Predicting deterioration in patients with lobar haemorrhages
- aDepartment of Neurology, Neurological and Neurosurgical Intensive Care Unit, Saint Mary’s Hospital, bSection of Biostatistics, Mayo Clinic and Foundation, 200 First Street SW, Rochester, MN 55905, USA
- Dr E F M Wijdicks, Department of Neurology, Mayo Clinic W8A, 200 First Street SW, Rochester, MN 55905, USA. Telephone 001 507 284 2511; fax 001 507 284 4795; email wijde{at}mayo.edu
- Received 21 July 1998
- Revised 13 November 1998
- Accepted 24 November 1998
Abstract
OBJECTIVE To study the clinical course and determine predictors of deterioration in patients with lobar haemorrhages).
METHODS A comprehensive review of 61 consecutive patients with lobar haemorrhages was performed. Neurological deterioration was defined as (1) decrease in Glasgow coma sum score by 2 points, (2) new neurological deficit, or (3) clinical signs of brain herniation. A univariate logistic regression was performed and expressed in odds ratios.
RESULTS Sixteen of 61 (26%) patients with lobar haemorrhages deteriorated after admission. In a univariate analysis, only a Glasgow coma score <14 predicted deterioration (75% of deterioratorsv 24% who did not deteriorate; p<0.0001). Initial CT characteristics predictive of deterioration included haemorrhage volume >60 ml (63% v 16%, p< 0.0001), shift of the septum pellucidum (75%v 36%, p<0.01), effacement of the contralateral ambient cistern (33% v 0%, p<0.0001), and widening of the contralateral temporal horn (50%v 0%, p<0.0001). Patients presenting and deteriorating within 12 hours of ictus declined due to enlargement of the haemorrhage. Those who deteriorated more than 12 hours after initial neurological symptoms, showed increased mass effect secondary to oedema.
Conclusion—Patients with lobar haemorrhages presenting immediately after ictus are at risk for deterioration from enlargement of the haemorrhage and predictors of deterioration may be absent. Patients with large volume lobar haemorrhages presenting to the emergency department with decreased level of consciousness and shift on CT are at risk for further deterioration from worsening oedema. These patients require close observation and early aggressive management may be warranted.
