CT angiography "spot sign" predicts hematoma expansion in acute intracerebral hemorrhage

Systemic Inflammatory Response Syndrome is Associated with Hematoma Expansion in Intracerebral Hemorrhage

OBJECTIVES

Systemic inflammatory response syndrome (SIRS) and hematoma expansion are independently associated with worse outcomes after intracerebral hemorrhage (ICH), but the relationship between SIRS and hematoma expansion remains unclear.

MATERIALS AND METHODS

We performed a retrospective review of patients admitted to our hospital from 2013 to 2020 with primary spontaneous ICH with at least two head CTs within the first 24 hours. The relationship between SIRS and hematoma expansion, defined as ≥6 mL or ≥33% growth between the first and second scan, was assessed using univariable and multivariable regression analysis. We assessed the relationship of hematoma expansion and SIRS on discharge mRS using mediation analysis.

RESULTS

Of 149 patients with ICH, 83 (56%; mean age 67±16; 41% female) met inclusion criteria. Of those, 44 (53%) had SIRS. Admission systolic blood pressure (SBP), temperature, antiplatelet use, platelet count, initial hematoma volume and rates of infection did not differ between groups (all p>0.05). Hematoma expansion occurred in 15/83 (18%) patients, 12 (80%) of whom also had SIRS. SIRS was significantly associated with hematoma expansion (OR 4.5, 95% CI 1.16 - 17.39, p= 0.02) on univariable analysis. The association remained statistically significant after adjusting for admission SBP and initial hematoma volume (OR 5.72, 95% CI 1.40 - 23.41, p= 0.02). There was a significant indirect effect of SIRS on discharge mRS through hematoma expansion. A significantly greater percentage of patients with SIRS had mRS 4-6 at discharge (59 vs 33%, p=0.02).

CONCLUSION

SIRS is associated with hematoma expansion of ICH within the first 24 hours, and hematoma expansion mediates the effect of SIRS on poor outcome.

Artificial Intelligence Can Effectively Predict Early Hematoma Expansion of Intracerebral Hemorrhage Analyzing Noncontrast Computed Tomography Image

This study aims to develop and validate an artificial intelligence model based on deep learning to predict early hematoma enlargement (HE) in patients with intracerebral hemorrhage. A total of 1,899 noncontrast computed tomography (NCCT) images of cerebral hemorrhage patients were retrospectively analyzed to establish a predicting model and 1,117 to validate the model. And a total of 118 patients with intracerebral hemorrhage were selected based on inclusion and exclusion criteria so as to validate the value of the model for clinical prediction. The baseline noncontrast computed tomography images within 6 h of intracerebral hemorrhage onset and the second noncontrast computed tomography performed at 24 ± 3 h from the onset were used to evaluate the prediction of intracerebral hemorrhage growth. In validation dataset 1, the AUC was 0.778 (95% CI, 0.768–0.786), the sensitivity was 0.818 (95% CI, 0.790–0.843), and the specificity was 0.601 (95% CI, 0.565–0.632). In validation dataset 2, the AUC was 0.780 (95% CI, 0.761–0.798), the sensitivity was 0.732 (95% CI, 0.682–0.788), and the specificity was 0.709 (95% CI, 0.658–0.759). The sensitivity of intracerebral hemorrhage hematoma expansion as predicted by an artificial intelligence imaging system was 89.3%, with a specificity of 77.8%, a positive predictive value of 55.6%, a negative predictive value of 95.9%, and a Yoden index of 0.671, which were much higher than those based on the manually labeled noncontrast computed tomography signs. Compared with the existing prediction methods through computed tomographic angiography (CTA) image features and noncontrast computed tomography image features analysis, the artificial intelligence model has higher specificity and sensitivity in the prediction of early hematoma enlargement in patients with intracerebral hemorrhage.

Imaging of Spontaneous Intracerebral Hemorrhage

Primary or nontraumatic spontaneous intracerebral hemorrhage (ICH) comprises approximately 15% to 20% of all stroke. ICH has a mortality of approximately 40% within the first month, and 75% mortality and morbidity rate within the first year. Despite reduction in overall stroke incidence, hemorrhagic stroke incidence has remained steady since 1980. Neuroimaging is critical in detection of ICH, determining the underlying cause, identification of patients at risk of hematoma expansion, and directing the treatment strategy. This article discusses the neuroimaging methods of ICH, imaging markers for clinical outcome prediction, and future research directions with attention to the latest evidence-based guidelines.

