(Stroke. 1995;26:1764-1767.)
© 1995 American Heart Association, Inc.
Articles |
Predictors of Early Deterioration and Mortality in Black Americans With Spontaneous Intracerebral Hemorrhage
From the Departments of Neurology (A.I.Q., K.S., C.B., D.L.B., B.M., M.R.F.), Medicine (E.J.W.), and Neurosurgery (A.R.C.), Emory University School of Medicine, Atlanta, Ga.
Correspondence to Michael R. Frankel, MD, Chief of Neurology, Grady Memorial Hospital, 80 Butler St SE, PO Box 26036, Atlanta, GA 30335.
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Abstract |
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Background and Purpose Black Americans with spontaneous intracerebral hemorrhage (SICH) may have unique clinical characteristics that affect outcome. The aim of this study was to determine the prognostic value of clinical characteristics and initial CT scan for outcome in black Americans with SICH.
Methods Clinical and demographic data were extracted from the
charts of 182 consecutive black Americans admitted for SICH diagnosed
by clinical criteria and initial CT scan. Hemorrhage volumes
were calculated from admission CT scans by a computerized method.
Univariate and multiple logistic regression
analyses were performed to determine independent predictors of
early deterioration (defined as a decrease from an initial Glasgow Coma
Scale score >12 by 
4 points within 24 hours from
presentation) and mortality.
Results Both hemorrhage volume and
ventricular extension were significant, independent
predictors of early deterioration (odds ratio [OR], 6.78; 95%
confidence interval [CI], 1.89 to 24.35 and OR, 4.67; 95% CI, 1.30
to 16.72, respectively) and mortality (OR, 6.66; 95% CI, 2.85 to 15.58
and OR, 4.23; 95% CI, 1.82 to 9.82, respectively). A Glasgow Coma
Scale score 
12 also predicted mortality (OR, 3.23; 95% CI, 1.46 to
7.14). Initial mean arterial pressure was not an
independent predictor of early deterioration or mortality.
Conclusions Hemorrhage volume and ventricular extension are the best predictors of early deterioration and mortality in black Americans with SICH.
Key Words: blacks • intracerebral hemorrhage • mortality • racial differences • tomography
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Introduction |
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TopAbstractIntroductionSubjects and MethodsResultsDiscussionReferences |
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It has been shown that SICH accounts for 4% to 14%1 2 3 4 5 6 7 of all cases of stroke and is associated with higher morbidity and mortality than other kinds of stroke. In previous studies of SICH, predictors of poor outcome have included hematoma volume, level of consciousness, VE, hypertension, and pulse pressure.8 9 10 11 12 13 14 15 In most of these studies, subjects were predominantly white. Unfortunately, there are minimal data on SICH in black populations. Many reports have suggested that the risk of cerebrovascular disease differs between blacks and whites.16 17 Blacks have a substantially higher risk of subarachnoid and intracerebral hemorrhage, particularly at younger ages, and have a higher mortality.18 19 20 21 The higher risk of SICH among blacks may be related to the higher prevalence and greater severity of hypertension in this population.16 17 22 23 To determine the predictors of outcome of SICH in black Americans, we undertook a retrospective study in our university-affiliated teaching hospital to determine significant predictors easily determined at the time of admission.
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Subjects and Methods |
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TopAbstractIntroductionSubjects and MethodsResultsDiscussionReferences |
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Patients
All black Americans admitted to Grady Memorial Hospital in Atlanta, Ga, with the diagnosis of SICH confirmed by CT scan between January 1990 and July 1993 were evaluated for inclusion in the study. Race was determined by the registration clerk upon presentation to the emergency room on the basis of skin color and place of birth. Eligible patients were sought by medical record retrieval with the use of the International Classification of Diseases, 9th Revision, Clinical Modification codes for intracerebral hemorrhage (ICD-9-CM codes 431 and 432.9). To be sure that only patients with SICH were included, charts and CT scans were reviewed. We excluded patients in whom intracerebral hemorrhage was known or suspected to be secondary to infection, brain tumor, vasculitis, trauma, arteriovenous malformation, rupture of berry aneurysm, or hemorrhagic transformation of prior cerebral infarction. Patients with a history of sympathomimetic drug abuse were not excluded. The number of these patients included is not known. However, accessible data on 89 of the most recent charts in this cohort revealed 7 with cocaine or amphetamine present of 30 patients screened with urine toxicology.
