Prognostic predictors of thalamic hemorrhage

Neurophysiological Examinations as Adjunctive Tool to Imaging Techniques in Spontaneous Intracerebral Hemorrhage: IRONHEART Study

Introduction: Intracerebral hemorrhage (ICH) is a devastating disease, which may lead to severe disability or even death. Although many factors may influence the outcome, neurophysiological examinations might also play a role in its course. Our aim was to examine whether the findings of electroencephalography (EEG) and transcranial magnetic stimulation (TMS) can predict the prognosis of these patients.

Methods: Between June 1 2017 and June 15 2021, 116 consecutive patients with ICH were enrolled prospectively in our observational study. Clinical examinations and non-Contrast computed tomography (NCCT) scan were done on admission for ICH; follow-up NCCT scans were taken at 14 ± 2 days and at 3 months ± 7 days after stroke onset. EEG and TMS examinations were also carried out.

Results: Of the patients in the study, 65.5% were male, and the mean age of the study population was 70 years. Most patients had a history of hypertension, 50.8% of whom had been untreated. In almost 20% of the cases, excessive hypertension was measured on admission, accompanied with >10 mmol/L blood glucose level, whereas their Glasgow Coma Scale was 12 on average. Presence of blood in the ventricles or subarachnoid space and high blood and perihematomal volumes meant poor prognosis. Pathological EEG was prognostic of a worse outcome. With TMS examination at 14 days, it might be possible to estimate outcome in a univariate model and the absence, or reduction of the amplitude of the motor evoked potentials was associated with poor prognosis.

Conclusion: Together with the clinical symptoms, the volume of bleeding, perihematomal edema (or their combined volume), and neurophysiological examinations like EEG and TMS play an important role in the neurological outcome of patients with ICH. This might affect the patients' rehabilitation plans in the future, since with the help of the examinations the subset of patients with potential for recovery could be identified.

Prognostic Value of Various Hemostasis Parameters and Neurophysiological Examinations in Spontaneous Intracerebral Hemorrhage: The IRONHEART Study Protocol

Rationale: Stroke is one of the leading causes of death in all developed countries. In Hungary, more than 10,000 patients die annually due to cerebrovascular diseases according to the WHO Mortality Database. Of these patients, 10–15 % suffer non-traumatic intracerebral hemorrhage (ICH). ICH results in a higher rate of mortality as compared to ischemic stroke and outcomes are difficult to predict. In the IRONHEART study, we aim to test various hemostasis parameters and clinical neurophysiological examinations in evaluating outcome in ICH.

Methods: In this prospective, observational study, we plan to enroll consecutive patients with non-traumatic spontaneous ICH admitted to a single Stroke Center (Department of Neurology, University of Debrecen, Hungary). The protocol of the IRONHEART study includes the investigation of detailed clinical, laboratory investigations, and various neurophysiological examinations. Stroke severity is quantified based on the National Institutes of Health Stroke Scale (NIHSS) on admission and day 7, 14, and 90 after the onset of stroke. Cranial CT is performed on admission, day 14, and 90 to estimate the ICH volume. Modified Rankin Scale (mRS) is used for evaluating the long-term outcome (90 days post-event). Blood is drawn immediately on admission for specific hemostasis tests. Digital and quantitative EEG techniques and motor evoked potential (MEP) are performed to evaluate the prognosis of cerebral hemorrhage on admission (within 24–48 h), immediately before discharge (~10–14 days later), and 3 months after the event.

Outcomes: The following outcomes are investigated: primary outcomes: mortality by day 14 and day 90, secondary long-term outcome at 90 days post-event where mRS 0–2 is defined as favorable long-term outcome.

Discussion: If associations between outcomes and the investigated parameters (hemostasis and neurophysiological examinations) are confirmed, results might aid prognosis assessment in this subtype of stroke with particularly high mortality. Improving clinical grading systems on ICH severity and outcomes by including the investigated parameters could help to better guide the management of these patients in the future.

