Modified Graeb Score Research Articles

Development and validation of a nomogram for predicting early acute hydrocephalus after spontaneous intracerebral hemorrhage: a single-center retrospective study

Acute hydrocephalus is a severe complication that may occur early after an intracerebral hemorrhage (ICH). However, clinical factors predicting the occurrence of acute hydrocephalus have rarely been studied. This study aimed to establish a nomogram model to predict early acute hydrocephalus after ICH. We retrospectively analyzed the data of 930 patients with ICH who were treated at our hospital between January 2017 and May 2024. Least absolute shrinkage and selection operator (LASSO) regression analysis was used to screen for risk factors for acute hydrocephalus, and stepwise logistic regression analysis was used to construct the prediction model, which was visualized using a nomogram. Data were randomly divided into training (n = 652) and test (n = 278) sets at a 7:3 ratio. A total of 930 patients were included, of whom 123 (13.2%) developed acute hydrocephalus within 6 h of being diagnosed with ICH. Univariate analysis revealed that 11 indicators were associated with acute hydrocephalus. In the training set, LASSO and stepwise logistic regression analyses identified four independent risk factors that were used to establish a prediction model. These were the modified Graeb score, age, infratentorial hemorrhage > 15 mL, and thalamic hemorrhage > 15 mL. A graphical nomogram was then developed. The area under the receiver operating characteristic (ROC) curve was 0.974 (95% confidence interval 0.961–0.987). In the Hosmer–Lemeshow test, the p-value was 0.887. The mean absolute error of the calibration plot was 0.012. The decision curve analysis (DCA) validated the fitness and clinical application value of this nomogram. Internal validation showed the test set was in good accordance with the training set. The nomogram prediction model showed good accuracy and could be used to predict the risk of early acute hydrocephalus after ICH, thereby aiding neurologist in making rapid clinical decisions.

Predictive factors for shunt dependency in patients with spontaneous intraventricular hemorrhage

Intraventricular hemorrhage (IVH) occurs in approximately 30–50% patients with spontaneous intracerebral hemorrhage (ICH), with a high 30-day mortality rate. Excess accumulation of parenchymal or ventricular blood associated with the development of acute hydrocephalus leads to poor outcomes. The prediction of shunt dependency is important to identify patients susceptible to requiring permanent shunt placement and benefit from the diversion. This retrospective analytical study aimed to establish a predictive model of shunt dependency in patients with IVH. This study included 179 patients with primary IVH with supratentorial origin or spontaneous ICH with extension into the ventricles between 2015 and 2021. Patients were grouped into “shunt required” and “shunt not required” groups. Variables, including age, sex, preexisting hypertension and diabetes, initial Glasgow Coma Scale scores, ICH location and volume, urokinase administration, modified Graeb score (mGraeb score), and bicaudate index, were analyzed. The shunt required group had significantly higher mGraeb scores (12.0 (6.5–15.0) vs. 7.0 (4.0–12.0), p = 0.001) and higher bicaudate index (0.20 (0.17–0.23) vs. 0.16 (0.13–0.18), P < 0.001) than the shunt not required group. The receiver operating characteristic curve (ROC curve) analysis revealed that a cut-off value of 0.16 of the bicaudate index was significantly related to shunt dependency. The subgroup statistical analysis revealed that neither urokinase administration (p = 0.533) nor urokinase dosage (p = 0.117) showed significant relevance in shunt dependency in patients who received external ventricular drainage. In logistic regression adjusted for the confounders, thalamic ICH (odds ratio (OR) 3.55; 95% confidence interval [(95%CI), 1.13–11.18], an mGraeb score greater than 8 (OR, 3.93; 95%CI, 1.84–8.38), and a bicaudate index greater than 0.16 (OR, 9.87; 95%CI, 3.79–25.73) were factors associated with a higher tendency for shunting. The findings of this study may help identify patients at risk for a permanent shunt after IVH.

Prognosticators of Functional Outcome After Supratentorial Minimally Invasive Intracranial Hemorrhage Evacuation With Tubular Retractor Systems.

