Clinical and radiological features of 43 patients admitted for ganglionic (21) and thalamic (22) haemorrhages were studied to ascertain the factors that would determine prognosis in the acute stage of the illness. Nineteen patients died, 16 of them in the first week. The adverse clinical factors were an altered state of consciousness, decorticate/decerebrate posturing, ataxic respiration, abnormalities of gaze and presence of bilateral Babinski\u27s sign. Adverse radiological factors were the presence of thalamic haemorrhage of 3 cm or more, intraventricular spread of the haemorrhage and midline shift of 0.5 cm of more. The significance of these findings is discussed

Abbas, Z

Khan, Mohammed Ataullah

Sonawalla, Aziz

English

eCommons@AKU

eCommons@AKUDepartment of Medicine Department of MedicineMarch 1992Prognostic factors in ganglionic and thalamichaemorrhages: a clinical and radiological study.Aziz SonawallaAga Khan University, aziz.sonawalla@aku.eduZ AbbasAgha Khan University, zaigham.abbas@aku.eduMohammed Ataullah KhanAga Khan UniversityFollow this and additional works at: http://ecommons.aku.edu/pakistan_fhs_mc_med_medPart of the Neurology CommonsRecommended CitationSonawalla, A., Abbas, Z., Khan, M. A. (1992). Prognostic factors in ganglionic and thalamic haemorrhages: a clinical and radiologicalstudy.. JPMA. The Journal of the Pakistan Medical Association, 42(3), 62-4.Available at: http://ecommons.aku.edu/pakistan_fhs_mc_med_med/408PROGNOSTIC FACTORS IN GANGLIONIC ANDTHAL4MIC HAEMORRBAGES: A CLINICAL ANDRADIOLOGICAL STUDYPages with reference to book, From 62 To 64 Aziz Badruddin Sonawalla, Zaigham Abbas, Mohammed Ataullah Khan ( Department of Medicine, The Aga KhanUniversity Hospital, Karachi. ) ABSTRACT Clinical and radiological features of 43 patients admitted for ganglionic (21) and thalamic (22)haemorrhages were studied to ascertain the factors that would determine prognosis in the acute stage ofthe illness. Nineteen patients died, 16 of them in the first week. The adverse clinical factors were analtered state of consciousness, decorticate/decerebrate posturing, ataxic respiration, abnormalities ofgaze and presence Of bilateral Babinski\'s sign. Adverse radiological factors were the presence ofthalamic haemorrhage of 3 cm or more, intraventricular spread of the haemorrhage and midline shift of0.5 cm of more. The significance of these findings is discussed (JPMA 42: 62, 1992).INTRODUCTION The most common causes of non-traumatic intracerebral haemorrhages - which account for about 10%of the stroke syndromes - are spontaneous hypertensive haemorrhage, ruptured congenital berryaneurysms or arteriovenous malformations1. The common locations of the haemorrhage are thethalamus and striatum, the other sites being the hemispheric white matter, pons and cerebellum2.Factors that determine the outcome of intracerebral haemorrhages in general, have been fairly wellstudied3-5. Specific behaviour of deep subcortical haemorrhage, in this context, has not been frequentlystudied as an entity1,6,7. We report below our experience with ganglionic and thalamic haemorrhages.PATIENTS AND METHODS Included in this study are 43 patients admitted to the medical service of the Aga Khan UniversityHospital over a period of 1 year, from November, 1987 to October, 1988, who had deep cerebralhaemorrhages diagnosed by a CT scan. The haemorrhage was labelled as thalamic or ganglionic(caudate nucleus and lentiform nucleus) depending upon which site was primarily involved. In each ofthese, a detailed history, physical examination and neurological assessment was carried out at the timeof admission and then on a daily basis for the next 7 days followed by assessment every 3rd day. Thestate of consciousness was graded as follows: 1) fully conscious - when the patient was fully alert to thesurroundings and oriented, ii) struporose - when the patient was drowsy but arousable by vigorousstimuli and verbal responses were slow or absent, iii) semicomatose - when the patient would respondto deep stimulation by unsustained stirring, moaning or agitation and iv) comatose when there was lackof response to any sensory stimulation8. Although increased blood pressure was noted in 42 out of 43cases at admission (BP _ 160/90 mmHg) a history and clinical evidence of long standing hypertensionwas eventually noted in 