(Stroke. 2001;32:1195.)
© 2001 American Heart Association, Inc.
Original Contribution |
Hypertensive Caudate Hemorrhage Prognostic Predictor, Outcome, and Role of External Ventricular Drainage
From the Departments of Neurosurgery (P.-C.L., C.-L.L., C.-H.C., T.-C.L., H.-J.C.) and Neurology (C.-H.L.), Chang Gung Memorial Hospital, Kaohsiung Medical Center; and the Department of Biological Sciences (H.-W.C.), National Sun Yat-Sen University, Kaohsiung, Taiwan.
Correspondence to Han-Jung Chen, MD, PhD, Department of Neurosurgery, Chang Gung Memorial Hospital, Kaohsiung Medical Center, 123 Tapei Rd, Niaosung Hsiang, Kaohsiung Hsien, Taiwan. E-mail chenmd{at}ms8.hinet.net
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Abstract |
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Background and Purpose—The purpose of the present study was to analyze the outcome and outcome predictors of caudate hemorrhage and role of external ventricular drainage in acute hydrocephalus.
Methods—Clinical data from 36 consecutive patients with hypertensive caudate hemorrhage was used in the present study. Age, gender, volume of parenchymal hematoma, hematoma in the internal capsule, initial Glasgow Coma Scale (GCS), hydrocephalus, severity of intraventricular hemorrhage, and hemorrhagic dilatation of the fourth ventricle were analyzed for effect on outcome. Effect of external ventricle drainage for hydrocephalus was evaluated by comparing preoperative and postoperative GCS scores.
Results—By univariate analyses, poor outcome was associated with a poor initial GCS score (P=0.016), hydrocephalus (P<0.001), intraventricular hemorrhage severity (P<0.01), and hemorrhagic dilatation of the fourth ventricle (P=0.02). By multivariate analysis, stepwise logistic regression revealed that hydrocephalus was the only independent prognostic factor for poor outcome (P<0.001). Postoperative 48-hour GCS score was better than the preoperative score by use of paired-sample t test (P<0.001).
Conclusions—Hydrocephalus is the most important predictor of poor outcome. External ventricular drainage response for hydrocephalus was good in the present study, whereas an early decision should be made regarding preoperative neurological condition.
Key Words: hydrocephalus • intracerebral hemorrhage • ventriculostomy
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Introduction |
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TopAbstractIntroductionSubjects and MethodsResultsDiscussionReferences |
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Caudate hemorrhage has been reported only rarely in the literature, because it is usually included with putaminal hemorrhage as an example of "basal ganglia" hematoma.1 Caudate hemorrhage represents approximately 0.1% to 7% of intracerebral hemorrhage (ICH) cases.2 3 4 5 6 7 The most common cause of caudate hemorrhage has been arterial hypertension.2 3 4 5 6 7 The head of the caudate nucleus receives its blood supply from Heubner’s artery and the anterior lenticulostriate and lateral lenticulostriate arteries, which also supply the anterior internal capsule and putamen.6 A rupture in these arteries causes parenchymal hemorrhage. Caudate hemorrhage can be separated from putaminal and thalamic hemorrhage clinically and radiographically. However, outcome focus on caudate hemorrhage is controversial in the limited literatures.2 3 4 5 6 7 Studies of prognostic factors focused on isolated caudate hemorrhage have not been established. Acute hydrocephalus is not uncommon after caudate hemorrhage.7 8 However, appropriate treatment is unclear. Some authors performed external ventricular drainage (EVD) for acute hydrocephalus,7 8 although this experience has not been discussed thoroughly. The aim of the present study is to identify the outcome of caudate hemorrhages, prognostic predictors, and effect of EVD on acute hydrocephalus that complicates caudate hemorrhages.
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Subjects and Methods |
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We retrospectively reviewed medical records of all patients who had a diagnosis of spontaneous ICH at Koahsiung Chang Gang Memorial Hospital during the period January 1995 to December 1999. We diagnosed caudate hemorrhage when CT scan revealed a high-density area mainly at the head of the caudate nucleus contiguous to the anterior horn of the lateral ventricle with or without intraventricular extension. Thirty-six consecutive cases with hypertensive caudate hemorrhage were included in this study. Hypertension was defined as blood pressure recorded during admission with a sustained systolic pressure >160 mm Hg or a diastolic pressure >90 mm Hg on >2 occasions, a history of hypertension, or current or previous antihypertensive treatment.5 Moreover, patients who were initially treated at other hospitals but were transferred to our hospital were also included in the study. Initial clinical and laboratory data collected at the hospitals from which the patients were transferred were accepted. We excluded hemorrhages that resulted from cerebral trauma, rupture of arteriovenous malformation, ruptured aneurysm with spontaneous subarachnoid hemorrhage (known previously or later documented angiographically), tumor bleeding, or bleeding diathesis. Patients with neurological deficits from previous head injury, cerebral infarction, or intracranial hemorrhage were also excluded.
