Specific Prognostic Features Hydrocephalus

Hydrocephalus is present in as many as half of ICH patients at some time during the course of their illness; however, it has received relatively little attention as a prognostic factor.

In a descriptive study of 100 patients with thalamic hemorrhage, hydrocephalus was noted as an important predictor of mortality, but a multivariate analysis was not performed (56). Similarly, another descriptive study noted 67% mortality in patients with contralateral ventricular dilatation, compared with 30% overall mortality among 200 consecutive ICH patients (57) . In a separate study of the significance of ventricular blood in supratentorial hemorrhage, hydrocephalus correlated with mortality, but external ventricular drainage did not appear to alter outcome (58). A more definitive, multivariate study analyzed 81 ICH patients treated in a neurointensive care setting, creating a detailed method of assessing the degree of hydrocephalus (49). Forty patients with at least some degree of hydrocephalus fared much worse (50% mortality) than those without (2% mortality). Only male gender, GCS, pineal shift, and hydrocephalus were independent predictors of mortality in this patient population. ICH location did not affect outcome or modify the effect of hydrocephalus on outcome. This latter finding is at odds with the findings of a later study that used the same method to quantify hydrocephalus in 100 consecutive ICH patients and then divided them into those with medial (thalamic and caudate) or lateral (putaminal) hemorrhages (53 ). Hydrocephalus, thus calculated, was present in 86% of those who died and was an independent predictor of mortality in the whole group. However, when the medial and lateral groups were considered separately, hydrocephalus was an independent predictor of outcome only in the lateral group. The authors noted that hydrocephalus in the medical group might be caused by a small dorsomedial thalamic hemorrhage with intraventricular extension, while in the lateral group, hydrocephalus was associated with larger intraparenchymal hemorrhage volume. This implies that hydrocephalus might be confounded with hemorrhage size in that population. In summary, hydrocephalus appears to be a poor prognostic sign in ICH. In the two studies that performed multivariate analyses, hydrocephalus, rather than hemorrhage size, appeared in the final model, although hemorrhage size, as in many other studies, was associated with outcome when considered alone.

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