| BackgroundSpontaneous intracerebral hemorrhage(SICH)is a frequent form of cerebrovascular diseases that accounts for 30%of all stroke cases in China,which is approximately double that in Western countries.This is a fatal stroke,with a higher mortality than ischemic stroke.SICH classify as primary cerebral hemorrhage and secondary cerebral hemorrhage according to the pathogenesis.Primary intracerebral hemorrhage is the hemorrhage with no clear reasons,which accounted for 80-85%of SICH,including hypertension Cerebral Hemorrhage,amyloidosis cerebrovascular disease cerebral hemorrhage(CAAH)and cerebral hemorrhage with unknown origin.The proportion of patients with them are 50-70%,20-30%and 10%patients of ICH respectively.Hypertensive cerebral hemorrhage is more common in elderly people over 50 years old,especially in the age group of 51-70 years,wihich is slightly more common male incidence than female.The patients have clear medical history of hypertension.These conditions further confirm that elderly patients,especially those with hypertension,are prone to cerebral hemorrhage.Craniocerebral detail and arteriosclerosis in patients with hypertension are the pathological basis.Winter and spring are the peak season of hypertensive cerebral hemorrhage.On the basis of long-term hypertension and cerebrovascular disease,suddenly the spirit of the emotional or physical activity enhancement,causes the blood pressure to rise.When the rise in blood pressure more than cerebrovascular bearing ability,it would cause cerebral vascular rupture and bleeding in the brain.Hypertensive intracerebral hemorrhage often involves putamen,thalamus,subcortical,cerebellum,pons and cerebral ventricles.Thalamic hemorrhage is a common subtype of SICH,incidence of which is only the second to the putamen hemorrhage.The prevalence of thalamic hemorrhage ranges from 6%to 25%of intracerebral hemorrhage.It usually ruptures into the ventricular system,damages the posterior limb of the internal capsule,and even compresses the midbrain and cerebral aqueduct,which can lead to obstructive hydrocephalus,paralysis,or even death.Further,peri-hematomal edema develops over time,resulting in secondary injury and neurological deterioration after the first day.According to the current literature,it is still debatable as to which is the best therapeutic regimen for thalamic hemorrhage.Some studies showed that there was no significant benefit of surgical treatment over conservative medical treatment for thalamic hemorrhage,while others provide contrary evidence.Therefore,future studies are required to explore the effectiveness of these treatment options for thalamic hemorrhage.In recent years,CT-positioned thalamic hematoma drainage(THD)combined with urokinase application was used in our hospital to treat thalamic hematoma,with satisfactory results.In the current study,we collected clinical data from 54 patients with thalamic hemorrhage,and analyzed the effect of minimally invasive THD on the prognosis and predictors of the 6-month clinical outcome.Methods1.Study populationAll patients with spontaneous thalamic hemorrhage,who were admitted to the Emergency Neurosurgery Department of Shandong University Qilu Hospital from August 2011 to January 2015,were screened for this study.The inclusion criteria were the presence of primary thalamic hemorrhage and an intracerebral hematoma volume of 5-40ml.The intracerebral hemorrhage volume was measured using the ABC/2 method with CT scanning.The exclusion criteria were as follows:hematoma involving the basal ganglia region,non-first-time bleeding,secondary ICH(due to head trauma,aneurysm,vascular malformation,hemorrhagic infarction,cerebral vein and sinus thrombosis,tumor,anticoagulants,or coagulopathy-related hemorrhage),or a loss of follow-up.The study protocol was approved by the ethics committee of the hospital.The families of all the patients received a comprehensive description of the study and provided written informed consent for the patient’s participation in the study.2.Surgery and intraoperative treatmentBilateral external ventricular drainage(EVD)was performed for patients with acute hydrocephalus or intraventricular hemorrhage(IVH).The necessity and risks of THD and conservative treatment were explained to the relatives of all patients,and surgery was performed for patients with informed consent from their relatives.The puncture position,depth(generally 7-8 cm),and direction were defined in accordance with the preoperative CT scan.A hole was bored in the temporal bone with a directional skull drill and the bone residue was removed with a special curette.Thereafter,a brain needle was punctured to the predetermined depth and direction,and the hematoma was drawn out gently by syringe to confirm the tube position.Finally,the passageway was formed using a 12F or 14F smooth rod,and the corresponding polyester tube with two side holes was punctured into the hematoma cavity.The position of the drainage tube and residual hematoma volume were immediately checked with a portable CT(NL3000,Neurologica CereTom,USA),and adjusted if necessary.3.Postoperative treatmentTo liquefy the hematoma,the liquefacient(i.e.,a urokinase injection)was injected into the hematoma cavity(3ml saline solution/30,000 U urokinase)and to the lateral ventricle with the hematoma(4-5ml saline solution/20,000 U urokinase),twice a day.The risks such as re-bleeding,allergy,etc.,were explained to the patients’ relatives,and their written informed consent was received before the injection.Urokinase injection was discontinued when the hematoma was eliminated or it could no longer be removed using the urokinase injection,according to the CT scan.The THD was then removed.Other treatments(such as blood pressure control,sedation,antibiotics,water and electrolyte balance,dehydration drug use,pneumonia treatment,nutritional support,etc)were performed when necessary.4.Clinical data collectionClinical data of the patients were collected on admission or during hospitalization.The variables included demographics(age