Primary Thalamic Haemorrhage – Clinical Profile and Prognostic Predictors from a Series of 117 Cases

Background:

Studies on isolated primary thalamic hematomas are limited. This study analyses 117 patients with primary thalamic hematomas and attempts to identify the various prognostic factors influencing the outcome.

Materials and Methods:

A retrospective analysis of the case records was carried out to analyse the following prognostic parameters - GCS on admission, comorbidities like systemic hypertension and diabetes mellitus, side and site of hematoma, volume of the clot, presence of intraventricular haemorrhage (IVH), development of hydrocephalus, and the role of surgical intervention. A Chi-square test was used to compare categorical variables, and Student t-test and Mann Whitney test were applied to calculate the P-value for continuous variables for univariate statistics. Binary Logistic regression was used for multivariate analysis.

Results and Discussion:

This study group comprised 67 men and 50 women with a mean age of 62.05±11.71years. The mean GCS on admission in the study group was 11.56±3.28. The mean clot volume was 13±9.5ml and majority (89.74%) of the patients had clots with a volume of less than 20 ml. An intraventricular extension was noted in 98 patients. Craniotomy and surgical evacuation were performed in only two patients while external ventricular drainage with urokinase instillation was performed in 23 patients. Of the 117 patients, 3 had anterior thalamic clots, 19 had posterior thalamic clots, 13 had medial clots, 53 had lateral thalamic bleeds and 29 had global clots. The overall three-month mortality with thalamic bleeds was 28.2%. At the end of three months, 59 patients (50.42%) had a favourable outcome (mRS < 4). On univariate analysis, male sex, dominant side bleed, preoperative GCS of less than 8 (p < 0.001), presence of hydrocephalus (p< 0.004) and a need for EVD (p<0.012) were found to be significantly associated with mortality and poor outcome. Similarly, clot volume less than 20 ml, right-sided bleed and surgical evacuation were associated with a favourable outcome (p < 0.001). On multiple logistic regression, age, volume of hematoma and GCS on admission were predictors for mortality and volume of hematoma was a significant predictor of poor outcome.

Conclusion:

Thalamic hematomas include a spectrum of clots of varying dimensions at different locations and the outcomes need not be uniformly poor. Isolated thalamic hemorrhages are generally small in volume preferentially located in the lateral thalamus. Patients with right-sided bleeds and small clot volume perform well. Male sex, poor GCS on admission, clot volume above 20 ml, intraventricular extension and a need for external ventricular drainage adversely influence the outcome.

Prognostic models for intracerebral hemorrhage: systematic review and meta-analysis

Background

Prognostic tools for intracerebral hemorrhage (ICH) patients are potentially useful for ascertaining prognosis and recommended in guidelines to facilitate streamline assessment and communication between providers. In this systematic review with meta-analysis we identified and characterized all existing prognostic tools for this population, performed a methodological evaluation of the conducting and reporting of such studies and compared different methods of prognostic tool derivation in terms of discrimination for mortality and functional outcome prediction.

Methods

PubMed, ISI, Scopus and CENTRAL were searched up to 15th September 2016, with additional studies identified using reference check. Two reviewers independently extracted data regarding the population studied, process of tool derivation, included predictors and discrimination (c statistic) using a predesignated spreadsheet based in the CHARMS checklist. Disagreements were solved by consensus. C statistics were pooled using robust variance estimation and meta-regression was applied for group comparisons using random effect models.

Results

Fifty nine studies were retrieved, including 48,133 patients and reporting on the derivation of 72 prognostic tools. Data on discrimination (c statistic) was available for 53 tools, 38 focusing on mortality and 15 focusing on functional outcome. Discrimination was high for both outcomes, with a pooled c statistic of 0.88 for mortality and 0.87 for functional outcome. Forty three tools were regression based and nine tools were derived using machine learning algorithms, with no differences found between the two methods in terms of discrimination (p = 0.490). Several methodological issues however were identified, relating to handling of missing data, low number of events per variable, insufficient length of follow-up, absence of blinding, infrequent use of internal validation, and underreporting of important model performance measures.

