Skip to main content

Advertisement

SpringerLink
Log in

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

  • Clinical Article - Vascular
  • Published:
Acta Neurochirurgica Aims and scope Submit manuscript

Abstract

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.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Fig. 1
Fig. 2

Similar content being viewed by others

References

  1. Alqadri SL, Qureshi AI (2012) Management of acute hypertensive response in patients with intracerebral hemorrhage. Curr Atheroscler Rep 14:322–327

    Article  PubMed  Google Scholar 

  2. Arac A, Blanchard V, Lee M, Steinberg GK (2009) Assessment of outcome following decompressive craniectomy for malignant middle cerebral artery infarction in patients older than 60 years of age. Neurosurg Focus 26:E3

    Article  PubMed  Google Scholar 

  3. Arboix A, Rodriguez-Aguilar R, Oliveres M, Comes E, Garcia-Eroles L, Massons J (2007) Thalamic haemorrhage vs internal capsule-basal ganglia haemorrhage: clinical profile and predictors of in-hospital mortality. BMC Neurol 7:32

    Article  PubMed  Google Scholar 

  4. Balami JS, Buchan AM (2012) Complications of intracerebral haemorrhage. Lancet Neurol 11:101–118

    Article  PubMed  Google Scholar 

  5. Broderick JP, Brott TG, Duldner JE, Tomsick T, Huster G (1993) Volume of intracerebral hemorrhage. A powerful and easy-to-use predictor of 30-day mortality. Stroke 24:987–993

    Article  PubMed  CAS  Google Scholar 

  6. Cesarini KG, Hardemark HG, Persson L (1999) Improved survival after aneurysmal subarachnoid hemorrhage: review of case management during a 12-year period. J Neurosurg 90:664–672

    Article  PubMed  CAS  Google Scholar 

  7. Chen CC, Liu CL, Tung YN, Lee HC, Chuang HC, Lin SZ, Cho DY (2011) Endoscopic surgery for intraventricular hemorrhage (IVH) caused by thalamic hemorrhage: comparisons of endoscopic surgery and external ventricular drainage (EVD) surgery. World Neurosurg 75:264–268

    Article  PubMed  Google Scholar 

  8. Chen M, Wang Q, Zhu W, Yin Q, Ma M, Fan X, Li Y, Ni G, Liu C, Liu W, Zhang R, Xu G, Liu X (2012) Stereotactic aspiration plus subsequent thrombolysis for moderate thalamic hemorrhage. World Neurosurg 77:122–129

    Article  PubMed  Google Scholar 

  9. Chen YC, Wu YR, Hsu WC, Chen CM, Lee TH, Chen ST (2006) Basal Ganglia-thalamic hemorrhage in young adults: a hospital-based study. Cerebrovasc Dis 22:33–39

    Article  PubMed  CAS  Google Scholar 

  10. Chui C, Howng SL (1989) Thalamic hemorrhage: a computed tomographic-clinical study in prognostic prediction. Gaoxiong Yi Xue Ke Xue Za Zhi 5:231–240

    PubMed  CAS  Google Scholar 

  11. Chung CS, Caplan LR, Han W, Pessin MS, Lee KH, Kim JM (1996) Thalamic haemorrhage. Brain 119(Pt 6):1873–1886

    Article  PubMed  Google Scholar 

  12. Daverat P, Castel JP, Dartigues JF, Orgogozo JM (1991) Death and functional outcome after spontaneous intracerebral hemorrhage. A prospective study of 166 cases using multivariate analysis. Stroke 22:1–6

    Article  PubMed  CAS  Google Scholar 

  13. de Haan R, Limburg M, Bossuyt P, van der Meulen J, Aaronson N (1995) The clinical meaning of Rankin ‘handicap’ grades after stroke. Stroke 26:2027–2030

    Article  PubMed  Google Scholar 

  14. Delcourt C, Huang Y, Wang J, Heeley E, Lindley R, Stapf C, Tzourio C, Arima H, Parsons M, Sun J, Neal B, Chalmers J, Anderson C (2010) The second (main) phase of an open, randomised, multicentre study to investigate the effectiveness of an intensive blood pressure reduction in acute cerebral haemorrhage trial (INTERACT2). Int J Stroke 5:110–116

