Prachi Mehndiratta, MD
Lord AS, Gilmore E, Choi HA, and Mayer SA, on behalf of VISTA-ICH Collaboration. Time Course and Predictors of Neurological Deterioration After Intracerebral Hemorrhage. Stroke. 2015
Spontaneous Intracerebral Hemorrhage (sICH) can be serious and life threatening based on hemorrhage and clinical characteristics. If you remember the Hemphill ICH score, you can predict 30 day mortality from ICH based on a combination of clinical and imaging characteristics. We also know from prior studies that hematomas often snowball and increase in size in the first 24 hours and our best chance of good recovery lies in halting hematoma growth. The authors of this study aim to identify the predictors of neurological deterioration after a sICH. They enrolled patients into a retrospective cohort from the VISTA database and attempted to identify clinical and radiological features associated with a pre-defined neurological deterioration at various points in time. These patients were enrolled in the placebo arms of prospective, randomized trials of acute treatment for ICH and baseline as well as follow up CT scans, rigorous physical exam data and a 3 month mRS score.
Neurological deterioration (ND) was defined as hyper-acute ( <1 hour), acute (1-24 hours), sub-acute (1-3 days) and delayed (3-15 days). Univariate and multivariate analyses were performed to identify demographic, clinical and radiographic factors that were associated with deterioration in each subgroup. Chi-square, Fisher’s exact test, Mann-Whitney-U test and logistic regression were used for analysis. A total of 376 patients were included in the cohort and ND occurred in 176 patients, 170 at discrete pre specified time points and in 6 patients gradually over multiple time periods. The predictors of ND were intuitive – patients with hyperacute and acute ND had lower GCS, higher NIHSS, larger hematoma volumes and presence of IVH. Patients with subacute ND were similar to those with acute ND but in addition had higher rates of fever and increased IVH blood volumes. Multivariate analysis revealed that delayed ND was associated with older age, higher troponin levels and infection in the 3-15 day period.
The study was well done and well-intended but does it really affect my practice? I don’t think so. I know that patients with certain ICH clinical and radiographic characteristics can get worse and as a stroke physician I need to make sure their hemorrhage volume does not increase, provide them the best supportive neurocritical care and make sure they don’t get infected in order to improve their chances for survival from an illness that already carries a very high morbidity and mortality.
Why not discuss the various causes of the neuronal cascade of death as predictors of continuing neurological damage?
1. glutamate poisoning
3. Capillaries that don't open due to pericytes
4. Inflammatory action leaking through the blood brain barrier.
5. Lysosomal Membrane Permeabilization as a Key Player in Brain Ischemic Cell Death