Data Collection
Medical Records
In addition to age and sex, the following information was
extracted from the patients' charts and used for statistical
analyses. (1) We determined initial MAP,24
calculated by the equation MAP=Diastolic Blood Pressure+1/3
Pulse Pressure; we used the first blood pressure measured by a health
professional and documented in the chart. In most cases the initial
blood pressures were measured either by the Emergency Medical Service
personnel or by the triage nurse in the emergency department. (2) We
assessed neurological status at presentation using the
initial GCS25 score provided by the Emergency Medical
Service personnel or by the emergency department records. (3) Two
end points were assessed for each patient: early deterioration, defined
as a decline from an initial GCS score of >12 by 4 points within 24
hours from presentation, and mortality. GCS was monitored
approximately every 2 hours during the first 24 hours after admission.
Therapeutic interventions were determined to be medical or surgical.
Condition upon discharge was also recorded.
CT Scan Images
The following data were extracted by a single neurologist from
the patients' CT scans obtained at the time of admission. (1) The site
of hemorrhage was broadly classified into one of two groups:
supratentorial or infratentorial. (2) We determined
VE by assessing CT scans for the presence or absence of blood in the
ventricles. (3) ICHV was calculated by computerized image
analysis. Each CT image was placed on a light box, and after an
appropriate degree of clarity and brightness was obtained, an image was
captured by a camera, digitized, and reproduced on a video monitor. The
region of the hemorrhage was identified, and its borders were
approximated on the screen with electronic markers. The number of
pixels constituting the area of the hemorrhage was determined.
With the linear centimeter scale on each CT image, a calibration square
was used to determine the calibration factor (pixels per square
centimeter). The number of pixels of hemorrhage in an
individual CT slice was then divided by the calibration factor to
obtain real surface area measurements in square centimeters. The
surface area was multiplied by the image slice thickness (0.5 to 1.0
cm) to obtain a slice volume. Slice volumes were then added to obtain
the ICHV.
Statistical Analysis
Statistical analysis was performed with the use of
EPI INFO 5.126 and
SAS.27 First we performed
univariate analyses using EPI INFO to determine which variables significantly
predicted the outcomes of early deterioration and mortality.
Variables included age, sex, initial MAP (dichotomized as <140 or
140 mm Hg), site of hemorrhage (infratentorial or
supratentorial), VE (presence or absence of
ventricular blood), ICHV (<30 or 30 cm3),
and for mortality, initial GCS score (12 or >12). To appreciate the
relative contributions of variables predicting early deterioration
and mortality, we performed a series of multiple logistic regressions
using the PROC LOGISTIC subprogram of
SAS.
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Results |
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TopAbstractIntroductionSubjects and MethodsResultsDiscussionReferences |
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There were 212 cases of SICH. The records of 193 patients were accessible. Of these, 182 patients were black and met the other inclusion criteria. The mean age for this patient group was 57.9±13.5 years, and the group was composed of 106 men and 76 women. Sixteen patients had surgical intervention; of these, 10 had craniotomies and 6 had percutaneous evacuations. Of the 22 patients who had early deterioration, 3 had surgical management. Mortality was similar in patients who had medical and surgical management (50.6% and 50.0%, respectively).
Early Deterioration
A total of 95 patients presented with an initial GCS score
>12. Of these, 22 (23.1%) had early deterioration. The mean time from
presentation to early deterioration was 7.9±5.1 hours.
Results of the univariate analysis are shown in
Table 1
. The following three variables were
associated with early deterioration: MAP, VE, and ICHV. Results of the
multiple logistic regression analysis are shown in Table 2. In this analysis, only VE and ICHV were
independently associated with early deterioration.
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Mortality
Of the 182 patients, mortality during hospitalization was 50.5%
(n=92). Of the patients who died, 45% died within the first 48 hours.
Univariate analyses showed the following
variables to be significantly associated with mortality: initial
MAP, GCS score, VE, and ICHV (Table 3).
Multiple logistic regression analysis showed that only VE, GCS
score, and ICHV remained independently associated with mortality (Table 4).
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Discussion |
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TopAbstractIntroductionSubjects and MethodsResultsDiscussionReferences |
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The high rates of morbidity and mortality in patients with SICH are well recognized. During the course of the last decade, several groups of investigators have attempted to identify and quantify prognosticators of outcome in patients with SICH (Table 5
). Although the general approaches and
methods of interpretation have varied from one study to another, many
of the findings have been remarkably consistent.