    Article  PubMed  CAS  Google Scholar 

  15. Diringer MN, Edwards DF (2001) Admission to a neurologic/neurosurgical intensive care unit is associated with reduced mortality rate after intracerebral hemorrhage. Crit Care Med 29:635–640

    Article  PubMed  CAS  Google Scholar 

  16. Elf K, Nilsson P, Enblad P (2002) Outcome after traumatic brain injury improved by an organized secondary insult program and standardized neurointensive care. Crit Care Med 30:2129–2134

    Article  PubMed  Google Scholar 

  17. Fewel ME, Thompson BG Jr, Hoff JT (2003) Spontaneous intracerebral hemorrhage: a review. Neurosurg Focus 15:E1

    PubMed  Google Scholar 

  18. Hijdra A, Brouwers PJ, Vermeulen M, van Gijn J (1990) Grading the amount of blood on computed tomograms after subarachnoid hemorrhage. Stroke 21:1156–1161

    Article  PubMed  CAS  Google Scholar 

  19. Hokama M, Tanizaki Y, Mastuo K, Hongo K, Kobayashi S (1993) Indications and limitations for CT-guided stereotaxic surgery of hypertensive intracerebral haemorrhage, based on the analysis of postoperative complications and poor ability of daily living in 158 cases. Acta Neurochir (Wien) 125:27–33

    Article  CAS  Google Scholar 

  20. Honda E, Hayashi T, Shimamoto H, Hara K, Sato Y (1987) A comparison between stereotaxic operation and conservative therapy for thalamic hemorrhage. Kurume Med J 34:9–18

    Article  PubMed  CAS  Google Scholar 

  21. Howells T, Elf K, Jones PA, Ronne-Engstrom E, Piper I, Nilsson P, Andrews P, Enblad P (2005) Pressure reactivity as a guide in the treatment of cerebral perfusion pressure in patients with brain trauma. J Neurosurg 102:311–317

    Article  PubMed  Google Scholar 

  22. Huttner HB, Kohrmann M, Berger C, Georgiadis D, Schwab S (2006) Influence of intraventricular hemorrhage and occlusive hydrocephalus on the long-term outcome of treated patients with basal ganglia hemorrhage: a case–control study. J Neurosurg 105:412–417

    Article  PubMed  Google Scholar 

  23. Johansson M, Cesarini KG, Contant CF, Persson L, Enblad P (2001) Changes in intervention and outcome in elderly patients with subarachnoid hemorrhage. Stroke 32:2845–2949

    Article  PubMed  CAS  Google Scholar 

  24. Juvela S (1996) Prevalence of risk factors in spontaneous intracerebral hemorrhage and aneurysmal subarachnoid hemorrhage. Arch Neurol 53:734–740

    Article  PubMed  CAS  Google Scholar 

  25. Kumral E, Kocaer T, Ertubey NO, Kumral K (1995) Thalamic hemorrhage. A prospective study of 100 patients. Stroke 26:964–970

    Article  PubMed  CAS  Google Scholar 

  26. Kurtsoy A, Oktem IS, Koc RK, Menku A, Akdemir H, Tucer B (2001) Surgical treatment of thalamic hematomas via the contralateral transcallosal approach. Neurosurg Rev 24:108–113

    Article  PubMed  CAS  Google Scholar 

  27. Kwak R, Kadoya S, Suzuki T (1983) Factors affecting the prognosis in thalamic hemorrhage. Stroke 14:493–500

    Article  PubMed  CAS  Google Scholar 

  28. Lampl Y, Gilad R, Eshel Y, Sarova-Pinhas I (1995) Neurological and functional outcome in patients with supratentorial hemorrhages. A prospective study. Stroke 26:2249–2253

    Article  PubMed  CAS  Google Scholar 

  29. Marklund N, Enblad P, Hårdemark H-G (1999) Thalamic hemorrhage- Impact of neurosurgical treatment on prognosis. 8th European Stroke Conference Venice, Italy

  30. Matsumoto K, Hondo H (1984) CT-guided stereotaxic evacuation of hypertensive intracerebral hematomas. J Neurosurg 61:440–448