To study prognostic factors that determine functional outcome for each patient, the following initial aspects of each case were observed and analyzed: (1) age at admission; (2) gender; (3) Glasgow Coma Scale (GCS) score; (4) volume of parenchymal hematoma; (5) hematoma involved the internal capsule; (6) hydrocephalus; (7) severity of intraventricular hemorrhage (IVH); and (8) hemorrhagic dilatation of the fourth ventricle.
GCS Score
All patients were examined clinically and graded into
3 groups on the basis of GCS for statistical analysis. A GCS
score of 13 to 15 was considered to be grade 1; 7 to 12, grade 2; and 3
to 6, grade 3. GCS also was used for periodic patient
assessment.
Evaluation of Volume of Parenchymal
Hematoma
Volume of parenchymal hemorrhage was
calculated by use of a simplified method. Cubic content of the hematoma
was calculated from maximum measured width (A), length (B), and height
(C), and volume was taken as
1/2AxBxC.9
Hydrocephalus
Hydrocephalus was judged retrospectively with
the dilated temporal horn of the lateral ventricle without obvious
brain atrophy and a ventriculocranial ratio of
>0.155.10 Ventriculocranial
ratio is the ratio of ventricular width behind the frontal
horns between the caudate nuclei, where the walls are nearly parallel,
to width of the brain at the same level
(Figure 1
).
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Intraventricular
Hemorrhage
Severity of IVH was graded according to the amount of
blood in each ventricle. Maximum score was 12; 0 to 4 was considered to
be mild; 5 to 8, moderate; and 9 to 12,
severe.11 Final score was
the sum of each lateral ventricle score (1 to 4 points each) and third
and fourth ventricle scores (1 to 2 points
each).
Hemorrhagic Dilatation of the Fourth
Ventricle
Hemorrhagic dilatation was defined as a clot filling
the entire fourth ventricle with no surrounding cerebrospinal fluid
when anteroposterior diameter was >1.25 cm and lateral diameter was
>2.0
cm.12
Surgical Management
Acute hydrocephalus complicating caudate
hemorrhage was treated by use of EVD. Patients without
hydrocephalus received medical treatment. The decision to set up EVD
was based on poor or worsening clinical status contributed to by the
acute hydrocephalus. Under sterile conditions, a
ventricular catheter (Codman system,
Johnson&Johnson Medical Ltd) was placed in the
frontal horn (the side contralateral to the main hematoma was usually
chosen) through a twist-drill craniostomy. The catheter was tunneled
under the scalp for a distance of 30 to 40 mm, brought out through
a separate incision, and connected to a closed system, which was
maintained at a height of 150 mm above the foramen of Monro.
Sometimes an EVD obstruction was encountered in the drain tube by the
intensive care unit. The obstruction was resolved by gently flushing
the drain tube with normal saline. In some rare cases, if the above
management did not resolve the problem, a new ventricular
catheter was applied. EVD weaning was performed gradually by closing
the system to outflow in the following 7 to 10 days. Persistent
hydrocephalus presented with a worsening neurological status
after closing the EVD was treated by ventriculoperitoneal (VP) shunting
(Figure 2).
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Outcome
Outcome was categorized by use of the Glasgow Outcome
Scale as asymptomatic, mild disability, moderate
disability, major disability, vegetative status, and death. For
analysis, patients were divided into a favorable outcome group
of patients who were functionally independent (first 3 categories) and
a poor outcome group of patients who were functionally dependent or
worse (last 3 categories). Neurological outcome for the survivors was
determined at 6 months after hemorrhage. Some patients were
followed by the outpatient department after discharge, and others were
interviewed by telephone to identify neurological
outcome.
Statistical Analysis
Data were first analyzed in
univariate fashion by use of either
2 test or Fisher’s Exact Test. Effects
of age and volume of hematoma on outcome were determined by an
independent-sample t test.
