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Prognosis

Clinical conditions, alcohol consumption, and hemorrhage location predicted death and poor outcome after intracerebral hemorrhage

ACP J Club. 1996 May-June;124:77. doi:10.7326/ACPJC-1996-124-3-077


Source Citation

Juvela S. Risk factors for impaired outcome after spontaneous intracerebral hemorrhage. Arch Neurol. 1995 Dec;52:1193-200. [PubMed ID: 7492294]


Abstract

Objective

To determine the independent risk factors for impaired outcome at 1 year after spontaneous intracerebral hemorrhage (ICH).

Design

Inception cohort followed for up to 1 year.

Setting

A university hospital in Finland.

Patients

156 consecutive patients (median age 50 y, age range 16 to 60 y, 62% men) who were hospitalized with a first-ever ICH. Exclusion criteria were hematoma caused by head trauma, brain tumor, saccular arterial aneurysm, arteriovenous malformation, or moyamoya disease; late-stage, severe disease with bleeding tendency or coagulation disorders; and other severe disabling disorders or diseases.

Assessment of Prognostic Factors

Patient and family interviews were used to gather the time of disease onset, patient characteristics, previous diseases and hospitalizations, use of medications, smoking status, and current and long-term alcohol use. The Glasgow Outcome Scale (GOS) was used to assess the patient's clinical condition. Medical charts, autopsy data, radiographs, and laboratory results were used for data that related to ICH.

Main Outcome Measures

Death and impaired outcome (death, vegetative state, or severe disability measured by the GOS).

Main Results

Of 57 patients who died of hemorrhage, 30% died during the first 24 hours, 53% within 3 days, and 98% within 4 weeks. At 1 year, 64 patients were independent, and 34 were dependent in activities of daily living. Independent predictors of death using multivariate analysis (adjusted for age, sex, body mass index, and hypertension) were GOS scores (odds ratio [OR] 0.46, 95% CI 0.36 to 0.59, P < 0.001) and the presence of a subcortical hematoma (OR 0.18, CI 0.04 to 0.91, P = 0.04). Independent predictors of poor outcomes (adjusted for sex, hypertension, body mass index, smoking, intraventricular hemorrhage, and surgery) were GOS scores (OR 0.57, CI 0.44 to 0.73, P < 0.001); presence of subcortical hematoma (OR 0.04, CI 0.01 to 0.27, P < 0.001); hematoma volume per 10 mL (OR 1.31, CI 1.03 to 1.67, P = 0.03); age per year (OR 1.10, CI 1.03 to 1.18 P = 0.004); alcohol consumed within the previous week per 100 g/wk (OR 1.21, CI 1.01 to 1.43, P = 0.03); and the presence of cerebellar hematoma (OR 0.13, CI 0.02 to 0.95, P = 0.04).

Conclusions

Death after intracerebral hemorrhage was associated with the patient's clinical condition as measured by the Glasgow Outcome Scale and the location of hemorrhage. Poor outcome was associated with clinical condition, location of hemorrhage, size of hematoma, age, alcohol consumption within the previous week, and the presence of cerebellar hematoma.

Sources of funding: Paavo Nurmi Foundation and Maire Taponen Foundation, Helsinki.

For article reprint: Dr. S. Juvela, Department of Neurosurgery, Helsinki University Central Hospital, Topeliuksenkatu 5, FIN-00260 Helsinki, Finland. FAX 358-0471-87560.


Commentary

This study by Juvela is the first to assess the clinical factors before the hemorrhage as independent predictors for the prognosis of spontaneous ICH.

The study design, sample selection, and data collection are methodologically adequate. The multivariate analysis adjusted for several known risk factors for impaired outcome after spontaneous ICH. Death alone and death or severe disability at 1 year after hemorrhage have been examined as poor outcomes.

The study confirms the earlier reports that the patient's age, GOS score, volume of the hematoma, and intraventricular hemorrhage are independent prognostic factors for spontaneous ICH. It adds 2 more independent predictors of prognosis to the list: alcohol use in the week before the hemorrhage and the location of the hematoma. Subcortical and cerebellar hematomas have strong and independent associations with good long-term outcome, irrespective of other prognostic factors or surgery. Alcohol use in the week before the hemorrhage has a relatively weak association with poor long-term outcome. Tuhrim and colleagues (1) reported an interaction between the GOS and intraventricular hemorrhage that suggests that intraventricular hemorrhage carried an especially grave prognosis in patients who were comatose, but the study by Juvela does not confirm this interaction.

Besides age, volume of hematoma, clinical condition, and intraventricular hemorrhage, the location of the hematoma should be considered an important factor for assessing the long-term outcome in patients with spontaneous ICH. This study should motivate clinicians to also consider clinical factors that are present before the hemorrhage, specifically alcohol that was consumed within the previous week.

Kameshwar Prasad, MD, DM, MSc
All India Institute of Medical SciencesNew Delhi, India


Reference

1. Tuhrim S, Dambrosia JM, Price TR, et al. Intracerebral hemorrhage: external validation and extension of a model for prediction of 30-day survival. Ann Neurol. 1991;29:658-63.