Role of neuroradiology in predicting outome in spontaneous intracerebral hemorrhage
V O L .
Role of neuroradiolog y in predicting outome in spontaneous intracerebral hemorrhage
Sumaira Nabi 0 1 5
Ali Zohair Nomani 0 1 5
Pakistan Institute of Medical Sciences,Islamabad, Pakistan.
0 Pakistan Institute of Medical Sciences , 44000, Islamabad , Pakistan
1 Pakistan Institute of Medical Sciences , Islamabad , Pakistan
2 , Ali Zohair Nomani
3 , Shahzad Ahmed
4 , Mazhar Badshah
5 Sumaira Nabi
6 , Anum Irfan Abbassi
7 , Umair Hassan
8 , Sadaf Fayyaz
Follow this and additional works at: http://ecommons.aku.edu/pjns Part of the Neurology Commons Recommended Citation
ROLE OF NEURORADIOLOGY IN PREDICTING OUTOME
IN SPONTANEOUS INTRACEREBRAL HEMORRHAGE
Spontaneous intracerebral hemorrhage (ICH) leads to
hemorrhage in the brain parenchyma in the absence of
trauma or surgery. It accounts for 8-13% of all strokes
and is associated with a high mortality and morbidity
especially in countries of the developing world like
Pakistan. Statistics indicate that in the first 30 days
almost 50% patients of ICH will expire with one half of
these deaths occurring in the first 2 days.[1-3]
Spontaneous ICH is one of the most disabling varieties
of stroke and only 20% patients attain functional
independence after 6 months.[
] So far no therapy has
been documented to improve outcome after
spontaneous ICH with a proven role in reducing either
mortality or profound long-term disability. Several
international studies have identified various clinical and
radiological factors which help in predicting outcome in
patients with spontaneous ICH.[
] The clinical
parameters include altered conscious level (low
Glasgow coma scale [GCS]), high blood pressure and
renal dysfunction. The radiological parameters include
hydrocephalus, baseline volume of the hematoma,
midline shift, intra ventricular extension and
infratentorial location of the bleed.
Very few local and regional studies have been done on
this subject. Most of the data is from studies conducted
on western population. The aim of this study was to
identify the radiological parameters in patients of
spontaneous ICH and its in-hospital outcome in our
local population to generate local data for allocation of
resources; and to identify patients at high risk for
MATERIALS AND METHODS
This was a prospective, single center observational
study carried out at the department of Neurology
Pakistan Institute of Medical Sciences, Islamabad from
1stJanuary 2014 to 30th June, 2014. The study was
approved by the hospital ethical committee and carried
P A K I S T A N J O U R N A L O F N E U R O L O G I C A L S C I E N C E S
out according to international ethical standards of the
responsible committee on human experimentation and
with the latest version of Helsinki Declaration of
1975.A consecutive series of 100 patients diagnosed
with spontaneous ICH admitted to the neurology
department were enrolled using non-probability
consecutive sampling. This study was an independent
project of the department and was not funded by any
pharmaceutical organization. Informed consent was
obtained from all patients (and in case of unconscious
patients from their next of kin). Patients above the age
of 13 years with diagnosis of spontaneous ICH who
presented within 24 hours of the event onset were
included in the study.
Spontaneous ICH was defined as stroke with
hemorrhage into the brain parenchyma identified as
hyperdense area on computed tomography (CT) scan
brain (plain) done at the time of admission (without
history of trauma or surgery). Hydrocephalus for this
study was defined by the presence of the following on
CT brain: Size of both temporal horns greater than 2
mm, ratio of the largest width of the frontal horns to
maximal biparietal diameter (ie, Evans ratio) greater
than 30% and ballooning of frontal horns of lateral
ventricles and/or the third ventricle. Other imaging
details noted on CT scan (plain) included volume of
hematoma (calculated using ABC/2 formula by
radiologist), site of ICH (supratentorial or infratentorial),
intraventricular extension and midline shift (measured
as maximum displacement of septum pellucidum in
millimetres from midline by radiologist with 6mm as the
cut-off between the two groups).In-hospital outcome
was measured at the end of 7 days of hospital stay in
terms of survival or mortality. The disability status was
assessed by modified Rankin scale (mRS) in the
patients who survived at the time of discharge.