    Article  PubMed  CAS  Google Scholar 

  31. Mirski MA, Chang CW, Cowan R (2001) Impact of a neuroscience intensive care unit on neurosurgical patient outcomes and cost of care: evidence-based support for an intensivist-directed specialty ICU model of care. J Neurosurg Anesthesiol 13:83–92

    Article  PubMed  CAS  Google Scholar 

  32. Morgan T, Zuccarello M, Narayan R, Keyl P, Lane K, Hanley D (2008) Preliminary findings of the minimally-invasive surgery plus rtPA for intracerebral hemorrhage evacuation (MISTIE) clinical trial. Acta Neurochir Suppl 105:147–151

    Article  PubMed  CAS  Google Scholar 

  33. Mori S, Sadoshima S, Ibayashi S, Fujishima M, Iino K (1995) Impact of thalamic hematoma on six-month mortality and motor and cognitive functional outcome. Stroke 26:620–626

    Article  PubMed  CAS  Google Scholar 

  34. Naff NJ, Carhuapoma JR, Williams MA, Bhardwaj A, Ulatowski JA, Bederson J, Bullock R, Schmutzhard E, Pfausler B, Keyl PM, Tuhrim S, Hanley DF (2000) Treatment of intraventricular hemorrhage with urokinase: effects on 30-day survival. Stroke 31:841–847

    Article  PubMed  CAS  Google Scholar 

  35. Naff NJ, Williams MA, Keyl PM, Tuhrim S, Ross Bullock M, Mayer SA, Coplin W, Narayan RK, Haines S, Cruz-Flores S, Zuccarello M, Brock D, Awad I, Ziai WC, Marmarou A, Rhoney D, McBee N, Lane K, Hanley DF (2011) Low-dose recombinant tissue-type plasminogen activator enchances clot resolution in brain hemorrhage. The intraventricular hemorrhage thrombolysis trial. Stroke 42:3009–3116

    Article  PubMed  CAS  Google Scholar 

  36. Nieuwkamp DJ, de Gans K, Rinkel GJ, Algra A (2000) Treatment and outcome of severe intraventricular extension in patients with subarachnoid or intracerebral hemorrhage: a systematic review of the literature. J Neurol 247:117–121

    Article  PubMed  CAS  Google Scholar 

  37. Niizuma H, Yonemitsu T, Jokura H, Nakasato N, Suzuki J, Yoshimoto T (1990) Stereotactic aspiration of thalamic hematoma. Overall results of 75 aspirated and 70 nonaspirated cases. Stereotact Funct Neurosurg 54–55:438–444

    Article  PubMed  Google Scholar 

  38. Nishikawa T, Ueba T, Kajiwara M, Miyamatsu N, Yamashita K (2009) A priority treatment of the intraventricular hemorrhage (IVH) should be performed in the patients suffering intracerebral hemorrhage with large IVH. Clin Neurol Neurosurg 111:450–453

    Article  PubMed  Google Scholar 

  39. Nomura S, Ishihara H, Yoneda H, Shirao S, Shinoyama M, Suzuki M (2010) Neuroendoscopic evacuation of intraventricular hematoma associated with thalamic hemorrhage to shorten the duration of external ventricular drainage. Surg Neurol Int 1:43. http://www.surgicalneurologyint.com/text.asp?2010/1/1/43/68342

  40. Patel HC, Menon DK, Tebbs S, Hawker R, Hutchinson PJ, Kirkpatrick PJ (2002) Specialist neurocritical care and outcome from head injury. Intensive Care Med 28:547–553

    Article  PubMed  Google Scholar 

  41. Phan TG, Koh M, Vierkant RA, Wijdicks EF (2000) Hydrocephalus is a determinant of early mortality in putaminal hemorrhage. Stroke 31:2157–2162

    Article  PubMed  CAS  Google Scholar 

  42. Piepgras U, Rieger P (1981) Thalamic bleeding: diagnosis, course and prognosis. Neuroradiology 22:85–91

    Article  PubMed  CAS  Google Scholar 

  43. Qureshi A, Palesch Y (2012) Expansion of recruitment time window in antihypertensive treatment of acute cerebral hemorrhage (ATACH) II trial. J Vasc Interv Neurol 5:6–9

