Sonographic Monitoring of Midline Shift Predicts Outcome after Intracerebral Hemorrhage

Abstract

<b><i>Background:</i></b> Spontaneous intracerebral hemorrhage (ICH) and the evolution of subsequent perihemorrhagic edema lead to midline shift (MLS), which can be assessed by transcranial duplex sonography (TDS). In this observational study, we monitored MLS with TDS in patients with supratentorial ICH up to day 14 after the ictus, and then correlated MLS with the outcome 6 months after hospital discharge. <b><i>Methods:</i></b> Sixty-eight patients with spontaneous ICH (volume >20 cm<sup>3</sup>) were admitted during a 1-year period between April 2009 and April 2010. Sixty-one patients fulfilled the inclusion criteria and were eligible for analysis. TDS to measure MLS was performed upon admission and then subsequently, using serial examinations in 24-hour intervals up to day 14. Statistical tests were used to determine cut-off values for functional outcome and mortality after 6 months. <b><i>Results:</i></b> The median National Institutes of Health Stroke Scale (NIHSS) score upon admission was 21 and the mean hematoma volume was 52 cm<sup>3</sup>. NIHSS score, functional outcome, hematoma volume and MLS were correlated in the examined patient cohort. ICH score upon admission, hematoma volume and the extent of MLS on days 1–14 were predictive of functional outcome and death. Values of MLS showed two peaks, the first between day 2 and day 5 and the second between day 12 and day 14, indicating that edema progresses not only during the acute but also during the subacute phase. Depending on the time point, an MLS of 4.5–7.5 mm or greater indicated an impending failure of conservative therapy. An MLS of 12 mm or greater at any time indicated mortality with a sensitivity of 69%, a specificity of 100% and positive and negative predictive values of 100 and 74%, respectively. <b><i>Conclusions:</i></b> MLS seems to be a crucial factor for outcome after ICH. Apart from the hematoma volume itself, edema adds to the intracranial pressure. To monitor MLS in early patient management after ICH, TDS is a useful noninvasive bedside alternative, avoiding increased radiation exposure and repeated transportation of critically ill patients. Cut-off values may help to reliably predict functional outcome and treatment failure in patients undergoing maximal neurointensive therapy.

Prediction and prognostication of neurological deterioration in patients with acute ICH: a hospital-based cohort study

“…Further, little is known about late ND (LND), even though the existence of LND is well established among clinicians. 4 6 Evidence indicates that structural damage as well as secondary space-occupying lesions in the brain occurs predominantly during the very first days of illness [7][8][9][10][11][12] ( provoking END and LND). Assuming minimisation of complications by means of adequate stroke unit care (including aspiration pneumonia,…”

Doppler Pulsatility Index in Spontaneous Intracerebral Hemorrhage

“…Formation of perihemorrhagic edema is dynamic [25,26], may last up to 14 days [27] and may peak in the early as well as in the subacute phase [18,28], leading to an increase in ICP that can cause subfalcial and uncal herniation. However, increased ICP may not only appear directly as tissue shift which can be imaged in cross-sectional imaging or TDS, but also indirectly as decreased end-diastolic flow velocity leading to characteristic changes in the Doppler waveform and increased PI [29] (fig.…”

“…TDS was performed at the same time points as the TCD examinations with a phased-array ultrasound system equipped with a 1.33-MHz transducer (Siemens Acuson Antares) through the contralateral temporal bone window as described before [12,18]. The third ventricle was visualized in a depth of 6-8 cm and identified by its parallel hyperechogenic margins and the surrounding hypoechogenic thalami.…”

“…Transcranial Doppler (TCD) and duplex sonography (TDS) present noninvasive, inexpensive bedside tools to diagnose and monitor intracranial pathology such as midline shift (MLS), cerebral artery flow velocities and, in special cases, hematoma volume [12,13,14,15] and is therefore applicable in patients with cerebral ischemia, subarachnoid hemorrhage and ICH [12,13,15,16,17,18]. Furthermore, elevated ICP may be detected by increased PI [19], which is not only more easily accessible than direct ICP measurement through ventriculostomy or microtransducers in the majority of patients but may also represent the ICP of a larger part of the supratentorial compartment due to the course of the respective intracranial vessel.…”

Measurement and Management of Increased Intracranial Pressure

“…Transcranial duplex sonography (TDS) is a useful noninvasive bedside alternative to CT scan, avoiding increased radiation exposure and repeated transportation of critically ill patients, to monitor MLS in early patient management after ICH. TDS monitoring of the early dynamics of MLS reliably predicts early mortality and outcome in conservatively treated hemispheric ischemic stroke [36]. Studies revealed a high correlation of the imaging of the third ventricle between TDS and CT and a robust inter-and intra-observer reliability.…”