Objective: To determine whether the usual mortality prediction systems (APACHE and SAPS) can be complemented by cranial computed tomography (CT) brain herniation findings in patients with structural neurological involvement.
Design: Prospective cohort study.
Setting: Trauma ICU in university hospital.
Patients: One hundred and fifty five patients admitted to ICU in 2003 with cranial trauma or acute stroke.
Main variables of interest: Data were collected on age, diagnosis, mortality, admission cranial CT findings and on APACHE II, APACHE III and SAPS II scores.
Results: Mean age was 47.8 +/- 19.4 years; APACHE II, 17.1 +/- 7.2 points; SAPS II, 43.7 +/- 17.7 points; and APACHE III, 55.8 +/- 29.7 points. Hospital mortality was 36% and mortality predicted by SAPS II was 38%, by APACHE II 30% and by APACHE III 36%. The 56 non-survivors showed greater midline shift on cranial CT scan versus survivors (4.2 +/- 5.5 vs. 1.6 +/- 3.22 mm, p = 0.002) and higher severity as assessed by SAPS II, APACHE II and APACHE III. The mortality rate was significantly higher in patients with subfalcial herniation (61% vs. 30%, p < 0.001). In the multivariate logistic regression analysis, hospital mortality was associated with the likelihood of death according to APACHE III (OR 1.07; 95% CI: 1.05-1.09) and with presence of subfalcial herniation (OR 3.15; 95% CI: 1.07-9.25).
Conclusions: In critical care patients with structural neurological involvement, cranial CT signs of subfalcial herniation complement the prognostic information given by the usual severity indexes.