compared clinical courses and outcomes. Methods: We included adult patients (≥18) with angiography-negative, non-traumatic SAH treated at a comprehensive stroke center (1/2015-5/2018). We excluded patients with known etiologies and convexity bleeds (N=41). Patients were categorized by bleed location on CTA: Peri-1: focal prepontine; Peri-2: pan-suprasellar cisterns; Peri-3: pan-suprasellar cisterns + sylvian fissures + intraventricular extension. Outcomes were cerebral ischemia (CI), hydrocephalus and severity, neuro critical care length of stay (NCCU LOS), and hospital LOS. Results: Of the 43 patients included in the study, 37% were Peri-1, 28% were Peri-2, and 35% were Peri-3. A majority were male (67%), with a median (IQR) age of 57 (44-63), and often presented with a headache (93%), nausea (72%), and a Hunt and Hess score of 1-3 (93%). Patients presenting with lethargy (6% vs. 17% vs. 67% p=0.006) and a modified Fisher score of 3 vs. 4 (100% vs. 92% vs. 33% p<0.001) were significantly different between groups in Peri-1-3, respectively. A history of hypertension (19% vs. 25% vs. 60% p=0.04) and mean (SD) days on nimodipine treatment (9.1(4.8) vs. 11.9(7.3) vs. 15.1(5.9), p=0.03) were significantly different between groups. Six (14%) patients had severe hydrocephalus and eight (19%) had CI. Median NCCU and hospital LOS, and proportion with hydrocephalus, were significantly different between groups. (Table 1). There were no other significant differences in outcomes between groups. Conclusions: Our study suggests that patients with the best outcomes were those in Peri-1, followed by Peri-2, and then Peri-3. Because there are no clear risk factors for PSAH, understanding differences by bleed patterns may help tailor better treatment strategies for this population.

Hematoma location and morphology of anticoagulation-associated intracerebral hemorrhage.

To study hematoma location and morphology of intracerebral hemorrhage (ICH) associated with oral anticoagulants (OAC) and delineate causes and mechanism. We performed a systematic literature research and meta-analysis of studies comparing neuroimaging findings in patients with OAC-ICH compared to those with ICH not associated with OAC (non-OAC ICH). We calculated pooled risk ratios (RRs) for ICH location using the Mantel-Haenszel random-effects method and corresponding 95% confidence intervals (95% CI). We identified 8 studies including 6,259 patients (OAC-ICH n = 1,107, pooled OAC-ICH population 17.7%). There was some evidence for deep ICH location (defined as ICH in the thalamus, basal ganglia, internal capsule, or brainstem) being less frequent in patients with OAC-ICH (OAC-ICH: 450 of 1,102/40.8% vs non-OAC ICH: 2,656 of 4,819/55.1%; RR 0.94, 95% CI 0.88-1.00, p = 0.05, I 2 = 0%) while cerebellar ICH location was significantly more common in OAC-ICH (OAC-ICH: 111 of 1,069/10.4% vs non-OAC ICH: 326 of 4,787/6.8%; RR 1.45, 95% CI 1.12-1.89, p = 0.005, I 2 = 21%) compared to non-OAC ICH. There was no statistically significant relationship to OAC use for lobar (OAC-ICH: 423 of 1,107/38.2% vs non-OAC ICH: 1,884 of 5,152/36.6%; RR 1.02, 95% CI 0.89-1.17, p = 0.75, I 2 = 53%, p for heterogeneity = 0.04) or brainstem ICH (OAC-ICH: 36 of 546/6.6% vs non-OAC ICH: 172 of 2,626/6.5%; RR 1.04, 95% CI 0.58-1.87, p = 0.89, I 2 = 59%, p for heterogeneity = 0.04). The risk for intraventricular extension (OAC-ICH: 436 of 840/51.9% vs non-OAC ICH: 1,429 of 3,508/40.7%; RR 1.26, 95% CI 1.16-1.36, p < 0.001, I 2 = 0%) was significantly increased in patients with OAC-ICH. We found few data on ICH morphology in OAC-ICH vs non-OAC ICH. The overrepresentation of cerebellar ICH location and intraventricular extension in OAC-ICH might have mechanistic relevance for the underlying arteriopathy, pathophysiology, or bleeding pattern of OAC-ICH, and should be investigated further.

