|Year : 2020 | Volume
| Issue : 2 | Page : 103-108
Computed tomographic evaluation of acute hemorrhagic stroke volume and its relationship with clinical outcome
Yetunde Folake Taiwo1, Anthony Epga Gabkwet1, Margaret Isioma Ojeahere2, Ohunene Nafisat Usman3, Femi Olu Taiwo4, Philip Oluleke Ibinaiye5
1 Department of Radiology, Faculty of Clinical Sciences, College of Health Sciences, Jos University Teaching Hospital, University of Jos, Jos, Nigeria
2 Department of Psychiatry, Jos University Teaching Hospital, Jos, Nigeria
3 Department of Community Medicine, Faculty of Clinical Sciences, College of Medicine, Kaduna State University, Kaduna, Nigeria
4 Department of Orthopedics and Trauma, Jos University Teaching Hospital, Jos, Nigeria
5 Department of Radiology, Ahmadu Bello University Teaching Hospital, Ahmadu Bello University, Zaria, Nigeria
|Date of Submission||28-Jun-2020|
|Date of Decision||16-Jul-2020|
|Date of Acceptance||04-Aug-2020|
|Date of Web Publication||30-Nov-2020|
Yetunde Folake Taiwo
Department of Radiology, Faculty of Clinical Sciences, College of Health Sciences, Jos University Teaching Hospital, University of Jos, Jos
Source of Support: None, Conflict of Interest: None
Background: Hemorrhagic stroke outcome has been poorly studied in this region despite being a significant cause of morbidity and mortality. The use of computed tomography to assess the volumes of lesion, the sites of the brain affected, and their relationship with patients' clinical outcome will add to the body of knowledge in the management of hemorrhagic stroke. Objectives: The objectives of this study are to determine if the volume of hemorrhagic stroke lesion correlates with patient clinical outcome at 30 days poststroke. Materials and Methods: Acute hemorrhagic stroke patients were recruited consecutively over 18 months. Intracerebral hemorrhage (ICH) volume and the sites affected were correlated with the patients' modified Rankin Scale (mRS) assessment outcome at 30 days poststroke. The mRS scores of (0–3) were regarded as favorable and (4–6) as unfavorable. Student's t-test, logistic, and linear regression analyses were done using the Statistical Package for the Social Sciences software version 20.0, level of significance was set at P ≤ 0.05. Results: Forty-four patients were included in the study. Overall, mean (standard deviation) ICH lesion volume of 30.8 (33.2) ml was observed. Mean volumes of 32.2 (35.7) ml and 29.2 (30.9) ml were seen in patients with favorable and unfavorable outcomes, respectively. Linear and logistic regression analyses of the volume of the lesion on mRS outcome and patient outcome (alive vs. dead) were not statistically significant with P values of 0.982 and 0.868, respectively. Conclusion: Hemorrhagic stroke lesion volume though important in the assessment of patients does not significantly correlate with patient outcome at 1-month poststroke.
Keywords: Computed tomography, intracerebral hemorrhage, modified Rankin Scale, volume
|How to cite this article:|
Taiwo YF, Gabkwet AE, Ojeahere MI, Usman ON, Taiwo FO, Ibinaiye PO. Computed tomographic evaluation of acute hemorrhagic stroke volume and its relationship with clinical outcome. J Radiat Med Trop 2020;1:103-8
|How to cite this URL:|
Taiwo YF, Gabkwet AE, Ojeahere MI, Usman ON, Taiwo FO, Ibinaiye PO. Computed tomographic evaluation of acute hemorrhagic stroke volume and its relationship with clinical outcome. J Radiat Med Trop [serial online] 2020 [cited 2021 Aug 4];1:103-8. Available from: http://www.jrmt.org/text.asp?2020/1/2/103/301897
| Introduction|| |
Stroke is a common neurological disorder and is the second leading cause of death (after heart disease and before cancer) and a major cause of long-term disability among survivors., Hemorrhagic stroke accounts for a significant cause of morbidity and mortality with increasing incidence noted globally.,, Acute stroke care includes the distinction of the type of stroke that has occurred. Computed tomography (CT) is the routine imaging modality of choice for acute stroke evaluation, because it is relatively more accessible, reproducible, convenient, has a short imaging time, and is sensitive for detection of acute hemorrhage. CT scans have been found to accurately identify as well as quantify hematoma volume and also monitor hematoma evolution in patients with intracerebral hemorrhage (ICH).
