Transcript Slide 1

TRAUMATIC
INTRACEREBRAL
HAEMORRHAGE:IS THE CT
PATTERN RELATED TO
OUTCOME
INTRODUCTION
• Traumatic brain injury is the leading cause
of death and disability.
• Every year worldwide 1.5 million
(especially young population) die and
several million receive emergency
treatment.
• In addition to age and neurological status
(GCS);it is believed by many
neurosurgeons that CT pattern of
traumatic intra-cerebral
haemorrhage(TICH) are related to
outcome.
• Aim of current study was to find whether
this is true after adjusting for age and
neurological status.
PATIENTS AND METHODS
• It is retrospectively analysed, prospectively
collected data study over 4 yrs.
period(2001-2004) at regional level 1
trauma centre in Hongkong.
• Data inclusion reviewed taking into
consideration under-mentioned factors:
- Age
- Sex
Contd.
-GCS on admission
-GCS motor component score
-site &laterality(unilateral/bilateral)traumatic
intra-cerebral haemorrhage.
-Associated EDH/SDH/SAH(traumatic)
-Duration of stay in hospital.
-Duration of ICU stay
-Significant extra-cranial injuries.
-Mechanism of injury.
• Cerebral contusion (traumatic intracerebral haematoma)was defined as
haemorrhagic focus within the brain
parenchyma secondary to external
trauma.
• Surgical evacuation of contusion was
performed in patients with :
-progressive neurological deterioration
-medical refractory hypertension
-signs of mass effect on CT scan.
• Operative procedures involved:
- Craniotomy with evacuation of haematoma
- Decompressive craniectomy with or
without
- ICP monitoring
• One year outcome measured and
classified as :
A)Favourable
B)Unfavourable
Favourable outcome includes performance
of independent activities of daily living
based on Glasgow outcome scale(good
recovery and moderate disability)at one
year.
RESULTS
• Total patients with significant head injuries
were 464.
• Mean age+/- SD was 48.4+/- 22.5 yrs. with
M:F 7:3
• 107 (23%)considered as elderly(age>65
yrs.)
• 321(69%)were male.
• Higher percentage of female(42%) in
elderly age group.(p value:0.004)
Contd.
• Median GCS of entire study group :10
• 213 (45.9%)had severe head injury with
GCS<8
• In elderly there is increase incidence of
contusion, SDH (p<0.001)and traumatic
SAH(p<0.004)
• In hospital mortality was significantly higher
for elderly (47%)than young population(34%)
• Elderly people had unfavourable outcome at
one year(75%)versus young(41%) {p<0.001)
• Of 464 patients 114 (24.6%) had traumatic
intra-cerebral haematoma and formed the
focus of current study group.
• Mean age +_SD was 48.9+_24.9.( M:F
2:1)
• Median GCS score on admission was 12
and median GCS motor component score
was 6.
• 85(74.6%)had frontal TICH, 51(44.7%)had
temporal TICH,25(21.9%)had bilateral
traumatic intra-cerebral haemorrhage.
• 42(36.8%) had associated subdural
haematoma(SDH)
• ICU stay (mean +_SD) was 3.7+_7days.
• Hospital stay (mean+_SD)was
21.0+_37.1days.
• Most common mechanism of injury were
falls(46,40.3%) & road traffic accidents
(48;42.0%)
• Inpatient mortality observed in 21(18.4%)
patients and 52 (36%)patients were
discharged to rehab hospital.
• One year favourable outcome observed in
75(65.8%) and 56(49.1%) had attained
good recovery .
• Mortality occurred in 25 (21.9%) patients
at one year.
FACTORS ASSOCIATED WITH
INPATIENT MORTALITY.
•
•
•
•
Older age
Glasgow coma scale at resuscitation time.
GCS motor component score
Temporal traumatic intra-cerebral
haematomas.
• Bilateral traumatic intra-cerebral
haematomas
• Associated SDH
• Binary logistic regression analysis showed
age and GCS motor score were
significantly associated with inpatient
mortality.
• Association between temporal TICH and
inpatient mortality.
• Association between TICH and SDH.
• Traumatic haematoma of >50 ml showed a
trend towards higher inpatient
mortality.(80%versus31.3%){p=0.057}
FACTORS ASSOCIATE WITH
ONE YEAR MORTALITY
• Binary logistic regression analysis showed
that age and GCS score remained
significantly associated with one year
mortality.
• There was also an association between
SDH and one year mortality.
FACTORS ASSOCIATED WITH
ONE YEAR OUTCOME(favourable
versus unfavourable)
• One year unfavourable outcome was
associated with :
-older age
-GCS
-GCS motor component scores
-frontal TICH
-left sided TICH
-SDH and TICH volume > 50 ml.
• Binary logistic regression analysis showed
that age and GCS motor component score
remained significantly associated with one
year outcome.
• An association between bilateral
contusions and one year outcome was
noted.
DISCUSSION AND
CONCLUSION
• After age and GCS/GCS motor component
score adjustment inpatient mortality of
patient with TICH was related to :
- Temporal traumatic intra-cerebral
haematoma.
- Associated SDH.
. One year unfavourable outcome related
to bilateral TICH
Whether aggressive monitoring and early
surgical evacuation could improve the
neurological outcome remains to be determined
in a randomised controlled clinical trial settings.
Previous cases series (Andrew &
colleagues;caroli &colleague)have reported
between anatomical pattern & poor outcome
but data were not adjusted for the age and
neurological status which could create
confounding effects.
• Author( kumchev & colleagues)concluded
that temporal haematomas,especially
those larger that 30 cc resulted in greater
risk for brain stem compression.
• In addition to strategies space ;lack of
compensatory space offered by temporal
horn of lateral ventricle might account for
in hospital increase in mortality rate.
• Subdural haematoma increase mortality
might be to cortical injuries in addition to
subcortical injuries as indicated by
traumatic intra-cerebral haemorrhage.
moreover SDH causes significant
intracranial haematoma.
• B/L TICH;the relationship of which to the
poor outcome has not been previously
documented ,were associated with poor
neurological outcome at one year.
• Bilateral injuries remove the possibility of
compensation from the other hemisphere,
resulting in poor prognosis for the
recovery.
• The weakness are that quality-of-life
assessments and cognitive assessments
were not carried out and that data on
pathophysio-logical mechanisms such as
occipital impact of
acceleration/deceleration are lacking.
• Despite above limitations it was studied
that CT patterns of temporal contusions,
cerebral contusions associated with SDH
and bilateral contusions were associated
with mortality and poor outcome ,after
adjusting for the age and neurological
status which could be useful for
counselling, formulation of management
strategies and as background multi-centre
study.