Multivariate analysis with stepwise logistical
regression then was done to determine which factors were
simultaneously prognostically important for the outcome as
defined above. We used a paired-sample
t test to evaluate the EVD
effect by comparing preoperative and postoperative GCS scores in the
surgical patients. All statistical results were declared significant if
P<0.05. Analysis was
performed with the SPSS 10.0 package
software.
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Results |
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General characteristics of the 36 patients and statistical analysis of the caudate hemorrhage outcome are listed in Tables 1
and 2, respectively. A total of 36
patients had hypertensive caudate hemorrhage (20 men and 16
women). Age (mean±SD) was 59±10 years (range, 39 to 76 years). Ages
(mean±SD) for the different outcome groups were 58.5±10.4 years (good
outcome) and 60.3±10.9 years (poor outcome). No age differences were
observed in the different groups
(P=0.64). Twenty-four patients
(66.7%) had left and 12 patients (33.3%) had right caudate
hemorrhage. A total of 13 patients (36.1%) had initial grade 1
consciousness (GCS, 13 to 15), 15 (41.7%) had grade 2 (GCS, 7 to 12),
and 8 (22.2%) had grade 3 (GCS, 3 to 6). Volume of parenchymal
hematoma (mean±SD) was 5.3±4.9 mL (range, 0.4 to 25.0 mL). Volumes
(mean±SD) for the different outcome groups were 4.9±3.9 mL (good
outcome) and 6.1±6.6 mL (poor outcome). No differences were observed
in the various groups (P=0.48).
Eight patients (22.2%) had a radiological finding of hematoma that
involved the internal capsule. Twenty-two patients (61.1%) developed
hydrocephalus, 35 (97.2%) had IVH, and 11 (30.6%) had hemorrhagic
dilatation of the fourth ventricle. Nine patients (25%) were graded as
having severe, 15 (41.7%) as having moderate, and 12 (33.3%) as
having mild IVH, including 1 patient without hemorrhagic rupture into
the ventricle. Twenty patients (55.6%) underwent EVD for acute
hydrocephalus
(Table 3). Sixteen (44.4%) received medical treatment
only because they had an improved GCS score or for a lack of evidence
of hydrocephalus. Five patients (13.9%) underwent acute deterioration
of consciousness due to progressive hydrocephalus during the first 72
hours of hospitalization. Overall, 24 patients (66.7%) had a favorable
outcome (functionally independent) and 12 (33.3%) had a poor outcome,
including 3 patients (8.3%) who died.
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By use of univariate analyses, poor outcome was significantly associated with the following features at presentation: poor initial GCS score (P=0.016), hydrocephalus (P<0.001), severity of IVH (P<0.01), and hemorrhagic dilatation of the fourth ventricle (P=0.02). Multivariate analysis with stepwise logistic regression was performed to determine the most important and independent factors that influenced outcome of caudate hemorrhage, which were considered significant in the univariate analyses. Analysis revealed that hydrocephalus was the only independent prognostic factor for poor outcome (P<0.001).
Twenty patients were treated by EVD
(Table 3
), and 16 patients were treated medically
(Table 4). Outcome of the surgical group was good for 8
(40%) and poor for 12 (60%) patients. One patient had an EVD
obstruction and died (patient 16). Five patients (patients 5, 7, 14,
17, and 19) with persistent hydrocephalus needed a permanent VP shunt.
Preoperative GCS score for the surgical patients was 7.1±2.3
(mean±SD), whereas postoperative 48-hour GCS score was 9.2±4.0
(mean±SD). Postoperative 48-hour GCS score was better than
preoperative score
(P<0.001).
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Discussion |
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TopAbstractIntroductionSubjects and MethodsResultsDiscussionReferences |
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Cause, neurological presentations, radiological findings, and caudate hemorrhage treatment have been established in limited literature, whereas outcome for caudate hemorrhage is controversial.2 3 4 5 6 7 Some reports declared a benign caudate hemorrhage outcome,2 4 5 6 7 but 1 report did not.3 Stein et al2 reported 8 cases of hypertensive caudate hemorrhage. Outcome in Stein’s series was benign, and most of the patients recovered fully, without permanent neurological deficits and complicating hydrocephalus. Weisberg3 also reported a small series of caudate hemorrhages, but the outcome in this series was poor. In this series, stuporous consciousness and a massive amount of IVH were associated with poor outcome. Asakura et al7 reported 24 cases of hypertensive caudate hemorrhage. Intraventricular hematoma was observed in 23 patients (96%). In this series, 4 patients with acute hydrocephalus complicating the caudate hemorrhage were treated by continuous ventricular drainage. However, the authors judged retrospectively that continuous ventricular drainage had been necessary in only 2 cases, in which the disturbance of consciousness progressed due to acute hydrocephalus. Outcome in this series was quite good. Twenty-one (88%) patients had a good outcome, and only 1 died.