Prediction of shunt dependent hydrocephalus following aneurysmal subarachnoid hemorrhage “algorithm based management”

Aneurysmal subarachnoid hemorrhage (aSAH) is a devastating disease with a high rate of mortality and permanent morbidity. An important neurologic complication is hydrocephalus reported to range from 6 to 67% while only 10-20% of them will require permanent CSF diversion. The purpose of this study was to identify predictive factors for the development of shunt dependant hydrocephalus among patients with aSAH.&#x0D; This is a retrospective study conducted in among 72 patients who underwent clipping of aneurysm for subarachnoid hemorrhage in our institute during 2 years. EVD placement done for acute hydrocephalus while VP shunt was done for chronic hydrocephalus or requiring prolonged EVD placement. Various clinical and radiological factors were registered on admission and during the intensive care stay. Multivariate logistic regression analysis was done to predict risk of shunt dependant hydrocephalus. P value less than 0.05 was considered significant.&#x0D; Among 72 patients with aSAH. Intraventricular extension of blood was seen in 24 (33.3%) patients while hydrocephalus was seen among 19 (26.4%) patients. Eight patients (11.1%) required EVD placement for acute hydrocephalus while 10 (13.9%) patients required permanent shunt placement for chronic hydrocephalus. In univariate analysis, SAH with fisher grade &gt;2, presence of hydrocephalus, intraventricular extension of hemorrhage and need of EVD placement were found to have significant association in shunt dependency. However multivariate logistic regression model showed EVD requirement for acute hydrocephalus as an independent predictor of shunt dependent hydrocephalus at p value 0.006 (OR=21.3; 95% CI=2.38 to 191.51).&#x0D; Hydrocephalus is a common complication following aneurysmal subarachnoid hemorrhage. SAH with fisher grade &gt;2, presence of hydrocephalus, intraventricular extension of hemorrhage and need of EVD placement were found to have significant association in shunt dependency however only EVD requirement is an independent predictor of SDH

Basal ganglia hemorrhage in a case report following spinal surgery

BackgroundIntracranial hemorrhage is a rare but potentially severe complication of spinal surgery. Most reported post-operative ICH cases consist of cerebellar hemorrhage. There are fewer reported cases of supratentorial ICH following spinal surgery.Case presentationA 56-year-old woman underwent spinal surgery complicated by bilateral supratentorial intraparenchymal basal ganglia hemorrhage with both intraventricular extension and subarachnoid hemorrhage in both cerebral hemispheres.ConclusionThe occurrence of neurological deterioration post-operatively following spinal surgery should alert physicians to the possibility of intracranial hemorrhage in order to facilitate rapid and optimal management. To our knowledge, this is the first case reporting basal ganglia hemorrhage following spinal surgery. Moreover, consideration should be given to the possibility of this complication prior to recommendation of elective spinal surgery.

Neuroimaging and clinical outcomes of oral anticoagulant-associated intracerebral hemorrhage.

