JOURNRL OF MIUTRRV PHRRMflCO-MCDICINC 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, prospecf/Ve analysis of 188 acute supratentorial hemonhage patients associated with hypertension at admission, admitted within six hours after onset, fmm 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 NffiSS at admission and after 72 hours. HV average on T" CT was 26.54 cm^, 1^ CT was 22.35 cm^, rate has increased HV on T" CT after 72 hours was 12.77%.
* Key words: Supratentorial hemorrhage; Noncontrast and contrast brain CT-Scahner images.
INTRODUCTION
Although stroke is a classic pathology of the neurology, but still a topical Issue in the worid because it is the cause of death ranks third after cancer and heart disease, the cause of leading death in neuropathy. According to Orgogozo (1995) and R.Hart (1994), intracerebral hemorrhage (ICH) accounts for 15% to 20%
of brain stroke patients, and this condition can cause death or severe disability than cerebral infarction [2], Every year, more than 20,000 Americans die of ICH. ICH frequency of 10 - 20 people per 100,000 population and increases with age [7].
Al^er ICH, the clinical status changes and hematoma volume (HV) in the brain associated with the prognosis of patients. In our daily work, we have to treat brain stroke patients in general, and particular in ICH, but the results are not as expected, because of some patients thought to be rescued and clinical outcomes will be better but worse go and die. TherefcHB, we studied 188 supratentorial ICH patients in order to: Comments changes ofdinical and intracerebral hematoma volume, noncontrast and contrast brain CT-Scan images in acute supratentorial hemontiage for 72 hours after onset
* 103 Hospital
•* 115 Hospital
Address correspondence to Nguyen Van Chuong: 103 Hosptal E.mail: [email protected]
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JOURNHL OF MIUTBBV PHBBMaCO-MtDICINt 7-2013 SUBJECTS AND METHODS
1. Study subjects.
Patienls with acute supratentorial hemorrtiage associated with hypertension, admission before six hours after onset, treated at the Department of Cerebral-Vascular Pathology, 115 People Hospital from 1 - 2011 to 4 - 2013 agreed with inclusion criteria will be included in the study.
* Inclusion critena:
ICH is the first acute supratentorial hemorrhage associated with hypertension at admission, admitted within six hours after onset, with brain innages computerized tomography (CT) to confirm the diagnosis of supratentorial hemorrhage.
Hypertension diagnostic criteria (the JNC VII); The systolic blood pressure (SBP) is higher than 140 and/or diastolic blood pressure (DBP) higher than 90 mmHg.
* Exclusion criteria:
- Supratentorial hemonrhage (STH) due to aneurysm rupture, due to arteriovenous malformations, moyamoya disease, by using anticoagulants or anti-platelet drugs.
- STH with blood rntraventricular (intraventricular hemorrhage).
- Patients die before the second CT-Scan shot.
- STH transformation of cerebral infarction.
- Renal failure, creatinine a 1.7 mg/dl.
- History of allergy to contrast drugs.
2. Research methodology.
Study design: descriptive, prospective analysis
* Data collection:
- The clinical data:
+ BP, consciousness at admission, paralysis of cranial nen/e VII, strength of the arms and legs paralyzed.
+ Tlie Glasgow, NIHSS, Rankin at admission and 72 hours after onset.
+ BP at 6 hour, then BP measurement every 4 hours to 72 hours after stroke.
- Tests data:
+ Noncontrast brain CT on admission.
+ Brain CT-angiography (CTA) in the first 24 hours after onset.
+ Second noncontrast brain CT when clinical status worsening (Glasgow score decreased from 2 points or more) or at the time of 72 hours after onset.
* Assessment criterial:
- Clinical status after 72 hours was assessed by Glasgow scale, NIHSS, mRS.
Change clinically was evaluated by comparing the Glasgow, NIHSS, mRS at admission and after 72 hours.
- STH status of patients after 72 hours were evaluated in two groups: blood volume without increased and inaeased (enlargement).
HV in the brain increases granted under Kazui [8] as V2 - V I a 12.5 cm^ orV2W1
£ 1.4, where V I , V2 respectively HV on brain CT-Scan 1 " and 2"" time.
