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intracerebral_hemorrhage_case_series

Intracerebral hemorrhage case series

Sakuta et al. retrospectively reviewed 142 consecutive primaries intracerebral hemorrhage patients admitted to a hospital between September 2016 and December 2018. The NAG scale consists of three factors: National Institute of Health Stroke Scale (NIHSS) score ≥ 10, anticoagulant use, and glucose ≥133 mg/dl (1 point each). Patients underwent non-contrast computed tomography (CT) within 24 h of symptom onset and follow-up CT 6 h, 24 h, and 7 days after admission. They defined hematoma expansion (HE) as increased hemorrhage volume > 33% or an absolute increase of >6 mL on follow-up CT. Poor prognosis was defined as a modified Rankin scale score of 4-6 at discharge. We performed logistic regression analysis and created receiver operating characteristic curves to determine the discrimination ability of the NAG score.

Patients constituted 96 men and 46 women (median age: 64 years; median NIHSS: 11), and HE was observed in 38/142 patients (27%). Higher NAG sores were associated with HE (P < .001), poor prognosis (P < .001), and in-hospital death (P < .001). The C statistic was 0.72 (95% confidence interval [CI]: 0.63-0.82) for HE, 0.67 (95% CI: 0.58-0.76) for poor prognosis, and 0.85 (95% CI: 0.74-0.95) for in-hospital death. Multivariate logistic regression analysis with known risk factors showed that NAG scale score was an independent risk factor for HE (odds ratio: 2.95; 95% CI: 1.57-5.52; P = .001)

The NAG scale showed good discrimination in a multi-institutional validation. 1).


In a cohort (n=1094), there were 306 deaths (per 100 patient-years: absolute event rate 11.7, 95% CI 10.5 to 13.1); 156 were “early” and 150 “late”. In multivariable analyses, early death was independently associated with age (per year increase, HR 1.05, p=0.003), history of hypertension (HR 1.89, p=0.038), pre-event mRS (per point increase, HR 1.41, p<0.0001), admission NIHSS (per point increase, HR 1.11, p<0.0001), and hemorrhage volume > 60ml (HR 4.08, p<0.0001). Late death showed independent associations with age (per year increase, HR 1.04, p=0.003), pre-event mRS (per point increase, HR 1.42, p=0.001), prior anticoagulant use (HR 2.13, p=0.028) and the presence of intraventricular hemorrhage (HR 1.73, p=0.033) in multivariable analyses. In further analyses where time was treated as continuous (rather than dichotomized), the hazard ratio of previous cerebral ischaemic events increased with time, whilst those for GCS, NIHSS and ICH volume decreased over time.

They provided new evidence that not all baseline factors associated with early mortality after intracerebral hemorrhage are associated with mortality after 6 months, and that the effects of baseline variables change over time. The findings could help design better prognostic scores for later death after intracerebral hemorrhage 2).


Xu et al., reviewed the medical records of patients treated with minimally invasive surgery plus local thrombolysis for intracerebral hemorrhage between November 2013 to December 2015 in an intensive care unit of a tertiary care hospital. Depending upon the vascular images, unruptured intracranial aneurysms were identified. The primary outcome was any of postoperative intracranial rebleeding. The second outcome included the 30-day death and 6-month follow up graded by Modified Rank Scale. Blind abstractors reviewed the medical data and binary logistic regression was performed to investigate the risk factors of poor prognosis.

They identified a cohort of consecutive 188 patients, of whom 23 (12.2%) harbored unruptured intracranial aneurysms. There were 28 aneurysms documented in this study, among which 3 were in the posterior circulation. And in total, 20 (11.3%) cases suffered from postoperative hematoma growth, of which 4 were with aneurysms. Additionally,the 30-day mortality after stroke in patients with aneurysms was 8.69% (2/23), comparable to 13.33% in without (22/165,p = 0.744). The proportion of the favorable outcome at 6-month follow-up in patients with aneurysms was comparable to that in without (47.8% versus 48.5%,p = 1.000) Insignificant associations were demonstrated between the unruptured intracranial aneurysms and postoperative intracranial rehemorrhage (p = 0.092), 30-day death(p = 0.588) and poor long-term prognosis (p = 0.332), respectively.

The findings suggest that unruptured intracranial aneurysms seem to represent no increased risks of poor outcome after local thrombolysis for intracerebral hematomas 3).