The volume and anatomical location of the brain tissue affected by acute stroke is an important tool employed in predicting the clinical outcome, which can be easily evaluated using CT., Studies have found volumes ranging from 10 ml to 60 ml as the median value that determines patient outcome.,,,
The modified Rankin Scale (mRS) is a well-founded clinical tool used in the assessment of disability among stroke survivors. It has been correlated with the sites and volume of stroke insult in other studies and has been found to be reliable.
Several foreign studies have established the findings in this aspect of hemorrhagic stroke,, these findings, however, cannot be generalized. Studies of this kind are sparce in our environment and the need to have baseline values will add to the body of knowledge on patient care outcome and prognosis.
This study aim to determine the volume of hemorrhagic stroke lesions and to relate it to the patients' clinical outcome using “being alive” versus “dead” as well as using the mRS.
| Materials and Methods|| |
This hospital-based case study spanned over a period of 18 months from April 2014 to September 2015. Approval was obtained from the Research and Ethical Committee of Jos University Teaching Hospital, for this study with clearance reference number (JUTH/DCS/ADM/127/XIX/5905 March 21, 2014). Written informed consent was obtained from all the participants or their legal representatives.
Participants aged ≥18 years with intracerebral hemorrhagic stroke history of <7 days were included in the study. Patients presenting with a repeat stroke were excluded from the study.Patients having causes of focal neurologic deficit other than stroke or stroke-like syndromes after CT had been done were also excluded.
Participants who met the inclusion criteria were recruited consecutively by the lead author.
All scans were done using a made in U. S. A. Milwaukee, Wisconsin. Four slice General Electric (Bright speed) series CT scanner year 2006/2007, model number XG001G-JS-001-GAN.
With the patient placed in the supine position and head immobilized face-up in the gantry, a series of contiguous axial scan from the base of the skull to the vertex at 2.5 mm for the base of the skull and 5 mm for the rest of the skull was obtained angled parallel to the orbitomeatal line. Sagittal and coronal reformatted images were used to corroborate the axial images in the evaluation of the patient.
A semi-structured interviewer-administered questionnaire was used to obtain relevant biodata from the patients or their relatives where the patient was incapable of providing such information.
Review of cranial CT findings was done by the lead author to get information about the imaging details of the exact site and volume of acute intracerebral hemorrhagic stroke lesion using the formula for the volume of an ellipse “ABC/2” (where A is the greatest diameter, B is the diameter 90° to A, and C is the approximate number of CT slices multiplied by the slice thickness or the approximate height measurements) [Figure 1] and [Figure 2].
Patients that had a repeat CT scan during the hospital stay and the findings observed were noted.
|Figure 1: Axial computed tomography of the brain showing anteroposterior and width measurements of acute intracerebral hemorrhage in the left thalamus. Hemorrhage into the anterior and posterior horns of the left lateral ventricle is also seen|
Click here to view
|Figure 2: Coronal reformatted computed tomography of the brain showing height and width measurements of an acute hemorrhagic stroke lesion involving the left thalamic region. There is effacement of the ipsilateral lateral ventricle|
Click here to view
A further follow-up of each patient's case note was done to get the 30-day outcome. The primary outcome was defined as either “death or survival” within the hospital and the mRS was used to assess disability outcome at 30 days poststroke with scores: 0 = No symptom at all, 1 = No significant disability despite symptoms; able to carry out all usual duties and activities, 2 = Slight disability; unable to carry out all previous activities, but able to look after own affairs without assistance, 3 = Moderate disability, requiring some help, but able to walk without assistance, 4 = Moderately severe disability; unable to walk without assistance unable to attend to own bodily needs without assistance, 5 = Severe disability; bedridden, incontinent and requiring constant nursing care and attention, and 6 = Dead., We defined the poor outcomes as mRS score of 4 through 6.
Frequency distribution and percentages for sites affected by ICH were done. Similarly, the mean and standard deviation of values of ICH volumes were measured. Student's t-test or analysis of variance was used for normally distributed data. Chi-square for the categorical values and correlations were used as appropriate. Logistic regression analysis was used for binary outcomes (alive vs. dead), linear regression for the volume of lesion on mRS outcome. The collected data were analyzed with the Statistical Package for the Social Sciences (SPSS) software version 20.0 (Microsoft® Inc. Chicago, IL, USA. 2011). The statistical level of significance was set at P ≤ 0.05.
| Results|| |
A total of 44 patients who met the inclusion criteria were studied. The mean age was 54.3 ± 16.1 years. There were more 23 (52.3%) female than male patients 21 (47.7%).