Conclusions

Prognostic tools for ICH discriminated well for mortality and functional outcome in derivation studies but methodological issues require confirmation of these findings in validation studies. Logistic regression based risk scores are particularly promising given their good performance and ease of application.

Electronic supplementary material

The online version of this article (10.1186/s12874-018-0613-8) contains supplementary material, which is available to authorized users.

Prognostic Factors of Clinical Outcomes in Patients with Spontaneous Thalamic Hemorrhage

Background

Intracerebral hemorrhage (ICH) is a well-known condition, but ICH restricted to the thalamus is less widely studied. We investigated the prognostic factors of thalamic ICHs.

Material/Methods

Seventy patients from January 2009 to November 2014 were retrospectively reviewed. Patients who demonstrated spontaneous ICH primarily affecting the thalamus on initial brain computed tomography (CT) were enrolled. Patients were categorized into 2 groups based on their Glasgow Outcome Scale (GOS) scores. Various presumptive prognostic factors were analyzed to investigate relationships between various clinical characteristics and outcomes.

Results

Of the enrolled patients, 39 showed a GOS of 4–5, and were categorized as the good outcome group, while another 31 patients showed a GOS of 1–3 and were categorized as the poor outcome group. Initial GCS score, calculated volume of hematoma, presence of intraventricular hemorrhage (IVH), coexisting complications, hydrocephalus, performance of external ventricular drainage, and modified Graeb’s scores of patients with IVH were significantly different between the 2 groups. In multivariate analysis, among the factors above, initial GCS score (P=0.002, Odds ratio [OR]=1.761, Confidence interval [CI]=1.223–2.536) and the existence of systemic complications (P=0.015, OR=0.059, CI=0.006–0.573) were independently associated with clinical outcomes. Calculated hematoma volume showed a borderline relationship with outcomes (P=0.079, OR=0.920, CI=0.839–1.010).

Conclusions

Initial GCS score and the existence of systemic complications were strong predictive factors for prognosis of thalamic ICH. Calculated hematoma volume also had predictive value for clinical outcomes.

Thalamic Stroke: Precursors and Outcomes for Ten Patients

Objective: The purpose of this study was to examine susceptibility factors in thalamic stroke, as well as outcomes in order to identify rehabilitation needs.

Methods: Ten patients with thalamic stroke were interviewed and administered the Audio Recorded Cognitive Screen. Magnetic resonance imaging (MRI) scans were examined to determine location and size of the lesion, as well as basilar artery size and anatomical variances in the circle of Willis.

Results: Risk factors such as high cholesterol, high blood pressure and pre-existing heart conditions were identified. Circle of Willis variations were found in 6 of the 10 participants, with MR angiography indicating that the posterior communication artery was absent or failed to join the posterior cerebral artery. Basilar artery diameter measurements were no larger than normal. All participants reported post-stroke changes, including decreased coordination and mobility, poor balance, reduced energy, memory deficits and mood changes. Participants’ overall scores on cognitive tests were significantly lower than age-matched norms. Performance on the test domains of memory, fluency, language and attention were all significantly below age norms.

Conclusions: The variability of outcome measures demonstrates the difficulty of defining patterns of relationship between risk factors and severity of functional sequelae in thalamic stroke.

Improved outcome of patients with severe thalamic hemorrhage treated with cerebrospinal fluid drainage and neurocritical care during 1990-1994 and 2005-2009

INTRODUCTION

Patients with thalamic hemorrhage, depressed level of consciousness and/or signs of elevated intracranial pressure may be treated with neurocritical care (NCC) and external ventricular drainage (EVD) for release of cerebrospinal fluid.

METHODS

Forty-three patients with thalamic hemorrhage treated with NCC from 1990 to 1994 (n = 21) and from 2005-2009 (n = 22) were evaluated. Outcome was assessed using the Glasgow Coma Scale (GCS) score at discharge from our unit and the modified Rankin Scale (mRS) for long-term outcome.