Prognosticators of good functional outcome after minimally invasive surgical (MIS) intracranial hemorrhage (ICH) evacuation are poorly defined. This study aims to investigate clinical and radiographic prognosticators of poor functional outcome after MIS evacuation of ICH with tubular retractor systems. Single-center retrospective review of adult (age ≥18 years) patients who underwent surgical evacuation of a spontaneous supratentorial ICH evacuation using tubular retractors from 2013 to 2022 was performed. Clinical and radiographic factors, such as antiplatelet/anticoagulant use, initial NIH Stroke Scale, ICH score, premorbid modified Rankin Scale (mRS), intraventricular hemorrhage (IVH) severity according to the modified Graeb scale, and preoperative/postoperative ICH volume, were collected. The main outcome was poor functional outcome, defined as mRS score of 4-6 within 1 year postoperatively. Eighty-eight patients were included. Clinical follow-up data were available for 64 (73%) patients. Of those, 43 (67%) had a poor functional outcome. On multivariate Cox regression, postoperative ICH volume ≥15 mL (hazard ratio [HR] = 2.46 [95% CI: 1.25-4.87]; P = .010) and higher modified Graeb score (HR = 1.04 [95% CI: 1-1.1]; P = .035] significantly increased the risk of poor functional outcome. Elevated postoperative ICH volume was predicted by the presence of lobar ICH (vs nonlobar, OR = 3.32 [95% CI: 1.01-11.55]; P = .043) and higher preoperative ICH volume (OR = 1.05 [1.02-1.08]; P < .001). A minimum of 60% ICH evacuation yielded an improvement in mRS 4-6 rates (HR 0.3 [95% CI: 0.1-0.8], P = .013). In patients without IVH and with a >80% ICH evacuation, the rate of mRS 4-6 was 42% compared with 67% in the whole patient sample ( P = .017). Increased IVH volumes and residual postoperative ICH volumes are associated with poor functional outcome after MIS ICH evacuation. Postoperative ICH volume was associated with lobar ICH location as well as preoperative ICH volume. These factors may help to prognosticate patient outcomes and improve selection criteria for MIS ICH evacuation techniques.

Does preventive external ventricular drainage benefit patients with mild ventricular hemorrhage?

External ventricular drainage (EVD) is the routine intraventricular hemorrhage (IVH) treatment. Neurological deterioration and symptomatic hydrocephalus are often the default indications for EVD insertion. However, the outcome of preventive EVD is unclear in patients with mild IVH. This study aimed to determine whether EVD is beneficial in patients with mild IVH. This study aimed to determine whether EVD is beneficial in patients with mild IVH. Data from IVH patients treated conservatively or with EVD at two hospitals from January 2017 to December 2022 were analyzed retrospectively. Patients with a Glasgow Coma Scale (GCS) score of 12-14 and a modified Graeb score (mGS) ≥ 5 at admission were included. The primary outcome was poor functional status, defined as a modified Rankin Scale (mRS) score of 3-6 at 90days. Secondary outcomes included the distribution of mRS score categories, the resolution time of intraventricular blood clots, and complications. Forty-nine patients were enrolled in the study: 21 patients in the EVD group, 28 in the non-EVD group, and 13 in the EVD group who received urokinase injections. ICH volume was an independent predictor of poor functional status. Currently, no evidence supports that preventive EVD benefits patients with mild IVH.

Clinical Comparison of FD-CT and MS-CT in Aneurysmal Subarachnoid Haemorrhage: A Single Center Experience.

Single-center comparison of postinterventional multislice computed tomography (MS-CT) and flat-detector computed tomography (FD-CT) in patients with subarachnoid haemorrhage (SAH) and endovascularly treated cerebral aneurysms with a focus on detection of posttherapeutical complications. Patients with endovascularly treated aneurysmal SAH undergoing both MS-CT and FD-CT within 24 h after intervention were included. Datasets were compared regarding image quality (IQ) as well as qualitative (detection of SAH, intracerebral haemorrhage [ICH], intraventricular haemorrhage [IVH], external ventricular drain [EVD] position, acute obstructive hydrocephalus [AOH]) and quantitative (cella media distance [CMD], modified Graeb score [GS]) parameters. 410 patients with endovascularly treated aneurysmal SAH were included. IQ was equal between MS-CT and FD-CT. FD-CT allowed equal detection of SAH and ICH in comparison to MS-CT. FD-CT allowed excellent detection of IVH and delineation of EVD position with strong agreement to MS-CT findings. FD-CT allowed equal detection of AOH in comparison to MS-CT. There was no significant difference of CMD and GS between FD-CT and MS-CT. Postinterventional FD-CT yields equivalent diagnostic value in patients with endovascular treated SAH as MS-CT. Enabling reliable detection of SAH-associated complications within the angiosuite, FD-CT might be an efficient and safe imaging modality in these clinical emergencies.

Combining modified Graeb score and intracerebral hemorrhage score to predict poor outcome in patients with spontaneous intracerebral hemorrhage undergoing surgical treatment.