The majority of patients had lobar affectation with the parietal lobe (18.5%) being the site most affected, then putamen (12.6%), caudate (11.7%), and the thalamus (9.7%) in that order. The cerebellum was not affected in any of the patients.
Frequency distribution of the sites affected by stroke in patients alive and those dead at 30 days poststroke showed that many of the patients with parietal lobe lesions were noted to have more numbers alive, while most patients with lesions of thalamus, midbrain, pons, and medulla were dead, as shown in [Table 1] and [Figure 3].
|Table 1: Frequency table distribution of sites affected among “alive versus dead” patients|
Click here to view
|Figure 3: Distribution of sites affected among alive and dead patients n= 44|
Click here to view
The mean volume of acute ICH stroke lesion in the study group was 30.8 ± 33.2 ml. The mean volume in patients that were alive and those that were dead at 30 days poststroke were 31.2 ± 33.2 ml and 29.3 ± 34.6 ml, respectively, the Student's t-test analysis was not statistically significant (P = 0.872) [Table 2].
|Table 2: t -test analysis showing relationship between hemorrhagic stroke lesion volume and patient outcome|
Click here to view
Mean volumes of 32.2 ± 35.7 ml and 29.2 ± 30.9 ml were seen in patients with favorable (mRS score 0–3) and unfavorable (mRS score 4–6) outcomes, respectively, the Student's t-test analysis was also not statistically significant (P = 0.774) [Table 2].
Our study revealed that 25% of the study population died within 30 days of diagnosis while 75% survived.
mRS assessment frequency showed that 4 (9.1%) patients had no significant disability despite symptoms, majority 12 (27.3%) had moderately severe disability, while 11 (25.0%) died [Table 3]. Less than half of the patients, 21 of them accounting for 47.7% had favorable outcomes (mRS scale range between 0 and 3) while 23 of them accounting for 52.3% had unfavorable outcome, i.e., mRS scale range between 4 and 6 [Table 4]. An overall mean mRS value of 4.24 was observed.
|Table 3: Frequency distribution of outcome assessment by modified ranking scale|
Click here to view
Logistic regression showed a nonsignificant relationship between volume of hemorrhagic stroke and clinical outcome; dead/alive (P = 0.868; odds ratio = 0.998) [Table 5].
|Table 5: Regression analyses for patient outcome at 30 days postacute hemorrhagic stroke|
Click here to view
The linear regression model between the volume of stroke and the outcome assessment by the modified ranking scale was not significant (P = 0.982) [Table 5].
Only 1 (2.3%) of all the patients recruited in this study had a repeat CT scan. The patient initially presented at 12 h poststroke and had the repeat CT on the 3rd day poststroke insult due to deteriorating level of consciousness. The scan revealed one-third increase in the volume of hemorrhage, increased perilesional edema, and brain swelling.
| Discussion|| |
This study aimed to determine the volume of hemorrhagic stroke lesion and to relate it to the patients' clinical outcome. We found the site most affected in our study to be the parietal lobe 18.5%, followed by temporal lobe 14.6%, putamen 12.6%, caudate 11.7%, and thalamus 9.7%. The pons and medulla were each affected in 4.8% of patients, whereas the cerebellum was not found to be affected among the patients recruited within the study period. The study done in Abuja, North Central Nigeria by Alkali et al. also found lobar hemorrhage to be the most common at 35.1%, followed by the basal ganglia 28.7%, thalami 18.1% and pons 9.6%, similar to the findings in other studies. These findings are at variance with studies done in India by Bhatia et al. where the common sites affected were basal ganglia 70.6%, thalamic 16.8%, brainstem 7%, lobar 4.2%, and cerebella 1.4%. These findings also vary with what was noted in Turkey where the most common site was the thalamus 38% followed by putamen 28%, lobar 16%, pons 6%, and cerebellar 4%. Sarder et al. also found basal ganglia as the most common site 31.3% followed by lobar 25.5%.
The basal ganglia and thalamus are noted to be more commonly affected in previous studies compared to our study. The reasons for variation in the frequencies of the sites affected may be because the underlying causes of hemorrhagic stroke in these different regions of the world are different and remains to be evaluated in further studies.
