TRAUMATIC INTRACEREBRAL HAEMORRHAGE:IS THE CT PATTERN RELATED TO OUTCOME

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TRAUMATIC INTRACEREBRAL HAEMORRHAGEIS THE CT
PATTERN RELATED TO OUTCOME
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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.

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• 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.

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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

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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.

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• Cerebral contusion (traumatic intra-cerebral
  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.

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• Operative procedures involved
• Craniotomy with evacuation of haematoma
• Decompressive craniectomy with or without
• ICP monitoring

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• One year outcome measured and classified as
• Favourable
• Unfavourable
• Favourable outcome includes performance of
  independent activities of daily living based on
  Glasgow outcome scale(good recovery and moderate
  disability)at one year.

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RESULTS

• Total patients with significant head injuries
  were 464.
• Mean age/- SD was 48.4/- 22.5 yrs. with MF 73
• 107 (23)considered as elderly(agegt65 yrs.)
• 321(69)were male.
• Higher percentage of female(42) in elderly age
  group.(p value0.004)

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Contd.

• Median GCS of entire study group 10
• 213 (45.9)had severe head injury with GCSlt8
• In elderly there is increase incidence of
  contusion, SDH (plt0.001)and traumatic
  SAH(plt0.004)
• 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) plt0.001)

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• 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.( MF 21)
• 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.

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• 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
  (4842.0)
• Inpatient mortality observed in 21(18.4)
  patients and 52 (36)patients were discharged to
  rehab hospital.

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• 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.

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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

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• 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 gt50 ml showed a trend
  towards higher inpatient mortality.(80versus31.3
  )p0.057

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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.

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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 gt 50 ml.

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• 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.

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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

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• 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 colleaguescaroli
  colleague)have reported between anatomical
  pattern poor outcome but data were not adjusted
  for the age and neurological status which could
  create confounding effects.

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• 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.

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• 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 TICHthe relationship of which to the poor
  outcome has not been previously documented ,were
  associated with poor neurological outcome at one
  year.

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• 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/decelerat
  ion are lacking.

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• 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.