ObjectiveSpontaneous intracerebral hemorrhage (sICH) is a frequently encountered neurosurgical disease. The purpose of this study was to evaluate the relationship between modified Graeb Score (mGS) at admission and clinical outcomes of sICH and to investigate whether the combination of ICH score could improve the accuracy of outcome prediction.MethodsWe retrospectively reviewed the medical records of 511 patients who underwent surgery for sICH between January 2017 and June 2021. Patient outcome was evaluated by the Glasgow Outcome Scale (GOS) score at 3 months following sICH, where a GOS score of 1–3 was defined as a poor prognosis. Univariate and multivariate logistic regression analyses were conducted to determine risk factors for unfavorable clinical outcomes. Receiver operating characteristic (ROC) curve analysis was performed to detect the optimal cutoff value of mGS for predicting clinical outcomes. An ICH score combining mGS was created, and the performance of the ICH score combining mGS was assessed for discriminative ability.ResultsMultivariate analysis demonstrated that a higher mGS score was an independent predictor for poor prognosis (odds ratio [OR] 1.207, 95% confidence interval [CI], 1.130–1.290, p < 0.001). In ROC analysis, an optimal cutoff value of mGS to predict the clinical outcome at 3 months after sICH was 11 (p < 0.001). An increasing ICH-mGS score was associated with increased poor functional outcome. Combining ICH score with mGS resulted in an area under the curve (AUC) of 0.790, p < 0.001.ConclusionmGS was an independent risk factor for poor outcome and it had an additive predictive value for outcome in patients with sICH. Compared with the ICH score and mGS alone, the ICH score combined with mGS revealed a significantly higher discriminative ability for predicting postoperative outcome.

Role of External Ventricular Drainage (EVD) in Treating Spontaneous Intraventricular Haemorrhage

Background: There is no consensus in the literature on the effects of the development of hydrocephalus on survival and disability after intracerebral haemorrhage (ICH) and the benefits of external ventricular drainage (EVD). This study is planned to describe the role of external ventricular drainage in treating patients of spontaneous, either primary or secondary, intraventricular haemorrhage with hydrocephalus.Material &amp; Methods:A hospital based prospective interventional study was conducted in the Department of Neurosurgery of Dhaka Medical College Hospital, which is a tertiary level hospital, from April 2016 to September 2017.Total 42 patients of spontaneous intraventricular haemorrhage, either primary or secondary, with hydrocephalus were selected for this study. All the collected data were entered into IBM SPSS software, Version 24. For statistical analysis, paired t-test to compare the preoperative GCS with postoperative GCS at 24 hours was done.Results:Among 42 patients, age range was 26-75 years with the mean age 65.2 ± 10.87 years. Male were 26 (61.9%) and female were 16 (38.1%). Male-Female ratio was 1.625:1. No patient needed conversion of EVD into VP shunt. EVD drain became blocked in 5 cases which were managed accordingly. 5 patients developed ventriculitis among which 2 patients died and rest 3 improved with antibiotics.Conclusions:The results of present study shows that EVD has a good role in the treatment of spontaneous IVH with hydrocephalus when ICH volume is low (&lt;30ml) and modified Graeb Score is low (≤10 found in this in this study. Preoperative higher GCS or initial improvement in GCS or initial improvement in GCS at 24 hours positively correlates with Glasgow outcome scale which is an indication of good function outcome.

Clinical Significance of Modified Greab Score in Patients of Intra Ventricular Hemorrhage when Treating with External Ventricular Drainage

Background: There is no consensus in the literature on the effects of the development of hydrocephalus on survival and disability after intracerebral hemorrhage (ICH) and the benefits of external ventricular drainage (EVD). Some studies showed good outcomes whereas some showed poor outcomes after insertion of EVD in patients with spontaneous intraventricular hemorrhage with hydrocephalus. Objective: This study is planned to describe the role of external ventricular drainage in treating patients with spontaneous, either primary or secondary, intraventricular hemorrhage with hydrocephalus. Method: A hospital-based prospective interventional study was conducted in the Department of Neurosurgery of Dhaka Medical College Hospital, which is a tertiary level hospital, from April 2016 to September 2017. A total of 42 patients of spontaneous intraventricular hemorrhage, either primary or secondary, with hydrocephalus were selected for this study. Glasgow Coma Scale score for level of consciousness and Modified GRAEB score for severity of ventricular hemorrhage were recorded preoperatively. All the collected data were entered into IBM SPSS software, Version 22.0. Correlations were determined by linear regression analysis. Results: Among 42 patients, the age range was 26-75 years with a mean age of 65.2±10.87 years. Male were 26(61.9%) and females were 16(38.1%). The male-Female ratio was 1.625:1. A total of 9(21.42%) patients had a primary intraventricular hemorrhage and the rest of 33(78.58%) had an intraventricular hemorrhage. Preoperative GCS ranged from 4 to13 with a mean value of 7.14 ± SD 1.995. Modified GRA Escoresre was ranged from 5 to 19 with the mean 8.85± SD 0.7693. The difference in GCS at 24 hours was ranged from a minimum of 3 to a maximum of +10 with an increase of +1.67± SD 2.09. Collected CSF volumes at 24 hours were ranged from a minimum of 50 to a maximum of 480 ml with a mean of 338 of 0.33 ml ±SD 113.329. Total 5 patients died within 30 days. ...........

