TRAUMATIC INTRACEREBRAL

HAEMORRHAGE:IS THE CT PATTERN RELATED TO

OUTCOME

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.

• 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.

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

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.

• 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.

• Operative procedures involved:

- Craniotomy with evacuation of haematoma

- Decompressive craniectomy with or without- ICP monitoring

• One year outcome measured and classified as :

A)FavourableB)UnfavourableFavourable outcome includes performance of

independent activities of daily living based on Glasgow outcome scale(good recovery and moderate disability)at one year.

RESULTS

• Total patients with significant head injuries were 464.

• Mean age+/- SD was 48.4+/- 22.5 yrs. with M:F 7:3

• 107 (23%)considered as elderly(age>65 yrs.)• 321(69%)were male.• Higher percentage of female(42%) in elderly

age group.(p value:0.004)

Contd.• Median GCS of entire study group :10• 213 (45.9%)had severe head injury with

GCS<8• In elderly there is increase incidence of

contusion, SDH (p<0.001)and traumatic SAH(p<0.004)

• 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%) {p<0.001)

• 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.( M:F 2:1)• 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.

• 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 (48;42.0%)

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

• 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.

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

• 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 >50 ml showed a

trend towards higher inpatient mortality.(80%versus31.3%){p=0.057}

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.

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 > 50 ml.

• 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.

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

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

• 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.

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

• 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/deceleration are lacking.

• 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.