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In those studies of predominantly white patients, mortality ranges between 23% and 58%. Results of previous studies suggest that SICH may differ between white patients and black patients, according to risk of developing SICH,20 21 age of onset,18 20 and mortality.18 The present study is the largest study of outcomes in black Americans with SICH. Although this study does not examine risk factors for SICH, the mean age of onset and overall mortality for blacks with SICH were comparable to those in white populations.
Among our patients with SICH, 23.1% of those with an initial GCS score >12 underwent early deterioration. Although there are no published data on the prevalence of early deterioration, the Harvard Cooperative Stroke Registry found that 56% of all patients admitted with SICH (n=115) experienced further worsening and 25% of these deteriorated suddenly,3 a value similar to our own. The only variables independently predictive of early deterioration in our study are ICHV and VE.
Our overall mortality was 50.5%, a value within the range of previous
studies. Previous studies have shown that the best predictors of
mortality for patients with SICH are pulse pressure, GCS score, VE, and
ICHV (Table 5
). In the present study independent
predictors of mortality included VE, GCS score, and ICHV but not
initial MAP (Table 4). This may be an important
difference between our study and those preceding ours. Carlberg et
al28 showed that elevated MAP at the time of admission was
associated with increased mortality, particularly in patients with
impaired consciousness. It is unclear to what extent our results may be
specific to blacks.
One limiting factor of this study is that the time from onset of SICH until presentation to the emergency department was not controlled. Because patients undoubtedly presented at different points in the natural history of SICH, some of our initial measurements may reflect in part the delay between onset and presentation. By using the earliest reliable measurements, this study has attempted to minimize the effect of time between onset and presentation, although one drawback of using such measurements is that there are multiple observers and no standardization of observations. Another limiting factor in this study is its retrospective design, which does not control prospectively for therapeutic interventions.
The most important finding of our study is that ICHV and VE are independent predictors of both early deterioration and mortality. As the treatment of SICH evolves, it will be necessary to determine which patients are most likely to benefit from new therapeutic options. This study suggests that among patients with an initial GCS score >12, ventricular bleeding and large ICHV are the most important predictors of early deterioration. Early recognition and treatment could potentially have the greatest impact in this subgroup of patients. These patients may therefore represent the best candidates for randomized clinical trials of novel therapeutic approaches.
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Selected Abbreviations and Acronyms |
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Received October 21, 1994; revision received June 30, 1995; accepted June 30, 1995.
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References |
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|
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|---|
1. Whisnant JP, Fitzgibbons JP, Kurland LT, Sayre GP. Natural history of stroke in Rochester, Minnesota, 1945 through 1954. Stroke. 1971;2:11-22.
2.
Matsumoto N, Whisnant JP, Kurland LT, Okazaki
H. Natural history of stroke in Rochester, Minnesota
1955-1969: an extension of a previous study, 1945 through 1954.
Stroke. 1973;4:20-29.
3.
Mohr JP, Caplan LR, Melsky JW, Goldstein RJ, Duncan
GW, Kistler JP, Pessin MS, Bleich HL. The Harvard
Cooperative Stroke Registry: a prospective registry.
Neurology. 1978;28:754-762.
4. Chambers BR, Donnan GA, Bladin PF. Patterns of stroke: an analysis of the first 700 consecutive admissions to the Austin Hospital stroke unit. Aust N Z J Med. 1983;13:57-64. [Medline] [Order article via Infotrieve]
5.
Kunitz SC, Gross CR, Heyman A, Kase CS, Mohr JP, Price
TR, Wolf PA. The pilot Stroke Data Bank: definition,
design and data. Stroke. 1984;15:740-746.
6.
Gross CR, Kase CS, Mohr JP, Cunningham SC, Baker
WE. Stroke in south Alabama: incidence and
diagnostic features: a population-based study.
Stroke. 1984;15:249-255.
7.
Bamford J, Sandercock T, Dennis M, Burn J, Warlow
C. A prospective study of acute cerebrovascular disease
in the community: the Oxfordshire Community Stroke Project
1981-1986, II: incidence, case fatality rates and overall outcome at
one year of cerebral infarction, primary intracerebral
and subarachnoid haemorrhage. J
Neurol Neurosurg Psychiatry. 1990;53:16-22.
8. Dixon AA, Holness RO, Howes WJ, Garner JB. Spontaneous intracerebral haemorrhage: an analysis of factors affecting prognosis. Can J Neurol Sci. 1985;12:267-271. [Medline] [Order article via Infotrieve]
9.