Whether intracerebral hemorrhage (ICH) associated with non-vitamin K antagonist oral anticoagulants (NOAC-ICH) has a better outcome compared to ICH associated with vitamin K antagonists (VKA-ICH) is uncertain. We performed a systematic review and individual patient data meta-analysis of cohort studies comparing clinical and radiological outcomes between NOAC-ICH and VKA-ICH patients. The primary outcome measure was 30-day all-cause mortality. All outcomes were assessed in multivariate regression analyses adjusted for age, sex, ICH location, and intraventricular hemorrhage extension. We included 7 eligible studies comprising 219 NOAC-ICH and 831 VKA-ICH patients (mean age = 77 years, 52.5% females). The 30-day mortality was similar between NOAC-ICH and VKA-ICH (24.3% vs 26.5%; hazard ratio = 0.94, 95% confidence interval [CI] = 0.67-1.31). However, in multivariate analyses adjusting for potential confounders, NOAC-ICH was associated with lower admission National Institutes of Health Stroke Scale (NIHSS) score (linear regression coefficient = -2.83, 95% CI = -5.28 to -0.38), lower likelihood of severe stroke (NIHSS > 10 points) on admission (odds ratio [OR] = 0.50, 95% CI = 0.30-0.84), and smaller baseline hematoma volume (linear regression coefficient = -0.24, 95% CI = -0.47 to -0.16). The two groups did not differ in the likelihood of baseline hematoma volume < 30cm3 (OR = 1.14, 95% CI = 0.81-1.62), hematoma expansion (OR = 0.97, 95% CI = 0.63-1.48), in-hospital mortality (OR = 0.73, 95% CI = 0.49-1.11), functional status at discharge (common OR = 0.78, 95% CI = 0.57-1.07), or functional status at 3 months (common OR = 1.03, 95% CI = 0.75-1.43). Although functional outcome at discharge, 1 month, or 3 months was comparable after NOAC-ICH and VKA-ICH, patients with NOAC-ICH had smaller baseline hematoma volumes and less severe acute stroke syndromes. Ann Neurol 2018;84:702-712.

Complicated Case of Acute Fatty Liver of Pregnancy Without Deadly Outcome: Case Report

Background: Acute fatty liver of pregnancy (AFLP) is a rare disorder during pregnancy which is associated with microvesicular fatty infiltration of hepatocytes. We present a patient who was admitted with acute fatty liver of pregnancy. Case: 27-year old female gravida1, para 0 with a past medical history of gestational hypertension presented at her 32 weeks of gestation with uncontrolled hypertension; which evolved to preeclampsia. The patient was complaining of right upper quadrant pain and headache and had moderate tenderness in the right upper quadrant. Initially she received hydralazine, magnesium sulfate and betamethasone. Emergency cesarean section was done for fetal distress and severe preeclampsia. Her presentation was complicated with seizure requiring intubation. Initial labs showed: Na 129 ((mEq/L) K 6.3 (mEq/L) CO2 18 ((mEq/L) Creatinine 2.7 MG/DL) Magnesium 7.7 (mEq/L) phosphorus 7.9 (MG/DL) AST 3323 (U/L) ALT 2618 (U/L) WBC 24.5 (x109/L) hemoglobin 7.4 (MG/DL) platelets 70 (x109/L) INR 1.40 D Dimer 8418 (NG/ML) Fibrinogen 41(MG/DL) Uric acid 11.5 MG/DL). Patient AFLP was complicated by disseminated intravascular coagulation, intra-abdominal and intrahepatic/subscapular liver hematoma and hemoperitonium requiring emergent and laparotomy. She received multiple transfusions of packed red blood cells, fresh frozen plasma and cryoprecipitates. Head CT showed scattered parenchymal hemorrhage with significant intraventricular extension and development of obstructive hydrocephalus. She had emergent ventriculostomy placement followed by decompression craniotomy with bone flap removal.She had acute kidney injury requiring renal replacement therapy. Her protracted course ended up with discharged to a rehab facility after about 2 months of hospitalization. Later her neurological exam improved significantly. During rehabilitation, patient was able to practice with the treadmill, but she continued to have muscle stiffness. Discussion: AFLP is considered as an autosomal recessive genetic disorder. and considered as a diagnosis of exclusion.Labratory data such as Uric acid, ammonia and glocuse might assist with establishing the diagnosis.. About half of the patinets have PE/HELLP syndrome and this makes the initial diagnosis challenging. AFLP carries high mortality rate wich prompt multidisciplinary involvement is required to mange this condition in collaborative fashion to prevent fatal outcomes.2391_A Figure 1. CT head-scattered parenchymal hemorrhage within the right basal ganglia as well as corpus callosum, as described above, with significant intraventricular extension and development of obstructive hydrocephalus.2391_B Figure 2. CT abdomen- moderate ascites/hemoperitoneum. The heterogeneous density lateral to the liver is likely evolving hemorrhage.2391_C Figure 3. US of the liver showed small to moderate fluid lateral to the liver. Edematous and thick gallbladder wall.