External Ventricular Drainage Reduces Mortality in Spontaneous Intraventricular Hemorrhage of Brain: A Comparative Study

Introduction: External ventricular drain (EVD) usage in patients with intraventricular hemorrhage (IVH) is variable in current practice and clinical trials, and its impact on outcome remains controversial. Aim of this study was to see the outcome of EVD in management of spontaneous IVH of brain assessing by Glasgow outcome scale (GOS) and modified Rankin scale (mRS) score compared with conservative management. Materials and Methods: Between July 2018 and June 2019, a consecutive 125 admitted patients with spontaneous IVH were enrolled in this quasi-experimental study. Among them 56 patient’s relative agreed to surgery who were accepted as case group and had EVDs. Remaining 69 patient’s relative declined authorization for surgery and were accepted as control group and underwent conservative management. Baseline demographics, clinical presentation, and hospital course, Glasgow coma scale score (GCS) for level of consciousness and modified Graeb score (mGS) for severity of ventricular haemorrhage were recorded at baseline and postoperatively. Admission Computed tomography (CT) scans performed within 24 hours of admission were reviewed for IVH type and hydrocephalus. Patients were followed up for 3 months post operatively and assessed using the GOS score and mRS score. Results: Both the groups were similar at baseline in terms of age (mean±SD: 59±14 vs 60±14, p = 0.645), sex and comorbidity distributions. However, patients who received EVDs had lower mean GCS score (p=&lt;0.001) and higher mean mGS score (p= 0.015) than those who did not receive an EVD. Incidence of hydrocephalus was similar in both groups (57.4% vs 46.7%, p = 0.268). Among the 77 survivors at 3 months, there were 23.1% (6/21) patients scored mRSd”2 in case group, while 38.2% (13/34) in control group (P=0.211). After binary logistic regression analysis, EVD placement was independently associated with reduction of 90 days mortality than conservative management (OR: 3.982; 95% CI: 1.3-12.19) but no effect on morbidity and functional dependence. Other independent predictors for mortality were higher age (p=0.002), lower GCS at admission (p=&lt;0.001) and presence of hydrocephalus (p= &lt;0.001) on CT scan. Conclusion:These results suggest that EVD placement may be beneficial for patients with IVH, who have particularly poor prognosis at admission, but our results must be validated in future randomized clinical trial with larger cohorts and longer follow-up periods that are sufficiently powered to control for the heterogeneity of the study population and managements. Bang. J Neurosurgery 2021; 11(1): 3-12

Abstract WP109: Association Of Cisternal Blood Clot Burden And Ventriculoperitoneal Shunt Requirement In Subarachnoid Hemorrhage

Background: Aneurysmal Subarachnoid hemorrhage (aSAH) can be complicated by refractory hydrocephalus requiring a ventriculoperitoneal shunt (VPS). In an effort to optimize external ventricular drain (EVD) management, we sought to identify early radiographic predictors for refractory hydrocephalus requiring VPS placement. Methods: We conducted a retrospective case-control study of patients admitted for aSAH to a referral academic center from 2016 to 2021. We included those who survived their hospital course and compared radiographic features on admission non-contrast head CTs of patients who required a VPS and those who did not. We calculated modified GRAEB scores and measured total blood clot thickness (blood clot cisternal score) in the basal cisterns including interpeduncular, ambient, crural, prepontine, suprasellar, and interhemispheric cisterns plus bilateral Sylvian fissures (in mm). Binary logistic regression was used to test the association of VPS requirement with radiographic features. Receiver operating characteristics (ROC) curve analysis was performed to compare predictive accuracy of cisternal score to other predictors. Results: Our inclusion criteria yielded 176 patients (mean age of 54.9 years [SD 12.8]; 57% female, 70% white) of which 29 (16.5%) required a VPS. Cisternal score was greater in patients who required a VPS than those who did not (median 61.6 mm, IQR 49.8-74.3 mm vs 26.8mm, IQR 12.4-46.7; p&lt;0.001). Binary logistic regression showed higher blood clot cisternal score on admission head CT scan was associated with higher odds of developing refractory hydrocephalus with VPS requirement (odds ratio 1.06 per each millimeter increase, 95% CI 1.03-1.09; p&lt;0.001), independent of age, Hunt and Hess grades and modified GRAEB scores. Blood clot cisternal score has higher accuracy in predicting VPS requirement than modified GRAEB score (AUC 0.83, 95% CI 0.74-0.93 vs AUC 0.72, 95% CI 0.63-0.82) and other clinical or radiographic predictors on admission. Conclusions: While further validation is needed, our model suggests that blood clot cisternal score on admission head CT scan has high accuracy in predicting VPS requirement. This may allow for more efficacious and cost-effective treatment of hydrocephalus in aSAH patients.

