Evaluation of intraventricular hemorrhage assessment methods for predicting outcome following intracerebral hemorrhage

Clinical article

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Object

Intraventricular hemorrhage (IVH) associated with intracerebral hemorrhage (ICH) is an independent predictor of poor outcome. Clinical methods for evaluating IVH, however, are not well established. This study sought to determine the best IVH grading scale by evaluating the predictive accuracies of IVH, Graeb, and LeRoux scores in an independent cohort of ICH patients with IVH. Subacute IVH dynamics as well as the impact of external ventricular drain (EVD) placement on IVH and outcome were also investigated.

Methods

A consecutive cohort of 142 primary ICH patients with IVH was admitted to Columbia University Medical Center between February 2009 and February 2011. Baseline demographics, clinical presentation, and hospital course were prospectively recorded. Admission CT scans performed within 24 hours of onset were reviewed for ICH location, hematoma volume, and presence of IVH. Intraventricular hemorrhage was categorized according to IVH, Graeb, and LeRoux scores. For each patient, the last scan performed within 6 days of ictus was similarly evaluated. Outcomes at discharge were assessed using the modified Rankin Scale (mRS). Receiver operating characteristic analysis was used to determine the predictive accuracies of the grading scales for poor outcome (mRS score ≥ 3).

Results

Seventy-three primary ICH patients (51%) had IVH. Median admission IVH, Graeb, and LeRoux scores were 13, 6, and 8, respectively. Median IVH, Graeb and LeRoux scores decreased to 9 (p = 0.005), 4 (p = 0.002), and 4 (p = 0.003), respectively, within 6 days of ictus. Poor outcome was noted in 55 patients (75%). Areas under the receiver operating characteristic curve were similar among the IVH, Graeb, and LeRoux scores (0.745, 0.743, and 0.744, respectively) and within 6 days postictus (0.765, 0.722, 0.723, respectively). Moreover, the IVH, Graeb, and LeRoux scores had similar maximum Youden Indices both at admission (0.515 vs 0.477 vs 0.440, respectively) and within 6 days postictus (0.515 vs 0.339 vs 0.365, respectively). Patients who received EVDs had higher mean IVH volumes (23 ± 26 ml vs 9 ± 11 ml, p = 0.003) and increased incidence of Glasgow Coma Scale scores < 8 (67% vs 38%, p = 0.015) and hydrocephalus (82% vs 50%, p = 0.004) at admission but had similar outcome as those who did not receive an EVD.

Conclusions

The IVH, Graeb, and LeRoux scores predict outcome well with similarly good accuracy in ICH patients with IVH when assessed at admission and within 6 days after hemorrhage. Therefore, any of one of the scores would be equally useful for assessing IVH severity and risk-stratifying ICH patients with regard to outcome. These results suggest that EVD placement may be beneficial for patients with severe IVH, who have particularly poor prognosis at admission, but a randomized clinical trial is needed to conclusively demonstrate its therapeutic value.

Abbreviations used in this paper: AUROC = area under the ROC curve; EVD = external ventricular drain; GCS = Glasgow Coma Scale; ICH = intracerebral hemorrhage; IVH = intraventricular hemorrhage; mRS = modified Rankin scale; ROC = receiver operating characteristic; tPA = tissue plasminogen activator.

Article Information

Current affiliation for Dr. Hwang: Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland.

Address correspondence to: Geoffrey Appelboom, M.D., Department of Neurosurgical Surgery, Columbia University Medical Center, New York, New York 10032. email: ga2294@columbia.edu.

Please include this information when citing this paper: published online October 14, 2011; DOI: 10.3171/2011.9.JNS10850.

© AANS, except where prohibited by US copyright law.

Headings

Figures

  • View in gallery

    Grading scales for assessing IVH severity. A: The IVH score (range 0–23). The IVH score is calculated using the following equation: 3 × (right lateral ventricle score + left lateral ventricle score + hydrocephalus score) + third ventricle score + fourth ventricle score. B: The Graeb score (range 0–12). C: The LeRoux score (range 0–16).

  • View in gallery

    Comparison of ROC curves and AUROCs of admission (left) and postadmission (right) IVH scores, Graeb scores, and LeRoux scores as predictors of discharge poor functional outcome (mRS score ≥ 3).

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