|Year : 2019 | Volume
| Issue : 2 | Page : 113-117
Factors influencing the outcome of spontaneous intracerebral haematoma in a Neurosurgical Hospital in South-East Nigeria
Chika Anele Ndubuisi, Mark Oseghale Okhueleigbe, Tobechi Nwankwo Mbadugha, Kelechi Onyenekeya Ndukuba, Moses Osaodion Inojie, Samuel Chukwunoyerem Ohaegbulam
Department of Neurosurgery, Memfys Hospital, Enugu, Nigeria
|Date of Web Publication||10-Jun-2019|
Dr. Chika Anele Ndubuisi
Memfys Hospital for Neurosurgery, KM 2 Enugu-Onitsha Expressway, P. O. Box 2292, Enugu
Source of Support: None, Conflict of Interest: None
Introduction: Spontaneous intracerebral haemorrhage (SICH) is a major cause of stroke worldwide. SICH management is still challenging, especially in developing countries. This study highlights certain factors affecting outcome of SICH managed in a Nigerian Neurosurgical centre, on a background of the modernisation of the patient care facilities. Materials and Methods: Retrospective analysis of patients managed for SICH at Memfys Hospital for Neurosurgery and Neurology in Enugu from years 2009–2016. All patients had computed tomography or magnetic resonance imaging for diagnosis. Treatment included medical, surgical and intensive care unit (ICU) care. Patients with aneurysmal subarachnoid haemorrhage and trauma were excluded. Factors analysed include age, admission Glasgow Coma Score (GCS), haematoma location, complications encountered during admission, duration of hospital stay and 6-month Glasgow Outcome Score (GOS). Results: There were 66 cases, age range of 21–85 years (mean 57 years). A total of 30 (45.5%) patients were admitted with GCS ≤ 8/15; 63.3% of these died within 6 months. The proportion of mortalities was 63.6% (>70 years) and 35.6% (41–70 years). Most commonly associated complication was chest infection 27 (40.9%), with 56.6% mortality. Common haematoma locations were basal ganglia (43.9%) and lobar haemorrhage (40.9%) with a similar effect on outcome (P = 0.098). Outcomes were GOS 1: (43.9%), GOS 5: (30.3%) and GOS 4: (13.6%). Among 42 (63.3%) admitted to ICU, 25 (59.5%) died, while 11 (26.2%) achieved GOS of ≥ 4 at 6 months. Those discharged between days 11 and 20 had 26.7% mortality while 53.3% were independent. Conclusion: Good admission GCS, absence of chest infections, younger age group are predictors of good outcome following SICH. Anatomical location of haemorrhage alone does not have a significant impact on 6 months' mortality.
Keywords: Factors, intracerebral haemorrhage, outcome, spontaneous
|How to cite this article:|
Ndubuisi CA, Okhueleigbe MO, Mbadugha TN, Ndukuba KO, Inojie MO, Ohaegbulam SC. Factors influencing the outcome of spontaneous intracerebral haematoma in a Neurosurgical Hospital in South-East Nigeria. Niger Postgrad Med J 2019;26:113-7
|How to cite this URL:|
Ndubuisi CA, Okhueleigbe MO, Mbadugha TN, Ndukuba KO, Inojie MO, Ohaegbulam SC. Factors influencing the outcome of spontaneous intracerebral haematoma in a Neurosurgical Hospital in South-East Nigeria. Niger Postgrad Med J [serial online] 2019 [cited 2019 Aug 22];26:113-7. Available from: http://www.npmj.org/text.asp?2019/26/2/113/259913
| Introduction|| |
Spontaneous Intracerebral haematoma (SICH) is an acute onset cerebrovascular event that results from a non-trauma induced bleeding into the brain parenchyma. Often times, this condition is associated with high mortality and significant morbidity among the survivors.,,, The management of SICH is still a challenge, especially in developing countries partly due to delay in presentation, lack of workforce and poor access to critical care.,, These peculiar local factors may further affect the short- and long-term outcomes of SICH management. The past decade has experienced significant improvement in both the armamentarium and quality of care for stroke patients in the study location. Hence, the retrospective review of this nature was deemed necessary to help assess the impact of these improvements on stroke management and outcomes locally. The aim of this study is to highlight certain factors affecting the outcome of SICH managed in a Neurosurgical centre in Nigeria, on a background of the modernisation of the patient care facilities.
