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Table of Contents    
Year : 2013  |  Volume : 61  |  Issue : 3  |  Page : 244-248

A prospective study of in-hospital mortality and discharge outcome in spontaneous intracerebral hemorrhage

1 Department of Neurology, All India Institute of Medical Sciences, New Delhi, India
2 Department of Biostatistics, All India Institute of Medical Sciences, New Delhi, India

Date of Submission01-Feb-2013
Date of Decision16-Mar-2013
Date of Acceptance09-Jun-2013
Date of Web Publication16-Jul-2013

Correspondence Address:
Rohit Bhatia
Department of Neurology, All India Institute of Medical Sciences, New Delhi - 110 029
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/0028-3886.115062

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 » Abstract 

Background: Intracerebral hemorrhage (ICH) is associated with high mortality and morbidity. Various clinical and imaging predictors of mortality have been observed in previous studies. Aims: To study factors associated with in-hospital mortality in patients with ICH and observe the disability status of patients [assessed by modified Rankin scale (mRS)] at the time of discharge. Design: Prospective observational study. Materials and Methods: All consecutive patients with acute hypertensive ICH admitted during the study period were enrolled. Data recorded included: Demographics, clinical, biochemical and cranial computed tomography (CT) findings. Primary outcome was defined as either death or survival within the hospital. mRS was used to assess outcome at discharge. Results: Of the total 214 patients with ICH (193 supratentorial and 21 infratentorial), 70 (32.7%) patients died during the hospital stay. On bivariate analysis, low Glasgow Coma Scale (GCS) score, ventilatory assistance, higher hematoma volume, midline shift, hydrocephalus and intraventricular hematoma (IVH) were associated with mortality. ICH grading scale (ICH-GS) and ICH scores were higher in patients who died (P < 0.0001). Ninety-five (44.6%) patients underwent a neurosurgical intervention; 66 (45.8%) patients among the survivors compared with 29 (41.4%) among those who died (P = 0.54, Odds Ratio (OR) 0.83, 95% Confidence Interval (CI) 0.46-1.48). Independent predictors of mortality included a higher baseline hematoma volume ( P = 0.04 OR 1.01, 95% CI 1.00-1.02), lower GCS ( P = 0.01 OR 2.57, 95%CI 1.25-5.29), intraventricular extension of hematoma ( P = 0.007 OR 2.66, 95% CI 1.26-5.56) and ventilatory requirement (P < 0.0001 OR 8.34, 95%CI 2.75-25.38). Among survivors (n = 144), most were disabled [mRS 0-3, 7 (4.8%) and mRS 4-5, 137 (95.13%)] at discharge. Conclusions: Low GCS, higher baseline ICH volume, presence of IVH and need for ventilatory assistance are independent predictors of mortality. Most of the patients at discharge were disabled. Surgery did not improve mortality or outcome.

Keywords: Intracerebral hemorrhage, mortality, outcome, stroke

How to cite this article:
Bhatia R, Singh H, Singh S, Padma MV, Prasad K, Tripathi M, Kumar G, Singh MB. A prospective study of in-hospital mortality and discharge outcome in spontaneous intracerebral hemorrhage. Neurol India 2013;61:244-8

How to cite this URL:
Bhatia R, Singh H, Singh S, Padma MV, Prasad K, Tripathi M, Kumar G, Singh MB. A prospective study of in-hospital mortality and discharge outcome in spontaneous intracerebral hemorrhage. Neurol India [serial online] 2013 [cited 2022 Nov 26];61:244-8. Available from: https://www.neurologyindia.com/text.asp?2013/61/3/244/115062

 » Introduction Top

Spontaneous intracerebral hemorrhage (ICH) accounts for approximately 4-14% of all strokes with a higher reported incidence in Asian countries compared to west and is associated with a high mortality and morbidity. [1],[2] Between 32% and 50% of patients die within the first month and only 20% are independent at 6 months. [3],[4] The burden of stroke occurrence, morbidity and mortality is much higher in developing nations. There has been considerable interest in predicting outcome after ICH and a number of studies have investigated the relationship of various clinical and radiological factors and poor outcome. [5],[6],[7],[8],[9],[10] Few hematological and biochemical parameters at the time of onset of ICH have also been associated with outcome in these patients. Most of the literature on morbidity and mortality predictors is available from the West and some East Asian countries. This prospective observational study was designed to assess clinical, biochemical and radiological predictors of mortality in patients with spontaneous ICH. We also aimed to observe the disability status of survivors as assessed by modified Rankin scale (mRS) at the time of discharge from the hospital.