Abstract WP104: Radiographic Predictors Of Aneurysmal Etiology In Patients With Aneurysmal Pattern Subarachnoid Hemorrhage

Introduction: Spontaneous angiogram-negative subarachnoid hemorrhage (anSAH) can represent a diagnostic dilemma as there is no vascular etiology identified and patients may require further imaging, including multiple angiograms, and have prolonged hospital stays. We sought to determine radiographic predictors of aneurysmal cause based on admission non-contrast head CT. Methods: We performed a retrospective case control study of patients who were admitted for spontaneous subarachnoid hemorrhage (SAH) with suspected aneurysmal etiology to an academic center from 2016 to 2021. Patients with pure convexity SAH were excluded. We compared blood thickness (continuous variable) in the basal cisterns and Sylvian fissures and modified GRAEB scores on admission head CT between the two groups. We subsequently developed a predictive model to identify aneurysmal etiology. Results: Of 148 included patients (mean age 56 years [SD 12.7]; 55% female, 70% white), 61 were aneurysmal SAH (aSAH) and 87 were anSAH with no vascular etiology. Median modified GRAEB score was higher in aSAH than anSAH (6 [IQR2-10] vs 0 [IQR0-4], p&lt;0.001). Mean blood thickness was greater in the Sylvian fissure (8mm [SD 5.8]vs 3mm [SD 5.2]; p&lt;0.001), interpeduncular (9mm [SD 5.3]vs 6mm [SD 4.2]; p=0.005), quadrigeminal (3mm [SD 3.7] vs 1mm [SD 2]; p=0.003), crural (6mm [SD 3.7] vs 3mm [SD 2.2]; p=0.014), and ambient cisterns (6mm [SD 7.1] vs 3mm [SD 2.6], p=0.0015) in aSAH compared to anSAH, but less in prepontine cistern (3mm [SD 3.8] vs 5mm [5.2], p=0.006). Our 8-point scoring model is based on differences in radiographic features. Receiver operating characteristics (ROC) curve analysis showed high accuracy in predicting aneurysmal etiology (area under the curve [AUC] 0.79, 95% CI 0.70-0.88; odds ratio 1.45 per point increase, 95% CI 1.24-1.70; p&lt;0.001). Conclusion: The proposed scoring tool can aid clinicians in predicting aneurysmal etiology in patients with aneurysmal pattern SAH using measurements from admission head CTs. Eliminating an aneurysmal etiology of anSAH earlier may reduce the need for further extensive work up, hospital length of stay and associated complications, thereby reducing health care related costs. This model needs to be validated in a larger multi-center study.

Abstract 97: Development And Validation Of A Deep Machine Learning Tool For Automated Intraventricular Hemorrhage Segmentation And Volume Measurement Using 3d Convolutional Neural Networks

Introduction: Development of new intraventricular hemorrhage (IVH) within 24 hours of presentation or expansion of 1mL or more independently predicts poor outcome. Current methods for IVH volume estimation lack sufficient precision to detect this level of change. The best method of quantification with manual/semi-automated segmentation remain clinically impractical. We aimed to train and validate a convolutional neural network (CNN) to autonomously segment and quantify IVH volume in acute intracerebral hemorrhage (ICH) patients. Methods: Imaging data for training and validation was obtained from 3 international multicenter studies. IVH volumes were assessed using CNN, IVH Score (IVHS), Original Graeb Score (oGS), Modified Graeb Score (mGS), and manual segmentation using ITK-SNAP. Agreement between CNN volume and IVHS estimated volume compared to manual segmentation was assessed using intraclass correlation coefficient (ICC) and Bland-Altman charts. Accuracy of CNN segmentation was compared to manual segmentation with Dice similarity coefficient (DSC). Accuracy of hematoma expansion detection was assessed using receiver operating characteristic curves. Results: A total of 172 patients and 311 CT scans were included. Intra-rater reliability was significantly greater for CNN versus IVHS method (ICC 0.99 [95%CI 0.99 - 1.00] vs 0.76 [95%CI 0.66 - 0.83]). Accuracy of CNN segmentation was satisfactory (DSC 0.76 [95%CI 0.75 - 0.78]). Accuracy of hematoma expansion detection was substantially greater in CNN (AUC 0.91 [95%CI 0.85 - 0.97]) versus IVHS, oGS and mGS. Conclusion: Our results demonstrate that a fully automated CNN algorithm is capable of segmenting IVH volumes on multi-center data with higher intra-rater reliability and satisfactory accuracy over the current methods of IVH volume measurement tools. The algorithm has proven to be capable of detecting hematoma expansion with substantially greater accuracy over existing methods of IVH measurement.

Shunt Dependence after Intraventricular Hemorrhage and Intraventricular Fibrinolysis with uPA versus rt-PA.

