Defining the Optimal Midline Shift Threshold to Predict Poor Outcome in Patients with Supratentorial Spontaneous Intrace
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ORIGINAL ARTICLE
Defining the Optimal Midline Shift Threshold to Predict Poor Outcome in Patients with Supratentorial Spontaneous Intracerebral Hemorrhage Wen-Song Yang1 • Qi Li2 Li-Bo Zhao1 • Peng Xie1
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Rui Li2 • Qing-Jun Liu1 • Xing-Chen Wang2
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Ó Springer Science+Business Media, LLC 2017
Abstract Background Midline shift (MLS) has been associated with unfavorable outcome in patients with intracerebral hemorrhage (ICH). However, the optimal criteria to define the MLS measurements that indicate future outcome in ICH patients are absent, and the quantitative threshold of MLS that differentiates favorable and poor clinical outcome should be further explored. Methods We enrolled patients with ICH who underwent admission computed tomography (CT) within 6 h after onset of symptoms. We assessed MLS at several locations, including the pineal gland, septum pellucidum, and cerebral falx. MLS(max) was defined as the maximum midline shift among these locations. Functional outcomes were assessed with the Modified Rankin Scale (mRS) at 3 months. We performed multivariate logistic regression analysis to investigate the MLS locations for predicting poor outcome. ROC curve analysis was used to establish whether MLS values were predictive of 90-day poor outcome. Results In 199 patients with ICH, 78 (39.2%) patients had poor functional outcome at 3-month follow-up. Pineal gland shift, septum pellucidum shift, cerebral falx shift, and MLS(max) all showed a significant difference between poor outcome and favorable outcome (p < 0.001). After & Qi Li [email protected] & Peng Xie [email protected] 1
Department of Neurology, Yongchuan Hospital of Chongqing Medical University, Chongqing 402160, China
2
Department of Neurology, The First Affiliated Hospital of Chongqing Medical University, Chongqing 400016, China
adjustment for age, baseline Glasgow Coma Scale score, ICH location, time to initial CT, baseline ICH volume, and intraventricular hemorrhage, the MLS(max) was independently associated with poor outcome (p = 0.032). MLS(max) > 4 mm (our proposed optimal threshold) was more likely to have poorer outcomes than those without (p < 0.001). Conclusions MLS(max) can be a good independent predictor of clinical outcome, and MLS(max) > 4 mm is an optimal threshold associated with poor outcome in patients with ICH. Keywords Intracerebral hemorrhage Midline shift Outcome CT Predictor
Introduction Intracerebral hemorrhage (ICH) is a devastating event associated with high mortality and disability [1]. The mortality ranges from 35% at 7 days to 59% at 1 year, and < 40% of patients who survived regain functional independence [2]. The baseline hematoma volume combined with other factors, such as age, presence of intraventricular hemorrhage (IVH) at baseline computed tomography (CT), admission Glasgow Coma Scale (GCS) scores, can be a powerful predictor to evaluate the clinical implications and outcome after spontaneous ICH (sICH) [3–7]. Mass effect is caused by the mechanical extrusion of the hematoma, which can induce neuronal
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