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Third Ventricle Midline Shift Due to Spontaneous Supratentorial Intracerebral Hemorrhage Evaluated by Transcranial Color-Coded Sonography

Stroke Center (S.-C.T., J.-S.J., P.-K.Y.), Department of Neurology (S.-C.T., S.-J.H., J.-S.J., P.-K.Y.), and Division of Neurosurgery, Department of Surgery (S.-J.H.), National Taiwan University Hospital, Taipei, Taiwan.

Address correspondence to Dr Jiann-Shing Jeng, MD, Department of Neurology, National Taiwan University Hospital, 7 Chung-Shan South Rd, Taipei 100, Taiwan. E-mail: jsjeng{at}ha.mc.ntu.edu.tw

Objective. We aimed to assess the clinical usefulness of the third ventricle midline shift (MLS) evaluated by transcranial color-coded sonography (TCCS) in acute spontaneous supratentorial intracerebral hemorrhage (ICH). Methods. Consecutive patients with acute (<24 hours after symptom onset) ICH were recruited for this TCCS study. Sonographic measurement of MLS and the pulsatility index (PI) of the middle cerebral arteries were compared with head computed tomographic (CT) data, including MLS, and hematoma volume. Poor functional outcome at 30 days after stroke onset was defined as modified Rankin scale greater than 2. Results. There were 51 patients with spontaneous supratentorial ICH who received CT and TCCS studies within a 12-hour window. Correlation between MLS by TCCS (mean ± SD, 3.2 ± 2.6 mm) and CT (3.0 ± 2.4 mm) was high ( = 0.91; P < .01). There was also a good linear correlation between hematoma volume and MLS by TCCS ( = 0.81; P < .01). Compared with ICH volume less than 25 mL, those with greater volume had more severe MLS and a higher PI of the ipsilateral middle cerebral artery (P < .001). Midline shift by TCCS was more sensitive and specific than the PI in detecting large ICH (accuracy = 0.82 if MLS 2.5 mm), and it was also a significant predictor of poor outcome (odds ratio, 2.09 by 1-mm increase; 95% confidence interval, 1.06–4.13). Conclusions. Midline shift may be measured reliably by TCCS in spontaneous supratentorial ICH. Our study also showed that MLS on TCCS is a useful and convenient method to identify patients with large ICH and hematoma expansion and to predict short-term functional outcome.

Key Words: intracerebral hemorrhage • third ventricle midline shift • transcranial color-coded sonography

Abbreviations: CT, computed tomography • GCS, Glasgow Coma Scale • ICH, intracerebral hemorrhage • IVH, intraventricular hemorrhage • MCA, middle cerebral artery • MLS, midline shift • mRS, modified Rankin scale • NIHSS, National Institutes of Health Stroke Scale • NPV, negative predictive value • OR, odds ratio • PI, pulsatility index • PPV, positive predictive value • TCCS, transcranial color-coded sonography

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