All previous series produced limited information because they included a relatively small number of cases and lacked statistical analysis. In our series, outcome for caudate hemorrhage was not as good as is in the series of Stein et al2 and Asakura et al7 series. The factors influencing caudate hemorrhage outcomes had not been discussed before.2 3 4 5 6 7 Acute hydrocephalus was common in our series (61.1%), but this was not well recognized as a complication of caudate hemorrhage in previous reports.2 3 4 5 6 7 8
Univariate analysis of our data showed poor initial consciousness, hydrocephalus, IVH severity, and hemorrhagic dilatation of the fourth ventricle to be associated with poor outcome. Poor GCS scores and acute hydrocephalus complicating spontaneous ICH were the most important predictors associated with poor prognosis in the numerous studies on spontaneous supratentorial ICH.13 14 15 16 17 18 19 20 21 These 2 factors were also associated with a poor outcome for caudate hemorrhage in the present study. Extension of blood into the ventricles is related to a poor outcome in some spontaneous ICH studies.11 13 14 15 16 21 22 However, this factor was presented in most caudate hemorrhage cases.2 3 4 5 6 7 8 Amount of IVH was also identified as an important factor associated with poor outcome in some IVH studies.11 15 22 In the present study, outcome was related to amount of intraventricular blood: the more severe the hemorrhage, the worse the outcome. Volume of parenchymal hematoma consistently had been found to be a strong outcome predictor in ICH patients13 but was not associated with poor outcome in caudate hemorrhage. We speculate that volume of parenchymal hematoma is usually small and out of proportion to the intraventricular clot. Hemorrhagic dilatation of the fourth ventricle was identified to be an ominous predictor in an important IVH study,12 although little attention had been given to it. In the present study, hemorrhagic dilatation was also found to be associated with poor outcome.
Multivariate analysis with stepwise logistical regression revealed that hydrocephalus was the most important factor associated with a poor outcome in our study. Caudate hemorrhage recovery can be predicted by hydrocephalus. This analysis can access the interaction between the above factors and provide prognostic indicators in caudate hemorrhage patients. This information may assist in clinical decision-making and in advising patients or family about functional recovery and neurological outcome.
Treatment of caudate hemorrhage was usually approached medically in the previous reports.2 3 4 5 6 7 EVD was used only in patients in which consciousness disturbance progressed due to acute hydrocephalus complicating ICH.7 8 20 21 23 However, few EVD experiences involving acute hydrocephalus complicating caudate hemorrhage had been discussed. Early EVD produced significant prolonged survival before death but did not influence mortality in some IVH and spontaneous subarachnoid hemorrhage studies.23 24 Moreover, the immediate response to EVD was disappointing in 1 ICH study.21 In the present study, postoperative 48-hour GCS scores were better than preoperative scores. Patients in poor GCS (preoperative GCS score <6 especially) with hydrocephalus and severe IVH had irreversible damage to the brain tissue before hydrocephalus correction by use of EVD, which was certainly associated with poor response and outcome. Perhaps early EVD could be useful in a selected group of patients for limiting further brain injury. In our opinion, the benefits of this procedure in acute hydrocephalus complicating caudate hemorrhage outweigh the risks.
Bloody cerebrospinal fluid not only produces obstructions within the ventricular system; it may also do so within the drainage catheter. EVD obstruction is a problem that is sometimes encountered in the intensive care unit. Flushing the drain tube gently with normal saline is the usual resolution for this problem. In some rare cases, if the above management cannot resolve the problem, a new ventricular tube is applied. Some authors prefer administration of thrombolytic agents in combination with EVD to dissolve the clot.25 However, the benefits of thrombolytic agents are not clear.
In conclusion, the hydrocephalus is the most important factor associated with a poor outcome. Recovery from caudate hemorrhage can be predicted by presence of hydrocephalus. The effect of EVD on acute hydrocephalus complicating caudate hemorrhage seems good, but an early decision should be made regarding the preoperative neurological condition and progressive hydrocephalus. To our knowledge, the present study is the largest that had focused on isolated caudate hemorrhage. However, drawing conclusions from our single study is risky. We look forward to more investigations in the future.
Received August 22, 2000; revision received October 26, 2000; accepted January 5, 2000.
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