Changes of clinical and intracerebral hematoma volume, noncontrast and contrast brain ct - scan images in acute supratentorial hemorrhage

Nội dung text: Changes of clinical and intracerebral hematoma volume, noncontrast and contrast brain ct - scan images in acute supratentorial hemorrhage

1. Journal of military pharmaco-medicine 7-2013 CHANGES OF CLINICAL AND INTRACEREBRAL HEMATOMA VOLUME, NONCONTRAST AND CONTRAST BRAIN CT-SCAN IMAGES IN ACUTE SUPRATENTORIAL HEMORRHAGE Nguyen Van Chuong*; Dinh Vinh Quang** summary After intracerebral hemorrhage, the clinical status changes and hematoma volume (HV) in the brain associated with the prognosis of patients. Our goals were to comment changes of clinical and intracerebral hematoma volume, noncontrast and contrast brain CT-Scanner images in acute supratentorial hemorrhage. 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 of 58.2, including 128 males (68%) and 60 females (32%). There were no differences in the Glasgow, mRS score, only differences in the two time points NIHSS at admission and after 72 hours. HV average on 2nd CT was 26.54 cm3, 1st CT was 22.35 cm3, rate has increased HV on 2nd CT after 72 hours was 12.77%. * Key words: Supratentorial hemorrhage; Noncontrast and contrast brain CT-Scanner images. Introduction After ICH, the clinical status changes and hematoma volume (HV) in the brain Although stroke is a classic pathology of associated with the prognosis of patients. In the neurology, but still a topical issue in the our daily work, we have to treat brain stroke world because it is the cause of death ranks patients in general, and particular in ICH, but third after cancer and heart disease, the cause the results are not as expected, because of of leading death in neuropathy. According to some patients thought to be rescued and Orgogozo (1995) and R.Hart (1994), intracerebral hemorrhage (ICH) accounts for 15% to 20% clinical outcomes will be better but worse go of brain stroke patients, and this condition and die. Therefore, we studied 188 supratentorial can cause death or severe disability than ICH patients in order to: Comments changes cerebral infarction [2]. Every year, more than of clinical and intracerebral hematoma volume, 20,000 Americans die of ICH. ICH frequency noncontrast and contrast brain CT-Scan of 10 - 20 people per 100,000 population and images in acute supratentorial hemorrhage increases with age [7]. for 72 hours after onset. * 103 Hospital ** 115 Hospital Address correspondence to Nguyen Van Chuong: 103 Hospttal E.mail: nvch@yahoo.com
2. Journal of military pharmaco-medicine 7-2013 Subjects and Methods + BP, consciousness at admission, paralysis of cranial nerve VII, strength of the arms 1. Study subjects. and legs paralyzed. Patients with acute supratentorial hemorrhage + The Glasgow, NIHSS, Rankin at admission associated with hypertension, admission before and 72 hours after onset. six hours after onset, treated at the Department of Cerebral-Vascular Pathology, 115 People + BP at 6 hour, then BP measurement Hospital from 1 - 2011 to 4 - 2013 agreed every 4 hours to 72 hours after stroke. with inclusion criteria will be included in the - Tests data: study. + Noncontrast brain CT on admission. * Inclusion criteria: + Brain CT-angiography (CTA) in the first ICH is the first acute supratentorial 24 hours after onset. hemorrhage associated with hypertension + Second noncontrast brain CT when at admission, admitted within six hours after clinical status worsening (Glasgow score onset, with brain images computerized decreased from 2 points or more) or at the tomography (CT) to confirm the diagnosis of time of 72 hours after onset. supratentorial hemorrhage. * Assessment criterial: Hypertension diagnostic criteria (the JNC - Clinical status after 72 hours was VII): The systolic blood pressure (SBP) is higher assessed by Glasgow scale, NIHSS, mRS. than 140 and/or diastolic blood pressure (DBP) Change clinically was evaluated by comparing higher than 90 mmHg. the Glasgow, NIHSS, mRS at admission * Exclusion criteria: and after 72 hours. - Supratentorial hemorrhage (STH) due - STH status of patients after 72 hours to aneurysm rupture, due to arteriovenous were evaluated in two groups: blood volume malformations, moyamoya disease, by using without increased and increased (enlargement). anticoagulants or anti-platelet drugs. HV in the brain increases granted under -.STH with blood intraventricular Kazui [8] as V2 - V1 ≥ 12.5 cm3 or V2/V1 (intraventricular hemorrhage). ≥ 1.4, where V1, V2 respectively HV on brain st nd - Patients die before the second CT-Scan CT-Scan 1 and 2 time. shot. - HV calculated by Kothari,s formulas (or - STH transformation of cerebral infarction. Broderich): V = (AxBxC)/2 [10]. Where A, B, C are the three largest diameter perpendicular - Renal failure, creatinine ≥ 1.7 mg/dl. to each other in three dimensions of the - History of allergy to contrast drugs. hematoma. 