Intracranial hemorrhage (ICH) is a collective term encompassing many different conditions characterised by the extravascular accumulation of blood within. Manejo quirúrgico de la hemorragia intraparenquimatosa primaria supratentorial. Do you want to read the rest of this article? Request full-text. Una paciente de 64 años de edad, con hidrocefalia secundaria a una hemorragia subaracnoidea, sufre una hemorragia intraparenquimatosa occipital derecha.
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To analyze mortality and functional outcome in patients with severe spontaneous intracerebral hemorrhage ICHand identify the clinical characteristics, radiological findings and therapeutic procedures predictive of mortality in the Intensive Care Unit ICU and during hospitalization, as well as of poor functional results at 6 months.
A prospective, observational study was carried out. Neurocritical Care Unit of a university hospital. Patients diagnosed with ICH were included over a period of 23 months. Demographic characteristics, cardiovascular risk factors, regular medication, laboratory test parameters, cranial CT findings, therapeutic procedures and outcome data.
A total of patients with ICH met the inclusion criteria. Surgery to evacuate ICH was performed in The mortality rate was The modified Rankin score at 6 months was 5 RI: Multivariate Cox regression analysis showed the presence of diabetes, prior anticoagulation, as well as APACHE II severity and the type of bleeding on the cranial CT scan to be predictors of mortality and poor functional outcomes.
On the other hand, neurosurgical procedures and intracranial pressure ICP monitoring were associated with better outcomes. The presence of intrapzrenquimatosa such as diabetes, or previous anticoagulation, as well as the CT findings were associated to poorer outcomes.
In contrast, ICP monitoring and early neurosurgery were predictive of longer survival and better functional outcomes. UCI de un hospital universitario. La mediana del Rankin modificado a los 6 meses fue de intraparenquimaosa RI: Cerebrovascular accident CVA or stroke is a common disorder. As a result of the increasing frequency of the disorder and the associated need for specialized treatment, affected patients often require admission to the Intensive Care Unit ICU for adequate management.
These considerations justify the different studies that have sought to establish predictive mortality and functional outcome models based on different demographic, clinical and biological variables, with the aim of optimizing the ulterior management of patients with ICH. On the other hand, uncertainty remains regarding the influence of different invasive procedures such as immediate surgery or intracranial pressure ICP catheter monitoring and brain tissue oxygenation pressure PtiO2 upon the final outcome.
The main objective of this study is to determine mortality and functional outcome in patients with severe ICH.
Likewise, an evaluation is made of the clinical, radiological and therapeutic variables with the strongest predictive capacity in relation to mortality in the ICU and during hospital admission, and to poor functional outcome after 6 months. The study was approved by the Clinical Research Ethics Committee of our center, and the obtainment of informed consent was not considered necessary, due to the strictly observational nature of the study.
We included all patients diagnosed with severe ICH. The inclusion criteria were: Patients with ICH secondary to aneurysms or vascular malformations were excluded, as were those with underlying tumor lesions or previous trauma, protuberance hemorrhage due to cerebral herniation Duret hemorrhageand secondary ischemic tissue reperfusion damage or hemorrhagic transformation.
We also excluded patients with neurological sequelae due to previous congenital or acquired disorders and those in which short- to middle-term follow-up was not possible. The clinical situation of the patients was evaluated upon admission by means of the Acute Physiology and Chronic Health Evaluation APACHE II score, while level of consciousness was scored with the GCS in the absence of pharmacological, metabolic or hemodynamic interferencesand neurological defects were assessed on the basis of clinical signs such as pupil response, focal neurological alterations, aphasia or Jacksonian seizures when the patient was not under the effects of sedation or neuromuscular blockers.
In these latter situations, in the event of clinical suspicion, an electroencephalographic study was made. A brain CT scan was made upon patient admission, and again after 24 h in the case of clinical stability for evolutive monitoring of the lesions or at any time during the clinical course in the event of neurological worsening. The information from these studies was obtained by two specialists in neurocritical care blinded to the clinical condition and prognosis of the patients.
The findings were subsequently contrasted with the corresponding radiological reports. The following data were recorded: In the case of hematomas of deep supratentorial location we used the Modified Intracerebral Hemorrhage Score MICHwhich quantifies the level of consciousness according to the GCS, the volume of the hematoma in cubic centimeters ccand the presence of hydrocephalus or intraventricular hemorrhage.
For prognostic purposes, and in addition to the routine parameters, we documented the hemoglobin level and blood glucose concentration upon admission and after 24 h in all patients. The indication of neurosurgery was based on the established clinical practice guides or on the criterion of the neurosurgeon. In all cases surgery was performed within the first 24 h following symptoms onset. A standard craniotomy was performed according to the location of the hematoma: External ventricular drainage was indicated in patients with moderate to severe IVH or secondary obstructive hydrocephalus pure IVH, deep hematomas with important intraventricular invasion or infratentorial hematomas of the cerebellum not amenable to craniotomy, with progressive worsening of level of consciousness clearly attributable to hydrocephalus.
The duration of the treatment was 5 days, with adjustment according to clinical criteria and the evolutive changes evaluated by CT every 48 h.
