Phan, Thanh G.

Background and Purpose —Previous studies have shown that the volume of intracerebral hemorrhage and Glasgow Coma Score (GCS) on admission are powerful predictors of 30-day mortality. However, the significance of hydrocephalus associated with deep cerebral hemorrhage has not been studied extensively. The purpose of this study was to determine the prognostic indicators of 30-day mortality in patients with deep cerebral hemorrhage. Methods —We studied 100 consecutive patients with deep cerebral hemorrhage between 1994 and 1998. Deep cerebral hemorrhage was divided into 2 groups: putaminal hemorrhage (lateral group) and thalamic and caudate hemorrhage (medial group). Univariate and multivariate logistic regression analyses were performed to determine independent prognostic indicators of 30-day mortality. Results —Hydrocephalus was present in 40 of the 100 patients. The 30-day mortality was 29%, and hydrocephalus was present in 76% of those who died. Multivariate analyses showed 2 independent prognostic indicators of 30-day mortality for putaminal hemorrhage: GCS ≤8 ( P =0.002, odds ratio [OR] 37.7, CI 3.6 to 396.9) and hydrocephalus ( P =0.005, OR 27.4, CI 2.7 to 282.6). However, only GCS ≤8 ( P =0.0002, OR 16.5, CI 3.7 to 73.4) was predictive of 30-day mortality for thalamic and caudate hemorrhage. This model (GCS ≤8 and hydrocephalus) has a sensitivity of 57% and a specificity of 91% for predicting 30-day mortality for putaminal hemorrhage. When both attributes were present in putaminal hemorrhage (GCS ≤8 and hydrocephalus), 1 (11%) of 9 patients survived, and when both attributes were missing 28 (100%) of 28 patients survived. Conclusions —Obstructive hydrocephalus on admission in a comatose patient with a putaminal hemorrhage predicts 30-day mortality.

Background and Purpose —The decision to proceed with surgery in cerebellar infarct with mass effect (CIMASS) in deteriorating patients is based on clinical features. The potential role of neuroimaging in predicting deterioration has not been systematically studied. In this study we determine the role of neuroimaging in predicting deterioration in CIMASS. Methods —We retrospectively reviewed the clinical and neuroimaging features in 90 patients with cerebellar infarcts. We selected for detailed analysis CIMASS in 35 patients. Results —Eighteen patients remained stable and 17 deteriorated. Of these 17 patients, 8 were treated conservatively and 9 had surgery. Radiological features indicative of progression were more common in deteriorating patients compared with stable patients: fourth ventricular shift (82.3% versus 50%, P =0.075, OR=4.67), hydrocephalus (76.5% versus 11.1%, P =0.0001, OR=26), brain stem deformity (47% versus 5.6%, P =0.0065, OR=15.1), and basal cistern compression (35.3% versus 0%, P =0.0076, OR=20.91). Differences in upward displacement of the aqueduct and pontomesencephalic junction from Twining’s line, tonsillar descent on sagittal MRI, and infarct volumes between stable and deteriorating patients were not statistically significant. Conclusions —Hydrocephalus, brain stem deformity, and basal cistern compression may herald deterioration in CIMASS. Admission to a neurological-neurosurgical intensive care unit and consideration of preemptive surgery are warranted in these patients. Vertical displacement of tonsils or aqueduct, demonstrated by MR imaging, did not predict deterioration.

Background and Purpose — Contrast-enhanced magnetic resonance angiography (CEMRA) permits acquisition of high-spatial-resolution, venous-suppressed, 3D MR angiograms of the cervical carotid and vertebral arteries. In this study, an elliptic centric-view ordering with either MR fluoroscopic triggering or test bolus timing was used. The use of CEMRA of the cervical vessels has changed our clinical practice and is replacing conventional angiography for the evaluation of most carotid and vertebral artery diseases. Methods — We retrospectively reviewed our experience with the use of CEMRA performed in 422 patients from January through December 1999. Results — CEMRA was performed to evaluate transient ischemic attack and ischemic stroke in 239 patients, asymptomatic carotid bruit in 88 patients, and other neurological symptoms in 95 patients. Carotid endarterectomies were performed in 97 patients (103 procedures), and conventional angiography was performed in 12 of these patients. CEMRA was used to evaluate for the presence of an arterial dissection in 85 of the 239 patients with transient ischemic attack and ischemic stroke. Of this group, 32 patients had cervical arterial dissection, and pseudoaneurysm was detected in 11 of these patients. Compared with ultrasonography of the cervical vessels, CEMRA provided additional information in 43 of 422 patients and led to changes in the decision as to whether to perform carotid endarterectomy in 5 patients. Conclusions — Use of CEMRA permits noninvasive evaluation of patients suspected of having carotid or vertebral disease and avoids the potential complications of conventional angiography.