Functional outcome and survival following spontaneous intracerebral hemorrhage: A retrospective population-based study.

BackgroundAccurate and reliable clinical and radiological predictors of intracerebral hemorrhage (ICH) outcomes are needed to optimize treatment of ICH. The aim of this study was to investigate functional outcome and identify predictors of severe disability or death following ICH.Materials and methodsRetrospective population‐based study of spontaneous ICH. Clinical and radiological data were obtained from electronic medical records, and functional outcome estimated using the modified Rankin Scale (mRS) before ICH and at 3 and 12 months after ICH.ResultsFour hundred and fifty‐two patients were included (mean age 74.8 years, 45.6% females). Proportion of fatal outcome at 1 week was 22.1%, at 3 months 39.2%, and at 12 months 44.9%. Median mRS score before the ICH was 1 (interquartile range [IQR] 2); for survivors at 3 months, it was 5 (IQR 3); and at 12 months, it was 3 (IQR 2). Independent predictors of severe disability (mRS of 5) or death (mRS of 6) were use of oral antithrombotic drugs (OR 2.2, 95% CI 1.3–3.8, p = 0.04), mRS score before the ICH (OR 1.8, 95% CI 1.4–2.2, p < 0.001), Glasgow Coma Scale (GCS) on admission (OR 8.3, 95% CI 3.5–19.7, p < 0.001), hematoma volume >60 ml (OR 4.5, 05% CI 2.0–10.2, p < 0.001), and intraventricular hematoma extension (OR 1.8, 95% CI 0.8–4.2, p < 0.001).ConclusionIntracerebral hemorrhage is associated with high mortality, and more than one third of survivors end up with severe disability or death 3 months later. Predictors of severe disability or death were use of oral antithrombotic drugs, functional disability prior to ICH, low GCS on admission, larger hematoma volume, and intraventricular hematoma extension.

Influence of Admission Blood Glucose in Predicting Outcome in Patients With Spontaneous Intracerebral Hematoma.

Background and Aims: Hyperglycemia or elevated blood glucose levels have been associated with poor outcomes in patients with ischemic stroke yet control of hyperglycemia has not resulted in good outcomes. High admission blood glucose (ABG) values have been mitigated by other poor prognosticators like large hematoma volume, intraventricular extension (IVE) of hematoma and poor GCS. The aim of this study was to evaluate the effects of blood glucose levels at admission, on mortality and functional outcomes at discharge and 3 months follow up.Methods: This was a retrospective observational study conducted at a tertiary care. Patients with spontaneous SICH were enrolled from a prospective SICH register maintained at our hospital. Blood glucose values were recorded on admission. Patients with traumatic hematomas, vascular malformations, aneurysms, and coagulation abnormalities were excluded from our study.Results: A total of 510 patients were included in the study. We dichotomised our cohort into two groups, group A with ABG>160 mg/dl and group B with ABG<160 mg/dl. Mean blood glucose levels in these two groups were 220.73 mg/dl and 124.37 mg/dl respectively, with group A having twice the mortality. mRS at discharge and 3 months was better in Group B (p ≤ 0.001) as compared to Group A. Age, GCS, volume of hematoma, ABG, IVE and Hydrocephalus were significant predictors of mortality and poor outcome on univariate analysis with a p < 0.05. The relationship between ABG and mortality (P = 0.249, 95% CI 0.948–1.006) and outcome (P = 0.538, 95% CI 0.997–1.005) failed to reach statistical significance on multivariate logistic regression. Age, Volume of hematoma and GCS were stronger predictors of mortality and morbidity.Conclusion: Admission blood glucose levels was not an independent predictor of mortality in our study when adjusted with age, GCS, and hematoma volume. The effect of high ABG on SICH outcome is probably multifactorial and warrants further research.

