(Stroke. 1995;26:620-626.)
© 1995 American Heart Association, Inc.
Articles |
Impact of Thalamic Hematoma on Six-Month Mortality and Motor and Cognitive Functional Outcome
From the Second Department of Internal Medicine, Faculty of Medicine, Kyushu University (S.M., S.S., S.I., M.F.), and Fukuoka Higashi National Hospital (K.I.), Fukuoka, Japan.
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Abstract |
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Background and Purpose In this study we examined the functional outcome of thalamic hemorrhage after 6 months as it related to neurological and computed tomographic (CT) findings in 104 patients.
Methods Level of consciousness was determined on admission. Extension and volume of hematoma were examined with CT within 3 days. After 6 months, motor function was evaluated using hemiplegic staging by the scale of Brunnström, and cognition was assessed by the Hasegawa dementia rating scale administered in Japanese.
Results Twelve patients (12%) died from stroke after 6±6 days (mean±SD), which correlated with volume of hematomas (P<.001), levels of consciousness (P<.005), and miosis (P<.01). Six patients (6%) died from systemic complications after 23±18 days, which correlated with age (P<.05). Initially, 88 patients (85%) had hemiparesis, which persisted in 78 (75%) patients (18 deaths and 60 survivors). After 6 months, the Brunnström scale scores were lower in patients with hematomas extending to the internal capsule (P<.01) than in those with hematomas localized within the thalamus, and scores were lowest in patients with hematomas extending to the midbrain or putamen (P<.01). Motor function was well correlated with the extension and volume of hematomas (P<.001) and with the consciousness level (P<.001). Activities of daily living were correlated with hematoma extension and advanced age. Cognitive impairment was correlated with disturbance of consciousness (P<.01) and ventricular extension of the hematoma (P<.05) in 80 nonaphasic patients.
Conclusions The extension and volume of hematomas, indicating direct cerebral damage, are useful indicators of mortality from thalamic hemorrhage, motor functional outcome, and level of activities of daily living after 6 months. The disturbance of consciousness and ventricular extension of the hematoma, suggesting diffuse brain damage, could be predictors of cognitive function.
Key Words: cognition • hematoma • hemiplegia • prognosis • thalamus
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Introduction |
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Since the development of computed tomography (CT), the localization of hematomas can be determined more easily and with greater accuracy. Mortality in acute thalamic hemorrhage, varying from 14% to 52%,1 2 3 4 5 6 7 depends on the severity of stroke, which is well reflected in the level of consciousness5 7 and the size1 2 3 5 7 and extent5 6 7 of the hematoma seen on initial CT. Hemiparesis has been observed in 81% to 100% of patients with thalamic hemorrhage.1 2 3 6 Improvement of motor function is one of the major factors determining the level of activities of daily living (ADL). The thalamus also plays an important role in cognitive function, and this may also affect the outcome of rehabilitation.8 9
At present, there is no consensus on the proper role of surgery in the management of thalamic hemorrhage.10 Recently, some patients with thalamic hematomas have been treated by stereotactic aspiration.11 12 In the decision of which patients to subject to this surgery, those with predictably bad outcomes are obviously excluded, but it is equally important to identify and exclude those patients who will ultimately become independent without surgical intervention.13 In this study we therefore attempted to identify the remainder as suitable candidates for any future trials of surgical intervention. Not only survival but also the brain functional outcome must be considered.
We studied 104 patients immediately after they had suffered thalamic hemorrhage confirmed by CT, and we examined the status of their 6-month survival, outcome of motor and cognitive functions, and ADL in relation to initial neurological and radiological factors, including level of consciousness and the location and size of the hematoma. The purpose was to determine which factors have clinical significance for predicting mortality, motor and cognitive functional outcomes, and ADL.
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Subjects and Methods |
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From February 1981 to March 1990, 111 consecutive patients with acute thalamic hemorrhage were admitted to the Stroke Care Unit and Rehabilitation Center. The criteria for including patients in this series were (1) unilateral thalamic hemorrhage confirmed by clinical examinations and CT performed within 48 hours after ictus, (2) no previous or recurrent stroke, and (3) conservative treatment. Patients with head injury, subarachnoid hemorrhage, arteriovenous malformations, or hemorrhagic infarctions were excluded. Four patients were treated surgically, 3 by hematoma evacuation and 1 by ventricular drainage. Three patients were excluded because they had had a previous stroke. Finally, 104 patients (age, 63.8±10.7 years, mean±SD [range, 40 to 95 years]; 63 men and 41 women) were included in this study. Hypertension (systolic blood pressure of
160 mm Hg or diastolic
blood pressure of 95 mm Hg on at least two separate occasions) was
observed in 72 (69%) of the 104 patients after stroke (Table 1
). The other 32 patients exhibited borderline
hypertension (systolic blood pressure of 140 mm Hg or diastolic
blood pressure of 90 mm Hg), and they had a history of hypertension
or treatment with antihypertensive medication lasting >2 months
confirmed by medical records.
