Materials and Methods This retrospective study, approved by a local institutional review board with written informed consent waived, recruited 106 patients diagnosed as ICH by non-enhanced computed tomography study. The hemorrhagic shape, hematoma size measured by computer-assisted volumetric analysis (CAVA) and estimated by ABC/2 formula, ICH score and GCS score was examined. The predicting performance of 30-day mortality of the aforementioned variables was evaluated.
Statistical analysis was performed using Kolmogorov-Smirnov tests, paired t test, nonparametric test, linear regression analysis, and binary logistic regression. The receiver operating characteristics curves were plotted and areas under curve (AUC) were calculated for 30-day mortality.
A P value less than 0.05 was considered as statistically significant. Citation: Wang C-W, Liu Y-J, Lee Y-H, Hueng D-Y, Fan H-C, Yang F-C, et al.
(2014) Hematoma Shape, Hematoma Size, Glasgow Coma Scale Score and ICH Score: Which Predicts the 30-Day Mortality Better for Intracerebral Hematoma? PLoS ONE 9(7): e102326. Editor: Jon Sherman, The George Washington University, United States of America Received: April 27, 2014; Accepted: June 16, 2014; Published: July 16, 2014 Copyright: © 2014 Wang et al. This is an open-access article distributed under the terms of the, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
Data Availability: The authors confirm that all data underlying the findings are fully available without restriction. All relevant data are within the paper and its Supporting Information files.
Funding: The corresponding author (Chun-Jung Juan) is receiving financial support from National Science Council (NSC 101-2314-B-016-031-MY2), Taiwan, R.O.C. For participating WFNRS 2014, XXth Symposium Neuroradiologicum and presenting this work in part. The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.
Competing interests: The authors have declared that no competing interests exist. Introduction Hematoma shape has been recently reported to be related to hematoma size and hematoma growth of intracerebral hematomas (ICH). An irregular shape of hematoma has been linked to a larger hematoma size and a higher risk of hematoma growth, which in turns is related to a poorer outcome. Whether the hematoma shape predicts the 30-day mortality for ICH patients is of clinical interest and importance.
It has not been reported in this regard, however. Hematoma size is an important prognostic factor predicting the mortality of ICH patients –. The hematoma size could be either estimated simply by the ABC/2 formula or measured by computed assisted volumetric analysis (CAVA).
Although the ABC/2 formula has been used to estimate the hematoma size for predicting clinical outcomes, it tends to overestimate the hematoma size as compared to the CAVA by 2% to 32% –. It remains unanswered whether the estimation error of hematoma size leads to imprecision in predicting the 30-day mortality of ICH patients. By weighting Glasgow coma scale (GCS) score, age, hematoma size, origin of ICH, and ventricular involvement, the ICH score has been raised as a simple method in predicting 30-day mortality. However, the performance of the ICH score in predicting the 30-day mortality varies in different studies, with the areas under the curve (AUC) in the receiver operating characteristics (ROC) curves ranging from 0.72 to 0.92 –. Whether the ICH score predicts the 30-day mortality better than the hematoma shape, hematoma size, and GCS score has not been assessed in a single study yet. In this study, we aimed to investigate the performance of hematoma shape, hematoma size, GCS score, and ICH score in predicting the 30-day mortality for ICH patients. In the meanwhile, we also examined the influence of the estimation error of hematoma size on the prediction of 30-day mortality.
Subjects Brain computed tomography (CT) images of 137 patients, who were admitted to our hospital under the diagnosis of acute intracerebral hemorrhage during a period of 10 months, were initially reviewed. All patients received non-enhanced CT with an interval between the time of CT study and the onset of symptoms within 24 hours. Twenty-three patients were excluded based on the following exclusion criteria including concurrent subarachnoid hemorrhage (N = 4), subdural hematoma (N = 1), brain tumor (N = 2), acute ischemic infarction with hemorrhagic transformation (N = 3), old ischemic infarction (N = 5), old hemorrhage (N = 2), severe motion artifact (N = 2), beam hardening artifact (N = 1), and recent intracranial operations (N = 3). Eight patients who had a ventricular shunting catheter seen on CT images were also excluded. Finally, 106 patients (62.8±15.3 years, M: F = 1.9: 1) with intracerebral hematomas were recruited in this study.
The clinical data (gender, age, GCS score, blood pressure, pulse rate, respiratory rate, and body temperature), clinical history (hypertension, diabetes mellitus, ischemic heart disease, and congestive heart failure), and laboratory data (blood sugar, white blood cell count, hemoglobin, platelet count, and international normalized ratio) obtained on admission were recorded. To assess the 30-day mortality, the survival statuses of patients were confirmed based on the medical records not only on admission but also in outpatient follow up. Imaging data acquisition Non-enhanced CT images were acquired using single or multi-row spiral CT scanners (Somatom Plus 4, Simens, Erlangen, Germany; PQ6000, Picker International Inc., Highland Heights, Ohio, U.S.A.; Brilliance, Philips Medical System, Cleveland, Ohio, U.S.A), which were compatible with the regulation of digital imaging and communications in medicine (DICOM). Imaging parameters included 140 kV, 170 mA, slice thickness of 5 mm, slice gap of 0 mm, field of view of 210 mm, matrix size of 512×512 and gantry angulation being parallel to the supraorbitomeatal line. Qualitative analysis of hematoma shape The hematoma shape was independently evaluated by two neuroradiologists (observer 1, C.W.W.; observer 2, C.J.J.) using a binary scoring system, which was first introduced here in this study. A score of 0 represented a regular hematoma shape, including a roundish or ellipsoid hematoma with smooth margin. A score of 1 represented an irregular hematoma shape, including a pleomorphic contour of hematoma , several adjacent but separated hematomas and multicentric hematomas.