The volume of ICH is important in patient outcome as shown in these studies.,, Our study found a mean volume of 30.8 ml for ICH with a mean volume of 31.2 ml seen in patients alive and 29.3 ml in patients that had died. The findings of 32.2 ml and 29.2 ml were seen in patients with favorable and unfavorable mRS outcomes, respectively. These findings are similar to the study by Tshikwela and Longo-Mbenza in DR Congo who found ICH volume of >25 ml to be associated with 30 days in-hospital mortality. Bhatia et al., however, found a significantly higher cutoff ICH volume of 42 ml. The mean value of ICH seen in our study falls within the range of values observed in studies done in other parts of the world.,, Our study found mean volume of ICH lesion associated with favorable outcome to be slightly larger than the volume for unfavorable outcome. This may be because, small volumes of hemorrhage observed in sites such as the thalamus and midbrain were seen in patients with poor outcomes and large volumes were seen in sites like the parietal lobe in patients that had good outcome. The midbrain and thalamus are relatively small structures of the brain that serves particularly important functions critical to patient consciousness and survival. Thalamus is the principal sensory relay nucleus which projects impulses from the main sensory pathways onto the cerebral cortex while the midbrain serves important function in movement, auditory, and visual processing. Hemorrhage into these smaller sites will have more severe and devastating effects compared to the lobes in the cerebral hemispheres that are larger structures that are not as critical to patient survival.
The different parts of the brain will respond differently to various types of insult, in a study by Broderick et al., it was observed that the volume of parenchymal hemorrhage that will predict a poor outcome varies with the lesion location. Hemorrhage into an area like the thalamus would probably cause more severe clinical features, compared with if the same volume of lesion is seen in the parietal lobe. In this study, the thalamus was observed to be a site commonly affected in mortality cases compared to patients with lesion in the parietal lobe, the majority of whom were noted to be alive at 30 days poststroke.
Thirty-day mortality rate in our study was 25%, this is lower than what was found other studies,,, this may be because the sites commonly affected in our study were the lobes and most of the patients with lobar affectation had good outcome or due to improved care of these patients in our facility.
In our study, linear regression of stroke volume on mRS outcome showed a nonsignificant relationship, other studies have however found significant relationships between volume of lesion and patient outcome.,,,, This maybe because in our study, large volumes of bleed were found in sites such as the lobes in patients noted to have had good outcomes compared to patients with much less volume of bleed in the thalamus who had poor outcomes. The mean mRS scores in this study was 4.24, this is similar to what was found in the study by Alkali et al. in Abuja where mean mRS score for ICH was 4.21. This further shows that patients with hemorrhagic stroke commonly have poor outcomes. Similarly, logistic regression of the stroke volume on the clinical outcome of the patient, i.e., “alive versus dead” was also not statistically significant. This may be due to the possibility of a larger volume of lesion forming over the ensuing hours/days after the CT had been done from a continuous bleed, leading to poor patient outcome as have been reported by studies in more advanced parts of the world on hematoma expansion following an initial CT scan., This, however, cannot be objectively assessed since only 1 (2.3%) patient had a repeat CT scan.
The shortcomings in our study include the nonexclusion of comorbidities such as hypertension, diabetes, bleeding disorders, and other important clinical conditions that may affect the patient outcome. Specific treatments instituted and complications that arose during hospital stay were also not considered in this study. There may be a need to address the above listed in subsequent studies in this part of sub-Saharan Africa.
| Conclusion|| |
Hemorrhagic stroke volume and lesion location though important in the assessment of patients; however, this study revealed it does not significantly correlate with patient outcome at 1-month poststroke. More studies that involve a larger sample size and repeat CT scans need to be carried out in this region to further evaluate the correlations that may exist between the volume of stroke lesions to patient outcome.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Mackay J, Mensah GA. The Atlas of Heart Disease and Stroke. Geneva: World Health Organization; 2004.
Murray CJ, Lopez AD. Global mortality, disability, and the contribution of risk factors: Global Burden of Disease Study. Lancet 1997;349:1436-42.
Thom T, Haase N, Rosamond W, Howard VJ, Rumsfeld J, Manolio T, et al
. Heart disease and stroke statistics-2006 update: A report from the American Heart Association Statistics Committee and Stroke Statistics Subcommittee. Circulation 2006;113:e85-151.