- HV calculated by Kothari's formulas (or Broderich): V = (AxBxC)/2 [10]. Where A, B, C are the three largest diameter perpendicular to each other in three dimensions of the hematoma.
RESULTS AND DISCUSSION After collecting data and statistical analysis in the study group of 188 patients from 2010 to 2013, we had the following results:
JOURNAL OF MIUTRRV PHRRMflCO-MCDICINC 7-2013 1. General characteristics of the study
group.
Age: The average age was 58.29, similar to the common age for stroke in general, but age in our study was slightly smaller than the age of the other ICH studies [1, 2, 6, 7]. According to the literature, the rate of brain stroke increased with age. In developed countries with aging populations, the average age of stroke in brain research in these countries was higher than in our study, as well as studies conducted in developing countries.
- Gender: 188 patients, including 128 males (68.08%) and 60 females (31 91%), male:females was 2:1,
- The time between admission and stroke:
average 4.03 hours, of which 10 patiente (5.3%) had stroke during the first hospitalization, 76 patients (40.4%) at 3 hours.
2. Clinical features.
* Symptoms at onset:
dimness headache vomit sojure dy^phaBS paralyzed
Figum 1: The symptoms of patients at onset.
When STH. ali patients in the plot study were paralyzed to varying degrees, headache was common symptoms of 2"^ following paralysis.
* Blood pressure:
Table 1: Blood pressure of patients at admission.
ON ADMISSION SBP DBP MAP
MEAN 165 97 100
MIN 140 90 79
MAX 240 140 128
* Consciousness at admission:
At the hospital: 72% had in Glasgow from 13 - 15, the number of patients in the group with consciousness disorders decreased with the severity of consciousness.
* Paralysis of cranial nerve VII: 93% of patients had paralyzed nerves VII, only 13 patients (6.9%) were not paralyzed nerve VII.
Hemiplegia: right (48.4%) and left (51 6%) hemiplegia were almost the same.
* Strength of the paralyzed amis and legs:
At admission, all patients (100%) in paralyzed anris to varying degrees, only 1 patient (0.53%) was not paralyzed in the legs,
* Neurological deficiencies at admission:
Table 2: Neurological deficiencies of patiente at admission according to neurological scales
AT ADMISSION Glasgow NIHSS*
Rankin MIN
5 2 2
MAX 15 36 6
MEAN 133 12 7
3.8 SD 2.27 6.49 0.49 (* fvledian [inter-quartile range] 12 (7, 16)
* Neurological deficiencies at admission was assessed by three neurological scales:
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JOURNRL OF MIUTflRV PHflRMflCO-MEDICINC 7-2013
Figure 2: Neurological deficiencies at admission were assessed by three
neurological scales.
Almost of patents with severe neurological deficiencies level (mRS ^ 4).
3. Brain computerized tomography at admission (I^Mime).
* Time of f' brain CT:
In 188 patients, brain CT-Scanner time was as early as 30 minutes after onset, median (inter-quartile range) of 200 (120 - 310) minutes. Only 5.85% of patients had done CT-Scanner before the first 1 hour after onset. The majority (30.32%) had a CT-Scanner first time over a period of 5 - 6 hours alter onset.
' Hematoma volume on f brain CT:
* Location othematoma 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 patiente wifri putamen hemorrhage.
* Shape othematoma on the 1^ brain CT:
20 patiente (10.64%) had irregular hematoma shape, 168 patients (89.36%) had regular hematoma shape on the 1^' brain CT.
* Spot sign: Image of contrast drug extravasation (spot sign) on brain CTA:
After ICH, the contrast brain CT scan and/or CT-angiography (CTA) in ttie early hours could be seen image of contrast drug extravasation and left in hematoma, the predicted blood sign still continues to fiow, and can identity patients at increased risk HV [3, 5, 9].
In this study, 20 patients (10.64%) had spot sign on CTA.
<l5(ml) 15-Z9(mlJ 3045 >iS[m\]
Figure 3: Hematoma volume on 1^ brain CT.
In the 188 patients studied, nearly half of patients with HV < 15 ml (cm^).