Can perihaematomal radiomics features predict haematoma expansion?

AIM

To evaluate the association between perihaematomal radiomics features and haematoma expansion (HE).

MATERIALS AND METHODS

Clinical and radiological data were collected retrospectively. The 1:1 propensity score matching (PSM) method was used to balance the difference of baseline characteristics between patients with and without HE. Radiomics features were extracted from the intra- and perihaematomal regions. Top HE-associated features were selected using the minimum redundancy, maximum relevancy algorithm. Support vector machine models were used to predict HE. Predictive performance of radiomics features from different regions was evaluated by receiver operating characteristic curve and confusion matrix-derived metrics.

RESULTS

A total of 1,062 patients were enrolled. After PSM analysis, the propensity score-matched cohort (PSM cohort) included 314 patients (HE: n=157; non-HE: n=157). The PSM cohort was distributed into the training (n=218) and the validation cohorts (n=96). The predictive performance of intra- and perihaematomal features were comparable in the training (area under the receiver operating characteristic curve [AUC], 0.751 versus 0.757; p=0.867) and the validation cohorts (AUC, 0.724 versus 0.671; p=0.454). By incorporating intra- and perihaematomal features, the combined model outperformed the single intrahaematomal model in the training cohort (AUC, 0.872 versus 0.751; p<0.001). Decision curve analysis (DCA) further confirmed the clinical usefulness of the combined model.

CONCLUSION

Perihaematomal radiomics features can predict HE. The integration of intra- and perihaematomal signatures may provide additional benefit to the prediction of HE.

Eliminating vascular interference from the Spot Sign contributes to predicting hematoma expansion in individuals with spontaneous cerebral hemorrhages

The computed tomography angiography (CTA) Spot Sign is an effective means of predicting hematoma expansion (HE) in the context of spontaneous intracerebral hemorrhage (ICH). We investigated whether continuous CTA source images could differentiate the Spot Sign and blood vessels in the hematoma, and whether it would improve Spot Sign accuracy as an HE predictor. We screened for the presence of CTA Spot Sign in individuals affected by spontaneous ICH within 24 h of symptom development. Based on our findings, we determined the sensitivity, specificity, and positive/negative predictive values of this sign as a predictor of HE both on its own and following the exclusion of blood vessels. In addition, a receiver-operating characteristic approach was used to assess the accuracy of Spot Sign with and without elimination of vascular interference. A total of 265 patients were included in this study. The Spot Sign was observed in 100 patients, including in 29 patients wherein it was confirmed to be blood vessels as determined based upon continuous CTA source images. With respect to predicting HE, Spot Sign sensitivity, specificity, positive predictive values, and negative predictive values were 57%, 71%, 48% and 78%, respectively. Following the exclusion of blood vessels, these values were 57%, 87%, 68% and 81%, respectively. Spot Sign area under the curve after excluding blood vessels was 0.718, which was higher than that of the Spot Sign (0.638). After continuous CTA, source images are used to exclude blood vessels in the hematoma, the Spot Sign is thus more accurate in predicting HE.

Intracerebral Hemorrhage: Advances in Emergency Care

Intracerebral hemorrhage is a stroke subtype with high mortality and poor functional outcome in survivors. Its main causes are hypertension, cerebral amyloid angiopathy, and anticoagulant treatment. Hematomas have a high frequency of expansion in the first hours after symptom onset, a process associated with neurologic deterioration and poor outcome. Control of severe hypertension, reversal of anticoagulant effect, and management of increased intracranial pressure are the mainstays of management of intracerebral hemorrhage in the acute phase. Surgical evacuation of the hematoma by conventional craniotomy does not improve outcomes, but minimally invasive techniques may be a valuable approach that deserves further evaluation.

Minimally Invasive Intracerebral Hemorrhage Evacuation Techniques: A Review

Intracerebral hemorrhage (ICH) continues to have high morbidity and mortality. Improving ICH outcomes likely requires rapid removal of blood from the parenchyma and restraining edema formation while also limiting further neuronal damage due to the surgical intervention. Minimally invasive surgery (MIS) approaches promise to provide these benefits and have become alluring options for management of ICH. This review describes six MIS techniques for ICH evacuation including craniopuncture, stereotactic aspiration with thrombolysis, endoport-mediated evacuation, endoscope-assisted evacuation, adjunctive aspiration devices, and the surgiscope. The efficacy of each modality is discussed based on current literature. The largest clinical trials have yet to demonstrate definitive effects of MIS intervention on mortality and functional outcomes for ICH. Thus, there is a significant need for further innovation for ICH treatment. Multiple ongoing trials promise to better clarify the potential of the newer, non-thrombolytic MIS techniques.