    Google Scholar 

  44. Qureshi AI, Tuhrim S, Broderick JP, Batjer HH, Hondo H, Hanley DF (2001) Spontaneous intracerebral hemorrhage. N Engl J Med 344:1450–1460

    Article  PubMed  CAS  Google Scholar 

  45. Rangel-Castillo L, Robertson CS (2006) Management of intracranial hypertension. Crit Care Clin 22:713–732, abstract ix

    Article  PubMed  CAS  Google Scholar 

  46. Rincon F, Mayer SA (2007) Neurocritical care: a distinct discipline? Curr Opin Crit Care 13:115–121

    Article  PubMed  Google Scholar 

  47. Rydvall A, Lynoe N (2008) Withholding and withdrawing life-sustaining treatment: a comparative study of the ethical reasoning of physicians and the general public. Crit Care 12:R13

    Article  PubMed  Google Scholar 

  48. Ryttlefors M, Howells T, Ronne-Engstrom E, Nilsson P, Enblad P (2010) Neurointensive care is justified in elderly patients with severe subarachnoid hemorrhage–an outcome and secondary insults study. Acta Neurochir (Wien) 152:241–249, discussion 249

    Article  Google Scholar 

  49. Shah SD, Kalita J, Misra UK, Mandal SK, Srivastava M (2005) Prognostic predictors of thalamic hemorrhage. J Clin Neurosci 12:559–561

    Article  PubMed  CAS  Google Scholar 

  50. Skoglund K, Enblad P, Marklund N (2009) Effects of the neurological wake-up test on intracranial pressure and cerebral perfusion pressure in brain-injured patients. Neurocrit Care 11:135–142

    Article  PubMed  Google Scholar 

  51. Steinke W, Sacco RL, Mohr JP, Foulkes MA, Tatemichi TK, Wolf PA, Price TR, Hier DB (1992) Thalamic stroke. Presentation and prognosis of infarcts and hemorrhages. Arch Neurol 49:703–710

    Article  PubMed  CAS  Google Scholar 

  52. Suarez JI (2006) Outcome in neurocritical care: advances in monitoring and treatment and effect of a specialized neurocritical care team. Crit Care Med 34:S232–S238

    Article  PubMed  Google Scholar 

  53. Teasdale G, Jennett B (1974) Assessment of coma and impaired consciousness. A practical scale. Lancet 2:81–84

    Article  PubMed  CAS  Google Scholar 

  54. Vanneste J, Augustijn P, Tan WF, Dirven C (1993) Shunting normal pressure hydrocephalus: the predictive value of combined clinical and CT data. J Neurol Neurosurg Psychiatry 56:251–256

    Article  PubMed  CAS  Google Scholar 

  55. Warme PE, Bergstrom R, Persson L (1991) Neurosurgical intensive care improves outcome after severe head injury. Acta Neurochir (Wien) 110:57–64

    Article  CAS  Google Scholar 

  56. Weisberg LA (1986) Thalamic hemorrhage: clinical-CT correlations. Neurology 36:1382–1386

    Article  PubMed  CAS  Google Scholar 

  57. Zahuranec DB, Brown DL, Lisabeth LD, Gonzales NR, Longwell PJ, Smith MA, Garcia NM, Morgenstern LB (2007) Early care limitations independently predict mortality after intracerebral hemorrhage. Neurology 68:1651–1657

    Article  PubMed  CAS  Google Scholar 

  58. Zuccarello M, Brott T, Derex L, Kothari R, Sauerbeck L, Tew J, Van Loveren H, Yeh HS, Tomsick T, Pancioli A, Khoury J, Broderick J (1999) Early surgical treatment for supratentorial intracerebral hemorrhage: a randomized feasibility study. Stroke 30:1833–1839

    Article  PubMed  CAS  Google Scholar 

Download references

Acknowledgments

The authors would like to acknowledge the Laerdahl Foundation for acute medicine, the Stroke Foundation and the Swedish Research Council.

Conflicts of interest

None.