We compare the effect of urokinase (urokinase-type plasminogen activator [uPA]) versus alteplase (recombinant tissue plasminogen activator [rt-PA]) for intraventricular fibrinolysis (IVF) in patients with intraventricular hemorrhage (IVH) on ventriculoperitoneal shunt (VPS) dependence, functional outcome, and complications in the management of IVH. We retrospectively reviewed the patients admitted with IVH or intracerebral hemorrhage (ICH) with IVH within 7 years in three different departments and found 102 patients who met the inclusion criteria. The primary end points were VPS dependence and Glasgow outcome score (GOS) at 3 months. Secondary end points were rate of rebleeding under IVF and incidence of treatment-related complications. Patients were divided into three groups: group I comprised patients treated with external ventricular drain (EVD) and IVF with uPA; group II comprised patients treated with EVD and IVF with rt-PA; and group III comprised patients treated with EVD alone. In all, 9.8% patients needed VPS: 12.2% in group I and 15.0% in group II, with no statistically significant difference. VPS patients had higher values of the modified Graeb score (mGS), IVH score, and IVH volume. We saw a trend for a better outcome in group II, with six patients achieving a GOS of 4 or 5 after 3 months. The mortality rate was higher in groups I and III. We found no statistical difference in the complication rate between groups I and II. Logistic regression analysis revealed that higher mGS and age predicted worse prognosis concerning mortality. The risk for death rose by 7.8% for each year of age. Any additional mGS point increased the chances of death by 9.7%. Our data suggest that both uPA and rt-PA are safe and comparable regarding incidence of communicating hydrocephalus, and age and mGS are predictive for mortality.

Risk factors for chronic hydrocephalus in patients with intracerebral hemorrhage complicated by coma after emergency hematoma removal.

BackgroundThe cerebrospinal fluid circulation of patients with intracerebral hemorrhage (ICH) can be blocked by blood clots, resulting in acute hydrocephalus. However, current research on chronic hydrocephalus (CH) is lacking.MethodsA total of 253 patients with ICH combined with coma treated at The Third People’s Hospital of Gansu Province after emergency hematoma removal from January 2018 to January 2020 were included. Patients were divided into the CH group (n=48) and the control group (n=205) depending on whether hydrocephalus occurred or not within 3–12 months after operation. The main clinical characteristics of the two groups were compared, and the risk factors for CH were analyzed. Counting data of the two groups were expressed as “n (%)”, and multivariate logistic regression analysis was used to explore the risk factors for CH.ResultsCompared with the control group, the proportion of patients with modified Graeb score ≥5 points in the CH group increased significantly (52.08% vs. 21.95%, P=0.000). The proportion of patients with preoperative cerebral hernia increased significantly (37.5% vs. 19.51%, P=0.008). The proportion of patients with preoperative obstructive hydrocephalus increased (43.75% vs. 24.39%, P=0.007). The proportion of patients with postoperative subdural effusion increased (41.67% vs. 13.66%, P=0.000). Multivariate logistic regression analysis showed that a modified Graeb score ≥5 points and postoperative subdural effusion were risk factors for the formation of CH in patients with ICH complicated by coma after emergency hematoma removal (P<0.05). The modified Graeb score has diagnostic value for the formation of CH in patients with ICH combined with coma after emergency hematoma removal, and the area under the curve was 0.653 [P=0.001, 95% confidence interval (CI): 0.561–0.744]. There was no significant difference in preoperative neurological deficit score between the control group and the CH group (19.75±3.03 vs. 19.86±3.01, P=0.113). Compared with the control group, the neurological deficit score at 12 months after operation in the CH group was significantly higher (12.73±2.99 vs. 10.64±2.82, P=0.000).ConclusionsA modified Graeb score >5 points and postoperative subdural effusion are risk factors for the formation of CH in patients with ICH combined with coma after emergency hematoma removal. The formation of CH affects postoperative neurological rehabilitation.

Validation of shunt dependency prediction scores after aneurysmal spontaneous subarachnoid hemorrhage.

Currently available scores for predicting shunt dependency after aneurysmal spontaneous subarachnoid hemorrhage (aSAH) are limited and not widely accepted. The key purpose of this study was to validate a recently created score for shunt dependency in aSAH (SDASH) in an independent population of aSAH patients. We compared this new SDASH score based on a combination of the Hunt and Hess grade, Barrow Neurological Institute (BNI) score, and the presence or not of acute hydrocephalus with other published predictive scores. The SDASH score, Hijdra score, BNI grading system, chronic hydrocephalus ensuing from SAH score (CHESS), Graeb score, and modified Graeb score (mGS) were calculated for a cohort of aSAH patients. Logistic regression analysis was used to determine the reliability of the SDASH score, and the area under the curve (AUC) of the receiver operating characteristics (ROC) curve was used to assess the discriminative ability of the model. In 214 patients with aSAH, 40 (18.7%) developed shunt-dependent hydrocephalus (SDHC). The AUC for the SDASH score was 0.816. The SDASH score reliably predicted SDHC in aSAH (odds ratio: 2.93, 95% CI: 1.99-4.31; p < 0.001) with no statistically significant differences being found between the SDASH score and the CHESS score (AUC: 0.816), radiological-based Graeb score (AUC: 0.742), or modified Graeb score (AUC: 0.741). However, the Hijdra score (AUC: 0.673) and BNI grading system (AUC: 0.616) showed lower predictive values than the SDASH score. Our findings support the ability of the SDASH score to predict shunt dependency after SAH in a population independent to that used to develop the score. The SDASH score may aid in the early management of hydrocephalus in aSAH, and it does not differ greatly from other predictive scores.