Obajimi MO, Nyame PK, Jumah KB, Wiredu EK. Spontaneous intracranial haemorrhage: Computed tomographic patterns in Accra. West Afr J Med 2002;21:60-2.
Alkali NH, Bwala SA, Akano AO, Osi-Ogbu O, Alabi P, Ayeni OA. Stroke risk factors, subtypes, and 30-day case fatality in Abuja, Nigeria. Niger Med J 2013;54:129-35.
] [Full text]
Bello TO, Aremu AA, Mustapha AF, Olugbenga-Bello AI. Cranial computerised tomographic assessment of cerebrovascular disease in Osogbo, Nigeria. West Afr J Med 2010;29:323-6.
Zimmerman RD, Maldjian JA, Brun NC, Horvath B, Skolnick BE. Radiologic estimation of hematoma volume in intracerebral hemorrhage trial by CT scan. AJNR Am J Neuroradiol 2006;27:666-70.
Broderick JP, Brott TG, Duldner JE, Tomsick T, Huster G. Volume of intracerebral hemorrhage. A powerful and easy-to-use predictor of 30-day mortality. Stroke 1993;24:987-93.
Brouwers HB, Goldstein JN, Romero JM, Rosand J. Clinical applications of the computed tomography angiography spot sign in acute intracerebral hemorrhage: A review. Stroke 2012;43:3427-32.
Tshikwela ML, Longo-Mbenza B. Spontaneous intracerebral hemorrhage: Clinical and computed tomography findings in predicting in-hospital mortality in Central Africans. J Neurosci Rural Pract 2012;3:115-20.
] [Full text]
Bhatia R, Singh H, Singh S, Padma MV, Prasad K, Tripathi M, et al
. A prospective study of in-hospital mortality and discharge outcome in spontaneous intracerebral hemorrhage. Neurol India 2013;61:244-8.
] [Full text]
Banks JL, Marotta CA. Outcomes validity and reliability of the modified Rankin scale: implications for stroke clinical trials: A literature review and synthesis. Stroke 2007;38:1091-6.
Wilson JT, Hareendran A, Grant M, Baird T, Schulz UG, Muir KW, et al
. Improving the assessment of outcomes in stroke: Use of a structured interview to assign grades on the modified Rankin Scale. Stroke 2002;33:2243-6.
Sarder A, Das B, Mondal K, Kabir M, Basu B, Alam M. 30-days' outcome of haemorrhagic stroke: Correlation between intracerebral hemorrhage score and modified Rankin score. Mediscope. 2018;5:10-4.
Kothari RU, Brott T, Broderick JP, Barsan WG, Sauerbeck LR, Zuccarello M, et al
. The ABCs of measuring intracerebral hemorrhage volumes. Stroke 1996;27:1304-5.
Garg RK, Liebling SM, Maas MB, Nemeth AJ, Russell EJ, Naidech AM. Blood pressure reduction, decreased diffusion on MRI, and outcomes after intracerebral hemorrhage. Stroke 2012;43:67-71.
Kumral E, Ozkaya B, Sagduyu A, Sirin H, Vardarli E, Pehlivan M. The Ege Stroke Registry: A hospital-based study in the Aegean region, Izmir, Turkey. Analysis of 2,000 stroke patients. Cerebrovasc Dis 1998;8:278-88.
Boulouis G, Morotti A, Brouwers HB, Charidimou A, Jessel MJ, Auriel E, et al
. Noncontrast computed tomography hypodensities predict poor outcome in intracerebral hemorrhage patients. Stroke 2016;47:2511-6.
van Asch CJ, Luitse MJ, Rinkel GJ, van der Tweel I, Algra A, Klijn CJ. Incidence, case fatality, and functional outcome of intracerebral haemorrhage over time, according to age, sex, and ethnic origin: A systematic review and meta-analysis. Lancet Neurol 2010;9:167-76.
Rathor MY, Rani MF, Jamalludin AR, Amran M, Shahrin TC, Shah A. Prediction of functional outcome in patients with primary intracerebral hemorrhage by clinical-computed tomographic correlations. J Res Med Sci 2012;17:1056-62.
Brott T, Broderick J, Kothari R, Barsan W, Tomsick T, Sauerbeck L, et al
. Early hemorrhage growth in patients with intracerebral hemorrhage. Stroke 1997;28:1-5.
[Figure 1], [Figure 2], [Figure 3]
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5]