Key exclusion criteria included patients with subdural
and epidural hematoma on CT brain, patients with
traumatic ICH, patients on anticoagulant or
coagulopathy-related hemorrhage and patients with
subarachnoid hemorrhage on CT brain. Patients of ICH
fulfilling the criteria underwent detailed history and
neurological examination. Demographic features
recorded included age and gender. Radiological
parameters as mentioned above were recorded. Every
patient was then observed for outcome within 7 days.
The data was entered on a standardized performa.
Data was analyzed using SPSS version 17. Descriptive
analysis was carried out and reported as mean± SD
forcontinuous variables whereas frequencies and
percentageswere calculated for categorical variables.
Different radiological parameters and their effect on
outcome were compared by using Chi square test.
Multivariate logistic regression analysis using stepwise
forward regression was performed to find independent
predictors of mortality (with mortality as the dependent
variable). A “p” value of < 0.05 indicated statistical
The mean age of patients was 47.95 years with SD ±
1.560, with 17% patients in the 18-30 years age
group, 41% in the 31-50 years age group, 39% in the
51-70 years group and 3% above the age of 70 years.
A male preponderance was seen with 56% being male
and 44% female.
Of the total cohort 34% patients expired and 66%
survived at the end of 1 week. The demographics
features and imaging characteristics of these patients
are represented in Table I.
On univariate analysis the radiological features
associated with mortality included a larger baseline
hematoma volume, greater midline shift,
intraventricular extension of hematoma and presence
of hydrocephalus with p value <0.05 (Figure no I). Site
of hemorrhage did not differ statistically among both
the patient groups of the cohort(Figure no II shows
Various CT brain images).However, on multivariate
logistic regression analysis only higher baseline
hematoma volume was an independent predictor of
mortality (p=0.00) while higher midline shift
(p=0.839), intraventricular extension of hematoma
(p=0.306) and presence of hydrocephalus (0.999)
didn’t prove likewise.
P A K I S T A N J O U R N A L O F N E U R O L O G I C A L S C I E N C E S
Relationship of different parameters with intracranial
bleed.Bar chart showing number of pat respecategory.
(Error bars with percentages)
a) Left Basal ganglia bleed as shown in CT brain of
one of our patients (arrow head) b) Left Basal
ganglia bleed with mass effect in CT brain of
another patient (arrow head) c) CT brain
showing Left parietal hematoma (arrow head) in
one of our patients. d) CT brain revealing
Massive Cerebellar bleed with mass effect and
intraventricular extension (arrow head) in one of
the cases e)Right thalamic hematoma (arrow
head) shown in CT brain of one of the patients.
f) Massive left sided hematoma (>80mL) with
midline shift and intraventricular extension
(arrow head) seen in CT brain of one of the
patients who expired.
Among the 66 patients who survived 18 (27.2 %) had
a modified Rankin score of 0-2 at the time of discharge
whereas 29 (44%) had moderately severe to severe
disability with mRS 4 and 5 at the time of discharge
[mRS 4, 21 (31.8) and mRS 5, 8 (12.1%)] as shown
in Figure no III.
Intracerebral hemorrhage is a catastrophic medical
emergency. Extensive research work is being carried out
internationally to salvage patients of ischemic stroke
and to reduce the resultant morbidity and mortality.
Intracerebral hemorrhage still requires more focus in
order to improve the outcome. There is no specific
medical treatment and the outcome of surgical
interventions is controversial and debatable. There has
been considerable interest in predicting outcome after
ICH and several studies (mostly western) have
identified the clinical and radiological parameters
associated with poor outcome. These studies vary in
complexity however most of them have identified
similar overlapping factors. This study mainly focuses
on the CT brain findings of patients of spontaneous ICH.