Heart rate variability is associated with outcome in spontaneous intracerebral hemorrhage

PurposeAutonomic imbalance as measured by heart rate variability (HRV) has been associated with poor outcome after stroke. Observations on HRV changes in intracerebral hemorrhage (ICH) are scarce. Here, we aimed to investigate HRV in ICH as compared to a control group and to explore associations with stroke severity, hemorrhage volume and outcome after ICH. MethodsWe examined the autonomic modulation using frequency domain analysis of HRV during the acute phase of the ICH and in a healthy age- and hypertension-matched control group. Hematoma volume, intraventricular extension, initial stroke severity and baseline demographic, clinical parameters as well as mortality and functional outcome were included in the analysis. Results47 patients with ICH and 47 age- and hypertension matched controls were analyzed. ICH patients showed significantly lower total high frequency band (HF) and low frequency band (LF) powers (p = 0.01, p < 0.001), higher normalized HF power (p = 0.03), and lower LF/HF ratio (p < 0.001) as compared to the controls. Autonomic parameters showed associations with stroke severity (p = 0.004) and intraventricular involvement (p = 0.01) and predicted poor outcome independently (p = 0.02). ConclusionsAutonomic changes seems to be present in acute ICH and are associated with poor outcome independently. This may have future monitoring and therapeutic implications.

Favorable clinical outcome following surgical evacuation of deep-seated and lobar supratentorial intracerebral hemorrhage: a retrospective single-center analysis of 123 cases

BackgroundIn spontaneous supratentorial intracerebral hemorrhage (ICH), the role of surgical treatment remains controversial, particularly in deep-seated ICHs. We hypothesized that early mortality and long-term functional outcome differ between patients with surgically treated lobar and deep-seated ICH.MethodPatients who underwent craniotomy for ICH evacuation from 2009 to 2015 were retrospectively evaluated and categorized into two subgroups: lobar and deep-seated ICH. The modified Rankin Scale (mRS) was used to evaluate long-term functional outcome.ResultOf the 123 patients operated for ICH, 49.6% (n = 61) had lobar and 50.4% (n = 62) deep-seated ICH. At long-term follow-up (mean 4.2 years), 25 patients (20.3%) were dead, while 51.0% of survivors had a favorable outcome (mRS score ≤ 3). Overall mortality was 13.0% at 30 days and 17.9% at 6 months post-ictus, not influenced by ICH location. Mortality was higher in patients ≥ 65 years old (p = 0.020). The deep-seated group had higher incidence and extent of intraventricular extension, younger age (52.6 ± 9.0 years vs. 58.5 ± 9.8 years; p < 0.05), more frequently pupillary abnormalities, and longer neurocritical care stay (p < 0.05). The proportion of patients with good outcome was 48.0% in deep-seated vs. 54.1% in lobar ICH (p = 0.552). In lobar ICH, independent predictors of long-term outcome were age, hemorrhage volume, preoperative level of consciousness, and pupillary reaction. In deep-seated ICHs, only high age correlated significantly with poor outcome.ConclusionsAt long-term follow-up, most ICH survivors had a favorable clinical outcome. Neither mortality nor long-term functional outcome differed between patients operated for lobar or deep-seated ICH. A combination of surgery and neurocritical care can result in favorable clinical outcome, regardless of ICH location.

A hospital based follow up study on predictors of mortality in patients with Intra cranial hemorrhage

