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

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

1. Journal of military pharmaco-medicine 7-2013 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 Identifying the factors that increase HV(HV) after ICH is important in the treatment and Stroke, one of the causes of death in prognosis of ICH patients. In the acute ICH neurological diseases, or prolonged sequelae phase, if hypertension uncontrolled can increase and disabilities, is a common disorder. the risk of continuous bleeding or re-bleeding, Intracerebral hemorrhage (ICH) accounted increased HV. For the treatment and better for 15 to 20% of stroke, causing death or care of ICH patients in the early hours, we severe disability more than cerebral infarction performed this study, aiming to: Evaluate the [3]. In ICH appeared, risk factors, hypertension relationship between tests, clinical factors to and cerebral amyloid angiopathy accounted change intracerebral HV in acute supratentorial for 78-88% [2]. hemorrhage in first 72 hours after onset. When ICH appears, there are some factors affecting to clinical status of the Subjects and Methods patient (PT). An increase in HV in the brain after ICH is a major cause worsening 1. Subjects. clinical condition and is an independent Patients with acute supratentorial hemorrhage predictor for mortality and outcome [8]. associated with hypertension, admission before * 115 Hospital ** 103 Hospital Address correspondence to Dinh Vinh Quang: 115 Hospital E.mail: quanghung115@yahoo.com.vn
2. Journal of military pharmaco-medicine 7-2013 six hours after onset, treated at Department + Glasgow, NIHSS, Rankin at admission of Cerebral-Vascular Pathology, 115 People and 72 hours after onset. Hospital from 1 - 2011 to 4 - 2013 agreed with + BP at 6 hour, then BP measurement enrollment in the study. Inclusion criteria will every 4 hours to 72 hours after stroke. be included in the study. - Tests data: * Inclusion criteria: + Take unenhanced CT at admission. ICH is the first acute supratentorial + Blood tests: Red blood cells (RBC), hemorrhage (STH) associated with hypertension hemoglobin (Hb), hematocrit (Hct), white at admission, admitted within six hours after blood cells (WBC), platelet count (PTC), onset. Brain images on computerized glycemie, total cholesterol, LDL-cholesterol, tomography (CT) help diagnose supratentorial HDL-cholesterol, triglyceride, liver function hemorrhage. tests (AST, ALT-aspartate aminotransferase, Hypertension diagnostic criteria (the JNC alanine aminotransferase), renal function (bun, VII): The systolic blood pressure (SBP) higher creatinine), PT (prothrombin time), APTT than 140 and/or diastolic blood pressure (DBP) (activated partial thromboplastin time), higher than 90 mmHg. fibrinogen, INR. * Exclusion criteria: + Brain CT-angiography (CTA) in the first 24 hours after onset. - Supratentorial hemorrhage (STH) due to aneurysm rupture, arteriovenous malformations, + Take the second unenhanced CT as moyamoya disease, by using anticoagulants clinical status worsen (Glasgow score or anti-platelet drugs. decreased from two points or more) or 72 hours after stroke. -.STH with blood intraventricular (intraventricular hemorrhage). 4. Assessment criterial. - Patients died before the second CT.Scan - STH status of patients after 72 hours shot. was evaluated in two groups: blood volume without increase and increase (enlargement). - STH transformation of cerebral infarction. HV in the brain increases under Kazui [16] - Renal failure, creatinine ≥ 1.7 mg/dl. as V2 - V1 ≥ 12.5 cm3 or V2/V1 ≥ 1.4, where - A history of allergy to contrast drugs. V1, V2 respectively HV on brain CT-scan 1st nd 2. Research methodology. and 2 time. , Study design: descriptive, prospective - HV calculated by Kothari s formular (or Broderich): V = (A x B x C)/2. Where A, B, C analysis, univariate regression and multivariate. are the largest three diameter perpendicular 3. Data collection. to each other in three dimensions of the - The clinical data: age, gender, time from hematoma. onset to hospitalization, history of hypertension, - Find the factors affecting changes HV diabetes, heart disease, liver disease, smoking, of STH in the first 72 hours after admission drinking, time of onset, the symptoms onset. by means of univariate regression analysis. + BP, consciousness at admission, paralysis - After univariate analysis, the significant of cranial nerve VII, strength of the arms important variables in univariate analysis will and legs paralyzed. be included in a multivariate regression analysis