RESULTS

Patients' age was 59.5 ± 7 years in 1990-1994, and 58.2 ± 9 years in 2005-2009. The median (25th and 75th percentile) GCS score on admission for the two time periods was 9 (6-12) and 9 (4-14), respectively. Long-term follow-up was assessed at a mean of 37.1 (range 19-65) months after disease onset for the 1990-1994 cohort and at 37.4 (range 14-58) months for the 2005-2009 cohort. Compared to patients from 1990 to 1994, patients from 2005 to 2009 had a significantly better outcome (median mRS [25th and 75th percentile]: 5 [4-6] vs. 4 [2-4.5]; p < 0.01). Most patients (13/21, 62 %) treated from 1990 to 1994 had unchanged or lower GCS scores during their NCC stay in contrast to 7/22 (32 %) from 2005 to 2009. At the last follow-up, 13/21 (62 %) patients from 1990 to 1994 were dead in comparison to 4/21 (19 %) from 2005 to 2009 (p < 0.05). Negative prognostic factors were the 120 h post-admission GCS score in the 1990-1994 patient cohort (p = 0.07) and high age in the recent cohort (p = 0.04).

CONCLUSIONS

Patients with thalamic hemorrhage and depressed level of consciousness on admission had a worse outcome in the early 1990s compared with the late 2000s, which may at least be partially attributed to refined neurocritical care.

Intracerebral hemorrhage in young patients from a tertiary neurology center in North India

OBJECTIVE

There is paucity of information on the etiology and predictors of outcome of intracerebral hemorrhage (ICH) in young patients which may have regional and ethnic differences. In this study, we report the etiology and predictors of outcome of ICH in young patients from North India.

METHODS

404 young patients with ICH (16-50 years) were retrospectively reviewed who were admitted in neurology service of a tertiary care teaching hospital in North India. The data were retrieved from the computerized hospital information service. The information about the demography, risk factors, clinical status, laboratory findings, CT/MRI features and angiography (CT, MRI or digital substraction) were noted. The etiology of ICH was ascertained based on clinical, laboratory and radiological findings. Outcome at 1 month was assessed using Glasgow Outcome Scale (GOS).

RESULTS

The mean age of the patients was 41.6 years and 23.8% were females. Hypertension (57.2%), hypocholesterolemia (33.7%), alcohol (15.8%) and anticoagulant (3.5%) were the important risk factors. The etiology of ICH was hypertension in 320 (79.2%), vascular malformation in 17 (4.2%), coagulopathy in 16 (4%), cerebral venous sinus thrombosis (CVST) in 9 (2.2%), thrombocytopenia in 3 (0.7%), vasculitis in 2 (0.5%) and cryptogenic in 37 (9.2%) patients. The patients with cryptogenic ICH were younger, had better Glasgow coma scale (GCS) on admission and good outcome compared those with known etiology. The most common location of ICH was basal ganglion and thalamus (71.3%). 102 (25%) patients died, 161 (39.9%) had poor and 141 (34.9%) had good outcome. Hypertensive ICH patients had frequent death or disability (P<0.001). On multivariate analysis, low GCS score (P <0.001), large ICH (P=0.01) and high leukocyte count on admission (P=0.03) were significantly related to the 1 month mortality.

CONCLUSION

Hypertension is the commonest cause of ICH in young Indian adults and its outcome is related to volume of ICH, GCS score and admission leukocyte count.

Prediction of motor outcome based on diffusion tensor tractography findings in thalamic hemorrhage

OBJECTIVES

Little is known about the usefulness of diffusion tensor tractography (DTT) findings of the corticospinal tract (CST) in terms of predicting motor outcome after thalamic hemorrhage. We investigated the predictive value of DTT for motor outcome in patients with thalamic hemorrhage.

METHODS

Twenty-one patients were recruited; DTTs were obtained within 7-30 d of thalamic hemorrhage. We determined fractional anisotropies (FAs), tract numbers, and tract lengths of CSTs and calculated affected CST versus unaffected CST ratios for each value. In addition, patients were classified into two groups; a DTT type A group, in which the CST was preserved around the hematoma, and a DTT type B group, in which the CST was interrupted. Six months after thalamic hemorrhage, motor functions of affected sides were evaluated using upper Motricity Index (MI), lower MI, total MI, the modified Brunnstrom classification (MBC) and functional ambulation category (FAC).