CT brain (plain) is the investigation of choice for
patients of ICH with a high sensitivity and specificity for
delineating ICH. It is readily available in the emergency
departments of most hospitals, takes less time and has
a lower cost than MRI brain.
ICH is a grave emergency with a high mortality of
almost 35-52%.[1-3 ]Review of different srevvariable
P A K I S T A N J O U R N A L O F N E U R O L O G I C A L S C I E N C E S
factors which can predict possible high risk of mortality.
In our study the mean age of patients was 47.95 years
with SD ± 1.560 with a male preponderance. The age
mean is lower than a similar study published in the
Indian journal of Neurology in 2013 and another
published in the AHA stroke journal in 2003 with mean
ages being above 55years and 65years respectively.
We had more patients of young stroke. This may be
related to genetic and environmental factors but needs
validation by further studies. Male preponderance
corresponds to the study done in India whereas
Western studies have documented predominately
In our study location of bleed was not associated with
an increased risk of mortality. These results correspond
to that of Salihović et al in 2013 where they concluded
that there was no statistically significant association
between the localization of the hematoma and the
outcome of patients.[
] Our study identified hematoma
volume as a predictor of mortality both on univariate
and multivariate analysis with statistical significance
(p<0.05). It was seen that hematoma volume less
than 30ml was associated with a favorable outcome
whereas higher baseline hematoma volumes were
associated with higher mortality. The highest mortality
rate was recorded in patients with the hematoma
volume more than 80 mL (100%), followed by the
group of >60 mL (77.8%). These findings are
consistent with those of previous studies.[
Therefore, volume of hematoma was an independent
factor influencing mortality in patients with ICH. Studies
of Godoy et al, Salihović et al and Bakhshayesh et al all
showed that mortality was higher in the patients with
greater hematoma volume.
On univariate analysis presence of hydrocephalus,
greater midline shift and intraventricular extension were
associated with significant mortality (p<0.05).
However, none of these were independent predictors of
unfavorable outcome on multivariate analysis
(p>0.05). Some previous studies have depicted these
as independent risk factors for mortality while others
failed to prove so as in our study. A study conducted by
Cheung and Zou in 2003 showed intraventricular
extension of ICH as a poor prognostic factor for
] The study byBhattathiri et al showed that
favorable outcomes were more frequent when IVH and
hydrocephalus were absent.[
] The study by Phan TG et
al proved that obstructive hydrocephalus on admission
was a predictor of mortality.[
] Our results correspond
to those of some other studies which didn’t prove
hydrocephalus or midline shift as independent
predictors of mortality.[
] Different studies have
conflicting results on the significance of these
Among the 66 survivors in this study almost half were
severely disabled at the time of discharge. One review
estimated that only 12- 39% of patients of
spontaneous ICH are functionally independent.[
Our study has certain limitations. The proportion of
infratentorial ICH in this cohort is low (12%) while the
major proportion was constituted by supratentorial ICH.
This small number cannot truly predict the extent of
mortality in infratentorial ICH. This was a single center
study with only 100 patients.An epidemiological
population-based study with larger sample would be
able to give results which can be applied on the general
population with more certainty. However, our center
being the largest specialized unit in the country renders
services to nearly one fifth of the population of Pakistan
so this data could be representative of patients who
have ICH in general population to some extent.
In conclusion, intracerebral hemorrhage is associated
with high in-hospital mortality and long-term morbidity
with almost half patients discharged in dependent state
with severe disability. Larger baseline hematoma
volume was an independent predictor of mortality in
this study. Presence of hydrocephalus, significant
midline shift, hematoma location and intraventricular
extension did not affect outcome. Therefore,
radiological parameters on CT brain can be used to
predict outcome when a patient of intracerebral bleed
is received in the emergency department.
Conflict of interest: Author declares no conflict of interest.
Funding disclosure: Nil
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