Patients with deep seated spontaneous ICH who were admitted to the Golestan Hospital, of Ahvaz, from November 2014 to February 2016, were prospectively enrolled in this study. A prospective clinical trial where 30 patients diagnosed having large hypertensive ICH was randomly allocated to either group A or B using permuted-block randomization. These patients (n = 30), who all had large deep seated supratentorial ICH with surgery indications, were randomly divided to two groups. ultimately, in one group (n = 13), large DHC was performed without clot evacuation, while in the other (n = 17), craniotomy with clot evacuation was done. Data pertaining to the patients' characteristics and treatment outcomes were prospectively collected.

There was no statistically significant difference between two treatment groups (P > 0.05). No significant difference was observed between the two groups in terms of mortality and GOS at 6 months (P > 0.05); nevertheless, the good outcome (Glasgow Outcome Scale = 4-5) for patients with hematoma evacuation was slightly higher (35.3%) as compared to the DHC patients without clot evacuation (30.7%).

Decompresive craniectomy without clot evacuation in deep seated ICH can be accomplished with identical mortality and outcome in comparison to patient that undergone clot evacuation 4).


A multicentre cohort study was conducted in all consecutive patients with ICH admitted to the ICUs of three hospitals with a neurosurgery department between 2009 and 2012 in Andalusia, Spain. Data collected included ICH, Glasgow Coma Scale (GCS) and Acute Physiology and Chronic Health Evaluation II (APACHE-II) scores. Demographic data, location and volume of haematoma and 30-day mortality rate were also collated.

A total of 336 patients were included. 105 of whom underwent surgery. Median (IQR) age: 62 (50-70) years.

APACHE-II: 21(15-26) points, GCS: 7 (4-11) points, ICH score: 2 (2-3) points. 11.1% presented with bilateral mydriasis on admission (mortality rate=100%). Intraventricular hemorrhage was observed in 58.9% of patients. In-hospital mortality was 54.17% while the APACHE-II predicted mortality was 57.22% with a standardised mortality ratio (SMR) of 0.95 (95% CI 0.81 to 1.09) and a Hosmer-Lemenshow test value (H) of 3.62 (no significant statistical difference, n.s.). 30-day mortality was 52.38% compared with the ICH score predicted mortality of 48.79%, SMR: 1.07 (95% CI 0.91 to 1.23), n.s. Mortality was higher than predicted at the lowest scores and lower than predicted in the more severe patients, (H=55.89, p<0.001), Gruppo Italiano per la Valutazione degli Interventi in Terapia Intensiva calibration belt (p<0.001). The area under a receiver operating characteristic (ROC) curve was 0.74 (95% CI 0.69 to 0.79).

ICH score shows an acceptable discrimination as a tool to predict mortality rates in patients with spontaneous ICH admitted to the ICU, but its calibration is suboptimal 5).


A retrospective study aimed to evaluate the effectiveness and safety of 3 surgical procedures for Spontaneous Supratentorial Intracerebral Hemorrhage (SICH).A total of 63 patients with SICH were randomized into 3 groups. Group A (n = 21) underwent craniotomy surgery, group B (n = 22) underwent burr hole, urokinase infusion and catheter drainage, and group C (n = 20) underwent neuroendoscopic surgery. The hematoma evacuation rate of the operation was analyzed by 3D Slice software and the average surgery time, visualization during operation, decompressive effect, mortality, Glasgow Coma Scale (GCS) improvement, complications include rebleeding, pneumonia, intracranial infection were also compared among 3 groups.All procedures were successfully completed and the hematoma evacuation rate was significant differences among 3 groups which were 79.8%, 43.1%, 89.3% respectively (P < .01), and group C was the highest group. Group B was smallest traumatic one and shared the shortest operation time, but for the lack of hemostasis, it also the highest rebleeding group (P = .03). Although there were different in complications, but there was no significant in pneumonia, intracranial infection, GCS improvement and mortality rate.All these 3 methods had its own advantages and shortcomings, and every approach had its indications for SICH. Although for neuroendoscopic technical's minimal invasive, direct vision, effectively hematoma evacuation rate, and the relatively optimistic result, it might be a more promising approach for SICH 6).