RESULTS

DTT parameters of CSTs, that is, FA ratios, tract number ratios and tract length ratios of affected/unaffected CSTs were found to be positively correlated with 6-month upper MIs, lower MIs, total MIs, MBCs and FACs. In addition, all motor function scores at 6 months after onset were higher in the DTT type A group than in the DTT type B group.

CONCLUSIONS

Early DTT evaluation of CSTs appears to be useful for predicting motor outcomes of affected extremities at chronic stage in patients with thalamic hemorrhage.

Influence of constraint-induced movement therapy upon evoked potentials in rats with cerebral infarction

Constraint-induced movement therapy (CIMT) is an effective treatment promoting motor recovery of upper extremity function in stroke patients. The objective of the present study was to determine the effect of CIMT on the evoked potentials in rats with focal cerebral cortical ischemia induced by endothelin-1 (ET-1). Thirty rats were randomly assigned to the sham, infarct or CIMT groups. ET-1 was injected stereotaxically into the forelimb area of the cerebral cortex in the dominant hemisphere. Custom-made constraint jackets were applied to limit movement of the unaffected forelimb in the CIMT group. Motor and sensory function of the forelimb was evaluated by a pellet retrieval task and forearm asymmetry test. Electrophysiologic changes were evaluated by motor-evoked potentials (MEPs) and somatosensory-evoked potentials (SEPs). The location and extent of cerebral ischemia were confirmed and compared histologically. The CIMT group showed better recovery in the pellet retrieval task. Forelimb use was more symmetrical in the CIMT group. The waveform of the SEP was reversed and delayed in the infarct group, but it was preserved in the CIMT group with amplitude decrease only. The estimated volume of infarction was smaller in the CIMT group, although statistically not significant. The results demonstrate that CIMT can promote recovery of motor function in focal cerebral cortical infarcts, and that recovery may be related to reorganization of the cerebral neuronal network in the somatosensory pathway.

Clinical analysis of electrolyte imbalance in thalamic hemorrhage patients within 24 h after admission

We have observed that patients with thalamic hemorrhage are more likely to have electrolyte disturbances than those with non-thalamic hemorrhage. Here, we are attempting to provide some comprehensive information on electrolyte disturbances in patients with thalamic hemorrhage. Retrospectively, 67 patients with thalamic hemorrhage (TH group) and 256 with non-thalamic hemorrhage (N-TH group) were found from computer tomography images. Electrolytes of these patients were tested within 24 h after hospitalization. Chi-square test was used to compare the incidence of electrolyte imbalance. Serum K+ levels were found to be abnormal in 37.31% of the patients in the TH group and 24.21% in the N-TH group, and the difference was significant (p<0.05). Such a difference was also observed for the levels of serum Na+ and Cl+. Incidences of abnormal serum K+ (p<0.05), Na+ (p<0.01) and Cl(-) (p<0.01) levels were different among thalamic hemorrhage, basal ganglia area hemorrhage and lobar hemorrhage patients. In the TH group, the mortality of patients with electrolyte disturbances (42.50%) was higher than that of patients with normal electrolyte levels (14.81%, p<0.05). The incidence of electrolyte imbalance is higher in patients with thalamic hemorrhage than in those with non-thalamic hemorrhage. The reason may be partly related to the location of the hemorrhage. Electrolyte disturbance may contribute to the higher mortality of patients with thalamic hemorrhage.

Early prediction of outcome of activities of daily living after stroke: a systematic review

BACKGROUND AND PURPOSE

Knowledge about robust and unbiased factors that predict outcome of activities of daily living (ADL) is paramount in stroke management. This review investigates the methodological quality of prognostic studies in the early poststroke phase for final ADL to identify variables that are predictive or not predictive for outcome of ADL after stroke.

METHODS

PubMed, Ebsco/Cinahl and Embase were systematically searched for prognostic studies in which stroke patients were included ≤2 weeks after onset and final outcome of ADL was determined ≥3 months poststroke. Risk of bias scores were used to distinguish high- and low-quality studies and a qualitative synthesis was performed.