The following neurological complications were recorded: The following general information was also collected: The patients that were still alive at discharge from hospital were evaluated after 6 months using the modified Rankin scale. A descriptive analysis was made of the numerical variables, which were summarized as the mean and standard deviation or—in the case of asymmetrical distributions—as the median and interquartile range IQR. We subsequently performed an inferential analysis, establishing relationships between categorical variables.
The chi-squared test or Fisher exact test was used to assess the relationship between two qualitative variables. The comparison of means was carried out to analyze the association between a dichotomic qualitative variable and a quantitative variable.
The Student t -test was used, following validation of the requirements referred to randomness, independence, normality and equality of variance. In the event of a non-normal distribution, we used the Mann—Whitney U -test. An initial univariate inferential analysis was performed, followed by a multivariate analysis based on the Cox regression proportional hazards model.
We used this method to investigate the effect of different variables e. This afforded incident hazard rates referred to the event of interest mortality adjusted to the effect of one or more predictive variables.
In this sense, and for analytical purposes, the functional outcomes were classified into two groups according to the modified Rankin score obtained: The SPSS version A total of patients with ICH met the study inclusion criteria. The patient characteristics, clinical parameters, CT findings, procedures and evolutive data of the sample are shown intraparenquimatksa Table 1. The median age was 60 years IQR 49; 66and patients were males The most common risk factor in our series was arterial hypertension The median hematoma volume was hemorrafia cc IQR A total of The overall mortality rate was General characteristics of the patients included in the study.
Table 2 shows the differences of the different variables between the patients that died and the survivors. Of note is the observation that elevated blood hdmorragia upon admission and after 24 h, diabetes, and oral anticoagulant therapy were associated to a higher mortality rate both in the ICU and in hospital.
Among other variables, the level of consciousness upon admission, pupil response, bleeding location at brainstem level, the presence of IVH assessed by the Graeb scale, and the APACHE II score all showed differences between the patients that died in the ICU or in hospital and the survivors. Neurosurgical intervention also resulted in differences between the two groups, since survival was found to be greater among the patients that underwent surgical treatment. These data are summarized in Table Distribution of the variables according to mortality in the ICU and in hospital.
Univariate Cox regression analysis referred to mortality in ICU and in hospital. Table 4 shows the results of the multivariate Cox regression analysis of those variables found to be independently associated to mortality after ICH both in the ICU and during admission to hospital.
Of note is the fact that the radiological findings associated to increased mortality in the ICU and in hospital were the presence of IVH, bleeding location at brainstem level, and the presence of radiological evidence of repeat bleeding.
On the other hand, hematoma volume upon admission and the presence of a mass effect he,orragia associated to mortality in the ICU and in hospital, respectively. Multivariate Cox regression proportional hazards analysis referred to mortality in the ICU and in hospital.
Hemorragia intraparenquimatosa cerebral | Spanish to English |
Lastly, the functional evaluation of the intraparsnquimatosa after 6 months is shown in Table 5. The multivariate analysis corresponding to Table 6 shows the presence of diabetes or previous anticoagulant treatment and the type of hemorrhage on the CT scan to be predictors of mortality and of poor functional outcome, while surgery was associated to increased survival and better functional outcomes.
In our series, ICH was associated to high mortality and intraparenquimatosx functional outcome. A history of diabetes, previous anticoagulation treatment, the location and volume intraparenqiimatosa the hematoma, and patient severity upon admission were associated to poor patient prognosis, while monitoring of ICP or the application of surgical treatment was associated to improved outcome. This situation in turn is probably attributable to the increased use of anticoagulants and antiplatelet drugs.
In our series the mortality rates were consistent with those reported in the literature. The systematic review and metaanalysis published by Van Asch et al.
Intracranial haemorrhage | Radiology Reference Article |
In our series mortality was in the upper range Firstly, our sample exclusively consisted of critical patients requiring admission to the ICU. Secondly, the median age of our patients was 60 years, and in this regard it is known that mortality in the 45—59 years age interval is even higher than among patients intraparenquimatoxa 75 years of age. On the other hand, the duration of follow-up in our study was longer than in other series.
Most publications analyze mortality after 30 days. In our study we extended this period, assessing also usually occult mortality occurring after discharge from the ICU and frequently beyond the intraparenuqimatosa day interval.
In our case this mortality rate was hemprragia However, methodological reasons precluded a more exhaustive and isolated analysis of this subgroup.
In concordance with other studies, a total of Recent studies have underscored the importance of adequate blood pressure control in these patients, though such control has only been shown to offer benefits in terms of functional outcome, with no demonstrated impact upon mortality—in coincidence with our own observations. On relating the study variables to mortality in the ICU and in hospital, diabetic patients were seen to have a twofold higher risk of death, in coincidence with the observations in other neurocritical conditions.
In contrast, mortality was found to be lower in patients subjected to surgical treatment or with Hemorragai monitoring—both of these factors being found to exert a protective effects against mortality. One of the main mechanisms implicated in mortality and in functional outcome after ICH refers to hematoma expansion in the first 24 h. In this regard, prompt surgical intervention could have an important impact upon outcome.