Author information

Authors and Affiliations

  1. Department of Neuroscience, Section of Neurosurgery, Uppsala University, Uppsala, Sweden

    Parmenion P. Tsitsopoulos, Per Enblad, Lovisa Tobieson & Niklas Marklund

  2. Department of Surgical Science, Section of Vascular Surgery, Uppsala University, Uppsala, Sweden

    Anders Wanhainen

  3. Department of Neuroscience, Section of Neurology, Uppsala University, Uppsala, Sweden

    Hans-Göran Hårdemark

  4. Department of Neurosurgery, Uppsala University, 751 85, Uppsala, Sweden

    Niklas Marklund

Authors
  1. Parmenion P. Tsitsopoulos
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Per Enblad
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Anders Wanhainen
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Lovisa Tobieson
    View author publications

    You can also search for this author in PubMed Google Scholar

  5. Hans-Göran Hårdemark
    View author publications

    You can also search for this author in PubMed Google Scholar

  6. Niklas Marklund
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Niklas Marklund.

Additional information

Comment

The authors attribute in their conclusion the improved outcome in patients with major thalamic hemorrhage mainly to improved general neurocritical care, rather than specific treatment of the thalamic hemorrhage. This is in line with the progress that has been noticed with other stroke entities over the last decades. The progress in the management of aneurysmal subarachnoid hemorrhage is also reflected most clearly in a continuously decreasing case fatality rate. Although data on intracerebral hemorrhage in general and ischemic stroke are less homogeneous, the respective data suggest that reduction of case fatalities could also be achieved with these types of stroke. Therefore, advances of general neurocritical care appear to be the common denominator responsible for the decreasing case fatality rates. Additionally, a change in practice with regard to more active treatment of elderly and poor grade patients may also be a factor.

Hans-Jakob Steiger

Duesseldorf, Germany

1. Andaluz N, Zuccarello M. (2009) Recent trends in the treatment of spontaneous intracerebral hemorrhage: analysis of a nationwide inpatient database. J Neurosurg 110(3):403–10

2. Bejot Y, Rouaud O, Durier J, Caillier M, Marie C, Freysz M, Yeguiayan JM, Chantegret A, Osseby G, Moreau T, Giroud M (2007) Decrease in the stroke case fatality rates in a French population-based twenty-year study. A comparison between men and women. Cerebrovasc Dis 24:439–44

3. Christensen MC, Munro V (2008) Ischemic stroke and intracerebral hemorrhage: the latest evidence on mortality, readmissions and hospital costs from Scotland. Neuroepidemiology 30(4):239–46

4. Lovelock CE, Rinkel GJ, Rothwell PM (2010) Time trends in outcome of subarachnoid hemorrhage: Population-based study and systematic review. Neurology 74(19):1494–501

5. Rothwell PM, Coull AJ, Giles MF, Howard SC, Silver LE, Bull LM, Gutnikov SA, Edwards P, Mant D, Sackley CM, Farmer A, Sandercock PA, Dennis MS, Warlow CP, Bamford JM, Anslow P; Oxford Vascular Study(2004) Change in stroke incidence, mortality, case-fatality, severity, and risk factors in Oxfordshire, UK from 1981 to 2004 (Oxford Vascular Study). Lancet 363(9425):1925–33

6. Sturgeon JD, Folsom AR(2007) Trends in hospitalization rate, hospital case fatality, and mortality rate of stroke by subtype in Minneapolis-St. Paul, 1980–2002. Neuroepidemiology 28(1):39–45

7. Truelsen T, Grønbaek M, Schnohr P, Boysen G (2002) Stroke case fatality in Denmark from 1977 to 1992: the Copenhagen City Heart Study. Neuroepidemiology 21(1):22-7

8.van Asch CJ, Luitse MJ, Rinkel GJ, van der Tweel I, Algra A, Klijn CJ(2010) 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 9(2):167–76

Rights and permissions

Reprints and permissions

About this article

Cite this article

Tsitsopoulos, P.P., Enblad, P., Wanhainen, A. et al. Improved outcome of patients with severe thalamic hemorrhage treated with cerebrospinal fluid drainage and neurocritical care during 1990–1994 and 2005–2009. Acta Neurochir 155, 2105–2113 (2013). https://doi.org/10.1007/s00701-013-1871-1

Download citation

  • Received:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s00701-013-1871-1

Keywords

Search

Navigation