Analysis of outcome predictors in patients with spontaneous intracerebral hemorrhage

Introduction. Spontaneous intracerebral hemorrhage is not a monophasic event, but a condition characterized by hematoma expansion with mechanical damage to the surrounding tissue. The development of multiple complications is associated with a high mortality rate of 40%. In order to make therapeutic decisions, it is important to know what factors predict the outcome in these patients. The aim of this study was to evaluate outcome prediction scales in patients with spontaneous intracerebral hemorrhage according to functional outcome at 7 and 30 days after the onset. Material and Methods. A three-year retrospective study (2017 - 2019) included 116 patients treated at the Emergency Center, Clinical Center of Vojvodina, Novi Sad, Serbia. The collected data included the National Institutes of Health Stroke Scale, the original intracerebral hemorrhage score, the modified Graeb score and Glasgow coma scale. Demographic data, localization, shape and volume of hematomas, as well as occurrence of intraventricular hemorrhage were compared. Results. In the group of 116 patients, male gender was dominant (82%) as well as the age over 65 years (56%); Glasgow coma scale: 1.5 interquartile range = 1 - 2 points, National Institutes of Health Stroke Scale 24, interquartile range = 15 - 32, intracerebral hemorrhage score 3 - 4 (68.1%). Intraventricular hemorrhage was found in 82.3% and oval hematoma in 71.6% of patients. The mortality rate was highest in the first 7 days (41.4%). The 7-day and 30-day mortality was significantly associated with the intracerebral hemorrhage score (p = 0.000) and the intracerebral hemorrhage volume (p = 0.014). Conclusion. Elderly men with known vascular risk factors are prone to spontaneous intracerebral hemorrhage. The intracerebral hemorrhage score and hematoma volume may be the potential indicators of poor outcome in the first 7 days of spontaneous intracerebral hemorrhage.

Supratentorial intracerebral hemorrhage volume and other CT variables predict the neurological pupil index

ObjectivesThere is growing interest in the ability of automated infrared pupillometry to assess severity of neurological illness. We studied the correlation between computed tomography (CT) indicators of intracerebral hemorrhage (ICH) severity with objective measures of the pupillary light reflex (PLR), and hypothesized that hemorrhage volume would predict the Neurological Pupil index™ (NPi™), an indicator of pupillary reactivity. MethodsThis study examined data from patients with supratentorial ICH who underwent serial pupillometer evaluations. CT images were examined to determine the location and laterality of the hemorrhage, along with hematoma volume (using the simplified ABC/2 method), midline shift, hydrocephalus score, and modified Graeb score (indicating interventricular hemorrhage). Demographics were examined with standard measures of central tendency, hypotheses with logistic regression, categorical data with Fisher’s Exact X2, and multivariate modeling with constructed MAX-R models. ResultsData were gathered from 44 subjects. ICH volume exhibited the strongest correlation with NPi (ipsilateral [r2 = 0.48, p < 0.0001, contralateral [(r2 = 0.39, p < 0.0001]). Horizontal midline shift of the septum pellucidum also correlated with NPi (ipsilateral [r2 = 0.25, p = 0.0006], contralateral [r2 = 0.15, p = 0.0106]), as did shift of the pineal gland (ipsilateral [r2 = 0.21, p = 0.0017], contralateral[r2 = 0.11, p = 0.0328]). ICH volume was the most predictive of abnormal NPi (AUC = 0.85 for ipsilateral and 0.88 for contralateral NPi), and multivariate modeling identified additional independent predictors of NPi. ConclusionICH volume and shift of midline structures correlate with NPi, and abnormalities in NPi can be predicted by hematoma volume and other CT indicators of ICH severity. Future studies should explore the role of NPi in detecting early hematoma expansion and worsening midline shift.

Original and Modified Graeb Score Correlation With Intraventricular Hemorrhage and Clinical Outcome Prediction in Hyperacute Intracranial Hemorrhage.

