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

Abstract

Background In patients with spontaneous intracerebral hemorrhage (ICH), pre-hospital markers of disease severity might be useful to potentially triage patients to undergo early interventions. Objective Here, we tested whether loss of consciousness (LOC) at the onset of ICH is associated with intraventricular hemorrhage (IVH) on brain computed tomography (CT). Methods Among 3000 ICH cases from ERICH (Ethnic/Racial Variations of Intracerebral Hemorrhage study, NS069763), we included patients with complete ICH/IVH volumetric CT measurements and excluded those with seizures at ICH onset. Trained investigators extracted data from medical charts. Mental status at symptom onset (categorized as alert/oriented, alert/confused, drowsy/somnolent, coma/unresponsive/posturing) and 3-month disability (modified Rankin score, mRS) were assessed through standardized interviews of participants or dedicated proxies. We used logistic regression and mediation analysis to assess relationships between LOC, IVH, and unfavorable outcome (mRS 4–6). Results Two thousand seven hundred and twenty-four patients met inclusion criteria. Median admission Glasgow Coma Score was 15 (interquartile range 11–15). 46% had IVH on admission or follow-up CT. Patients with LOC (mental status: coma/unresponsive, n = 352) compared to those without LOC (all other mental status, n = 2372) were younger (60 vs. 62 years, p = 0.005) and had greater IVH frequency (77 vs. 41%, p < 0.001), greater peak ICH volumes (28 vs. 11 ml, p < 0.001), greater admission systolic blood pressure (200 vs. 184 mmHg, p < 0.001), and greater admission serum glucose (158 vs. 127 mg/dl, p < 0.001). LOC was independently associated with IVH presence (odds ratio, OR, 2.6, CI 1.9–3.5) and with unfavorable outcome (OR 3.05, CI 1.96–4.75). The association between LOC and outcome was significantly mediated by IVH (beta = 0.24, bootstrapped CI 0.17–0.32). Conclusion LOC at ICH onset may be a useful pre-hospital marker to identify patients at risk of having or developing IVH.

Functional Outcomes and Mortality in Patients With Intracerebral Hemorrhage After Intensive Medical and Surgical Support

“…We have chosen to dichotomize our data to remain consistent with recent ICH studies, rendering mRS score 0-3 as favorable. 11,23,30 Recognizing, however, the significant heterogeneity native to mRS score 3, we have reported mRS score 3 independently (Tables 2 and 4) as perhaps an indeterminate outcome.…”

“…22 Favorable and unfavorable functional outcomes were defined as an mRS score of 0-3 and 4-6, respectively. 11,23,24 Based on the review of all pertinent clinical records of the entire cohort, radiologic images, and autopsy reports (when available), cause-specific mortality was categorized into neurologic vs medical. Primary pathophysiologic mechanisms leading to death or decision to withdraw lifesustaining therapy were categorized by adjudication.…”

Computed tomography in acute intracerebral hemorrhage: neuroimaging predictors of hematoma expansion and outcome

“…IVH is predictive of early (within 24 h) and late (up to 7 days) neurological deterioration [ 86 ] and poor outcome [ 87 , 88 ]. IVH is also strongly associated with pre-hospital loss of consciousness [ 89 ]. It has been shown that the prognostic value of hematoma expansion is even higher if the IVH component is also included [ 90 ].…”

Prognostication after intracerebral hemorrhage: a review

“…APACHE score [26,60] Serum hemoglobin [61] Serum neutrophil to lymphocyte ratio [62,63] Cerebral perfusion pressure and partial pressure of oxygen in interstitial brain tissue (PbtO2) [64] Serum iron/ferritin/transferrin [65] Chronic kidney disease [66] Imaging Variables IVH expansion [50,51,67] Peak PHE [68] Spot sign/island sign/black hole sign/blend sign [69] Non contrast CT-Hypodensities on CT [69,70]…”