2. Research methodology. Study design: descriptive, prospective Results and discussion analysis. After collecting data and statistical analysis * Data collection: in the study group of 188 patients from 2010 - The clinical data: to 2013, we had the following results:
3. Journal of military pharmaco-medicine 7-2013 1. General characteristics of the study * Blood pressure: group. Table 1: Blood pressure of patients at - Age: The average age was 58.29, admission. similar to the common age for stroke in general, but age in our study was slightly On admission Mean Min Max smaller than the age of the other ICH studies SBP 165 140 240 [1, 2, 6, 7]. According to the literature, the rate of brain stroke increased with age. In DBP 97 90 140 developed countries with aging populations, MAP 100 79 128 the average age of stroke in brain research in these countries was higher than in our study, * Consciousness at admission: as well as studies conducted in developing At the hospital: 72% had in Glasgow from countries. 13 - 15, the number of patients in the group - Gender: 188 patients, including 128 with consciousness disorders decreased with males (68.08%) and 60 females (31.91%), the severity of consciousness. male:females was 2:1. - The time between admission and stroke: * Paralysis of cranial nerve VII: 93% of average 4.03 hours, of which 10 patients (5.3%) patients had paralyzed nerves VII, only 13 had stroke during the first hospitalization, patients (6.9%) were not paralyzed nerve 76 patients (40.4%) at 3 hours. VII. 2. Clinical features. * Hemiplegia: right (48.4%) and left * Symptoms at onset: (51.6%) hemiplegia were almost the same. * Strength of the paralyzed arms and legs: At admission, all patients (100%) in paralyzed arms to varying degrees, only 1 patient (0.53%) was not paralyzed in the legs. * Neurological deficiencies at admission: Table 2: Neurological deficiencies of patients at admission according to neurological scales. at admission Min Max Mean SD Glasgow 5 15 13.3 2.27 NIHSS* 2 36 12.7 6.49 Figure 1: The symptoms of patients at onset. Rankin 2 5 3.8 0.49 When STH, all patients in the plot study were paralyzed to varying degrees, headache (* Median [inter-quartile range] 12 (7, 16) was common symptoms of 2 nd following * Neurological deficiencies at admission paralysis. was assessed by three neurological scales:
4. Journal of military pharmaco-medicine 7-2013 * Location of hematoma on brain CT: There were significant differences in the rate of hematoma location between groups according to location as follows: 82.98% basal ganglia, 2.66% capsule, 9.04% thalamus, 5.32% brain lobes. Over 85% of patients with putamen hemorrhage. * Shape of hematoma on the 1st brain CT: 20 patients (10.64%) had irregular hematoma Figure 2: Neurological deficiencies at admission were assessed by three shape, 168 patients (89.36%) had regular st neurological scales. hematoma shape on the 1 brain CT. Almost of patients with severe neurological * Spot sign: Image of contrast drug deficiencies level (mRS ≥ 4). extravasation (spot sign) on brain CTA: 3. Brain computerized tomography at admission (1st time). After ICH, the contrast brain CT scan * Time of 1st brain CT: and/or CT-angiography (CTA) in the early In 188 patients, brain CT-Scanner time hours could be seen image of contrast drug was as early as 30 minutes after onset, extravasation and left in hematoma, the median (inter-quartile range) of 200 (120 - predicted blood sign still continues to flow, 310) minutes. Only 5.85% of patients had and can identify patients at increased risk done CT-Scanner before the first 1 hour after onset. The majority (30.32%) had a HV [3, 5, 9]. CT-Scanner first time over a period of 5 - 6 In this study, 20 patients (10.64%) had hours after onset. spot sign on CTA. * Hematoma volume on 1st brain CT: Figure 3: Hematoma volume on 1st brain CT. In the 188 patients studied, nearly half of patients with HV < 15 ml (cm3).