and sex),alcohol and tobacco abuse,a detailed history of stroke risk factors[hypertension,diabetes mellitus,coronary heart disease,and chronic obstructive pulmonary diseases(COPD)],neuroimaging variables at presentation(hematoma volume,intraventricular extension,midline shift,acute hydrocephalus,and brain edema),GCS on admission,surgery or conservative treatment,continuous hydrocephalus and treatment,and outcome.The midline shift was determined by the distance between the midline and third ventricle,according to the CT scan.5.Functional outcome assessment:Clinical outcome was assessed using the modified Rankin Scale(mRS),six months after onset.Follow-up was conducted with a telephone interview or face-to-face assessment.In the current study,since the status of the patients was relatively serious owing to the hematoma volume,a mRS score of three points was considered a good prognosis.Therefore,poor clinical outcome was defined as a mRS score of ≥4,when assessed at the 6-month follow-up.6.Statistical analysis:Continuous variables that were normally distributed were expressed as mean±SD,while those that were not normally distributed were reported as median[interquartile range(IQR)].For the univariate analysis,normally distributed continuous variables were analyzed with a Student’s t-test,while those that were not normally distributed were analyzed with a Mann-Whitney U test.Categorical variables were analyzed with a chi-square test.Stepwise forward logistic regression was used to determine independent predictors for poor functional outcome at 6 months after SICH.All tests were two-tailed and statistical significance was determined at α-level of 0.05.Statistical analysis and charting were performed using SPSS19.0 and Excel 2010.Results1.Clinical dataOf the 89 patients with thalamic hemorrhage measuring 5-40ml,who were treated in our department,a total of 54 patients met the inclusion criteria of this study.The patient cohort in this study had a mean age of 54.74±10.85 years(IQR:33-78 years),and comprised 34 men and 20 women.A total of 37(82.2%)patients had one or more of the following underlying diseases:33(61.1%)patients had hypertension,14(25.9%)patients had diabetes mellitus,6(11.1%)patients had COPD,and 16(29.6%)patients had coronary artery diseases.There were 18(33.3%)patients who were smokers and 13(24.1%)patients who drank alcohol regularly.The GCS score on admission was 8.56±2.52(4-14).Conservative treatment was performed on five(9.3%)patients,EVD on 20(37.0%)patients,THD on four(7.4%)patients,and EVD combined with THD on 25(46.3%)patients.All of the operations were performed 3-36 h after onset.On average,urokinase injection with EVD was performed on 33 patients for 2.36 ±0.45days(1-5days)and the EVD was removed 6.21±0.71days(4-9days)after surgery.In contrast,urokinase injection with THD was performed on all 29 patients with THD for an average of 2.59±0.39days(2-5days),and the THD was removed 3.62±0.47days(2-7days)after surgery.At least 80%of the thalamic hematoma was removed in the 29 patients with THD.Nine patients suffered from continuous hydrocephalus.ETV was performed for four of these patients,while VPS was performed for the remaining five patients and for an additional patient after the failure of ETV.Mechanical ventilation was required for 19(35.2%)patients and pneumonia was diagnosed in 34(67.0%)patients.The body temperature was controlled between 36.0℃ and 37.0’C with the help of drugs or physical cooling.Osmotherapy(mannitol or hypertonic saline)was used pre-or post-operation.Mannitol was used in accordance with the clinical manifestations and CT imaging.Seven patients died during hospitalization owing to critical condition,and one patient died owing to atrial fibrillation and circulatory failure.At 6-month follow-up,0,4(7.4%),8(14.8%),9(16.7%),11(20.4%),14(25.9%),and 8(14.8%)patients had a mRS score of 0-6,respectively.Thus,21(38.9%)patients achieved a favorable functional outcome(i.e.,a mRS score≤3),while 33(61.1%)patients had a poor functional outcome(i.e.,a mRS score of 4-6).2.Predictors of poor outcome six months after thalamic hemorrhageAccording to the univariate analysis,the predictors of poor 6-month outcome were a low GCS score on admission(P = 0.001),larger hematoma volume(P<0.001),midline shift(P = 0.035),acute hydrocephalus on admission(P = 0.039),and no THD(P = 0.037).There were no significant differences in terms of sex,age,the rest of the evaluated risk factors,intraventricular extension,EVD,or continuous hydrocephalus(Table 3).The prognostic accuracy for 6-month outcome was assessed using receiver operating characteristic curve analysis.The area under the curve for no THD was 0.645(95%CI:0.494-0.796),while that for a low GCS score on admission,hematoma volume,acute hydrocephalus on admission,and midline shift were 0.765(95%CI:0.626-0.904),0.816(95%Cl:0.704-0.928),0.643(95%CI:0.490-0.796),and 0.641(95%CI:0.485-0.796),respectively.In the multivariate analysis,the entrance cutoff of the variables was set to 0.10,according to the results of univariate analysis.Therefore,GCS score on admission,acute hydrocephalus,hematoma volume,midline shift,and THD were selected for multivariate analysis using logistic regression.According to the stepwise logistic regression,no THD and a larger hematoma volume were independent predictors for a poor 6-month outcome.ConclusionsWe concluded that a lower GCS score on admission,larger hematoma volume,midline shift,acute hydrocephalus on admission,and no THD were risk factors affecting the 6-month outcome of thalamic hemorrhage,of which no THD and a larger hematoma volume were independent predictors of outcome according to the multivariate logistic regression analysis.Minimally invasive THD was adept at removing the majority of the hematoma within a few days,with limited damage to the perihematomal brain tissue and short operation duration.Thus,it is a good option for patients with thalamic hemorrhage.However,further prospective studies are required to explore the indications and ideal timing of THD. |