| Materials And Methods|| |
It is a retrospective analysis of data of 66 patients managed for SICH at Memfys Hospital for Neurosurgery and Neurology in Enugu, Nigeria, from years 2009–2016. The institution of study has a fully equipped neurointensive care unit, with neurosurgeons, neurologists, intensivist, intensive care unit (ICU) nurses and physical therapists. All the patients had brain computed tomography (CT) scan either before referral or immediately on admission and repeated whenever deemed necessary during treatment. Magnetic resonance imaging (MRI), CT angiography and clotting profile assessment were also done as a part of investigation for aetiology. Decisions for operative interventions versus non-operative care were based on the clinical impressions of the managing team. In general, surgery was indicated in patients presenting with significant haematoma size and low Glasgow Coma Score (GCS); cases with associated significant intraventricular haemorrhage, and/or patients that are not likely to benefit from stand-alone medical treatment. All patients received isotonic fluid based on body weight, anti-seizure prophylaxis, analgesia, mannitol depending on the severity of brain swelling, optimisation of blood pressure, electrolytes and mechanical measures to prevent deep vein thrombosis using the pneumatic compression device and stockings. Patients in coma (GCS < 8/15) were intubated and managed and in the ICU. Patients with aneurysmal subarachnoid haemorrhage and trauma-induced ICH were excluded. Data were analysed using descriptive and inferential statistics. Outcomes were assessed at 6 months using the Glasgow Outcome Score (GOS). Factors analysed include the age of patient, admission GCS, haematoma location, complications encountered during admission, duration of stay in the ICU and total hospital stay. Intracranial pressure monitoring was not done.
All procedures in this study involving human participants were performed in accordance with the ethical standards of the institutional research committee and with the 1975 Declaration of Helsinki and its later amendments.
| Results|| |
The mean age was 57 years. Most cases, 59 patients (89.4%) were referred and none presented within 24 h of the onset of symptom. Majority of the cases, 45 patients (68.2%) were between the fifth and seventh decades of life, but the proportion of the mortalities were 63.6% (>70 years), 60% (21–40 years) and 35.6% (41–70 years). Patients with GOS of 1 constituted 43.9%, followed by GOS of 5 in 30.3% and GOS of 4 in 13.6% of cases [Table 1].
|Table 1: Age of patient analysed against the Glasgow Outcome Score at 6 months|
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A total of 30 patients (45.5%) were admitted with GCS ≤ 8/15 and 63.3% of these cases had GOS of 1 at 6 months. The cases admitted with GCS of 9–12 were 14 (24.2%), out of which 6 (37.5%) were GOS of 1 at 6 months and 4 (25%) had a score of 5. Furthermore, 20 cases (30.3%) were admitted with a score of 13–15 and 4 (20%) of these died while 14 (70%) had a score of 5 [Table 2].
|Table 2: Admission Glasgow Coma Score analysed against the Glasgow Outcome Score|
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The most common associated complication was chest infection observed in 27 (40.9%), out of which 15 (56.6%) died. Other complications included pulmonary embolism (3), renal failure, adrenal insufficiency, functional intestinal obstruction and cardiac arrest. A total of 21 cases out of the 29 (72.4%) that had GOS of 1 at 6 months had a complication in the line of management [Table 3].
|Table 3: Complications observed during treatment and 6 months Glasgow Outcome Score|
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The most common haematoma location was the basal ganglia 43.9% out of which 14 (48.3%) died and 8 (27.6%) attained GOS of 5 at 6 months. Lobar haemorrhage represented 27 (40.9%) of the cases with 11 (40.7%) attaining GOS of 5 at 6 months while 12 (44.4%) were dead at 6 months.
Only four cases of cerebellar haemorrhage and two cases of brainstem haemorrhage were encountered. All cases of brainstem haemorrhage died [Table 4].
|Table 4: Haematoma location analysed against the Glasgow Outcome Score at 6 months|
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Among the 42 (63.3%) of cases that required ICU care, 25 (59.5%) died within 6 months of the event while 11 (26.2%) achieved GOS of 4 and above at 6 months [Table 5]. [Table 6] show a summary of the interventions received by the patients while on admission.
|Table 5: Length of intensive care unit stay against Glasgow Outcome Score at 6 months|
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Of the 46 (69.6%) patients discharged home within 3 weeks, 21 (45.6%) patients were independent at 6 months. However, among those discharged within 10 days, 58.1% died within 6 months, while 32.3% were independent at 6 months. Those discharged between days 11 and 20 had 26.7% mortality while 53.3% were independent. Among those discharged after 3rd week, 35% died, while 8 (40%) were independent at 6 months' post-event [Table 7].