36 cases. Besides history, other parameters for the diagnosis of hypertensionwere ECG and/or x-ray changes of left ventricular hypertrophy and fundoscopic examinationsuggestive of chronic hypertension. Other notable risk factors were diabetes (10), smoking (9),previous history of stroke or transient ischemic attack (6) and history or ECG changes of ischemic heartdisease (27). Besides a CT scan, the routine baseline investigations included a haemogram, liver andrenal function tests, blood sugar and electrolyte estimations, x-ray chest and an ECG. Otherinvestigations e.g., for sepsis etc., were done where necessary. Treatment consisted mainly of anappropriate control of blood pressure, treatment of infection where required and other conservativemeasures. I/V Mannitol and/or steroids - whilst not a routine treatment protocol - was restored to, incases where there was evidence to suggest a severe increase in intracranial pressure. Neurosurgicalintervention was attempted in 5 cases.RESULTS Of the 43 patients, 33 were males and 10 females with mean ages of 59.7 years and 58.6 yearsrespectively. Nineteen (44.2%) patients expired in the acute stage, 5 patients died on day 1, 5 on day 2and another 6 died within the first week, i.e., 84% of the total deaths occurred within the first week.Factors determining prognosis in the acute stage1. ClinicalThe clinical factors that were significant in determining the outcome in the acute stage are shown inTable I,the most significant amongst them being the initial state of consciousness, bilateral increase in tone andataxic respiration. More significant is the finding noted inTable II which shows that a conscious state at presentation as well as a deeply comatose state, bothhave a very significant bearing on the prognosis in the acute stage. Seventeen patients had gazeabnormalities, mainly in the form of lateral deviation of gaze (12), limitation of upward gaze (3) andconvergence spasm (2). The presence of gaze abnormalities and bilateral Bibinski\'s sign were alsoassociated with adverse prognosis.2. Radiological (CT scan)The significant CT scan factors are listed in Table III.The risk did not seem to increase with an increased size of 3 cm or beyond in ganglionic haemorrhages,as compared to thalamic haemorrhages. Ganglionic haemorrhages spreading to the ventricles had amore adverse prognosis than thalamic. A midline shift of 0.5 cm or more was also an adverse sign.DISCUSSION Our understanding of deep cerebral haemorrhages has improved considerably since the advent of theCT scan. Clinical factors, however, also remain an important means to determine the eventual outcome.The purpose of the present work was to study both of the above in determining the prognosis in theacute stage of the haemorrhage episode. The mortality figures in the acute stage are high in all series,though quite variable, ranging from 20% to 58% for ganglionic haemorrhages9 and 39% to 65% inthalamic haemorrhages10. Our mortality figure of 19 out of 43 patients (44.2%) is close to the figure of46% reported by Portenoy et al5 in their study comprising all supratentonal (lobar as well as deep)haemorrhages. This would, perhaps suggest that the prognosis in the acute stage in supratentorialhaemorrhages does not depend upon the primary site of the bleed. The significance of the state ofconsciousness as a prognostic factor in our series is consistent with the findings of others2,5,10,11 and isalso true of acute strokes due to all causes. Our finding of zero mortality in patients who wereconscious initially and 100% mortality in cases who were initially deeply comatose, is also significant.Kwak et al11 reported that in their series, the patients who were initially conscious and died, had causesof death that were either secondary or unrelated to the intracranial haemorrhage. Our finding ofdecorticate/decerebrate posturing being an important factor has not been elaborated by others. Weconsider this sign significant since it would indicate brainstem compression and only 1 out of 6 patientswith this finding survived the acute stage. Ataxic respiration, which would also indicate the eventualinvolvement of brainstem has a significant adverse prognostic value5. In comparison to the above, gazeabnormalities and presence of bilateral Babinski;\'s sign had lesser significance (P< 0.05) but