3. Journal of military pharmaco-medicine 7-2013 to find the binary logistic variable prognostic the two groups with p value of 0.78, 1.00, value after adjustment by other variables 1.00, 1.00, 0.75, 0.59 respectively . and evaluate odds ratio OR (odds ratio). 3. The clinical factors and test. Results and discussion - Symptoms at onset: 1. General characteristics of the study + There is no difference in symptoms at group. onset such as dizziness, headache, vomiting, - Age: mean age: 58.29, similar to the seizures, speech disorders between two common age for stroke in general. groups of increase and non-increase HV - Gender: 188 patients, including 128 males with p value of 0.75, 0, 45, 0.059, 1.00, and (68.08%) and 60 females (31.91%), ratio 0.13 respectively. between men and women was 2:1. + Rate enlargement HV in patients with - The onset period and admission: average paralysis on the left (70.83%) was significantly 4.03 hours, of which, 10 patients (5.3%) in higher than the right side paralyzed patients the first hour, 76 patients (40.4%) in 3 hours. (29.17%), this difference was statistically 2. The risk factors. 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 Figure 1: The risk factors of stroke is statistically significant with a p value of patients with STH. 0.02, 0.02, and 0.03 respectively. Patients with history of hypertension are Table 1: Comparison of neurological scales 4 times as many as those without history of between the two groups of increase and hypertension. In the study group, most patients non-increase in HV. had no history of liver disease, heart disease At non p and stroke before ICH. increase admission increase value In comparing the two groups of increase and non-increase HV in patients with history Glasgow 15 13.5 0.02 of non-and hypertension, diabetes, heart NIHSS 12.3 15.5 0.02 disease, liver disease, smoking, alcohol Rankin 3.8 4.0 0.03 drinking, we found no difference between
4. Journal of military pharmaco-medicine 7-2013 - 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. Non- p BP ( ) increase mmHg increase value Average SBP/72h 137 146 0.0016 st nd Figure 2: V1, V2 is HV on 1 and 2 CT taken nd Average DBP/72h 80 84 0.0001 at admission and 2 time. Average MAP/72h 99 105 0.0003 (Sources: CT-scans of 1 patient in this study). 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: nd st + HV on 2 CT compared with 1 CT: Figure 3: st nd HV on 1 and 2 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
5. Journal of military pharmaco-medicine 7-2013 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%, Figure 4: Shape of hematoma on the brain Nguyen Lien Huong: 38.6%. In a study by CT (Source: CT at admission and second Matthew L.Flaherty (2005) in Kentucky-North of 1 patients in this study). America, the rate of capsule - putamen - HV on the first CT: hemorrhage was 49%. Although the significant The relationship between increased HV difference in hematoma location between and HV was shown examining in 188 STH groups of patient was classified according to patients. HV increased in 20.83% of patients location as above, there was no significant with HV small (< 15 cm3), 29.17% in those difference in enlargement rate between with moderate HV (15 - 29 cm3), 16.67% in the groups hematoma location in the lobes, those with big hematoma (30 - 45 cm3), basal ganglia, capsule and thalamus and 33.33% in those with large hematoma (p = 0.26). This result was similar to the 3 (> 45 cm ). Enlargement HV rate increased study by Fujii [10]. significantly with an increase in blood volume - Shape of hematoma on the brain CT: in the series first CT. This result is similar to Ratio of enlargement hematoma in group the study by Fujii [10]. of irregular hematoma shape (10/22) was - Time CTA: significant higher than group of regular Ratio of enlargement hematoma in group hematoma shape (14/166) (p = 0.000). This of patients with time from onset to take the result is similar to the study by Fujii [10]. CTA < 6 hours, 6 - 12 hours before, 12 - before
6. Journal of military pharmaco-medicine 7-2013 18 hours, 18 - 24 hours: 34.78%, 30.43%, predicted sign blood still continues to flow, 0.0% and 34.78%, respectively. Ratio of which can identify the risk of increased enlargement hematoma in groups with HV [6]. different times taken CTA did not differ The results of our study revealed increased statistically significant (p = 0.12). HV in 18 of 168 patients without spot sign - Spot sign: Image of contrast drug (75%), 6 of 20 patients with a spot sign (25%). extravasation (spot sign) on brain CTA: When univariate analysis, this difference After ICH, the contrast brain CT scan is statistically significant (p = 0.005). The and/or CT.Angiography (CTA) in the early result is similar to the study by Ryan Wada hours, we can see image of contrast drug (p = 0.0001), and E. Josser Delgado Almandoz extravasation and left in hematoma, the (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. Non-increase increase p value RBC 4.66122 4.762083 0.4168 Hct 41.21159 41.87083 0.4934 Hb 13.97744 14.52083 0.1239 WBC 10.02238 11.71292 0.0337 Platelets 244.8659 244.4583 0.9794 AST 41.91463 43.08333 0.8878 ALT 36.29878 32.91667 0.6929 PT 13.09146 13.24583 0.6800
