Evaluation of relationship between tests, clinical factors to change intracerebral hematoma volume in acute supratentorial hemorrhage

Increase in hematoma volume (HV) in the brain after intracerebral hemorrhage (ICH) is a major cause of worsening clinical condition, and is an independent predictor for mortality and outcome. Our goals were to evaluate the relationship between subclinical, clinical factors to change intracerebral HV in acute supratentorial hemorrhage in first 72 hours after onset.

EVALUATION OF RELATIONSHIP BETWEEN TESTS, CLINICAL FACTORS TO CHANGE INTRACEREBRAL Hematoma Volume

IN ACUTE SUPRATENTORIAL HEMORRHAGE

Dinh Vinh Quang*; Nguyen Van Chuong**

summary

Increase in hematoma volume (HV) in the brain after intracerebral hemorrhage (ICH) is a major cause of worsening clinical condition, and is an independent predictor for mortality and outcome Our goals were to evaluate the relationship between subclinical, clinical factors to change intracerebral

HV in acute supratentorial hemorrhage in first 72 hours after onset

Descriptive, prospective analysis of 188 acute supratentorial hemorrhage patients associated with hypertension at admission, admitted within six hours after onset, from 2010 to 2013

Results: The average age was 58.2, including 128 males (68%) and 60 females (32%) Univariate analysis showed that 9 important factors related to increased HV were: (1) Glasgow on admission, (2) NIHSS on admission, (3) Rankin at admission, (4) SBP at admission, (5) Hematoma volume, (6) Shape of hematoma, (7) Spot sign, (8) WBC, and (9) Glycemie Multivariate analysis showed that two independent prognostic factors associated with increasing HV were: (1) The shape of the hematoma is irregular on CT, and (2) Spot sign on CTA

* Key words: Acute supratentorial hemorrhage; Subclinical, clinical factors.

INTRODUCTION

Stroke, one of the causes of death in

neurological diseases, or prolonged sequelae

and disabilities, is a common disorder

Intracerebral hemorrhage (ICH) accounted

for 15 to 20% of stroke, causing death or

severe disability more than cerebral infarction

[3] In ICH appeared, risk factors, hypertension

and cerebral amyloid angiopathy accounted

for 78-88% [2]

When ICH appears, there are some

factors affecting to clinical status of the

patient (PT) An increase in HV in the brain

after ICH is a major cause worsening

clinical condition and is an independent

predictor for mortality and outcome [8]

Identifying the factors that increase HV(HV) after ICH is important in the treatment and prognosis of ICH patients In the acute ICH phase, if hypertension uncontrolled can increase the risk of continuous bleeding or re-bleeding, increased HV For the treatment and better care of ICH patients in the early hours, we performed this study, aiming to: Evaluate the relationship between tests, clinical factors to change intracerebral HV in acute supratentorial hemorrhage in first 72 hours after onset

Subjects and Methods

1 Subjects

associated with hypertension, admission before

* 115 Hospital

** 103 Hospital

Address correspondence to Dinh Vinh Quang: 115 Hospital

E.mail: quanghung115@yahoo.com.vn

six hours after onset, treated at Department

of Cerebral-Vascular Pathology, 115 People

Hospital from 1 - 2011 to 4 - 2013 agreed with

enrollment in the study Inclusion criteria will

be included in the study

* Inclusion criteria:

ICH is the first acute supratentorial

hemorrhage (STH) associated with hypertension

at admission, admitted within six hours after

onset Brain images on computerized

tomography (CT) help diagnose supratentorial

hemorrhage

Hypertension diagnostic criteria (the JNC

VII): The systolic blood pressure (SBP) higher

than 140 and/or diastolic blood pressure (DBP)

higher than 90 mmHg

* Exclusion criteria:

- Supratentorial hemorrhage (STH) due to

aneurysm rupture, arteriovenous malformations,

moyamoya disease, by using anticoagulants

or anti-platelet drugs

-.STH wi th blood intra ve ntricul ar

(intraventricular hemorrhage)