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Neurological data were based on examinations at the time of admission
(Table 1
). On admission, the level of consciousness was classified into
four groups (1, alert; 2, drowsy; 3, semicoma; and 4, deep coma).
In all patients, CT scans were performed within 48 hours after the onset of stroke. From these transverse sections on the initial brain CT, the location of the hematoma was classified into three groups according to extent: 1, within the thalamus; 2, extending into the internal capsule; and 3, extending to the midbrain or putamen.5 7 The volume of the hematoma (in milliliters) was calculated as follows: hematoma volume (mL)=3.14xlengthxwidthxheight/6.
Mortality was observed for 6 months, and the cause of death was
classified as cerebrovascular or nonneurological (systemic). Eighteen
patients (17.3%) died within 6 months. Twelve patients (11.5%) died
of primary stroke after 1 to 18 (6.3±6.1; median, 3) days, and 6
patients (5.8%) died of respiratory or gastrointestinal complications
after 2 to 53 (22.7±17.8; median, 17.5) days (P<.01 versus
patients who died of stroke). Within 18 days after the stroke, 12
(80%) of 15 deaths were cerebrovascular, 1 was from pneumonia after 1
day, and the 2 others after 14 or 15 days were from gastrointestinal
bleeding or pneumonia. All 3 deaths after 19 days were due to
respiratory tract infection. The patients who died of systemic
complications were significantly older (75±8 years) than the survivors
(63±10 years, P<.05, Table 1). Cerebrovascular and
systemic mortalities were predicted from neurological data (level of
consciousness, hemiparesis, Babinski's sign, ocular sign), CT findings
(side, extent, and volume of hematoma; ventricular blood), and
demographic data (age, sex, blood pressure) on admission.
The length of stay in the hospital of the 86 survivors was 123±80 (11 to 347) days. After discharge, rehabilitation was performed at the day care unit. The motor functional outcome was evaluated 6 months after the onset of stroke using scores from the hemiplegic stage according to the Brunnström motor recovery scale.7 14 Movements of the fingers, arms, and legs were classified into six grades: 1 point for no voluntary movement to 6 points for normal movement. The averaged Brunnström score for each patient was calculated as the mean score for the upper and lower extremities by the following equation: average Brunnström score=([finger score+arm score] 2+leg score)/2.
ADLs were evaluated from the functions of upper and lower extremities. The function of the upper extremities was evaluated using subscores for the patients' ability to feed themselves and dress their upper body (1, independent; 2, needing help; and 3, impossible). Lower extremity function was scored as ability to walk or move about (1, able to walk independently; 2, able to walk with walking aids; 3, able to move in a wheelchair; and 4, bedridden).7 Total ADL was evaluated using subscores for the patients' ability (1, independent; 2, needing a little help or overseeing; 3, needing considerable help; and 4, impossible).
We also evaluated patients' intellectual status using the Hasegawa
dementia rating scale (HDS).15 16 This dementia rating
scale, which is very similar to the Mini-Mental State Examination, is a
simple and reliable method and has been widely used to estimate
cognitive impairment in Japan. This scale consists of five items
testing orientation, general information, calculation, memory, and
memory recall. The full score is 32.5 points, and the lowest score is
0. A score of 31 is normal, 22 to 30.5 indicates mild abnormality,
10.5 to 21.5 indicates moderate abnormality, and 
10 indicates severe
abnormality.
All data are expressed as mean±SD. For both deceased patients and
those surviving with various levels of consciousness, the localization
of the hematoma and ADL were analyzed by 
2 test.
The variables and scores of surviving and dead patients were also
compared by ANOVA or nonparametric Kruskal-Wallis ANOVA and
Scheffé's test. Nonparametric tests (Mann-Whitney U
test, Spearman's rank correlations) were used for analysis of
neurological and CT scores because these scores were not distributed
normally in the whole group. For standardized multiple regression
analysis, four variables were taken for the correlations with
total, cerebrovascular, and systemic mortality: age, level of
consciousness, miosis, and volume of the hematoma. The correlations
between clinical variables and functional scores or ADL were examined
by Spearman's rank correlation analysis. Stepwise multiple
regression analysis was used for the correlations between the
functional scores and variables, which were chosen according to the
significant results in Spearman's rank correlations. All probability
values were based on two-sided tests. Differences were considered
significant at a level of P<.05.