A multi-institutional, retrospective analysis of 563 patients with spontaneous ICH from 2010 to 2014 was performed with multivariate regression modeling. Primary outcomes were patient mortality and functional status with modified Rankin Scale score. To control for differences in patient and clinical characteristics influencing EVD utilization, a propensity score analysis was performed with patient-specific predicted probability of EVD use.

The multivariable logistic regression model showed odds of EVD use increased with younger age, lower ICH volume, ICH located outside the brainstem, increasing IVH volume, and concurrent IVH; the model showed high discriminability for EVD use (area under the receiver operating curve 0.84, R2McFadden = 0.27). The use of EVD was associated with lower 30-day mortality in patients with ICH score of 4 (odds ratio = 0.09, P = 0.002), greater ICH volume (>11 cc, odds ratio = 0.47, P = 0.019), and lower initial GCS (<13, 0.38, P = 0.003) in propensity score-adjusted analyses, as well as a trend toward lower mortality in patients with IVH and greater modified Graeb score. There was no benefit to morbidity in patients receiving an EVD.

Among a large, multi-institutional cohort, this statistical propensity analysis model accurately predicted EVD use in ICH. EVD use was associated with a trend towards decreased mortality but greater modified Rankin Scale score for functional outcomes 7).


Liu et al., selected 125 patients with acute cerebral hemorrhage admitted within 24 hours of symptom onset. Blood calcium levels were assessed by standard biochemical methods. Hematoma volume was measured by quantitative computed tomography. NIHSS (National Institutes of Health Stroke Scale) scores at one month, and the differences in survival rate and survival period at follow-up visits were assessed.

Hematoma volume and NIHSS scores of the hypocalcemic group were higher than those of the hypercalcemic group. Those of the normocalcemic group were the lowest, and the differences were statistically significant (p < 0.05). The survival rate and survival period of the normocalcemic group were higher than those of the other two groups and the differences were statistically significant (p < 0.05). The logistics regression analysis showed that the APACHE II score, blood calcium level upon admission and hematoma volume were independent risk factors for survival (p < 0.05).

If blood calcium level is too low or too high, hematoma volume and stroke severity of acute cerebral hemorrhage patients may increase and is related to long-term survival 8).


To determine whether hypodense regions, irrespective of their specific patterns, are associated with hematoma expansion in patients with ICH Boulouis et al analyzed a large cohort of 784 patients with ICH (the development cohort; 55.6% female), examined NCCT findings for any hypodensity, and replicated the findings on a different cohort of patients (the replication cohort; 52.7% female). Baseline and follow-up NCCT data from consecutive patients with ICH presenting to a tertiary care hospital between 1994 and 2015 were retrospectively analyzed. Data analyses were performed between December 2015 and January 2016.

Hypodensities were analyzed by 2 independent blinded raters. The association between hypodensities and hematoma expansion (>6 cm3 or 33% of baseline volume) was determined by multivariable logistic regression after controlling for other variables associated with hematoma expansion in univariate analyses with P ≤ .10.

A total of 1029 patients were included in the analysis. In the development and replication cohorts, 222 of 784 patients (28.3%) and 99 of 245 patients (40.4%; 321 of 1029 patients [31.2%]), respectively, had NCCT scans that demonstrated hypodensities at baseline (κ = 0.87 for interrater reliability). In univariate analyses, hypodensities were associated with hematoma expansion (86 of 163 patients with hematoma expansion had hypodensities [52.8%], whereas 136 of 621 patients without hematoma expansion had hypodensities [21.9%]; P < .001). The association between hypodensities and hematoma expansion remained significant (odds ratio, 3.42 [95% CI, 2.21-5.31]; P < .001) in a multivariable model; other independent predictors of hematoma expansion were a CT angiography spot sign, a shorter time to CT, warfarin use, and older age. The independent predictive value of hypodensities was again demonstrated in the replication cohort (odds ratio, 4.37 [95% CI, 2.05-9.62]; P < .001).

Hypodensities within an acute ICH detected on an NCCT scan may predict hematoma expansion, independent of other clinical and imaging predictors. This novel marker may help clarify the mechanism of hematoma expansion and serve as a useful addition to clinical algorithms for determining the risk of and treatment stratification for hematoma expansion 9).