Background and Purpose- The Graeb score is a visual rating scale of intraventricular hemorrhage (IVH) on noncontrast head CT. Little data exist in the hyperacute (<6 hour) period for reliability and predictive value of the modified Graeb Score (mGS) or the original Graeb Score (oGS) for clinical outcomes or their correlation with quantitative IVH volumes. Methods- A retrospective analysis of multicenter prospective intracranial hemorrhage study was performed. oGS and mGS inter-observer agreement and IVH volume correlation on the baseline noncontrast head CT were calculated by intraclass correlation coefficient and Pearson coefficient respectively. Predictors of poor outcome (modified Rankin Scale scores ≥4) at 3 months were identified using a backward stepwise selection multivariable analysis. oGS and mGS performance for modified Rankin Scale scores ≥4 was determined by receiver operating characteristic analysis. Results- One hundred forty-one patients (65±12 years) with median (interquartile range) time to CT of 82.5 (70.3-157.5) minutes were included. IVH was observed in 43 (30%) patients. Inter-observer agreement was excellent for both oGS (intraclass correlation coefficient, 0.90 [95% CI, 0.80-0.95]) and mGS (intraclass correlation coefficient, 0.97 [95% CI, 0.84-0.99]). mGS (R=0.79; P<0.01) correlated better than oGS (R=0.71; P<0.01) with IVH volumes (P=0.02). Models of thresholded oGS and mGS were not different from a model of planimetric baseline intracranial hemorrhage and IVH volume for poor outcome prediction. Area under the curves were 0.70, 0.73, and 0.72, respectively. Conclusions- Excellent correlation for oGS and mGS with IVH volume was seen. Thresholded oGS and mGS are reasonable surrogates for planimetric IVH volume for hyperacute intracranial hemorrhage studies.

Impact of Spot Sign Etiology in Supratentorial Intracerebral Hemorrhage on Outcomes of Endoscopic Surgery

The spot sign (SS) in spontaneous intracerebral hemorrhage has been reported to be a predictive factor of poor outcome; however, how SS is related with the clinical outcome remains unclear. We aimed to investigate how etiology associated with SS affects the clinical outcome of endoscopic surgery. We retrospectively analyzed data from 104 patients (43 women and 61 men, mean age: 64.2 ± 11.0 years) who underwent endoscopic surgery for supratentorial intracerebral hemorrhage. The outcome variables analyzed were in-hospital mortality and modified Rankin scale score at 90 days from onset. The prevalence of intraventricular hemorrhage and the mean initial modified Graeb score were greater in SS-positive than in SS-negative patients (100% vs. 47.7%, P < 0.001, and 14.4 ± 5.4 vs. 10.6 ± 6.0, P= 0.03, respectively). Postoperative rebleeding occurred more frequently in SS-positive than -negative patients (25.0% vs. 6.8%, P= 0.045). The in-hospital mortality rate was 7.7% and was not significantly different between the groups (18.8% vs. 5.7%, P= 0.09). There was a significant unfavorable shift in modified Rankin scale scores at 90 days among SS-positive patients compared with SS-negative patients in an analysis with ordinal logistic regression (adjusted common odds ratio, 4.38; 95% confidence interval 0.06-0.79, P= 0.02). Intraventricular hemorrhage and postoperative rebleeding were considered to be associated with the poor outcome in patients with SS. The SS on computed tomography angiography may be valuable in predicting rebleeding and clinical outcome after surgery.

Abstract WMP104: Complement System is Acutely Activated in Humans After Intracerebral Hemorrhage

Introduction: Intracerebral hemorrhage (ICH) generates a complex local and systemic inflammatory response, but prior studies have neglected the role of the complement system. While animal models of ICH have suggested complement is a key regulator of inflammation, human data are lacking. We investigated whether the complement system was activated in ICH patients. Hypothesis: We hypothesized complement system activation product levels would be acutely elevated in ICH patients compared to matched controls. We also examined the association of these complement fragment levels with established ICH severity markers and perihematomal edema (PHE) growth rates. Methods: We identified 25 ICH patients whose blood was collected within 5 days post stroke at the University of Maryland Medical Center from June 2016 to September 2017 as part of the Recovery After Cerebral Hemorrhage (REACH) and Genetic and Environmental Risk Factors for Hemorrhagic Stroke (GERFHS) studies. C3a, C5a, and sC5b-9 levels were measured via ELISA (Quidel, San Diego, CA) in patients and healthy controls matched for age, sex, and race. Six patients were excluded from PHE growth measurement for lack of available follow-up CT or MRI scans. Hematoma and PHE volumes were measured on the initial CT scan and the follow-up CT scan (or MRI scan if CT not done) closest to 72 hours post stroke via a semi-automated method. Results: Mean C3a (82.4 versus 49.2 ng/mL, p = 0.01), C5a (19.2 versus 9.1 ng/mL, p = 0.00005), and sC5b-9 (3000 versus 246 ng/mL, p = 0.00006) levels were elevated in ICH patients relative to matched controls. In secondary analyses, C5a level was correlated with presence of intraventricular hemorrhage (correlation coefficient 0.51, p = 0.03) and modified Graeb score (correlation coefficient 0.50, p = 0.03). Complement fragment levels were not correlated with PHE growth rates, age, ICH size, ICH location, or presence of at least 2 systemic inflammatory response syndrome (SIRS) criteria. Conclusions: Activated complement fragments C3a, C5a, and sC5b-9 are significantly (several-fold) elevated in ICH patients independently of age, ICH size, and ICH location. Considering complement’s role in initiating and augmenting inflammation, it represents a potential novel therapeutic target.