| Discussion|| |
SICH appears to be most common in the middle age group in the study environment and seems to occur at a younger age range compared to other parts of the world.,,,, Considering the very high proportion of basal ganglia haemorrhage from this study, a definite link with hypertension as the underlying cause of SICH is very strong in the study environment. Africans are prone to primary hypertension from previous studies, but the peak age frequency observed from the current study involves the middle age group as well as the productive workforce of the society. This may be a reflection of the low level of preventive health-seeking behaviour in low-income earning countries. This therefore calls for enhanced community-based awareness programme as a means of primary prevention and early management of the known risk factors for spontaneous ICH.,,,
Nigeria has very high mortality rate from strokes generally and SICH accounts for a significant proportion of this mortality.,, The overall mortality for SICH in this study of 43.9% at 6 months underscores the dangerous nature of this pathology, although 43.9% achieved independence (GOS 4 and 5) at 6 months. Interestingly, the mortality figure from this study is much lower than the findings from previous studies that reported a hospital discharge mortality of 62%–77% for stroke generally, and unfortunately, most of these deaths occur in the acute phase. The improved mortality result of this study could be a reflection of the level of critical care available in the study centre. This result shows that with proper early care and follow-up of patients with SICH, good long-term outcome can be achieved, bearing in mind that almost 50% of all the cases managed were admitted with a GCS of 8 or below and more than two-thirds of all the cases required ICU care at one time or another during in-hospital admission. However, the high mortality rate observed among the elderly is expected as it reflects the impact of comorbidities and impaired physiological reserve as age advances.
As observed in this study, low admission GCS was a predictor of mortality at 6 months. This suggests that the severity of illness was a predictor of the final outcome. Secondary brain injury may also partly explain the low admission GCS considering that more than 80% of these cases were referred from another facility and none was admitted within 24 h of the event. This underscores the need to update general practitioners on the potential adverse effect of secondary brain injury on outcome of SICH. As such, patients that were critically ill to require ICU admission had higher mortality. Similarly, as expected, patients who eventually required haematoma evacuation or external ventricular drainage surgery had slightly higher mortality. However, in this study, surgery was indicated for cases with significant haematoma volume that present with low GCS, cases with associated significant intraventricular haemorrhage, and/or patients that were not likely to benefit from stand-alone medical treatment. This reflects the impact of the big haematoma and extent of the associated intraventricular haemorrhage on outcome.,,
Complications are known to worsen outcomes at discharge of stroke patients, vis-à-vis morbidity and mortality.,, Furthermore, the current study identified associated chest infections and pulmonary embolism as significant factors influencing long-term mortality even after discharge in SICH. This strengthens the need to enforce early chest physiotherapy, aggressive routine chest examination and investigation as part of the protocol of care in these patients even at discharge. In addition, necessary precautions should be taken to make gag reflex and plain water swallowing-test standard protocols in stroke patients before the commencement of oral feeding as a means of preventing pneumonitis.
Apart from brain stem haemorrhage with 100% mortality, this study did not find any significant effect of haematoma-location alone on the eventual long-term outcome. This suggested that beyond the ICH location, other factors such as admission-GCS, presence of associated intraventricular extension, haematoma volume as well as the presence of comorbidities and other complications may have a collective influence on longer-term outcome. Unfortunately, the retrospective nature of this study did not allow these factors to be analysed further.
In addition, this study suggests that in-hospital admission duration of 2–3 weeks offers better long-term outcome. Patients discharged home earlier had a worst outcome due to delayed deterioration from complications. On the other hand, patients admitted to the hospital beyond 3 weeks had a poor outcome at 6 months. Although other factors may have contributed, this could be related to the risk of hospital-acquired infection and other morbidities of recumbence including deep vein thrombosis and eventual pulmonary embolism, especially among the elderly.
| Conclusion|| |
Good admission GCS, absence of chest infections as well as younger age group are predictors of good outcome following SICH. Anatomical location of haemorrhage alone does not seem to have a significant impact on 6-month mortality. Overall outcome in this study is modest, and an improvement of previous studies and this is a reflection of the level of critical care offered to patients at the initial presentation.
Authors would like to acknowledge the management of Memfys Hospital for supporting the study.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Flaherty ML, Haverbusch M, Sekar P, Kissela B, Kleindorfer D, Moomaw CJ, et al.
Long-term mortality after intracerebral hemorrhage. Neurology 2006;66:1182-6.
Qureshi AI, Tuhrim S, Broderick JP, Batjer HH, Hondo H, Hanley DF. Spontaneous intracerebral hemorrhage. N Engl J Med 2001;344:1450-60.
Mozaffarian D, Benjamin EJ, Go AS, Arnett DK, Blaha MJ, Cushman M, et al.
Heart disease and stroke statistics-2015 update: A report from the American Heart Association. Circulation 2015;131:e29-322.
Steiner T, Al-Shahi Salman R, Beer R, Christensen H, Cordonnier C, Csiba L, et al.
European Stroke Organisation (ESO) guidelines for the management of spontaneous intracerebral hemorrhage. Int J Stroke 2014;9:840-55.
Sagui E. Stroke in Sub-Saharan Africa. Med Trop (Mars) 2007;67:596-600.
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.