 » Materials and Methods Top

Between June 2008 and June 2012, all consecutive patients of spontaneous ICH admitted under stroke services of the neurology department at All India Institute of Medical Sciences, New Delhi, were recruited. We excluded patients with subdural and epidural hematoma, aneurysmal, arteriovenous malformation (AVM), anticoagulant or coagulopathy-related hemorrhage and patients who denied informed consent.

Detailed history of the presentation including headache, vomiting, seizures, loss of consciousness and focal neurological deficits was obtained. History of risk factors was recorded. At admission, details of examination including vitals, systemic examination, Glasgow Coma Scale (GCS), National Institute of Health stroke scale (NIHSS), ICH score [8] and ICH grading scale (ICH-GS) [9] were recorded. Baseline hematological and biochemical parameters were assessed. All subjects underwent a plain computed tomography (CT) head at the time of admission, after 24 h and later as when required. Imaging details on CT scan including volume of hematoma (using formula ABC/2), site of hematoma, intraventricular extension (present or absent), hydrocephalus (present or absent), mid line shift (measured as maximum deviation of septum pellucidum in millimetres from midline) were recorded. During hospital stay, we also recorded the reason for and details of mechanical ventilation, presence, site and etiology of infection and details of neurosurgical intervention including time and type of intervention. Primary outcome was either death or survival within the hospital.

Statistical analysis

Data was entered in Microsoft excel work sheet and analysed using SPSS software version 20 and Stata version 11. All continuous variables were analysed using unpaired 't' test for normally distributed data and Mann-Whitney U test for skewed data. Categorical variables were analysed using Chi-square test. We also derived cutoff values using ROC curve with optimal sensitivity and specificity for midline shift, volume of hematoma and GCS for dichotomised analysis. Bivariate and multivariate logistic regression analysis using stepwise forward regression was performed to find independent predictors of mortality. Odds ratio (OR) and 95% confidence intervals (CI) were calculated. A P value of less than or equal to 0.05 was taken as significant.

 » Results Top

Of the 214 patients with ICH, 193 (90.2%) were supratentorial. The mean age was 57.32 ± 12.84 years and 140 (65.4%) were males. The sites of hematoma included ganglionic (70.6%), thalamic (16.8%), lobar (4.2%), brainstem (7%) and cerebellar (1.4%). Of the total cohort, 144 (67.3%) patients survived and 70 (32.7%) died [Table 1]. Bivariate analysis of the variables is outlined in [Table 1]. The onset to emergency times was comparable between the two groups. The survivors had a longer hospital stay compared to the patients who died (median 19 vs. 13 days, P < 0.0001). Among clinical variables, there were a higher number of patients with diabetes, a significantly lower GCS (dichotomized at 8), and higher NIHSS, ICHGS and ICH scores among the patients who died. The mortality rates observed with individual ICH scores was 0 (6.25%), 1 (0%), 2 (25%), 3 (36%), 4 (81%) and with ICHGS score was 5 (0%), 6 (11%), 7 (10%), 8 (24%), 9 (26%), 10 (40%),11 (82%),12 (90%) and 13 (100%). No significant difference in infection rates was found between the two groups. The main sites of infection included chest (24.3%), urinary tract (4.7%), blood stream (7.9%) and meningeal (8.9%). In 8 (3.7%) patients the site of infection could not be identified. The rate of infection was significantly higher among the patients who underwent a neurosurgical intervention than without; 68.4% vs. 32.8% (Odds Ratio (OR) 4.45, 95% Confidence Interval (CI) 2.49-7.91, P < 0.0001). The radiological features associated with mortality included a higher baseline hematoma volume, higher midline shift (dichotomized at 6mm), intraventricular extension of hematoma and presence of hydrocephalus. Site of hemorrhage did not differ statistically among the patients who survived versus who died; ganglionic (67.4% vs. 72.9%), thalamic ( 17.4% vs. 15.7%), lobar (5.5% vs. 1.4%), respectively.
Table 1: Unadjusted logistic regression analysis of demographic, clinical, biochemical and imaging predictors of mortality (N=214)

