Can we predict poor outcome at presentation in patients with lobar hemorrhage?
OBJECTIVE
Supratentorial lobar hemorrhage can be devastating. Outcome prediction at presentation is important in triage and management decisions as well as appropriate resource utilization. We performed a decision tree analysis combining clinical and CT scan features to predict poor and hopeless outcome at initial presentation in patients with lobar hemorrhage.


METHODS
We analyzed 81 patients with spontaneous lobar hemorrhage presenting within 48 hours of initial neurologic symptoms. In the first analysis, poor outcome was defined as Glasgow outcome score (GOS) of 1 (death), 2 (vegetative state) or 3 (dependence) at discharge. A second analysis was based on worst possible outcome (GOS 1-2). Binary recursive partitioning was fitted in a model, and odds ratios with 95% confidence intervals (CI) were calculated.


RESULTS
Lobes involved were temporal (36%), parietal (33%), frontal (25%) and occipital (6%). Seventy-three percent of patients presented less than 17 h after initial ictus. The probability of poor outcome was 97% (CI 85-100%) in patients with hemorrhage greater than 40 cm(3). In the subset of patients with a volume less than 40 cm(3), time interval from ictus to presentation (< 17 h) together with a Glasgow coma score (GCS) less than or equal to 13 predicted poor outcome. Eighty-five percent (CI 42-99%) of those presenting early with GCS less than or equal to 13 had a poor outcome. In the second analysis, all patients with GCS less than or equal to 12 and septum pellucidum shift > 6 mm had GOS of 1 or 2 (CI 72-100%).


CONCLUSIONS
Poor outcome in patients with lobar hemorrhage is associated with a hemorrhage size of more than 40 cm(3), GCS less than or equal to 13, but also dependent on time interval between ictus and presentation. This is consistent with prior studies demonstrating deterioration from enlargement may occur when patients present early on. Stupor and septum pellucidum shift greater than 6 mm on CT scan at presentation predict a hopeless outcome in conservatively treated patients. Ninety-one percent of patients were treated medically, thus these outcomes are largely a reflection of the natural history of spontaneous lobar hemorrhage. These signs may influence triage and management decisions.
Flemming
K D
KD
Department of Neurology, Neurological and Neurosurgical Intensive Care Unit, Saint Mary's Hospital, Rochester, Minn, USA.
Wijdicks
E F
EF
Li
H
H
D000293:Adolescent; D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D000925:Anticoagulants / Q000627:therapeutic use; D001794:Blood Pressure; D002543:Cerebral Hemorrhage / Q000175:diagnosis / Q000188:drug therapy* / Q000401:mortality / Q000503:physiopathology; D002648:Child; D016001:Confidence Intervals; D005260:Female; D005625:Frontal Lobe; D015600:Glasgow Coma Scale; D006801:Humans; D008279:Magnetic Resonance Imaging; D008297:Male; D008875:Middle Aged; D009778:Occipital Lobe; D016017:Odds Ratio; D010296:Parietal Lobe; D018458:Persistent Vegetative State; D010975:Platelet Aggregation Inhibitors / Q000627:therapeutic use; D011379:Prognosis; D015996:Survival Rate; D013702:Temporal Lobe; D014057:Tomography, X-Ray Computed; D016896:Treatment Outcome
D000925:Anticoagulants; D010975:Platelet Aggregation Inhibitors