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Results |
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The profiles of patients with thalamic hematoma are shown in Table 1
. On admission, 88 (85%) developed hemiparesis, and 57 (55%)
had a positive Babinski sign. Ocular signs (oculomotor dysfunction,
pupil abnormalities) were observed in 29 patients (28%), and 23 of
these patients developed miosis. On early CT, ventricular rupture of
the hematoma into the lateral ventriculus was observed in 46 patients
(44%). The volume of hematomas ranged from 1 to 138 (14.0±18.3;
median, 8) mL.
Six-Month Mortality
Six-month mortality increased up to 80% with deterioration in the
level of consciousness in patients in deep coma (Table 1).
Cerebrovascular death occurred in 1 drowsy patient (6%), 7 patients in
semicoma (33%), and 4 patients in deep coma (80%).
The volume of the hematoma was significantly larger in 18 patients who
died than in 86 survivors (Table 1). The volume of the hematoma was
larger (45±36 mL) in 12 patients who died of stroke than in 6 patients
who died of systemic complications (15±14 mL, P<.001).
Mortality increased with the volume of the hematoma: 3 (5%) of 58
patients with a hematoma <10 mL, 1 (6%) of 17 patients with a
hematoma of 10 to 14 mL, 7 (33%) of 21 patients with a hematoma of 15
to 29 mL, and 7 (88%) of 8 patients with a hematoma >30 mL died (Fig 1). Thus, only 1 patient with a hematoma >30 mL
survived. Stroke-related deaths occurred in 1 (6%) patient with a
hematoma of 10 to 14 mL, in 5 (24%) with a hematoma of 15 to 29 mL,
and in 6 (75%) with a hematoma >30 mL (Fig 1). Eleven (92%)
stroke-related deaths were associated with hematomas >15 mL. In
contrast, 71 (95%) survivors had hematomas <15 mL.
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Standardized multiple regression analysis showed that cerebrovascular mortality within 6 months was correlated with three variables: hematoma volume (P<.001), level of consciousness (P<.005), and miosis (P<.01). Systemic death was correlated only with age (P<.05).
Motor Functional Outcome
Among 86 survivors, 72 patients (84%) had motor dysfunction, and
60 of them showed hemiparesis after 6 months (Table 2).
Seventeen patients presented with limb ataxia. Sensory disturbance
persisted in 64 patients, and 61 of them developed hypesthesia (Table 2). Hemiplegic scores were similar in patients with right- and
left-side lesions. The Brunnström scores were better for fingers
than for arms in 12 (20%) of 60 patients. Hemiparesis persisted in 34
(60%) of 57 alert patients, 14 (88%) of 16 drowsy patients, 11 (92%)
of 12 patients in semicoma, and 1 (100%) patient in deep coma
(P<.05). The average Brunnström score was lower in 13
comatose patients than in 56 alert patients (P<.01) and 16
drowsy patients (P<.05).
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Motor impairment was demonstrated in most patients with hematomas
extending into the internal capsule (91%) or midbrain or putamen
(94%, Table 2). In 47 patients with involvement of the internal
capsule, better function of the fingers than the arms (21%) was
observed more frequently than in 18 patients in whom the hematoma
extended into the midbrain or putamen (11%, P<.05). Fig 2
(top) shows the hemiplegic scores according to the
localization of the hematoma in the 86 survivors. The scores were
highest in patients with hematoma located within the thalamus
(P<.001), lower in patients in whom the internal capsule
was involved than in patients with localized hematoma, and lowest in
patients in whom it extended into the midbrain or putamen
(P<.001, Fig 2, top). The bottom panel of Fig 2 shows the
relationship between the average hemiplegic scores of the upper and
lower extremities and the hematoma volume in the 86 survivors. Average
scores inversely correlated with the volume of hematoma
(r=-.704, P<.001, Fig 2, bottom).
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Standardized multiple regression showed that the hemiplegic scores for legs were correlated with four variables: localization of the hematoma (P<.0005), consciousness level (P<.005), hematoma volume (P<.01), and hypesthesia (P<.05). The averaged hemiplegic scores were correlated with three variables: localization of the hematoma (P<.0005), consciousness level (P<.05), and hematoma volume (P<.05).