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Overall, 95 (44.6%) patients underwent a neurosurgical intervention with hematoma evacuation in 49 (22.9%) and external ventricular drainage (EVD) in 46 (21.5%). Among these surgically treated patients, the mean age was 54.94 ± 10.79 years and 61 (64.2%) were males. The median (IQR) time from onset to surgery was 24 (14-44.3) hours. Risk factors included hypertension in 78 (82.1%), diabetes 15 (15.8%), smoking 32 (33.7%) and alcohol intake 29 (30.5%). The mean systolic and diastolic blood pressure was 184.21 ± 34.47 and 104.46 ± 17.69 mmHg, respectively. The mean GCS was 7.81 ± 2.84, mean hematoma volume was 56.57 ± 25.79 ml, midline shift was 7.78 ± 4.45 mm and intraventicular extension of hematoma was observed in 49 (51.6%) patients. Ventilatory assistance was required in 83 (87.4%) patients. Sixty-six (45.8%) patients among survivors underwent an intervention compared with 29 (41.4%) among the group which died (P = 0.54, OR 0.83, 95%CI 0.46-1.48), with hematoma evacuation in 37 (56.1%) and 12 (41.4%), respectively, (P = 0.18, OR 0.55, 95% CI 0.22-1.34). Except a lower GCS among the patients who died, no difference in baseline variables was found among patients who survived and those who died within the surgically treated group.

Upon multivariate analysis using logistic regression analysis [Table 2], the independent predictors of mortality included a higher baseline hematoma volume (P = 0.04 OR 1.01, 95% CI 1.00-1.03), lower GCS (P = 0.01 OR 2.57, 95% CI 1.25-5.29), intraventricular extension of hematoma (P = 0.007 OR 2.66, 95% CI 1.31-5.41) and ventilatory requirement (P < 0.001 OR 8.34, 95% CI 2.75-25.32). This regression analysis had a good validation in our dataset with an area under curve (AUC) of 0.82 [Figure 1]. Among survivors (n = 144), only 7 (4.8%) patients had a modified Rankin score of 0-3 whereas others 137 (95.13%), were moderate to severely disabled (mRS 4,5) at the time of discharge [mRS 4, 68 (47.2%) and mRS 5, 69 (47.9%)] [Figure 2].
Table 2: Independent predictors of mortality using multivariate logistic regression analysis

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Figure 1: ROC curve depicting the AUC of the logistic regression analysis

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Figure 2: Modified Rankin score at discharge in patients who survived (N=144)

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 » Discussion Top

ICH still remains a grave medical emergency with high mortality and morbidity. Inspite of improvement in outcomes in ischemic stroke, outcomes in patients with ICH still remain poor with no specific medical treatment and poor consensus and controversial outcomes of surgical interventions. [11],[12] The mortality rate in the present study was 32.7%. The 30-day mortality from ICH ranges from 35 to 52%, with one-half of these deaths occurring within the first 2 days. [13],[14],[15] In a recent analysis using National Hospital Discharge Survey from USA, mortality rates of about 34% were reported and did not seem to change over the past two decades. Mortality was associated with race, female sex, age greater than 65 years, black women younger than 45 years, and middle-aged black men. [16] Predictors of outcome in early studies of ICH included age, ICH location, electrocardiographic abnormalities, and history of hypertension. More recent studies have also identified lesion size, level of consciousness, midline shift, blood pressure or pulse pressure, kidney dysfunction, IVH and pupillary abnormality, as factors influencing outcome. [17],[18],[19],[20] Review of these studies reveals considerable variability in the factors identified. This is likely as many of the factors are likely to interact strongly with each other. In our study, independent predictors for mortality were low GCS score, larger volume of hematoma on CT scan, presence of IVH and need for ventilatory support during hospital stay. Radiological findings seem to be closely associated with prediction of mortality and also clinical behavior. [18],[19],[21],[22] As in our results, baseline hematoma volume, IVH, hydrocephalus and midline shift are important variables influencing prognostication. Demchuk and colleagues in the recently published PREDICT study, observed that Spot Sign observed on CT-angiography was independently associated with a poor outcome. [10] This radiological parameter is currently being studied in two Factor VII A therapy trials in relationship to hematoma growth and outcome.