Portenoy RK, Lipton RB, Berger AR, Lesser ML, Lantos
G. Intracerebral haemorrhage: a
model for the prediction of outcome. J Neurol
Neurosurg Psychiatry. 1987;50:976-979.
10. Tuhrim S, Dambrosia JM, Price TR, Mohr JP, Wolf PA, Heyman A, Kase CS. Prediction of intracerebral hemorrhage survival. Ann Neurol. 1988;24:258-263. [Medline] [Order article via Infotrieve]
11.
Daverat P, Castel JP, Dartigues JF, Orgogozo JM.
Death and functional outcome after spontaneous
intracerebral hemorrhage: a prospective study
of 166 cases using multivariate
analysis. Stroke. 1991;22:1-6.
12. Tuhrim S, Dambrosia JM, Price TR, Mohr JP, Wolf PA, Hier DB, Kase CS. Intracerebral hemorrhage: external validation and extension of a model for prediction of 30 day survival. Ann Neurol. 1991;29:658-663. [Medline] [Order article via Infotrieve]
13.
Franke CL, van Sweiten JC, Algra A, van Gijn J.
Prognostic factors in patients with
intracerebral haematoma. J
Neurol Neurosurg Psychiatry. 1992;55:653-657.
14.
Broderick JP, Brott TG, Duldner JE, Tomsick T, Huster
G. Volume of intracerebral
hemorrhage: a powerful and easy to use predictor of 30 day
mortality. Stroke. 1993;24:987-993.
15.
Lisk DR, Pasteur W, Rhoades H, Putnam RD, Grotta
JC. Early presentation of hemispheric
intracerebral hemorrhage: prediction of outcome
and guidelines for treatment allocation. Neurology. 1994;44:133-139.
16.
Kittner SJ, White LR, Losonczy KG, Wolf
PA. Black-white differences in stroke incidence in a
national sample: the contribution of hypertension and diabetes
mellitus. JAMA. 1990;264:1267-1270.
17.
Heyman A, Karp HR, Heyden S, Bartel A, Cassel
JC, Tyroler HA, Hames CG. Cerebrovascular disease in the
biracial population of Evans County, Georgia. Arch Intern
Med. 1971;128:949-955.
18.
Kane WC, Arnonson SM.
Cerebrovascular disease in an autopsy population, I: influence
of ethnic background, sex and cardiomegaly on frequency of cerebral
haemorrhage. Arch Neurol. 1969;20:514-526.
19.
Freytag E. Fatal hypertensive
intracerebral haematomas: a survey of the pathological
anatomy of 393 cases. J Neurol
Neurosurg Psychiatry. 1968;31:616-620.
20. Broderick JP, Brott TG, Thomsick T, Huster G, Miller R. The risk of subarachnoid and intracerebral hemorrhage in blacks as compared to whites. N Engl J Med. 1992;326:733-736. [Abstract]
21. Broderick JP, Brott TG, Thomsick T, Huster G. Intracerebral hemorrhage more than twice as common as subarachnoid hemorrhage. J Neurosurg. 1993;78:188-191. [Medline] [Order article via Infotrieve]
22.
Becker C, Howard G, McLeroy KR, Yatsu FM,
Toole JF, Coull B. Community hospital based stroke
programs: North Carolina, Oregon and New York, II: description of study
population. Stroke. 1986;17:285-293.
23. Connett JE, Stamler J. Responses of black and white males to the special intervention program of the Multiple Risk Factor Intervention Trial. Am Heart J. 1984;108:839-848. [Medline] [Order article via Infotrieve]
24. Ganong WF. Review of Medical Physiology. 15th ed. Norwalk, Conn: Appleton & Lange; 1991:542.
25. Jenett B, Bond M. Assessment of outcome after severe brain damage: a practical scale. Lancet. 1975;1:480-484. [Medline] [Order article via Infotrieve]
26. Dean AG, Dean JA, Burton AH, Dicker RC. Epi Info Version 5: A Word Processing, Database and Statistics Program for Epidemiology on Microcomputers. Atlanta, Ga: Centers for Disease Control; 1990.
27. SAS Institute, Inc. SAS User's Guide: Statistics, Version 5. Cary, NC: SAS Institute, Inc; 1985:28.
28.
Carlberg B, Asplund K, Hagg E.
The prognostic value of admission blood pressure in patients
with acute stroke. Stroke. 1993;24:1372-1375.
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