Activities of Daily Living
The levels of ADL in patients with right- and left-side lesions
were similar. Functions of the upper and lower extremities deteriorated
with an increase in the extent of the hematoma (Table 2). Like the
averaged hemiplegic scores, the levels of upper extremity function were
correlated with the localization of the hematomas (P<.005).
The level of lower extremity function was correlated with three
variables: localization of the hematoma (P<.005), age
(P<.05), and level of consciousness (P<.05).
The total ADL was correlated with two variables: localization of the
hematoma (P<.005) and age (P<.01).
Cognitive Functional Outcome
Amnesia was observed in 4 patients in the acute stage (Table 2)
but in none after 6 months. Aphasia was observed in 13 survivors with
left-side lesions in the acute stage but in only 6 patients after 6
months. Excluding the 6 patients with aphasia, HDS score was normal in
50 patients (62.5%), mildly abnormal in 24 (30%), moderately abnormal
in 3 (3.75%), and severely abnormal in 3 (3.75%, Table 2). Cognitive
scores in patients with right- (29±6) and left-side (30±5) lesions
were similar. Thirteen patients with both consciousness disturbances
and ventricular extension of the hematoma demonstrated by CT had lower
HDS scores than alert patients with (n=20, P<.05) or
without (n=34, P<.01) ventricular extension (Fig 3). The HDS scores of 13 patients with consciousness
disturbance but without ventricular extension did not differ from those
of the alert patients. The HDS scores were correlated with the level of
consciousness (P<.01) and ventricular extension of the
hematoma (P<.05) in 80 nonaphasic patients.
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Discussion |
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TopAbstractIntroductionSubjects and MethodsResultsDiscussionReferences |
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The main findings in this study were as follows: (1) The volume of the hematoma, the level of consciousness, and miosis have the highest significance for prognosis of cerebrovascular mortality, while the frequency of death from systemic complications is correlated with advanced age. (2) Motor impairment was observed in 70% of survivors, and the motor functional status was well correlated with the extent and size of hematomas and the level of consciousness. (3) The level of ADL was correlated with the extent of hematomas and age. (4) Cognitive impairment was correlated with the disturbance of consciousness and ventricular rupture.
We assessed motor function 6 months after stroke because all our patients received rehabilitation and showed maximal recovery at this time.16 We did not use motor and cognitive function scores taken at the beginning of rehabilitation because these scores are not always the lowest, and recovery had already occurred in some patients.16 Moreover, many factors associated with the acute and subacute stage (such as brain edema, the mass effect of hematoma, and various therapies) could influence the functional assessment. Little attention has been paid, however, to the clinical status after full recovery from stroke.
Six-Month Mortality
Earlier studies report a mortality of 32% to 52% in acute
thalamic hemorrhage,1 2 3 but, as observed here, recent
studies in Japan have shown a decline in mortality to 14% to
17%.4 5 6 7 Recent reductions in systemic arterial
hypertension by antihypertensive treatment may be one potential reason
for the decrease in the incidence of fatal cases. Advances in therapy
in the Stroke Care Unit including treatment with glycerol for brain
edema, antibiotics for infection, and a deuterium blocker for peptic
ulcer may be other possible explanations. In severe cases, intensive
treatment for brain edema and herniation seem to be necessary up to the
subacute stage. Younger age is an important predictor of better
long-term survival,13 17 probably because systemic
complications may be fatal in the elderly. Patients should be carefully
monitored for treatable complications; early intervention may be
necessary. Therefore, in elderly patients with thalamic hematoma, even
if it is not of massive size, careful management for systemic
complications such as infection and gastrointestinal bleeding is
important for longer survival.
The most reliable indices of survival after thalamic hemorrhage are level of consciousness and hematoma size and extension.5 7 Direct measurement of the hematoma size by CT has the most accurate prognostic significance.1 2 3 4 7 Ventricular extension of the hematoma is not always a reliable prognostic factor.2 5 Other reports have indicated poor prognosis for patients with larger intraventricular hematomas.4 18 19 The hematoma volume (18±22 mL) was larger in our patients with ventricular extension than in those without (11±14 mL), but the difference was not statistically significant, probably because, in hematomas of medial thalamic nuclei, even smaller and nonfatal hematoma can cause ventricular extension. Larger extension of the hematoma itself, with or without ventricular penetration, is directly related to survival.