Early spot sign is associated with functional outcomes in primary intracerebral hemorrhage survivors

BACKGROUND

The computed tomography angiography (CTA) spot sign is a validated predictor of hematoma expansion and 30-day mortality in intracerebral hemorrhage (ICH). However, whether the spot sign predicts worse functional outcomes among ICH survivors remains unclear. This study investigated the frequency of the spot sign and its association with functional outcomes and length of hospital stay among ICH survivors.

METHODS

This was a retrospective analysis of consecutive patients with primary ICH who received CTA within 24 h from presentation to admission to the emergency department of a single medical center between January 2007 and December 2017. Patients who died before discharge and those referred from other hospitals were excluded. CTAs with motion artifacts were excluded from the analysis. The presence of a spot sign was examined by an experienced neuroradiologist. Functional outcomes were determined based on the modified Rankin Scale (mRS) score and Barthel Index (BI). Severe dependency in activities of daily living (ADL) was defined as BI of ≤60 and severe disability as an mRS score of ≥4. Odds ratio (OR) and multiple linear regression were used as measures of association.

RESULTS

In total, 66 patients met the inclusion criteria, of whom 9 (13.64%) were positive for a spot sign. No significant differences were observed in baseline characteristics between patients with and without a spot sign. Patients with a spot sign tended to be severely dependent in ADL at discharge (66.67% vs 41.07%; OR = 2.87; p = 0.15) and were more likely to require ICH-related surgery (66.67% vs 24.56%; OR = 6.14; p = 0.01). In multiple linear regression, patients with a higher spot sign score had a significantly longer hospital stay (coefficient = 9.57; 95% CI = 2.11-17.03; p = 0.013).

CONCLUSIONS

The presence of a spot sign is a common finding and is associated with longer hospital stay and possibly worse functional outcomes in ICH survivors.

Radiomics for intracerebral hemorrhage: are all small hematomas benign?

OBJECTIVES

We hypothesized that not all small hematomas are benign and that radiomics could predict hematoma expansion (HE) and short-term outcomes in small hematomas.

METHODS

We analyzed 313 patients with small (<10 ml) intracerebral hemorrhage (ICH) who underwent baseline non-contrast CT within 6 h of symptom onset between September 2013 and February 2019. Poor outcome was defined as a Glasgow Outcome Scale score ≤3. A radiomic model and a clinical model were built using least absolute shrinkageand selection operator algorithm or multivariate analysis. A combined model that incorporated the developed radiomic score and clinical factors was then constructed. The area under the receiver operating characteristic curve (AUC) was used to evaluate the performance of these models.

RESULTS

The addition of radiomics to clinical factors significantly improved the prediction performance of HE compared with the clinical model alone in both the training {AUC, 0.762 [95% CI (0.665-0.859)] versus AUC, 0.651 [95% CI (0.556-0.745)], p = 0.007} and test {AUC, 0.776 [95% CI (0.655-0.897) versus AUC, 0.631 [95% CI (0.451-0.810)], p = 0.001} cohorts. Moreover, the radiomic-based model achieved good discrimination ability of poor outcomes in the 3-10 ml group (AUCs 0.720 and 0.701).

CONCLUSION

Compared with clinical information alone, combined model had greater potential for discriminating between benign and malignant course in patients with small ICH, particularly 3-10 ml hematomas.

ADVANCES IN KNOWLEDGE

Radiomics can be used as a supplement to conventional medical imaging, improving clinical decision-making and facilitating personalized treatment in small ICH.

Recommendations for Research Assessing Outcomes for Patients With Anticoagulant-Related Intracerebral Bleeds

Intracerebral bleeds related to anticoagulant use have a poor prognosis and substantial risk of disability and death. Recent publications evaluating replacement or reversal therapies for anticoagulants lack consistency in controlling for key factors that significantly influence outcomes. In an effort to guide future research by providing a framework to improve consistency and reduce the potential for confounding in this dynamic and highly time-dependent brain insult, we provide here a brief overview of variables we consider critical in studies evaluating the risk and the reversal of anticoagulant therapies in anticoagulant-related intracerebral bleeds. Hematoma expansion stands out as one of the few potentially modifiable risk factors and its early control could mitigate secondary brain injury, and it, therefore, requires careful categorization. In addition to the baseline demographic, clinical, and radiological predictors of hematoma expansion, we specifically highlight time-dependent factors such as the time from the last dose, time from symptom onset and time to treatment, the computed tomography angiography spot sign, and the limitation of early care as especially critical predictors of outcomes in anticoagulant-related intracerebral bleeds. Intracerebral hemorrhage is a condition that requires fast diagnosis and treatment, especially when associated with anticoagulants. The advent of therapies with rapid reversal of anticoagulation open the opportunity to assess the scale to which faster reversal of anticoagulation modifies hematoma expansion and clinical outcomes. Thus, comprehensive assessment and reporting of these important potential confounding factors, particularly the critical time variables, is crucial to improving research and treatment of intracerebral hemorrhages.