RESULTS

Forty-eight of 8425 identified citations were included. The median risk of bias score was 17 out of 27 (range, 6-22) points. Most studies failed to report medical treatment applied, management of missing data, rationale for candidate determinants and outcome cut-offs, results of univariable analysis, and validation and performance of the model, making the predictive value of most determinants indistinct. Six high-quality studies showed strong evidence for baseline neurological status, upper limb paresis, and age as predictors for outcome of ADL. Gender and risk factors such as atrial fibrillation were unrelated to this outcome.

CONCLUSIONS

Because of insufficient methodological quality of most prognostic studies, the predictive value of many clinical determinants for outcome of ADL remains unclear. Future cohort studies should focus on early prediction using simple models with good clinical performance to enhance application in stroke management and research.

Gross-total hematoma removal of hypertensive basal ganglia hemorrhages: a long-term follow-up

BACKGROUND AND PURPOSE

Hypertensive basal ganglia hemorrhage (HBGH) accounts for 35%-44% of cases of hypertensive intracranial hemorrhage (ICH), which is one of the most devastating forms of cerebrovascular disease. In this study, intracerebral hematoma was evacuated with a burr hole craniectomy. The relationships of residue hematoma volume to brain edema, inflammation factors and the long-term prognosis of HBGH patients were studied.

METHODS

One hundred and seventy-six patients with HBGH were randomly divided into gross-total removal of hematoma (GTRH) and sub-total removal of hematoma (STRH) groups. The pre-operative and post-operative data of the patients in the two groups were compared. The pre-operative data included age, sex, hematoma volume, time from the ictus to the operation, Glasgow Coma Scale (GCS) scores, and the European Stroke Scale (ESS) scores. The post-operative information included edema grade, level of thromboxane B2 (TXB2), 6-keto-prostaglandin F1a (6-K-PGF1a), tumor necrosis factor-a (TNF-a) and endothelin (ET) in hematoma drainage or cerebral spinal fluid (CSF), ESS and Barthel Index (BI).

RESULTS

There was no statistical difference between the two groups (P>0.05) in the pre-operative data. The levels of TXB2, 6-K-PGF1a, TNF-a and ET in the GTRH group were significantly lower than those in the STRH group at different post-operative times. The ESS in the GTRH group increased rapidly after the operation and was higher than that in the STRH group. There was a significant difference between the two groups (P<0.05). The post-operative CT scan at different times showed that the brain edema grades were better in the GTRH group than in the STRH group. The BI was higher in the GTRH group than in the STRH group (P<0.05).

CONCLUSIONS

GTRH is an effective method to decrease ICH-induced injury to brain tissue. Such effect is related to decreased perihematomal edema formation and secondary injury by coagulation end products activated inflammatory cascade.

Effect of minimally invasive surgery for cerebral hematoma evacuation in different stages on motor evoked potential and thrombin in dog model of intracranial hemorrhage

OBJECTIVE

To observe the effect of minimally invasive surgery for cerebral hematoma evacuation in different stages on motor evoked potential (MEP) and thrombin in dog model of intracranial hemorrhage.

METHODS

Twenty dogs were selected to prepare the intracranial hemorrhage model, which were randomly divided into 6, 12, 18 and 24 hour groups, respectively. The animals in each group underwent a minimally invasive surgery to evacuate the cerebral hematoma after the models were prepared. Before and after procedures, Purdy score, MEP and thrombin in hematoma region were determined and compared.

RESULTS

Significant decreases in Purdy score, latency of MEP and thrombin expression were observed in 6 and 12 hour groups as compared with the 18 and 24 hour groups (p<0.01).

DISCUSSION

In the present experiment, we established a dog model of intracranial hemorrhage, which was minimally invasive, easy to operate, highly repeated, simulating the pathological and physiological changes of clinical hypertensive intracranial hemorrhage. Both the latency of MEP and the expression of thrombin decreased after evacuation of intracranial hematoma in early stages by minimally invasive procedures, indicating that minimally invasive procedures for cerebral hematoma in ultra-early and early stages might be more effective to limit brain injury and decrease the latency of MEP and thrombin expression.