importantin the overall assessment and have been reported as such by others10,11. Thalamic haemorrhages ofmore than 3 cm size, as measured on the CT scan, are usually associated with a poor outcome.Weisberg6 and Kwak11 reported 100% mortality in these patients. Our findings, though not sounequivocal, support the observation. This was, however, not borne out in case of ganglionichaemorrhages, suggesting perhaps, that the proximity to the ventricles and the brainstem could be asignificant contributory factor in the adverse prognosis of thalamic haemorrhages. However, inganglionic haemorrhages, once ventricular spread occurred, mortality figures were significantly high (P< 0.05). This has also been the observation of Stein et al12. The significance of these findings needsfurther study. Kwak et al. also studied the effect of a midline shift on CT scan of more than 2 mm andfound no difference in prognosis11. We attempted to study the significance when the shift was 0.5 cmor more and found a significant difference in the outcome of the 2 groups. We consider this observationas significant, since it would indicate a greater likelihood of herniation/brainstem compression in thetight cranial vault. The management of patients with deep intracerebral haemorrhages is still a dauntingtask. Despite advances in our understanding of its mechanisms, not much headway has been made intreatment, which mainly remains conservative. Although relief of oedema by steroids or mannitol andneurosurgical intervention in the early stages are logical therapeutic considerations, they have not beenfound to significantly alter the prognosis13,14. An analysis of the prognostic factors in this settingmight, in future, determine which of these cases would perhaps benefit from more aggressivetreatment.REFERENCES 1. Weisberg, LA. Caudate haemorrhage. Arch. Neurol., 1984; 41:971-4.2. Kase, CS. Intrscerebrsl haemorrhsges: Non-hypertensive causes (Progress Reviews). Stroke, 1986;17:590-95.3. Chambers, BR., Norris, J.W., Shurvell, B.L and Hachinski, v.c. Prognosis of acute stroke. Neurology,1987; 37:221-5.4. Feischi, C., cacolei, A., Fiorefli, M., Argentino, C, Bozzso, L., Fazio, C, Salvetti, M. and Bsstisnello,S. Changing prognosis of primary intracerebrsl hsemorrhsge: results of s clinical and computed follow-up study of 104 patients. stroke, 1988; 19:192-5.5. Portenoy, R.K., Upton, LB., Berger, A.R., Lesser, M.L and Lantos, G. lntrscerebrsl haemorrhage: amodel for the prediction of outcome. J. Neurol., Neurosurg. Psychiatry. 1987; 50:976-9.6. Weisberg, LA. Thalamic hsemorrhsge: clinical-cr correlations. Neurology, 1986; 36:1382-86,7. Kawshsrs, N., Ssto, K., Muraki, M., Tanaka, K., Ksneko, M. and Vemura, K. CT elassiflcationofsmall thalamic haemorrhagesand theirclinical implications. Neurology, 1986; 36:165-72.8. Ropper, A.H. and Martin, J.B. Coms and other disorders of consciousness, in Hsrrisons principles ofinternal medicine, 11th ed. New York, McGraw-Hill, 1987, pp. 114-20.9. Weisberg. CA., Nice, C. and Ketz, M. Cerebral computed tomography. A text atlas. 2nd ed.Philadelphia, Saunders, 1984, pp. 122-33.10. Barraquer-Bordas, L, Ills, I., Escartin, A., Ruscalleda, J. snd Marti-Vilalta, .1.L Thalsmichaemorrhsge. A studyof23 patientswith diagnosis bycomputed tomography. Stroke, 1981, 12:524-7.11. Kwsk, It, Ksdoya, S. and Suzuki, T. Factors affecting the prognosis in thslsmic haemorrhage.Stroke, 1983; 14:493-S®.12. Stein, LW., Caplan, LR., Hier, P.B. Intracerebral haemorrhage. Role of blood pressure, location andsizeof lesions, Ann. Neurol., 1983; 14:132.13. Poungvarin, N., Bhoopat, W., Viriysvarjskul, A., Rodprasert, P., Buranasiri, P., Sukondhabhsnc, S.,Hensley, M. and Strom, B.L. Effects of dexamethssone in primary suprstentorisl intracerebralhsemorrbsge. N. EngI. J.Med., 1987; 316:1229-33.14. Kanno, T., Sano, H., Shinomiya, Y., Katada, K., Nagate, J., Hoshing M. and Mitsuyama, F. Role ofsurgery in hypertensive intracerebral hematoms: A comparison study of 305 nonsurgical and 154surgical cases.). Neurosurg., 1984; 61:1091-9.

Prognostic factors in ganglionic and thalamic haemorrhages: a clinical and radiological study.

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Prognostic factors in ganglionic and thalamic haemorrhages: a clinical and radiological study.

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