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Time Is Brain and So Is Less Blood

2015; Lippincott Williams & Wilkins; Volume: 76; Issue: 6 Linguagem: Inglês

10.1227/01.neu.0000465851.32964.07

1524-4040

Samer G. Zammar, Richard S. Zimmerman, Michelle M. Tiano, Bernard R. Bendok,

Neurosurgical Procedures and Complications

Intracerebral hemorrhage (ICH) is associated with a significant risk of neurological deterioration (ND).1-3 It is estimated that ND can occur in up to 33% of patients with ICH. Large-volume hematomas (>45 mL), hematoma expansion, hypertension, and spot sign on computed tomography (CT) are significant risk factors for developing ND.3-5 Most NDs occur within the first 24 hours.2,6 Although ND is an established phenomenon after ICH, the time course of ND in the hyperacute phase (first several hours) has not been well defined. The risk factors for early deterioration have also not been well studied. To investigate this issue, Lord et al7 analyzed the Virtual International Stroke Trials Archive (VISTA) database (placebo patients in prospective ICH clinical trials) to retrospectively study the timeline of ND and the radiographic correlates in a cohort of patients who had ICH and underwent CT imaging within the first 3 hours of symptoms onset. The investigators examined the time course of ND based on predefined time windows: hyperacute deterioration (HD; 0-1 hours), acute deterioration (AD; 1-24 hours), subacute deterioration (1-3 days), and delayed deterioration (3-15 days). ND was defined as a ≥2-point decrease on the Glasgow Coma Scale (GCS) or a ≥4-point increase on the National Institutes of Health Stroke Scale (NIHSS). These clinical scores compared the patients at the beginning and end of each predefined time window. Patients had CT scans within 3 hours of symptom onset and follow-up CT at 24 and 72 hours. The authors also divided the patients into a nondeterioration group (NoD; those who remained stable or showed improvement within 15 days) and an any deterioration group (all patients who had ND as defined by NIHSS and GCS, plus patients who showed gradual decline across multiple time periods compared with baseline). A total of 376 patients were enrolled in the study, among whom 47% experienced ND at any point. Seventy percent of these NDs occurred during the first 24 hours, among which 34% occurred in the first hour (hyperacute). Patients with HD and AD were more likely to have lower GCS scores, higher NIHSS scores, larger hematoma volumes, and presence of intraventricular hemorrhage (IVH) than the NoD group (P < .05). Patients with AD were more likely to have lobar hemorrhage and higher serum glucose than NoD patients (P < .05). Although patients who had subacute deterioration shared many characteristics with patients with AD, increased rates of fever and higher IVH blood volumes were unique significant associations between the subacute deterioration group and the NoD group. Radiographic findings showed that hematoma expansion was more likely to be associated with HD and AD compared with NoD (P < .05). CT scans that showed IVH expansion at 24 and 72 hours were more likely to be associated with the odds of subacute deterioration. Although edema was not significantly associated with ND in either the HD or AD stage, higher edema volumes at 72 hours were significantly associated with subacute ND. The study also demonstrated that medical complications and the lack of functional reserve (increased age, high levels of troponin, infectious complications) are associated with delayed neurological deterioration. Death was more likely to occur in patients with ND than in the NoD group (42% vs 3%; P < .001). This study sheds light on the alarming rate of HD after ICH. This deterioration is associated with worsened outcome. Unsurprisingly, hematoma expansion and IVH are strongly associated with early ND, whereas cerebral edema, fever, and medical complications are associated with delayed ND. Neurosurgeons are uniquely positioned to play a constructive role in the multidisciplinary hyperacute management of patients with ICH. A better understanding of how and why patients with ICH deteriorate may lead to better therapeutic interventions.