1)
Sakuta K, Yaguchi H, Sato T, Mukai T, Komatsu T, Sakai K, Mitsumura H, Okuno K, Tanaka T, Iguchi Y. The NAG scale can screen for hematoma expansion in acute intracerebral hemorrhage-a multi-institutional validation. J Neurol Sci. 2020 Apr 11;414:116834. doi: 10.1016/j.jns.2020.116834. [Epub ahead of print] PubMed PMID: 32325359.
2)
Banerjee G, Ambler G, Wilson D, Hostettler IC, Shakeshaft C, Lunawat S, Cohen H, Yousry T, Al-Shahi Salman R, Lip GYH, Houlden H, Muir KW, Brown MM, Jäger HR, Werring DJ; CROMIS-2 collaborators. Baseline factors associated with early and late death in intracerebral haemorrhage survivors. Eur J Neurol. 2020 Mar 29. doi: 10.1111/ene.14238. [Epub ahead of print] PubMed PMID: 32223078.
3)
Xu F, Lian L, Liang Q, Pan C, Pan C, Hu Q, Chen R, Wang F, Zhang M, Tang Z, Zhu S. Is it dangerous to treat spontaneous intracerebral hemorrhage by minimally invasive surgery plus local thrombolysis in patients with coexisting unruptured intracranial aneurysms? Clin Neurol Neurosurg. 2019 Mar 15;180:62-67. doi: 10.1016/j.clineuro.2019.03.013. [Epub ahead of print] PubMed PMID: 30947028.
4)
Rasras S, Safari H, Zeinali M, Jahangiri M. Decompressive hemicraniectomy without clot evacuation in supratentorial deep-seated intracerebral hemorrhage. Clin Neurol Neurosurg. 2018 Nov;174:1-6. doi: 10.1016/j.clineuro.2018.08.017. Epub 2018 Aug 23. PubMed PMID: 30172088.
5)
Rodríguez-Fernández S, Castillo-Lorente E, Guerrero-Lopez F, Rodríguez-Rubio D, Aguilar-Alonso E, Lafuente-Baraza J, Gómez-Jiménez FJ, Mora-Ordóñez J, Rivera-López R, Arias-Verdú MD, Quesada-García G, Arráez-Sánchez MÁ, Rivera-Fernández R. Validation of the ICH score in patients with spontaneous intracerebral haemorrhage admitted to the intensive care unit in Southern Spain. BMJ Open. 2018 Aug 13;8(8):e021719. doi: 10.1136/bmjopen-2018-021719. PubMed PMID: 30104314; PubMed Central PMCID: PMC6091906.
6)
Cai Q, Zhang H, Zhao D, Yang Z, Hu K, Wang L, Zhang W, Chen Z, Chen Q. Analysis of three surgical treatments for spontaneous supratentorial intracerebral hemorrhage. Medicine (Baltimore). 2017 Oct;96(43):e8435. doi: 10.1097/MD.0000000000008435. PubMed PMID: 29069046; PubMed Central PMCID: PMC5671879.
7)
Lovasik BP, McCracken DJ, McCracken CE, McDougal ME, Frerich JM, Samuels OB, Pradilla G. The Effect of External Ventricular Drain Use in Intracerebral Hemorrhage. World Neurosurg. 2016 Oct;94:309-318. doi: 10.1016/j.wneu.2016.07.022. Epub 2016 Jul 17. PubMed PMID: 27436212.
8)
Liu J, Yang H, Yu B. The correlation between blood calcium level, hematoma volume, stroke severity and prognosis in patients with acute cerebral hemorrhage. Eur Rev Med Pharmacol Sci. 2016 Oct;20(19):4119-4123. PubMed PMID: 27775786.
9)
Boulouis G, Morotti A, Brouwers HB, Charidimou A, Jessel MJ, Auriel E, Pontes-Neto O, Ayres A, Vashkevich A, Schwab KM, Rosand J, Viswanathan A, Gurol ME, Greenberg SM, Goldstein JN. Association Between Hypodensities Detected by Computed Tomography and Hematoma Expansion in Patients With Intracerebral Hemorrhage. JAMA Neurol. 2016 Jun 20. doi: 10.1001/jamaneurol.2016.1218. [Epub ahead of print] PubMed PMID: 27323314.
intracerebral_hemorrhage_case_series.txt · Last modified: 2020/04/25 00:20 by administrador