5. Journal of military pharmaco-medicine 7-2013 * Time noncontrast 2nd brain CT: Table 3: Time taken 2nd brain CT-Scanner (at clinical worsening or 72 hours after stroke onset). 2nd brain Mean Min Max SD CT-Scanner Time (h) 66.60 5 72 16.10 * Evaluating patient’s clinical and CT, compared 2nd with the 1st times: Table 4: Clinical assessment of patients, compared 2nd with the 1st times. Scale Mean Min Max SD P value Glasgow 1st 13.3 5 15 2.27 0.07 2nd 12.9 3 15 3.32 NIHSS 1st 12.7 2 36 6.49 0.0005* nd 2 12.8 0 41 8.92 Figure 4: Spot sign on CTA (arrow). mRS 1st 3.8 2 5 0.49 0.37 (Source: Nonconstrast and contrast brain 2nd 3.7 1 6 0.83 CT of 1 patient from this study). (* Wilcoxon sign rank test) * Time CTA: * Change of Glasgow, NIHSS, Rankin score after 72 hours: When comparing the second Glasgow, NIHSS, Rankin to the first at admission, we found no differences in Glasgow at two time points (13.32 and 12.97) with p = 0.07, there was not difference in the mRS score at two time points (3.84 and 3.79) with p = 0.37, about the NIHSS scale, their differences in NIHSS score at two time points with median (quartile range) was 12 (7.16) and 11 (6.16) with p = 0.0005. Thus, over a period of 72 hours after stroke onset, Figure 5: The time from stroke onset NIHSS scale is one of three most sensitive to take CTA. scales to assess the neurological deficiencies after stroke. Only 39 patients (20.97%) took CTA in * HV on 2nd brain CT as compared with 1st: the first 6 hours after the onset of STH, mostly concentrated in the period from There were 24 patients (12.77%) with st 6 - 12 hours (32.26%) and 18 - 24 hours increased HV when compared HV on 1 nd (34, 41%) after stroke onset. brain CT with the 2 times. Enlargement
6. Journal of military pharmaco-medicine 7-2013 HV rate was 20.83% in patients with small - HV average on 2nd CT was 26.54cm3, hematoma volume (< 15 cm3), 29.17% in 1st CT was 22.35 cm3. 3 those with moderate HV (15 - 29 cm ), - 89.36% of patients had regular hematoma 16.67% in those who had big hematoma (30 shape, 10.64% had irregular hematoma shape, 3 - 45 cm ), and 33.33% in those with a large over 85% of STH located in the basal ganglia 3 hematoma (> 45 cm ). Enlargement HV rate and capsule. increased significantly with an increase in -10.64% of patients had spot sign on the blood volume in the first CT. Result was CTA. similar in a study by Fujii [4]. nd - The rate of increased HV on 2 CT after Conclusion 72 hours was 12.77%. Through prospectively study of 188 patients REFERENCES STH with hypertension at admission, we draw 1. Allyson R. Zazulia MD, Michael N. Diringer some conclusions: MD, Colin P. Derdeyn MD, William J. Powers MD. - The average age was 58 years old, the Progression of mass effect after intracerebral rate of men was an twice much as women. hemorrhage. Stroke. 1999, 30, pp.1167-1173. - When STH, all of the patients (100%) in 2. Anderson CS, Jamrozik KD, Broadhurst the plots study were paralyzed to varying RJ, Stewart-Wynne EG. Predicting survival for 1 degrees, the percentage of patients with year among different subtypes of stroke: results from the Perth Community Stroke Group. Stroke. right and left paralyzed almost the same; 1994, 25, pp.1935-1944. headache was common symptoms ranking 3rd 3. Becker KJ, Baxter AB, Bybee HM, following paralysis and paralyzed VII nerve. Tirschwell DL, Abouelsaad T, Cohen WA. - At the hospital: 72% of patients had in Extravasation of radiographic contrast is an Glasgow from 13 - 15, the number of patients independent predictor of death in primary in the group with consciousness disorders intracerebral hemorrhage. Stroke. 1999, 30, decreased with the severity of consciousness. pp.2025-2032. - SBP average was 165 mm Hg, DBP was 4. Fujii Y TR, Takeuchi S, Minakawa T, 97 and MAP was 100 mmHg at admission. Sasaki O. Multivariate analysis of hematoma - SBP 72 h average was 138, DBP was enlargement in spontaneous intracerebral 81mmHg. hemorrhage. Stroke. 1998, 29, pp.1160-1166. - Average of Glasgow, NIHSS, Rankin 5. Goldstein JN, Fazen LE, Snider R, Schwab K, Greenberg SM, Smith EE, Lev MH, score when assessing 2nd were 12.97, 12.86 Rosand J. Contrast extravasation on CT and 3.79, respectively. There was no difference angiography predicts hematoma expansion in in the Glasgow, mRS score, only differences intracerebral hemorrhage. Neurology. 2007, 68, in the two time points NIHSS at admission pp.889-894. and after 72 hours with p = 0.0005. During 6. Josser E. Delgado Almandoz MD; Albert J. the 72 hours after stroke, NIHSS scale was Yoo MD, Michael J. Stone MD, Pamela W. the most sensitive of three scales when Schaefer MD, Joshua N. Goldstein MD PhD, assessing neurological deficiencies after stroke. Jonathan Rosand MD MSc, Alexandra Oleinik BA, Michael H. Lev MD, R. Gilberto Gonzalez
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