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Intracranial hemorrhage occurrence low among cirrhotics with altered mental status

In a new study, cirrhotic patients presenting with altered mental status, without experiencing previous trauma, did not have an increased likelihood of experiencing intracranial hemorrhage.

“Our study shows that the yield of a head [computed tomography] is very poor for cirrhotic patients presenting with altered mental status in the absence of focal neurologic signs,” Elliot B. Tapper, MD, of the division of gastroenterology and hepatology at Beth Israel Deaconess Medical Center, Boston, told Healio.com/Hepatology.  

Elliot B. Tapper

In a retrospective cohort study, Tapper and colleagues analyzed 462 computed tomography (CT) scans performed in 357 patients (65.6% male) with cirrhosis after admittance to Beth Israel Deaconess Medical Center between 2003 and 2013. The researchers used blinded reviewers to code results of the scans and compared them with patient characteristics, according to the research.

A total of 146 patients had a history of high-risk indications, including falls or trauma, focal neurologic signs or intracranial hemorrhage (ICH). Thirteen of these patients had ICH (0.3%).

Data indicated that 316 patients had low-risk indications for ICH, including altered mental status (AMS), headache or fever; only one patient had ICH. Therefore, more patients with a history of trauma and ICH were found to have ICH compared with those without a history of trauma (P<.0001). The patients with low-risk indications for ICH had an odds ratio of 0.02 (95% CI, 0.001-0.14; P<.0001).

Multivariate analysis showed low-risk indications (OR=0.03; 95% CI, 0.001-0.15) and medical floor admittance (OR=0.25; 95% CI, 0.07-0.81), as opposed to ICU admittance, to be associated with no occurrence of ICH.

The number needed to scan for positive results from the CT varied by indication: nine for focal neurologic deficits, 20 for falls or trauma and 293 for AMS, according to the research.

No associations between new, acute ICH and platelet count, international normalized ratio, creatinine levels or model for end-stage liver disease scores were observed by the researchers. In addition, there were no differences observed in CT between patients admitted more than once vs. patients admitted to the emergency room only once.    

“We feel these results are important for two reasons. … First, despite a perceived tendency towards bleeding related to their low platelets and high [international normalized ratios], cirrhotic patients with nonfocal AMS are not at risk of intracranial hemorrhage,” Tapper said. “Second, we believe these data support simplifying the evaluation of the altered patient with cirrhosis, avoiding the risks of being relatively unobserved in a CT scanner.”

Tapper added: “We are actively studying the precise reasons why clinicians order this test for nonfocal AMS as well as interventions to reduce the rate of such orders. We welcome the chance to collaborate with others who may be interested.” – by Melinda Stevens

Disclosure: The researchers report no relevant financial disclosures.