title: Can specific patient variables be used to predict outcome of intracranial hemorrhage?
abstract: The study objective was to identify the demographic, physiologic, and anatomic variables associated with outcomes of patients with intracranial hemorrhages. We performed a prospective study of all patients with known or suspected intracranial hemorrhages transferred from a community hospital to the neurosurgical service of tertiary care centers in Toronto. Outcomes measured were patient disposition (admitted v discharged immediately), management (neurosurgical interventions v observation) and survival until discharge v death. Patient variables recorded pre- and post-transfer were analyzed using the statistical programs C.H.A.I.D. and C.A.R.T.(Answer-Tree Software, SPSS Inc.Headquarters, Chicago, IL). Two linear regression trees were constructed to reveal associations with each outcome. Sixty-seven patients between the ages of 24 and 89 were included in the study. Of these, 1 was referred for an epidural bleed, 20 for subdural bleeds, 21 for subarachnoid hemorrhages, and 25 for intracerebral hemorrhages. Thirteen of the patients in the study died or remained with permanent, severe neurological deficits. Of these, none had epidural hemorrhages, 4 had subdural hemorrhages, 5 had subarachnoid hemorrhages, and 4 had intracerebral hemorrhages. The linear regression tree constructed with C.A.R.T. revealed that the most important predictor of outcome was the GCS score of the patient on arrival at the neurosurgical center. Specifically, 71.43% of individuals arriving with a GCS score less than or equal to 7 died or remained with a severe neurological deficit, whereas only 5.66% of individuals arriving with a GCS score greater than or equal to 8 had such an outcome (P<.11). The regression tree constructed using C.H.A.I.D. revealed a similar result. Patients with a GCS score less than or equal to 5 on arrival at the neurosurgical center had a 70% chance of dying or remaining with a severe neurological deficit, whereas those with a GCS score greater than or equal to 13 had a 0% chance of having such an outcome (P <.0001). Furthermore, 100% of patients with post-transfer GCS scores less than or equal to 5 and an absent gag reflex died or remained with a severe neurological deficit compared with only 25% of those with a GCS score less than or equal to 5 with an intact gag reflex (P =.0005). This study also revealed a number of incidental findings. The presence of bilateral unreactive pupils, absent corneal reflex or absent vestibulo-ocular reflex (dolls-eye) independently predicted mortality in 100% of patients (not statistically significant). No patient with any of the following characteristics: any pupillary abnormality or age > 62 with a GCS < 5, achieved a normal functional outcome. Within the population of patients referred from community hospitals to a neurosurgical center for evaluation of intracranial hemorrhage, specific clinical findings are powerful predictors of mortality and poor functional outcome. Patients with a post-transfer GCS score <= 5 and an absent gag reflex had a 100% incidence of death or severe, permanent neurological dysfunction compared with only 25% of those arriving with GCS scores <= 5 with an intact gag reflex (P =.0005). Additionally, The presence of bilateral unreactive pupils, absent corneal reflex and absent vestibulo-ocular reflex independently predicted mortality in 100% of patients (not statistically significant). Other clinical findings including any pupillary abnormality and GCS <=5 combined with age => 62 negated the possibility of normal functional outcome (not statistically significant). These findings may have wide-ranging implications regarding the transfer and treatment of patients with intracranial hemorrhages, use of resources and counseling of families.
authors.affiliation: University Health Network and the Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada. idubinsky@millerthomson.ca
authors.forename: Isser
authors.initials: I
authors.lastname: Dubinsky
authors.forename: Daniel
authors.initials: D
authors.lastname: Penello
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D003657:Decision Making; D005260:Female; D006801:Humans; D020300:Intracranial Hemorrhages / Q000175:diagnosis* / Q000601:surgery*; D016014:Linear Models; D008297:Male; D008875:Middle Aged; D009864:Ontario; D010360:Patient Transfer; D011379:Prognosis; D011446:Prospective Studies; D016896:Treatment Outcome