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.
Journal of military pharmaco-medicine 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, prospective analysis of 188 acute supratentorial hemorrhage patients associated with hypertension at admission, admitted within six hours after onset, from 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 NIHSS at admission and after 72 hours HV average on 2nd CT was 26.54 cm3, 1st CT was 22.35 cm3, rate has increased HV on 2nd CT after 72 hours was 12.77% * Key words: Supratentorial hemorrhage; Noncontrast and contrast brain CT-Scanner images Introduction Although stroke is a classic pathology of the neurology, but still a topical issue in the world 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] After 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 Therefore, we studied 188 supratentorial ICH patients in order to: Comments changes of clinical and intracerebral hematoma volume, noncontrast and contrast brain CT-Scan images in acute supratentorial hemorrhage for 72 hours after onset * 103 Hospital ** 115 Hospital Address correspondence to Nguyen Van Chuong: 103 Hospttal E.mail: nvch@yahoo.com Journal of military pharmaco-medicine 7-2013 Subjects and Methods Study subjects Patients with acute supratentorial hemorrhage associated with hypertension, admission before six hours after onset, treated at the Department of Cerebral-Vascular Pathology, 115 People Hospital from - 2011 to - 2013 agreed with inclusion criteria will be included in the study * Inclusion criteria: ICH is the first acute supratentorial hemorrhage associated with hypertension at admission, admitted within six hours after onset, with brain images 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 hemorrhage (STH) due to aneurysm rupture, due to arteriovenous malformations, moyamoya disease, by using anticoagulants or anti-platelet drugs -.STH with blood intraventricular (intraventricular hemorrhage) - Patients die before the second CT-Scan shot - STH transformation of cerebral infarction - Renal failure, creatinine ≥ 1.7 mg/dl - History of allergy to contrast drugs + BP, consciousness at admission, paralysis of cranial nerve VII, strength of the arms and legs paralyzed + The Glasgow, NIHSS, Rankin at admission and 72 hours after onset + BP at hour, then BP measurement every 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 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 increased (enlargement) HV in the brain increases granted under Kazui [8] as V2 - V1 ≥ 12.5 cm or V2/V1 ≥ 1.4, where V1, V2 respectively HV on brain CT-Scan 1st and 2nd 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 Research methodology Study design: descriptive, prospective analysis * Data collection: - The clinical data: 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 military pharmaco-medicine 7-2013 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 patients (5.3%) had stroke during the first hospitalization, 76 patients (40.4%) at hours Clinical features * Symptoms at onset: * Blood pressure: Table 1: Blood pressure of patients at admission On admission Mean Min Max SBP 165 140 240 DBP 97 90 140 MAP 100 79 128 * 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 arms and legs: At admission, all patients (100%) in paralyzed arms to varying degrees, only patient (0.53%) was not paralyzed in the legs * Neurological deficiencies at admission: Table 2: Neurological deficiencies of patients at admission according to neurological scales at admission Figure 1: The symptoms of patients at onset When STH, all patients in the plot study were paralyzed to varying degrees, headache was common symptoms of nd following paralysis Min Max Mean SD Glasgow 15 13.3 2.27 NIHSS* 36 12.7 6.49 Rankin 3.8 0.49 (* Median [inter-quartile range] 12 (7, 16) * Neurological deficiencies at admission was assessed by three neurological scales: Journal of military pharmaco-medicine 7-2013 * Location of hematoma 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 patients with putamen hemorrhage * Shape of hematoma on the 1st brain CT: Figure 2: Neurological deficiencies at admission were assessed by three neurological scales Almost of patients with severe neurological deficiencies level (mRS ≥ 4) Brain computerized tomography at admission (1st time) * Time of 1st 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 hour after onset The majority (30.32%) had a CT-Scanner first time over a period of - hours after onset * Hematoma volume on 1st brain CT: Figure 3: Hematoma volume on 1st brain CT In the 188 patients studied, nearly half of patients with HV < 15 ml (cm 3) 20 patients (10.64%) had irregular hematoma shape, 168 patients (89.36%) had regular hematoma shape on the 1st 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 the early hours could be seen image of contrast drug extravasation and left in hematoma, the predicted blood sign still continues to flow, and can identify patients at increased risk HV [3, 5, 9] In this study, 20 patients (10.64%) had spot sign on CTA Journal of military pharmaco-medicine 7-2013 * Time noncontrast 2nd brain CT: Table 3: Time taken 2nd brain CT-Scanner (at clinical worsening or 72 hours after stroke onset) 2nd brain CT-Scanner Mean Min Max SD Time (h) 66.60 72 16.10 * Evaluating patient ’s clinical and CT, compared 2nd with the 1st times: Table 4: Clinical assessment of patients, compared 2nd with the 1st times Scale Glasgow NIHSS Figure 4: Spot sign on CTA (arrow) (Source: Nonconstrast and contrast brain CT of patient from this study) * Time CTA: Figure 5: The time from stroke onset to take CTA Only 39 patients (20.97%) took CTA in the first hours after the onset of STH, mostly concentrated in the period from - 12 hours (32.26%) and 18 - 24 hours (34, 41%) after stroke onset mRS Mean Min Max st 13.3 15 2.27 nd 12.9 15 3.32 1st 12.7 36 6.49 nd 12.8 41 8.92 1st 3.8 0.49 nd 3.7 0.83 SD P value 0.07 0.0005* 0.37 (* Wilcoxon sign rank test) * Change of Glasgow, NIHSS, Rankin score after 72 hours: When comparing the second Glasgow, NIHSS, Rankin to the first at admission, we found no differences in Glasgow at two time points (13.32 and 12.97) with p = 0.07, there was not difference 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) was 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 2nd brain CT as compared with 1st: There were 24 patients (12.77%) with increased HV when compared HV on 1st brain CT with the 2nd times Enlargement Journal of military pharmaco-medicine 7-2013 HV rate was 20.83% in patients with small hematoma volume (< 15 cm 3), 29.17% in those with moderate HV (15 - 29 cm3), 16.67% in those who had big hematoma (30 - 45 cm 3), and 33.33% in those with a large hematoma (> 45 cm 3) 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, the rate of men was an twice much as women - HV average on nd CT was 26.54cm 3, 1st CT was 22.35 cm - 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 the CTA - The rate of increased HV on 2nd CT after 72 hours was 12.77% REFERENCES Allyson R Zazulia MD, Michael N Diringer MD, Colin P Derdeyn MD, William J Powers MD Progression of mass effect after intracerebral hemorrhage Stroke 1999, 30, pp.1167-1173 - When STH, all of the patients (100%) in the plots study were paralyzed to varying degrees, the percentage of patients with right and left paralyzed almost the same; headache was common symptoms ranking 3rd following paralysis and paralyzed VII nerve - 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Journal of military pharmaco-medicine 7-2013 * Time noncontrast 2nd brain CT: Table 3: Time taken 2nd brain CT-Scanner (at clinical worsening or 72 hours after stroke onset) 2nd brain CT-Scanner... regular hematoma shape on the 1st 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 the... 4) Brain computerized tomography at admission (1st time) * Time of 1st brain CT: In 188 patients, brain CT-Scanner time was as early as 30 minutes after onset, median (inter-quartile range) of