Quantifying volume of intracerebral, subdural and extradural

hemorrhage: As easy as ABC/2

Poster No.: R-0129

Congress: 2014 CSM
Type: Scientific Exhibit
Authors: C. D. J. Barras, B. M. Tress, P. M. Desmond; PARKVILLE/AU
Keywords: Neuroradiology brain, CT, Computer Applications-General, Acute,
Hemorrhage
DOI: 10.1594/ranzcr2014/R-0129

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Page 1 of 7
Aim

Intracerebral haemorrhage (ICH) is the most fatal form of stroke. ICH volume is a
powerful predictor of morbidity and mortality and also correlates with outcome in subdural
and extradural haemorrhage. (1) Radiology reporting of these forms of intracranial
hemorrhage has usually been limited to axial imaging measurements. A simple method
for rapid calculation of intracranial hemorrhage volume from multi-planar CT imaging
in the emergency radiology setting is required, with direct prognostic significance for
patients.

The aims of this technical presentation are to:

• Derive the ABC/2 formula

• Present a methodology for application of the ABC/2 formula using multi-
planar CT reformats for the measurement if intracerebral, extradural and
subdural hemorrhage
• Discuss clinical implications of intracranial hemorrhage volume
measurement
• Present future research studies in intracranial hemorrhage volumetrics

Methods and materials

DERIVATION OF THE ABC/2 FORMULA

A simplified ellipsoid formula ABC/2 has been used for ICH volume calculation since the
1980s. (2) Intended for rapid application at the bedside, a readily applied formula for
the calculation of ICH volume was formulated, based on an ellipsoid model of ICH, the
volume of an ellipse in Cartesian coordinates being:(3,4)

Volume = 4/3 # x y z

where x, y and z are the semi-axes (radii) of the largest cross-sectional diameter, a
diameter at right angles to the first and the height of the ellipsoid, respectively.

If we express the above formula in terms of the complete axes, rather than semi-axes,
we obtain:

Volume = 4/3 # a/2 b/2 c/2

Page 2 of 7
where a, b and c are full-width axes corresponding to x, y and z, defined above.

If # is approximated by the value 3, we may simplify to obtain the familiar:

Volume = ABC/2

(See Fig.1)

The formula was subsequently adapted for the various configurations of

intracerebral, extradural and subdural hemorrhage.

Images for this section:

Fig. 1: ABC/2

Page 3 of 7
Results

The application of the ABC/2 formula to intracerebral hemorrhage (Fig.2), extradural

hemorrhage (Fig.3) and subdural hemorrhage (Fig.4) is shown.

CLINICAL IMPLICATIONS:

A simple technique for rapid calculation of intracerebral, extradural and subdural

hemorrhage is presented.

Conceptually, each hemorrhage is converted to an ellipsoid of equivalent volume. Though

yet to be quantified, the error of the ABC/2 formula measurement is likely to increase as
the shape from which it is derived becomes more irregular.

The skull represents a rigid bony 'box' of fixed-volume, and so the capacity
to accommodate intracranial hemorrhage is very limited. As a result, intracranial
hemorrhage results in high morbidity and mortality, up to 50% in ICH.

At this this stage, it is unknown whether there is a threshold volume at which surgery
is more likely to be performed and the prognostic significance of hemorrhage volumes
in different locations/configurations using these simple measurement techniques is
currently under active investigation.

FUTURE STUDIES:

Future research studies are planned to evaluate

• Current radiology reporting practices for each hemorrhage subtype and

their relevance to established literature on imaging predictors of intracranial
hemorrhage outcome
• Formal intra-rater and inter-rater reliability studies for volume measurement
in ICH, extradural and subdural hemorrhage
• Correlation of volume measurements derived from the
• ABC/2 method with those derived from planimetric volume calculations
• Correlation of hemorrhage subtype volume and whether surgery is
performed
• Correlation of hemorrhage subtype volume with day 30 clinical outcome
according to the modified Rankin score
• Fully automated volume calculation techniques

Page 4 of 7
Images for this section:

Fig. 2: Application of the ABC/2 formula to intracerebral hemorrhage

Fig. 3: Application of the ABC/2 formula to extradural hemorrhage

Page 5 of 7
Fig. 4: Application of the ABC/2 formula to subdural hemorrhage

Page 6 of 7
Conclusion

Rapid calculation of ICH, subdural and extradural hemorrhage volume is possible using
the simplified ellipsoid formula ABC/2. The reporting of these intracranial hemorrhage
volumes has direct implications for patient prognosis in the emergency radiology setting.

Personal information

Dr. Christen Barras MBBS, BMedSc, PhD, Did.Surg.Anat., Dip.OMS is a 5th year
registrar at Royal Melbourne Hospital.

Prof. Brian Tress MD, FRANZCR, FRCR is a consultant radiologist at Royal Melbourne
Hospital and former Professor and Director of Radiology, Royal Melbourne Hospital and
The University of Melbourne.

Prof. Patricia Desmond MD, FRANZCR is a consultant radiologist at Royal Melbourne

Hospital and current Professor and Director of Radiology, Royal Melbourne Hospital and
The University of Melbourne.

References

1. Broderick JP, Brott TG, Duldner JE, Tomsick T, Huster G. Volume of intracerebral
hemorrhage. A powerful and easy-to-use predictor of 30-day mortality. Stroke.
1993;24:987-993.

2. Ericson K, Hakansson S. Computed tomography of epidural hematomas.

Association with intracranial lesions and clinical correlation. Acta Radiol Diagn (Stockh).
1981;22:513-519.

3. Broderick JP, Brott TG, Grotta JC. Intracerebral hemorrhage volume measurement.
Stroke. 1994;25:1081.

4. Newman GC. Clarification of abc/2 rule for ICH volume. Stroke. 2007;38:862.

Page 7 of 7