The Modified Graeb Score: An Enhanced Tool for Intraventricular Hemorrhage Measurement and Prediction of Functional Outcome

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, R2 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 (intra- and inter- reader) 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.

[1]  D. Graeb,et al.  Computed tomographic diagnosis of intraventricular hemorrhage. Etiology and prognosis. , 1982, Radiology.

[2]  G. Ferguson,et al.  Intraventricular hemorrhage from ruptured aneurysm. Retrospective analysis of 91 cases. , 1983, Journal of neurosurgery.

[3]  T. Brott,et al.  Hypertension as a risk factor for spontaneous intracerebral hemorrhage. , 1986, Stroke.

[4]  R. Sclabassi,et al.  Lysis of intraventricular blood clot with urokinase in a canine model: Part 2. In vivo safety study of intraventricular urokinase. , 1986, Neurosurgery.

[5]  R. Sclabassi,et al.  Lysis of Intraventricular Blood Clot with Urokinase in a Canine Model: Part 2 , 1989 .

[6]  W. Rand,et al.  Prognostic significance of ventricular blood in supratentorial hemorrhage , 1990, Neurology.

[7]  J. Dartigues,et al.  Death and functional outcome after spontaneous intracerebral hemorrhage. A prospective study of 166 cases using multivariate analysis. , 1991, Stroke.

[8]  Raul G Nogueira,et al.  Spontaneous intracerebral hemorrhage. , 1992, Neurosurgery clinics of North America.

[9]  J. Grotta,et al.  Early presentation of hemispheric intracerebral hemorrhage , 1994, Neurology.

[10]  S. Tuhrim,et al.  Validation and comparison of models predicting survival following intracerebral hemorrhage. , 1995, Critical care medicine.

[11]  W. Alves,et al.  A report of the Cooperative Aneurysm Study , 1995 .

[12]  T Brott,et al.  The ABCs of measuring intracerebral hemorrhage volumes. , 1996, Stroke.

[13]  J. Gilsbach,et al.  Ventricular dilatation in experimental intraventricular hemorrhage in pigs. Characterization of cerebrospinal fluid dynamics and the effects of fibrinolytic treatment. , 1997, Stroke.

[14]  R. E. Adams,et al.  Response to external ventricular drainage in spontaneous intracerebral hemorrhage with hydrocephalus , 1998, Neurology.

[15]  S. Tuhrim,et al.  Volume of ventricular blood is an important determinant of outcome in supratentorial intracerebral hemorrhage. , 1999, Critical care medicine.

[16]  J. Broderick,et al.  Ultra-early clot aspiration after lysis with tissue plasminogen activator in a porcine model of intracerebral hemorrhage: edema reduction and blood-brain barrier protection. , 1999, Journal of neurosurgery.

[17]  P. F. Kauff.  Group , 2000, Elegant Design.

[18]  A. Algra,et al.  Treatment and outcome of severe intraventricular extension in patients with subarachnoid or intracerebral hemorrhage: a systematic review of the literature , 2000, Journal of Neurology.

[19]  P. Sandercock,et al.  Antithrombotic Therapy in Patients with Any Form of Intracranial Haemorrhage: A Systematic Review of the Available Controlled Studies , 2002, Cerebrovascular Diseases.

[20]  S. Mayer,et al.  Intraventricular Thrombolysis Speeds Blood Clot Resolution: Results of a Pilot, Prospective, Randomized, Double-blind, Controlled Trial , 2004, Neurosurgery.

[21]  Nugent,et al.  Computed Tomographic Diagnosis of Intraventricular Hemorrhage , 2005 .

[22]  J A Maldjian,et al.  Radiologic estimation of hematoma volume in intracerebral hemorrhage trial by CT scan. , 2006, AJNR. American journal of neuroradiology.

[23]  Johannes Wikner,et al.  Comparison of ABC/2 estimation technique to computer-assisted planimetric analysis in warfarin-related intracerebral parenchymal hemorrhage. , 2006, Stroke.

[24]  J. Castaldo,et al.  Predicting mortality after intracerebral hemorrhage: comparison of scoring systems and influence of withdrawal of care. , 2006, Journal of stroke and cerebrovascular diseases : the official journal of National Stroke Association.

[25]  S. Mayer,et al.  Efficacy and safety of recombinant activated factor VII for acute intracerebral hemorrhage. , 2008, The New England journal of medicine.

[26]  D. Hanley,et al.  Preliminary report of the clot lysis evaluating accelerated resolution of intraventricular hemorrhage (CLEAR-IVH) clinical trial. , 2008, Acta neurochirurgica. Supplement.

[27]  Imma Boada,et al.  Semi-automated method for brain hematoma and edema quantification using computed tomography , 2009, Comput. Medical Imaging Graph..

[28]  J. Grotta,et al.  The IVH Score: A novel tool for estimating intraventricular hemorrhage volume: Clinical and research implications* , 2009, Critical care medicine.

[29]  S. Sacco,et al.  Incidence and 10-Year Survival of Intracerebral Hemorrhage in a Population-Based Registry , 2009, Stroke.

[30]  D. Hanley,et al.  Management of Intraventricular Hemorrhage , 2010, Current neurology and neuroscience reports.

[31]  S. Mayer,et al.  Low-Dose Recombinant Tissue-Type Plasminogen Activator Enhances Clot Resolution in Brain Hemorrhage: The Intraventricular Hemorrhage Thrombolysis Trial , 2011, Stroke.

[32]  Vista Steering Committees.  Development, expansion, and use of a stroke clinical trials resource for novel exploratory analyses. , 2012 .

[33]  Marc Fisher,et al.  Development, Expansion, and Use of a Stroke Clinical Trials Resource for Novel Exploratory Analyses , 2012, International journal of stroke : official journal of the International Stroke Society.