7. Journal of military pharmaco-medicine 7-2013 (1) (2) (3) (4) aPTT 27.94207 26.74167 0.3793 INR 1.168963 1.021667 0.7391 Fibrinogen 3.117805 2.871667 0.1898 Glycemie 120.3902 146.25 0.0275 BUN 13.89634 10.57083 0.0542 Creatinine 0.9161585 0.8395833 0.2799 Total cholesterol 200.4207 196.1667 0.6834 LDL 113.5671 110.0833 0.6201 HDL 46.10429 48.04167 0.4055 TGR 46.10429 48.04167 0.4055 White blood cell count and glycemie levels showed the presence of 14 factors related in patients with increased HV was higher in to increased HV, which we picked out 9 key patients without increased HV, this difference factors related to increased HV for inclusion is statistically significant (p = 0.033) and in multivariate analysis with the dependent 0.027. Similar results in the study of Kazui variable of increased HV. and colleagues found that glycemie at Table 4: Multivariate analysis of factors admission ≥ 141 mg/dl is a risk factor of affecting the increase HV. increasing HV. According to Fisher CM (1971), glycemie at admission ≥ 200 mg/dl OR p CI 95% will aggrevate the clinical condition of the Glasgow at 1.07 0.69 0.7403871 1.568776 ICH patient in the acute phase [4]. admission Univariate analysis above showed that NIHSS at 0.99 0.91 0.8507506 1.155765 the presence of 14 factors related to admission increased HV, of which, 9 were important Rankin at 4.75 0.18 0.4700964 48.11052 factors related to increased HV such as: admission (1) Glasgow at admission, (2) NIHSS at SBP at 1.08 0.41 0.8942917 1.314039 admission, (3) Rankin at admission, (4) SBP admission at admission, (5) HV, (6) shape of hematoma, HV on 1st CT 1.01 1.02 0.9961331 1.044145 (7) spot sign, (8) WBC and (9) glycemie. Shape of 0.19 0.005 0.0606533 0.6088062 - Multivariate analysis of factors affecting hematoma increase HV: Spot sign 2.41 0.04 1.023745 5.692294 Our multivariate regression analysis WBC 1.05 0.43 0.9182124 1.217977 presented independent predictors of increased HV. Univariate analysis also Glycemie 1.00 0.08 0.9991597 1.014602
8. Journal of military pharmaco-medicine 7-2013 Results of multivariate analysis showed STH located in the basal ganglia and that two independent prognostic factors with capsule. increasing HV are: (1) the shape of the - 10.64% of STH patients had the spot hematoma is irregular on CT (OR = 0.19, sign on CTA. p = 0.005), and (2) Spot sign on CTA (OR = - Rate of increased HV on 2nd CT after 2.41, p = 0.044). 72 hours was 12.77% when compared with In this study, we identified two prognostic st 1 CT. factors that independently increased HV - Univariate analysis showed that 9 are: (1) the shape of the hematoma is irregular on CT, and (2) Spot sign on CTA. important factors related to increased HV Compared with previous studies, those by are: (1) Glasgow at admission, (2) NIHSS at Fujii [10], in addition to the shape of the admission, (3) Rankin at admission, (4) hematoma is irregular on CT factor, this SBP at admission, (5) hematoma volume, author also recorded 4 other factors with (6) shape of hematoma, (7) spot sign, (8) independent prognostic HV increase including: WBC and (9) glycemie. (1) time from onset to admission early (before - Multivariate analysis showed that two 6h), (2) the amount of alcohol consumed independent prognostic factors related to during the day, (3) consciousness disorders an increase in HV: (1) the shape of the at admission, and (4) low fibrinogen levels. hematoma was irregular on CT (OR = 0.19, As for spot sign, our results are similar to p = 0.005) and (2) spot sign on CTA (OR = two studies by Ryan Wada and Josser E, 2.41, p = 0.044). Delgado Almandoz that signals spot is an independent prognostic factor for the increase REFERENCES in HV. 1. Nguyen Minh Hien. Some of clinical features Conclusion and Siriraj diagnostic scale in distinguish supratentorial cerebral infarction. Journal of Through a prospective study of 188 STH Neurology. 2003, 4, pp.52-55. patients with hypertension at admission, we draw some conclusions: 2. Vu Anh Nhi. Thần kinh học. Department of Neurology Medical University Hochiminh City. - Average age: 58 years old, men were Medical Publisher. 2003. twice as many as women. 3. Anderson CS, Jamrozik KD, Broadhurst - The time between stroke onset and RJ, Stewart-Wynne EG. Predicting survival for hospitalization was 4 hour on average, only 1 year among different subtypes of stroke: results 5.3% during the first hour, 40.4% at 3 hours. from the Perth Community Stroke Group. Stroke. - Average HV on 2nd CT was 26.54 cm3, 1994, 25, pp.1935-1944. st 3 1 CT was 22.35 cm . 89.36% of patients 4. Badjatia N, Rosand J. Intracerebral had regular hematoma shape, 10.64% had hemorrhage. The Neurologist. 2005, 11 (6), irregular hematoma shape, over 85% of pp.311-324.
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