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Poor Accuracy of Manually Derived Head Computed Tomography Parameters in Predicting Intracranial Hypertension After Nontraumatic Intracranial Hemorrhage

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Abstract

Background

The utility of head computed tomography (CT) in predicting elevated intracranial pressure (ICP) is known to be limited in traumatic brain injury; however, few data exist in patients with spontaneous intracranial hemorrhage.

Methods

We conducted a retrospective review of prospectively collected data in patients with nontraumatic intracranial hemorrhage (subarachnoid hemorrhage [SAH] or intraparenchymal hemorrhage [IPH]) who underwent external ventricular drain (EVD) placement. Head CT scans performed immediately prior to EVD placement were quantitatively reviewed for features suggestive of elevated ICP, including temporal horn diameter, bicaudate index, basal cistern effacement, midline shift, and global cerebral edema. The modified Fisher score (mFS), intraventricular hemorrhage score, and IPH volume were also measured, as applicable. We calculated the accuracy, positive predictive value (PPV), and negative predictive value (NPV) of these radiographic features for the coprimary outcomes of elevated ICP (> 20 mm Hg) at the time of EVD placement and at any time during the hospital stay. Multivariable backward stepwise logistic regression analysis was performed to identify significant radiographic factors associated with elevated ICP.

Results

Of 608 patients with intracranial hemorrhages enrolled during the study time frame, 243 (40%) received an EVD and 165 (n = 107 SAH, n = 58 IPH) had a preplacement head CT scan available for rating. Elevated opening pressure and elevated ICP during hospitalization were recorded in 48 of 152 (29%) and 103 of 165 (62%), respectively. The presence of ≥ 1 radiographic feature had only 32% accuracy for identifying elevated opening pressure (PPV 30%, NPV 58%, area under the curve [AUC] 0.537, 95% asymptotic confidence interval [CI] 0.436–0.637, P = 0.466) and 59% accuracy for predicting elevated ICP during hospitalization (PPV 63%, NPV 40%, AUC 0.514, 95% asymptotic CI 0.391–0.638, P = 0.820). There was no significant association between the number of radiographic features and ICP elevation. Head CT scans without any features suggestive of elevated ICP occurred in 25 of 165 (15%) patients. However, 10 of 25 (40%) of these patients had elevated opening pressure, and 15 of 25 (60%) had elevated ICP during their hospital stay. In multivariable models, mFS (adjusted odds ratio [aOR] 1.36, 95% CI 1.10–1.68) and global cerebral edema (aOR 2.93, 95% CI 1.27–6.75) were significantly associated with elevated ICP; however, their accuracies were only 69% and 60%, respectively. All other individual radiographic features had accuracies between 38 and 58% for identifying intracranial hypertension.

Conclusions

More than 50% of patients with spontaneous intracranial hemorrhage without radiographic features suggestive of elevated ICP actually had ICP > 20 mm Hg during EVD placement or their hospital stay. Morphological head CT findings were only 32% and 59% accurate in identifying elevated opening pressure and ICP elevation during hospitalization, respectively.

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Authors and Affiliations

  1. Department of Neurology, New York University School of Medicine, 150 55th St., Brooklyn, New York, NY, USA

    Jennifer A. Frontera, Taolin Fang, Kammi Grayson, Rebecca Lalchan, Leah Dickstein, D. Ethan Kahn, Aaron S. Lord, Kara R. Melmed, Ting Zhou & Ariane Lewis

  2. Department of Neurosurgery, Mount Sinai School of Medicine, New York, NY, USA

    Jennifer A. Frontera

  3. Cerebrovascular Center of the Neurological Institute, Cleveland Clinic, Cleveland, OH, USA

    Jennifer A. Frontera & M. Shazam Hussain

  4. Department of Neurosurgery, New York University School of Medicine, New York, NY, USA

    Leah Dickstein, Daniel Mazzuchin, Kara R. Melmed, Caleb Rutledge & Ariane Lewis

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Contributions

All authors have met authorship criteria and approved the final manuscript. All authors agree to be accountable for all aspects of the work. JAF designed the study, acquired data, analyzed data, and drafted the manuscript. TF drafted the manuscript and analyzed the data. KG and RL acquired data and critically revised the manuscript. LD, DEK, ASL, DM, KRM, CR, TZ, and AL contributed to study conception and design and critically revised the manuscript. MSH contributed to data acquisition and critically revised the manuscript.

Corresponding author

Correspondence to Jennifer A. Frontera.

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This study was approved by the Mount Sinai Hospital and Cleveland Clinic Institutional Review Boards, and all patients or their surrogates consented to participation.

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Frontera, J.A., Fang, T., Grayson, K. et al. Poor Accuracy of Manually Derived Head Computed Tomography Parameters in Predicting Intracranial Hypertension After Nontraumatic Intracranial Hemorrhage. Neurocrit Care 39, 677–689 (2023). https://doi.org/10.1007/s12028-022-01662-5

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