Motor Functional Outcome and Activities of Daily Living
The extent and volume of hematomas seen by initial CT are useful
indicators of motor functional outcome. Damage of the internal capsule
may be responsible for persistent hemiparesis.2 20 Lower
hemiplegic scores for the legs were correlated with hypesthesia, and
sensory feedback may, at least in part, affect successful recovery of
motor function. Lesion of the ventrolateral thalamic nuclei may be
responsible for sensory loss associated with poor functional
outcome.20 In the patients with damage to the internal
capsule, damage of the medial part of the internal capsule and sparing
of motor fibers to the fingers could explain the proximal
hemiparesis.4 20 In contrast, damage to the lateral part
of the internal capsule and putamen may impair function of the fingers
more than the legs. The extension of hematomas was well correlated with
ADL of both the upper and lower extremities. Age was correlated with
level of ADL relating to the lower extremities. Advanced age may be
another negative prognostic factor for ability for movement, standing,
and walking during rehabilitation.8 Sensory impairment and
ataxia21 22 disturb recovery of motor function and ADL at
the chronic stage, especially in the lower extremities.
Cognitive Functional Outcome
Despite a number of early observations on thalamic
dementia23 and thalamic aphasia,24 25 the
fact that the thalamus has an important role in the maintenance of
consciousness and the performance of higher functions has only recently
been recognized. Studies and case reports have focused on
hemineglect26 27 or amnesia.28 29 30 Amnesia and
aphasia occur in patients with acute thalamic hemorrhage, and patients
may recover completely or only partially. Even after some recovery from
stroke, reductions in intellectual functions may persist associated
with decreases in global neuronal activity due to diffuse cortical or
subcortical damage or both.
Ipsilateral cortical hypometabolism has been demonstrated in patients with unilateral thalamic lesions by positron emission tomographic studies.31 32 33 In patients with deep lesions, reduction of ipsilateral cortical function of the lesion may be a predominantly remote effect33 called transneuronal depression or thalamocortical diaschisis. Thalamic dementia is usually associated with bilateral thalamic lesions.23 34 Even in patients with unilateral lesions, contralateral cortical hypofunction has been observed,16 probably due to transhemispheric diaschisis, underlying cerebral arterial changes, or decreases in global neuronal activities after stroke.35 We assume that in patients suffering from declines in physical, mental, daily living, and social activities after stroke,35 global neuronal activities also become decreased in the contralateral hemisphere. Cognitive impairment was correlated with the disturbance of consciousness, which suggested diffuse brain damage. It may be of interest that ventricular extension was associated with cognitive impairment even after the penetration of blood into the ventricle disappeared. The involvement of medial nuclei, which has an important role in memory,29 30 may be responsible for cognitive impairment at the chronic stage.
Regarding which patients should undergo surgery, patients with a hematoma <10 mL may not need surgery because their functional outcome will be quite good. Patients in deep coma or older than 80 years should be excluded because their mortality will be higher. Sasaki and Matsumoto12 suggested that even in patients with a hematoma >20 mL, aspiration surgery is beneficial for survival and functional outcome. In patients with massive hematoma >30 mL, however, surgery should be considered carefully with the family because of the potential for serious neurological deficit that would require total care of the survivor. Therefore, patients with a hematoma of 10 mL or more, not in deep coma, and younger than 80 years may be suitable candidates for surgical intervention. Our results support the finding that patients with thalamic hematoma that dissect downward toward subthalamic structures have a more unfavorable prognosis,6 but there is disagreement as to whether they may benefit from stereotactic surgery6 12 36 or not.37 It is not yet fully known whether stereotactic aspiration affects the prognosis and functional outcome including motor38 and cognitive functions; further randomized study is required to determine whether aspiration surgery will improve functional outcome compared with conservative therapy.
In summary, in thalamic hemorrhage the extension and volume of hematomas indicating direct cerebral damage are useful indicators of mortality, motor functional outcome, and level of ADL after 6 months. Death from systemic complications increased with age. The initial level of consciousness was correlated with mortality and motor and cognitive functional outcomes. Ventricular extension of the hematoma could predict only cognitive impairment. Further studies are required on the pathophysiology and clinical consequences of hematomas on brain function and long-term prognosis.
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Footnotes |
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Reprint requests to Sakan Mori, MD, Second Department of Internal Medicine, Faculty of Medicine, Kyushu University, Maidashi 3-1-1, Higashi-ku, Fukuoka 812, Japan.
Received September 20, 1994; revision received January 3, 1995; accepted January 3, 1995.
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  I. Miyai, T. Suzuki, J. Kang, and B. T. Volpe Improved Functional Outcome in Patients With Hemorrhagic Stroke in Putamen and Thalamus Compared With Those With Stroke Restricted to the Putamen or Thalamus Stroke, June 1, 2000; 31(6): 1365 - 1369. [Abstract] [Full Text] [PDF]
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