Using ROC curve, cut-off value with optimum sensitivity and specificity for hematoma volume in our dataset was 42 ml. Although many studies have observed a volume of 30 ml as a good cutoff, our population had a higher mean baseline hematoma volume compared to previous studies and also had severe strokes as suggested by high baseline NIHSS and low GCS. As observed in previous studies, mean ICH and ICHGS scores were significantly higher in patients who died in the present cohort. In a recent study the ICH score also correlated well with the 3 months mRS, Glasgow outcome scale (GOS) and Barthel index (BI). [23]

In the present cohort, neurosurgical intervention did not improve mortality or outcome. Although surgery in ICH has always been a controversial issue, outcomes after surgery are dependant on host of factors of which age, GCS, onset to surgery times, baseline hematoma volume, IVH and depth of hematoma are important predictors. [12] Most of the survivors in the present cohort were disabled at the time of discharge. A systematic review estimated that only between 12 and 39% of patients achieve independent function. [24] In a recently published study on post-surgically treated ICH patients, poor outcome on GOS at 6 months was observed in 86% patients. They identified midline shift of >5 mm as the strongest predictor of outcome. [25]

In conclusion, intracerebral hemorrhage is associated with high mortality and morbidity. Low GCS, higher baseline hematoma volume, presence of intraventricular hemorrhage and need for ventilatory assistance independently predicted mortality in the present cohort. Surgery did not affect outcome and most of the survivors were significantly disabled at discharge.

 » References Top

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5.Castellanos M, Leira R, Tejada J, Gil-Peralta A, Dávalos A, Castillo J; Stroke Project, Cerebrovascular Diseases Group of the Spanish Neurological Society. Predictors of good outcome in medium to large spontaneous supratentorial intracerebral haemorrhages. J Neurol Neurosurg Psychiatry 2005;76:691-5.  Back to cited text no. 5
6.Fieschi C, Carolei A, Fiorelli M, Argentino C, Bozzao L, Fazio C, et al. Changing prognosis of primary intracerebral hemorrhage: Results of a clinical and computed tomographic follow-up study of 104 patients. Stroke 1988;19:192-5.  Back to cited text no. 6
7.Lisk DR, Pasteur MD, Rhoades H, Putnam RD, Grotta JC. Early presentation of hemispheric intracerebral hemorrhage: Prediction of outcome and guidelines for treatment allocation. Neurology 1994;44:133-9.  Back to cited text no. 7
8.Hemphill JC 3 rd , Bonovich DC, Besmertis L, Manley GT, Johnston SC. The ICH score: A simple, reliable grading scale for intracerebral hemorrhage. Stroke 2001;32:891-7.  Back to cited text no. 8
9.Ruiz-Sandoval JL, Chiquete E, Romero-Vargas S, Padilla- Martinez JJ, Gonzalez-Cornejo S. Grading scale for prediction of outcome in primary intracerebral hemorrhages. Stroke 2007;38:1641-4.  Back to cited text no. 9
10.Demchuk AM, Dowlatshahi D, Rodriguez-Luna D, Molina CA, Blas YS, Dzialowski I, et al. Prediction of haematoma growth and outcome in patients with intracerebral haemorrhage using the CT-angiography spot sign (PREDICT): A prospective observational study. Lancet Neurol 2012;11:307-14.  Back to cited text no. 10
11.Wartenberg KE, Mayer SA. The STICH trial: The end of surgical intervention for supratentorial intracerebral hemorrhage? Curr Neurol Neurosci Rep 2005;5:473-5.  Back to cited text no. 11
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13.Sacco S, Marini C, Toni D, Olivieri L, Carolei A. Incidence and 10-year survival of intracerebral hemorrhage in a population-based registry. Stroke 2009;40:394-9.  Back to cited text no. 13
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15.Flaherty ML, Haverbusch M, Sekar P, Kissela B, Kleindorfer D, Moomaw CJ, et al. Long-term mortality after intracerebral hemorrhage. Neurology 2006;66:1182-6.  Back to cited text no. 15
16.Rincon F, Mayer SA. The Epidemiology of Intracerebral Hemorrhage in the United States from 1979 to 2008. Neurocrit Care. 2012 Oct 26. [Epub ahead of print]  Back to cited text no. 16
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