- Patients died before the second CT.Scan

shot

- STH transformation of cerebral infarction

- Renal failure, creatinine ≥ 1.7 mg/dl

- A history of allergy to contrast drugs

2 Research methodology

Study design: descriptive, prospective

analysis, univariate regression and multivariate

3 Data collection

- The clinical data: age, gender, time from

onset to hospitalization, history of hypertension,

diabetes, heart disease, liver disease, smoking,

drinking, time of onset, the symptoms onset

+ BP, consciousness at admission, paralysis

of cranial nerve VII, strength of the arms

and legs paralyzed

+ Glasgow, NIHSS, Rankin at admission and 72 hours after onset

+ BP at 6 hour, then BP measurement every 4 hours to 72 hours after stroke

- Tests data:

+ Take unenhanced CT at admission + Blood tests: Red blood cells (RBC), hemoglobin (Hb), hematocrit (Hct), white blood cells (WBC), platelet count (PTC), glycemie, total cholesterol, LDL-cholesterol, HDL-cholesterol, triglyceride, liver function tests (AST, ALT-aspartate aminotransferase, alanine aminotransferase), renal function (bun, creatinine), PT (prothrombin time), APTT (activated partial thromboplastin time), fibrinogen, INR

+ Brain CT-angiography (CTA) in the first

24 hours after onset

+ Take the second unenhanced CT as clinical status worsen (Glasgow score decreased from two points or more) or 72 hours after stroke

4 Assessment criterial

- STH status of patients after 72 hours was evaluated in two groups: blood volume without increase and increase (enlargement)

HV in the brain increases under Kazui [16]

as V2 - V1 ≥ 12.5 cm3 or V2/V1 ≥ 1.4, where V1, V2 respectively HV on brain CT-scan 1st and 2nd time

- HV calculated by Kothari,s formular (or Broderich): V = (A x B x C)/2 Where A, B, C are the largest three diameter perpendicular

to each other in three dimensions of the hematoma

- Find the factors affecting changes HV

of STH in the first 72 hours after admission

by means of univariate regression analysis

- After univariate analysis, the significant important variables in univariate analysis will

be included in a multivariate regression analysis

to find the binary logistic variable prognostic

value after adjustment by other variables

and evaluate odds ratio OR (odds ratio)

Results and discussion

1 General characteristics of the study

group

- Age: mean age: 58.29, similar to the

common age for stroke in general

- Gender: 188 patients, including 128 males

(68.08%) and 60 females (31.91%), ratio

between men and women was 2:1

- The onset period and admission: average

4.03 hours, of which, 10 patients (5.3%) in

the first hour, 76 patients (40.4%) in 3 hours

2 The risk factors

Figure 1: The risk factors of stroke

patients with STH

Patients with history of hypertension are

4 times as many as those without history of

hypertension In the study group, most patients

had no history of liver disease, heart disease

and stroke before ICH

In comparing the two groups of increase

and non-increase HV in patients with history

of non-and hypertension, diabetes, heart

disease, liver disease, smoking, alcohol

drinking, we found no difference between

the two groups with p value of 0.78, 1.00, 1.00, 1.00, 0.75, 0.59 respectively

3 The clinical factors and test

- Symptoms at onset:

+ There is no difference in symptoms at onset such as dizziness, headache, vomiting, seizures, speech disorders between two groups of increase and non-increase HV with p value of 0.75, 0, 45, 0.059, 1.00, and 0.13 respectively

+ Rate enlargement HV in patients with paralysis on the left (70.83%) was significantly higher than the right side paralyzed patients (29.17%), this difference was statistically significant with p = 0.043

+ Consciousness:

Enlargement HV rate in patients with glasgow 13 - 15, 9 - 12, ≤ 8 score at admission were 72%, 22% and 6% respectively It was noted that enlargement HV rate was different between groups of conscious disorder at admission (p = 0.04)

+ There is a difference in scores of neurological symptoms at admission assessed

by Glasgow, NIHSS, mRS scales in both groups

of increase and non-increase HV This difference

is statistically significant with a p value of 0.02, 0.02, and 0.03 respectively

Table 1: Comparison of neurological scales

between the two groups of increase and non-increase in HV

At admission

non increase

value

- Blood pressure:

When comparing the mean blood pressure

between the groups with and without increased

HV, we realized significant differences in

blood pressure between the two groups, the

SBP, DBP and MAP

Table 2: Comparison of blood pressure

between the two groups increased and did

not increase hematoma volume

p value

In the first 72 hours, the group increased

HV had average SBP > 140 mmHg compared

with the group of non-increase HV (average

SBP < 140 mmHg), this difference was

statistically significant (p = 0.0016) In a

study by Fujii [10], the results showed

enlargement HV rate increased significantly

with higher values SBP after admission,

the rate of HV increase in patients with

SBP < 145 mm Hg, 145 - 160 mm Hg,

> 160 - 175 mmHg, and ≥ 175 mmHg, 6.5%,

13.0%, 14.1%, and 21.7% respectively

- Characteristics of hematoma on CT:

+ HV on 2nd CT compared with 1st CT:

Figure 2: V1, V2 is HV on 1st and 2nd CT taken

at admission and 2nd time

(Sources: CT-scans of 1 patient in this study)

Figure 3: HV on 1st and 2nd CT of patients

In 188 patients, we recorded 24 patients (12.77%) with an increase in HV (enlargement cerebral hemorrhage), 164 patients (88.23%) without an increase when compared to HV

on CT.Scan 2nd to 1st, similar to the study

by Fujii et al: 14.0% and other studies : increased HV rate of 3% [5], 7% [9], 14% [10] Time blood continues to flow after ICH undetermined Bleeding time in ICH is usually supposed to end from a few minutes to an hour Fujii et al [11] studied 419 patients

with ICH, taken CT-scan within the first 24

hours after onset and the second within 24

hours of admission, 60 patients (14.3%) on

the 2nd CT increase HV The authors noted

that increased HV rate decreases over time

Some other studies showed that blood flow

may still continue and last longer than 6

hours after onset [7, 9]

- Location of hematoma on brain CT:

There were significant differences in the

rate of hematoma location between groups

divided according to location as follows:

82.98% basal ganglia, 2.66% capsule, 9.04%

thalamus, 5.32% brain lobes Over 85% of

patients had putamen hemorrhage Compared

with other studies, in a study by Nguyen

Minh Hien (1995) [1], the rate of putamen

hemorrhage was 48%, Nguyen Van Dang

(1997) was 50%, Duc Kiet Hoang with rate of

the capsule-striatum hemorrhage was 47.1%,

Nguyen Lien Huong: 38.6% In a study by

Matthew L.Flaherty (2005) in Kentucky-North

America, the rate of capsule - putamen

hemorrhage was 49% Although the significant

difference in hematoma location between

groups of patient was classified according to

location as above, there was no significant

difference in enlargement rate between

the groups hematoma location in the lobes,

basal ganglia, capsule and thalamus

(p = 0.26) This result was similar to the

study by Fujii [10]

- Shape of hematoma on the brain CT:

Ratio of enlargement hematoma in group

of irregular hematoma shape (10/22) was

significant higher than group of regular

hematoma shape (14/166) (p = 0.000) This

result is similar to the study by Fujii [10]

Figure 4: Shape of hematoma on the brain

CT (Source: CT at admission and second

of 1 patients in this study)

- HV on the first CT:

The relationship between increased HV and HV was shown examining in 188 STH patients HV increased in 20.83% of patients with HV small (< 15 cm3), 29.17% in those with moderate HV (15 - 29 cm3), 16.67% in those with big hematoma (30 - 45 cm3), and 33.33% in those with large hematoma (> 45 cm3) Enlargement HV rate increased significantly with an increase in blood volume

in the series first CT This result is similar to the study by Fujii [10]

- Time CTA:

Ratio of enlargement hematoma in group

of patients with time from onset to take the CTA < 6 hours, 6 - 12 hours before, 12 - before

18 hours, 18 - 24 hours: 34.78%, 30.43%,

0.0% and 34.78%, respectively Ratio of

enlargement hematoma in groups with

different times taken CTA did not differ

statistically significant (p = 0.12)

- Spot sign: Image of contrast drug

extravasation (spot sign) on brain CTA:

After ICH, the contrast brain CT scan

and/or CT.Angiography (CTA) in the early

hours, we can see image of contrast drug

extravasation and left in hematoma, the

predicted sign blood still continues to flow, which can identify the risk of increased

HV [6]

The results of our study revealed increased

HV in 18 of 168 patients without spot sign (75%), 6 of 20 patients with a spot sign (25%) When univariate analysis, this difference

is statistically significant (p = 0.005) The result is similar to the study by Ryan Wada (p = 0.0001), and E Josser Delgado Almandoz (p < 0.0001)

Figure 5: Spot sign on the CTA

(Source: CT at admission, CTA and CT 2nd times of 1 patient in this study)

- The test parameters:

Table 3: Comparison of the indices between the two groups of increase and

non-increase in HV

(1) (2) (3) (4)

White blood cell count and glycemie levels

in patients with increased HV was higher in

patients without increased HV, this difference

is statistically significant (p = 0.033) and

0.027 Similar results in the study of Kazui

and colleagues found that glycemie at

admission ≥ 141 mg/dl is a risk factor of

increasing HV According to Fisher CM

(1971), glycemie at admission ≥ 200 mg/dl

will aggrevate the clinical condition of the

ICH patient in the acute phase [4]

Univariate analysis above showed that

the presence of 14 factors related to

increased HV, of which, 9 were important

factors related to increased HV such as:

(1) Glasgow at admission, (2) NIHSS at

admission, (3) Rankin at admission, (4) SBP

at admission, (5) HV, (6) shape of hematoma,

(7) spot sign, (8) WBC and (9) glycemie

- Multivariate analysis of factors affecting

increase HV:

Our multivariate regression analysis

presented independent predictors of

increased HV Univariate analysis also

showed the presence of 14 factors related

to increased HV, which we picked out 9 key factors related to increased HV for inclusion

in multivariate analysis with the dependent variable of increased HV

Table 4: Multivariate analysis of factors

affecting the increase HV

Glasgow at

NIHSS at

Rankin at

SBP at

Shape of

Results of multivariate analysis showed

that two independent prognostic factors with

increasing HV are: (1) the shape of the

hematoma is irregular on CT (OR = 0.19,

p = 0.005), and (2) Spot sign on CTA (OR =

2.41, p = 0.044)

In this study, we identified two prognostic

factors that independently increased HV

are: (1) the shape of the hematoma is

irregular on CT, and (2) Spot sign on CTA

Compared with previous studies, those by

Fujii [10], in addition to the shape of the

hematoma is irregular on CT factor, this

author also recorded 4 other factors with

independent prognostic HV increase including:

(1) time from onset to admission early (before

6h), (2) the amount of alcohol consumed

during the day, (3) consciousness disorders

at admission, and (4) low fibrinogen levels

As for spot sign, our results are similar to

two studies by Ryan Wada and Josser E,

Delgado Almandoz that signals spot is an

independent prognostic factor for the increase

in HV

Conclusion

Through a prospective study of 188 STH

patients with hypertension at admission, we

draw some conclusions:

- Average age: 58 years old, men were

twice as many as women

- The time between stroke onset and

hospitalization was 4 hour on average, only

5.3% during the first hour, 40.4% at 3 hours

- Average HV on 2nd CT was 26.54 cm3,

1st CT was 22.35 cm3 89.36% of patients

had regular hematoma shape, 10.64% had

irregular hematoma shape, over 85% of

STH located in the basal ganglia and capsule

- 10.64% of STH patients had the spot sign on CTA

- Rate of increased HV on 2nd CT after

72 hours was 12.77% when compared with

1st CT

- Univariate analysis showed that 9 important factors related to increased HV are: (1) Glasgow at admission, (2) NIHSS at admission, (3) Rankin at admission, (4) SBP at admission, (5) hematoma volume, (6) shape of hematoma, (7) spot sign, (8) WBC and (9) glycemie

- Multivariate analysis showed that two independent prognostic factors related to

an increase in HV: (1) the shape of the hematoma was irregular on CT (OR = 0.19,

p = 0.005) and (2) spot sign on CTA (OR = 2.41, p = 0.044)

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