New and expanding ventricular hemorrhage predicts poor outcome in acute intracerebral hemorrhage

Abstract

ObjectiveTo describe the relationship between intraventricular hemorrhage (IVH) expansion and long-term outcome and to use this relationship to select and validate clinically relevant thresholds of IVH expansion in 2 separate intracerebral hemorrhage (ICH) populations.MethodsWe used fractional polynomial analysis to test linear and nonlinear models of 24-hour IVH volume change and clinical outcome with data from the Predicting Hematoma Growth and Outcome in Intracerebral Hemorrhage Using Contrast Bolus CT (PREDICT)-ICH study. The primary outcome was poor clinical outcome (modified Rankin Scale [mRS] score 4–6) at 90 days. We derived dichotomous thresholds from the selected model and calculated diagnostic accuracy measures. We validated all thresholds in an independent single-center ICH cohort (Massachusetts General Hospital).ResultsOf the 256 patients from PREDICT, 127 (49.6%) had an mRS score of 4 to 6. Twenty-four–hour IVH volume change and poor outcome fit a nonlinear relationship, in which minimal increases in IVH were associated with a high probability of an mRS score of 4 to 6. IVH expansion ≥1 mL (n = 53, sensitivity 33%, specificity 92%, adjusted odds ratio [aOR] 2.68, 95% confidence interval [CI] 1.11–6.46) and development of any new IVH (n = 74, sensitivity 43%, specificity 85%, aOR 2.53, 95% CI 1.22–5.26) strongly predicted poor outcome at 90 days. The dichotomous thresholds reproduced well in a validation cohort of 169 patients.ConclusionIVH expansion as small as 1 mL or any new IVH is strongly predictive of poor outcome. These findings may assist clinicians with bedside prognostication and could be incorporated into definitions of hematoma expansion to inform future ICH treatment trials.

Prediction of Poor Outcome in Intracerebral Hemorrhage Based on Computed Tomography Markers

“…Hypodensities and black hole sign could be regarded as useful predictors in ICH in our study. Recent studies found that intraventricular hemorrhage and intraventricular hemorrhage expansion were strongly predictive of poor outcome in ICH [20,21]. However, intraventricular hemorrhage was not independently associated with poor outcome in our study.…”

Predicting long-term outcomes in acute intracerebral haemorrhage using delayed prognostication scores

“…We hypothesise haematoma expansion and early neurological deterioration likely account for the improved performance of delayed ICH scores. [18][19][20] The observed improvement in mortality prognostication is consistent with previous published work, 6 21 22 and these results advise against early prognostication, which is in accordance with current American Heart Association guidelines. 5 Our findings are important for clinical practice, as discussions around withdrawal of care in ICH typically occur days after admission, with the average decision to institute withdrawal of care orders around day 5.…”

Intracerebral Hemorrhage with Intraventricular Extension Associated with Loss of Consciousness at Symptom Onset

“…With regard to its effect on outcome, IVH is not an "all or nothing" event. Increasing degrees of IVH correlate with an increasing risk of worse outcome [27][28][29][30]. These findings suggest that there might be a subgroup of patients with ICH in whom ICH is diagnosed early enough to potentially prevent IVH or contain an early stage IVH through blood pressure control or surgical intervention [12,31].…”