Figure 4: Spot sign on CTA (arrow).
(Source: Nonconstrast and contrast brain CT of 1 patient from this study).
JOURNfll OF MIUTflRY PHnRMflCO-MePICINC 7-tai3 ' Time CTA:
Figure 5: The time from stroke onset to take CTA.
Only 39 patients (20.97%) tool< CTA in the first 6 hours after the-'onset of STH, mostly concentrated in the period from 6 - 12 hours (32.26%) and 18 - 24 hours (34,41%) after strol<e onset.
* Time noncontrast 2"" brain CT:
Table 3: Time tal<en 2"" brain CT-Soanner (at clinical worsening or 72 hours after stroke onset).
2™ BRAIN CT.SCANNER T i m e (li)
MEAN
6 6 . 6 0 MIN
6 MAX
7 2 SD
1 6 . 1 0
* Evaluating patients clinical and CT, compared 2"" v/ith the f times:
Table 4: Clinical assessment of patients, compared 2"" with the 1^' times.
SCALE Glasgow
NIHSS
mRS 1 "
j n d
1 "
2"
1 *
2"?
MEAN 13.3 12.9 12.7 12,8 3.8 3.7
MIN 5 3 2 0 2 1
MAX 15 15 36 41 5 6
SD 2.27 3.32 6.49 8.92 0 49 0.83
RVALUE
0,07
0.0005*
0.37
(" Wilcoxon sign rank test)
* Change of Glasgov/, NIHSS, Ranliin score after 72 hours: When comparing the second Glasgow, NIHSS, Rankin to the first at admission, we fouhd no differences in Glasgow at two time points (13^32 and 12.97) with p = 0.07, there was not diffference 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) vyas 12 (7.16) and 11 (6.16) with p = 0.0005. Thus, over a period of 72 hours after stroke onset, NIHSS scale is one of three most sensitive scales to assess the neurological deficiencies after stroke.
* HV on 2 ^ brain CTas compared with 1^:
There were 24 patiente (12.77%) with increased HV when compared HV on 1®^
brain CT with the 2"^^ times. Enlargement HV rate was 20.83% in patients with small hematoma volume (< 15 cm^), 29.17% in those with moderate HV (15 - 29 cm^), 16.67% in those who had big hematoma (30 - 45 cm^), and 33.33% in those with a large hematoma (> 45 cm^). Enlargement HV rate increased significantly with an increase in blood volume in the first CT. Result was similar in a study by Fujii [4].
CONCLUSION
Through prospectively study of 188 patients STH with hypertension at admission, we draw some conclusions: ...
- The average age was 58 years old, ttie rate of men was an twice much as women.
- When STH, all of the patients (100%) in the plots study were paralyzed ,io;^va7ying degrees, the percentage of patients "with right and left paralyzed almost the same;
headache was common symptoms ranking 3"^
following paralysis and paralyzed VII nerve.
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JOURNAL OF flAIUTHRV PHflRMRCO-MCDICINC 7-2013
- At the hospital: 7 2 % of patients had in Glasgow from 13 - 1 5 , the number of patiente in the group with consciousness disorders decreased with the severity of consciousness.
- SBP average was 165 m m Hg, DBP was 97 and MAP was 100 m m H g at admission.
- SBP 72 h average w a s 138, D B P was 81mmHg.
- Average of Glasgow, NIHSS, Rankin score when assessing 2"^ were 12.97, 12.86 and 3.79, respectively. There was no difference in ttie Glasgow, mRS score, only differences in the two time points NIHSS at admission and after 72 hours with p = 0.0005. During the 72 hours after stroke, NIHSS scale w a s the most sensitive o f t h r e e s c a l e s w h e n assessing neurological deficiencies after stroke.
- HV average on 2"^* CT was 2 6 . 5 4 c m ^ l ^ ' C T was 22.35 c m ^
- 89.36% of patients had regular hematoma shape, 10.64% had irregular hematoma shape, over 85% of STH located in the basal ganglia and capsule.
-10.64% of patients had spot sign on t h e CTA.
- The rate of increased H V on 2"'' CT after 72 hours was 12.77%.
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