An Enhanced Tool for Intraventricular Hemorrhage Measurement and Prediction of Functional Outcome

Intraventricular hemorrhage (IVH) secondary to spontaneous intracerebral hemorrhage (ICH) results in death in 32% to 43% of cases and poor functional outcome in most survivors. In severe IVH with obstruction of the third or fourth ventricle, the placement of an extraventricular drain can help lower raised intracranial pressure. Meta-analysis shows this reduces mortality, but poor outcomes remain commonplace. In addition to extraventricular drain placement, the use of intraventricular thrombolytic therapy may improve outcomes and is being evaluated in the Clot Lysis Evaluating Accelerated Resolution of Intraventricular Hemorrhage trial program. A pivotal phase III study (Clot Lysis: Evaluating Accelerated Resolution of Hemorrhage with rtPA III [CLEAR III]) of the effect of thrombolytic based removal of ventricular blood on functional outcome is underway. The use of thrombolytic drugs in this setting is associated with bleeding risk. To reduce this risk, the CLEAR study criteria include ICH and IVH clot stability, defined by consecutive computed tomography scans of brain (CT) no less than 6 hours apart showing no increase in ICH and IVH volume. Although rapid, reliable, and well validated means of assessing ICH volume are available, IVH volume assessment remains laborious, time consuming, and subject to variability between readers. A reliable, simple, quick, and Background and Purpose—Simple and rapid measures of intraventricular hemorrhage (IVH) volume are lacking. We developed and validated a modification of the original Graeb scale to facilitate rapid assessment of IVH over time. Methods—We explored the relationship between the modified Graeb scale (mGS), original Graeb scale, measured IVH volume, and outcome using data from the Clot Lysis: Evaluating Accelerated Resolution of Hemorrhage with rtPA B (CLEAR B) study. We also explored its reliability. We then evaluated the relationship between mGS and outcome in a large sample of participants with IVH using data contained within the Virtual International Stroke Trials Archive (VISTA). We defined outcome using the modified Rankin scale (>3 signifying poor outcome). Results—The CLEAR B study included 360 scans from 36 subjects. The mGS score and IVH volume were highly correlated (R = 0.80, P<0.0001, R 0.65). Baseline mGS was predictive of poor outcome (area under receiving operating characteristic curve 0.74, 95% confidence interval, 0.57–0.91), whereas the original Graeb scale was not. The VISTA study included 399 participants. Each unit increase in the mGS led to a 12% increase in the odds of a poor outcome (odds ratio, 1.12; 95% confidence interval, 1.05–1.19). Measures of reliability (intraand interreader) were good in both studies. Conclusions—The mGS, a semiquantitative scale for IVH volume measurement, is a reliable measure with prognostic validity suitable for rapid use in clinical practice and in research. (Stroke. 2013;44:635–641.)