Feigin VL, Lawes CM, Bennett DA, Barker-Collo SL, Parag V. Worldwide stroke incidence and early case fatality reported in 56 population-based studies: A systematic review. Lancet Neurol 2009;8:355-69.
Ekeh B, Ogunniyi A, Isamade E, Ekrikpo U. Stroke mortality and its predictors in a Nigerian teaching hospital. Afr Health Sci 2015;15:74-81.
Ezeala-Adikaibe BA, Ohaegbulam SC. Pattern and location of intracerebral hemorrhage in Enugu, South-East Nigeria: A review of 139 cases. Niger J Clin Pract 2016;19:332-5.
] [Full text]
Qiu L, Upadhyaya T, See AA, Ng YP, Kon Kam King N. Incidence of recurrent intracerebral hemorrhages in a multiethnic South Asian population. J Stroke Cerebrovasc Dis 2017;26:666-72.
Jolink WM, Klijn CJ, Brouwers PJ, Kappelle LJ, Vaartjes I. Time trends in incidence, case fatality, and mortality of intracerebral hemorrhage. Neurology 2015;85:1318-24.
Stein M, Misselwitz B, Hamann GF, Scharbrodt W, Schummer DI, Oertel MF. Intracerebral hemorrhage in the very old: Future demographic trends of an aging population. Stroke 2012;43:1126-8.
Connor MD, Walker R, Modi G, Warlow CP. Burden of stroke in black populations in Sub-Saharan Africa. Lancet Neurol 2007;6:269-78.
Kissela B, Schneider A, Kleindorfer D, Khoury J, Miller R, Alwell K, et al.
Stroke in a biracial population: The excess burden of stroke among blacks. Stroke 2004;35:426-31.
Arima H, Chalmers J, Woodward M, Anderson C, Rodgers A, Davis S, et al.
Lower target blood pressures are safe and effective for the prevention of recurrent stroke: The PROGRESS trial. J Hypertens 2006;24:1201-8.
Juvela S. Risk factors for impaired outcome after spontaneous intracerebral hemorrhage. Arch Neurol 1995;52:1193-200.
Juvela S, Hillbom M, Palomäki H. Risk factors for spontaneous intracerebral hemorrhage. Stroke 1995;26:1558-64.
Thrift AG, McNeil JJ, Forbes A, Donnan GA. Risk factors for cerebral hemorrhage in the era of well-controlled hypertension. Melbourne risk factor study (MERFS) group. Stroke 1996;27:2020-5.
Komolafe MA, Ogunlade O, Komolafe EO. Stroke mortality in a teaching hospital in South Western Nigeria. Trop Doct 2007;37:186-8.
Ogun SA. Acute stroke mortality at LUTH. Niger J Clin Pract 2003;5:38-41.
Wahab KW, Okubadejo NU, Ojini FI, Danesi MA. Predictors of short-term intra-hospital case fatality following first-ever acute ischaemic stroke in Nigerians. J Coll Physicians Surg Pak 2008;18:755-8.
Odusote K. Management of stroke. Nig Med Pract 1996;32:36-62.
Ojini FI, Ogun SA, Danesi MA. Thirty days case fatality of stroke at LUTH. Nig Q J Hosp Med 2004;14:64-6.
Njoku CH, Adeloju AB. Stroke in Sokoto, Nigeria: A five year retrospective study. Ann Afr Med 2004;3:73-6.
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.
Hallevi H, Albright KC, Aronowski J, Barreto AD, Martin-Schild S, Khaja AM, et al.
Intraventricular hemorrhage: Anatomic relationships and clinical implications. Neurology 2008;70:848-52.
Tuhrim S, Horowitz DR, Sacher M, Godbold JH. Volume of ventricular blood is an important determinant of outcome in supratentorial intracerebral hemorrhage. Crit Care Med 1999;27:617-21.
Balami JS, Buchan AM. Complications of intracerebral haemorrhage. Lancet Neurol 2012;11:101-18.
Balami JS, Chen R, Grunwald IQ, Buchan AN. Neurological complication of acute ischaemic stroke. Lancet Neurolo 2011;10:357-71.
Weimar C, Mieck T, Buchthal J, Ehrenfeld CE, Schmid E, Diener HC, et al.
Neurologic worsening during the acute phase of ischemic stroke. Arch Neurol 2005;62:393-7.
Sheng WH, Chie WC, Chen YC, Hung CC, Wang JT, Chang SC. Impact of nosocomial infections on medical costs, hospital stay, and outcome in hospitalized patients. J Formos Med Assoc 2005;104:318-26.
Al Otair H, Chaudhry M, Shaikh S, Bahammam A. Outcome of patients with pulmonary embolism admitted to the intensive care unit. Ann Thorac Med 2009;4:13-6.
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6], [Table 7]