Background: Intra-cerebral hemorrhages account for approximately 10-15 percent of all stroke cases and are associated with the highest mortality rate (30-40%). Study of predictors can modify the mortality rates. The objective of the present study the predictors of mortality in patients with intra cranial hemorrhage.Methods: Hospital based cross sectional study was carried out. Forty patients with CT scan evidence of intra cranial hemorrhage admitted to our hospital were randomly selected. All investigations were done. Patient characteristics were noted down.Results: In the present study among 40 patients, 16 patients died. The mortality was 40%. As the age increased, the mortality rate increased. But there was no difference between the mortality among males and females. Mortality was more than twice among those with SBP more than 180 mmHg i.e. 58.8% compared to only 26.1% among those with SBP less than 180 mmHg. Similar findings were noted for DBP and MAP. As the severity of motor weakness increased, the mortality increased. Patients with presence of bilateral plantar extensor response were found to be more at risk of death with a death rate of 66.7% compared to only 18.2% among those without presence of bilateral plantar extensor response. As the Glasgow coma scale increased, the mortality decreased from 100% in patients with a score of 3-4 to only 31.2% in patients with a score of 9-13. Intra-ventricular extension of haemorrhage, presence of hydrocephalus, volume of hematoma &gt;30 ml, decreased consciousness level was important predictors.Conclusions: Bad prognosis i.e. death can be expected if the patient is older, low GCS, hematoma size &gt; 30 ml, gaze palsy, severe motor neuron weakness, abnormal pupils, ataxic respiration etc. hence intensive care should be given to such patients to bring down the mortality.

A study on short term outcome of stroke in a rural tertiary care center of Sub Himalayan Terai

Background: Stroke is the second most common cause of mortality in the world, causing immense morbidity and economic burden. The proper knowledge of the factors which influence the good clinical outcome in stroke is utmost strength of the clinicians in India, where post stroke rehabilitative measures are limited.Aims and Objective: To find out the association of outcome of stroke with different risk factors.Materials and Methods: A descriptive observational design study was formulated for a period of six months on hundred stroke patients in internal medicine unit of at North Bengal Medical College &amp; Hospital, India. Patients were selected after proper screening by inclusion and exclusion criteria. The “In-hospital-outcome” of CVA patient was determined by Glasgow outcome scale. The neurological condition was determined by National Institute of Health Stroke Scale (NIHSS). The Modified Rankin Scale and Barthel Index were utilized to asses disability status of patient in different period of hospital admission. The data were analyzed by EPI INFO software.Results: Clinical outcome showed statistically significant (P&lt;0.05) correlation with age, sex, level of consciousness, blood pressure, diabetes, past history, mass effect, size and depth of infarction and intra-ventricular extension of intra cerebral bleeding. Other parameters like type of stroke (ischemic or hemorrhagic), delay in admission, dyslipidemia, presence of heart disease, smoking, alcoholism, family history, depth and volume of intra cerebral bleeding, although showed poorer clinical outcome, their correlation was not statistically significant.Conclusion: In-hospital outcome of stroke as determined by Glasgow outcome scale correlates with diverse clinical parameters including various risk factors.Asian Journal of Medical Sciences Vol.9(4) 2018 1-9

Related Factors of Early Mortality in Young Adults with Cerebral Hemorrhage.

BackgroundThe main causes of intracerebral hemorrhage differ between young adults and older adults. Data regarding potential targets for early intervention in young adult patients with intracerebral hemorrhage are lacking.MethodsWe retrospectively analysed data for 196 young adult patients with intracerebral hemorrhage who were admitted to Tianjin Huanhu Hospital and died within 30 days of admission between June 2005 and June 2015. The Kaplan–Meier method was used to calculate survival rate, and the log-rank test was used to determine survival rate significance. A Cox proportional hazards regression model was used for univariate and multivariate analyses.ResultsUnivariate analysis revealed a statistically significant association of age, disturbance of consciousness, National Institutes of Health Stroke Scale and Glasgow Coma Scale scores, seizure occurrence, infratentorial hemorrhage, intraventricular extension, hernia, glucose level, white blood cell count, albumin level, creatinine level, uric acid level, and surgical treatment with early mortality (P<0.05). However, multivariate regression analysis revealed that only infratentorial hemorrhage (P=0.003) and intraventricular extension (P=0.003) were significant risk factors for early mortality.ConclusionsOur results suggest that young adult patients who exhibit infratentorial hemorrhage and intraventricular extension in the early stages of intracerebral hemorrhage onset exhibit an increased risk of early mortality.