Data analysis and volumetric analysis of ICH The DICOM data were firstly stored in the picture archiving and communication system (PACS) immediately after acquisition. Maximal diameters of the hemorrhage in three orthogonal directions were measured on a PACS viewer (EBM Technologies Inc., Taipei, Taiwan) by a 10-year experienced neuroradiologist (C.J.J.) for calculating the hemorrhagic size using the ABC/2 method as described by Kothari et al.CT image data were also digitally transferred to a personal computer for hemorrhagic volumetric analysis processed with the software programs developed (by Y.J.L.) using Matlab (MathWorks, Natick, MA, U.S.A.). All image processing, region-of-interest drawing, and data analyses were performed by a single author (C.J.J.). The data processing included histogram analysis of a large region of interest (ROI), threshold setting for the hemorrhage, manually polygonal ROI drawing, voxel counting and size calculation slice-by-slice, and finally summing hemorrhagic size of each slice. Thresholds with a lower level of 40∼45 HU and an upper level of 100∼150 HU were adjusted as a mask for the hemorrhage as described by Strik et al. Small polygonal ROIs encompassing the hyperdense hemorrhage were drawn to avoid the contamination of noises from the adjacent gray matter. The hematoma size was calculated by the equation.
Statistical analysis Statistical analyses were performed using SPSS Version 16.0 software (SPSS Inc, Chicago, III) and MedCalc Version 13.0 (MedCalc Software Inc, Ostend Belgium). The interobserver reliability was examined by linearly weighted kappa statistics. The normality of parameters was examined by using Kolmogorov-Smirnov tests. Cross-tabulations were analyzed using Fisher exact test. Paired student t test was used for 2-group comparisons regarding parameters with normal distribution, while nonparametric tests (Wilcoxon signed rank tests and McNemar tests) were used for 2-group comparisons regarding parameters without normal distribution. Linear regression analysis was used to assess the relationship between the hematoma size estimated by ABC/2 formula and the hematoma size measured by CAVA. Binary logistic regression was applied to examine the relationships between the independent variables (shape, size, GCS score, age, presence of IVH, presence of infratentorial location) and dependent variable (30-day mortality).
The nonparametric receiver operating characteristics (ROC) curves were plotted and areas under curve (AUC) were calculated for 30-day mortality. A P value less than 0.05 was considered as statistically significant. Results Of 106 patients, 77 (73%) had a history of hypertension, 21 (20%) had type II diabetes mellitus, four (3.8%) had impaired coagulation function with international normalized ratio (INR) ≧ 1.5, and 47 (44.3%) had simultaneous IVH.
The hematomas were located supratentorially in 93 (87.7%) patients, located infratentorially in 13 (12.2%) patients. The overall 30-day mortality was 15.1% (16 of 103). The demographic and clinical characteristics of our study were summarized in.
Factors that were significantly associated with outcomes in 30 days included platelet count ( P = 0.003), hematoma shape ( P = 0.003), hematoma size ( P = 0.009), presence of IVH ( P. Shape of hematomas: regular hematomas versus irregular hematomas Hematomas were judged as regular in 62 (58.5%) patients and irregular in 44 (41.5%) patients by observer 1, while regular in 61 (57.5%) patients and irregular in 45 (42.5%) patients by observer 2. Ten patients whose hematomas were judged as regular by observer 1 were considered as irregular by observer 2. On the other hand, 8 patients whose hematomas were judged as irregular by observer 1 were considered as regular by observer 2.
Linear weighted Kappa statistics showed a weighted kappa value of 0.632 with a confidence level from 0.483 to 0.782, suggestive of substantial agreement. The differences between regular hematomas and irregular hematomas were listed in. The irregular group did not differ from regular group in gender ( P = 1) and age ( P = 0.92). Regarding the vital signs, the irregular group had a significantly higher diastolic pressure ( P = 0.021) and higher pulse rate ( P = 0.022) than the regular group. The laboratory data showed that the irregular group had a significantly higher WBC count ( P = 0.003) than the regular group. With respect to the consciousness, the irregular group had a significantly lower GCS score than regular group ( P. Size of hematoma: ABC/2 formula versus CAVA The overall hematoma size estimated by the ABC/2 formula (38.7±51.0 ml) was significantly higher than that measured by the CAVA (27.8±35.6 ml) (P.
Receiver operating characteristic (ROC) curves Comparison of ROC curves in predicting the 30-day mortality by GCS, ICH scores, ICH size, and ICH shape was graphically demonstrated. The predicting performances of the variables were summarized in. The variables of hematoma shape, hematoma size, ICH score, and GCS score all significantly predicted the 30-day mortality with the AUC of 0.692 ( P = 0.0018), 0.715∼0.786 ( P≤0.0008), 0.877∼0.882 ( P. Discussion ICH shape is getting increasing attention recently. Compared to the regular hematoma, the irregular hematoma has been related to a higher risk of hematoma growth, which in turns serves a predictor of poor outcome and a determinant of mortality.
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