Thalamic haemorrhage vs internal capsule-basal ganglia haemorrhage: clinical profile and predictors of in-hospital mortality

BACKGROUND

There is a paucity of clinical studies focused specifically on intracerebral haemorrhages of subcortical topography, a subject matter of interest to clinicians involved in stroke management. This single centre, retrospective study was conducted with the following objectives: a) to describe the aetiological, clinical and prognostic characteristics of patients with thalamic haemorrhage as compared with that of patients with internal capsule-basal ganglia haemorrhage, and b) to identify predictors of in-hospital mortality in patients with thalamic haemorrhage.

METHODS

Forty-seven patients with thalamic haemorrhage were included in the "Sagrat Cor Hospital of Barcelona Stroke Registry" during a period of 17 years. Data from stroke patients are entered in the stroke registry following a standardized protocol with 161 items regarding demographics, risk factors, clinical features, laboratory and neuroimaging data, complications and outcome. The region of the intracranial haemorrhage was identified on computerized tomographic (CT) scans and/or magnetic resonance imaging (MRI) of the brain.

RESULTS

Thalamic haemorrhage accounted for 1.4% of all cases of stroke (n = 3420) and 13% of intracerebral haemorrhage (n = 364). Hypertension (53.2%), vascular malformations (6.4%), haematological conditions (4.3%) and anticoagulation (2.1%) were the main causes of thalamic haemorrhage. In-hospital mortality was 19% (n = 9). Sensory deficit, speech disturbances and lacunar syndrome were significantly associated with thalamic haemorrhage, whereas altered consciousness (odds ratio [OR] = 39.56), intraventricular involvement (OR = 24.74) and age (OR = 1.23), were independent predictors of in-hospital mortality.

CONCLUSION

One in 8 patients with acute intracerebral haemorrhage had a thalamic hematoma. Altered consciousness, intraventricular extension of the hematoma and advanced age were determinants of a poor early outcome.

Endoscopic surgery for thalamic hemorrhage: a technical note

BACKGROUND

Approximately 10% to 15% of cases of ICH involve the thalamus. Evacuation of a thalamic hematoma by craniotomy is associated with high rates of mortality and morbidity. Evacuation by endoscopic surgery is less invasive but is relatively inefficient because of limited visualization of the surgical field. Therefore, a procedure using a polypropylene endoscopic sheath was developed to improve endoscopic visualization and the efficiency of endoscopic evacuation of thalamic hematoma.

METHODS

From September 2004 to September 2005, 7 patients underwent endoscopic evacuation of posterial-lateral type thalamic hemorrhage that had ruptured into the lateral ventricle of the trigum and caused acute hydrocephalus. The clinical evaluation included pre- and postoperative Glasgow Coma Scale (GCS) score, 30-day mortality rate, and Glasgow Outcome Scale score 6 months later. The surgical procedure was performed with the patient in the supine position while under general anesthesia. A 3-cm incision was made across the occipital-parietal scalp ipsilateral to the thalamic hematoma. A burr hole, 1 cm in diameter, was drilled on the Keen's point, which is located 3 cm posterior and 3 cm superior to the pinna. A transcortical intraventricular puncture was made with a rigid endoscopic tube. A 2.7-mm endoscope and the necessary surgical instruments were then inserted through this tube, permitting the simultaneous removal of hematoma in the intraventricular space and thalamus. A surgical demonstration of this technique to evacuate thalamic hemorrhage in a patient with acute hydrocephalus is provided herein.

RESULTS

The preoperative mean GCS score was 8.4 and the postoperative mean GCS score was 9.4. The 30-day mortality rate was 15% and none of the patients developed shunt-dependent hydrocephalus. The average Glasgow Outcome Scale score was 3.7 six months later.

CONCLUSION

Use of a rigid endoscopic sheath in combination with an endoscope and an approach from Keen's point to the collateral trigone of the lateral ventricle improves the efficiency of evacuating thalamic hematomas and prevents shunt-dependent hydrocephalus.