Different criteria for defining "spot sign" in intracerebral hemorrhage show different abilities to predict hematoma expansion and clinical outcomes: a systematic review and meta-analysis

The "spot sign" is a well-known radiological marker used for predicting hematoma expansion and clinical outcomes in patients with intracerebral hemorrhage (ICH). We performed a meta-analysis to assess the predictive accuracy of spot sign, depending on the criteria used to identify them.We conducted a systematic review of clinical studies that clearly stated their definition of spot sign and that were indexed in the Cochrane Library, MEDLINE, EMBASE, and the China National Knowledge Infrastructure databases. We collected data on computed tomography (CT) parameters, spot sign diagnostic criteria, hematoma expansion, and clinical outcomes.Based on the eligibility criteria, we included 17 studies in this systematic review. CT imaging modality, type, time from symptom onset to CT, time from contrast infusion to scan, slice thickness, tube current, and tube electric discharge showed variation across studies. Three different definitions of the spot sign were applied: (1) a hyperdense spot within the hematoma; (2) one or more focal areas/regions of contrast pooling of any size and morphology that occurred within a hemorrhage, were discontinuous from the normal or abnormal vasculature adjacent to the hemorrhage, and showed an attenuation rate ≥ 120 UH; or (3) serpiginous or spot-like contrast density on CTA images that occurred within the hematoma margin, showed twice the density of the hematoma background, and did not contact vessels outside the hematoma. Three definitions for the spot sign were identified, all of which were associated with hematoma expansion, mortality, and unfavorable functional outcome. Subgroup analyses based on these definitions showed that spot sign identified using the second definition were more likely to be associated with hematoma expansion (OR 18.31, 95% CI 9.11-36.8) and unfavorable functional outcomes (OR 8.78, 95% CI 3.24-23.79), while those identified using the third definition were associated with increased risk of mortality (OR 6.88, 95% CI 1.43-33.13).Clinical studies identify spot sign using different CT protocols and criteria. These differences affect the ability of spot sign to predict hematoma expansion and clinical outcomes in ICH patients.

Noncontrast Computed Tomography Markers as Predictors of Revised Hematoma Expansion in Acute Intracerebral Hemorrhage

Background Noncontrast computed tomography (NCCT) markers are the emerging predictors of hematoma expansion in intracerebral hemorrhage. However, the relationship between NCCT markers and the dynamic change of hematoma in parenchymal tissues and the ventricular system remains unclear. Methods and Results We included 314 consecutive patients with intracerebral hemorrhage admitted to our hospital from July 2011 to May 2017. The intracerebral hemorrhage volumes and intraventricular hemorrhage (IVH) volumes were measured using a semiautomated, computer-assisted technique. Revised hematoma expansion (RHE) was defined by incorporating the original definition of hematoma expansion into IVH growth. Receiver operating characteristic curve analysis was used to compare the performance of the NCCT markers in predicting the IVH growth and RHE. Of 314 patients in our study, 61 (19.4%) had IVH growth and 93 (23.9%) had RHE. After adjustment for potential confounding variables, blend sign, black hole sign, island sign, and expansion-prone hematoma could independently predict IVH growth and RHE in the multivariate logistic regression analysis. Expansion-prone hematoma had a higher predictive performance of RHE than any single marker. The diagnostic accuracy of RHE in predicting poor prognosis was significantly higher than that of hematoma expansion. Conclusions The NCCT markers are independently associated with IVH growth and RHE. Furthermore, the expansion-prone hematoma has a higher predictive accuracy for prediction of RHE and poor outcome than any single NCCT marker. These findings may assist in risk stratification of NCCT signs for predicting active bleeding.

Deep learning for automatically predicting early haematoma expansion in Chinese patients

Background and purpose

Early haematoma expansion is determinative in predicting outcome of intracerebral haemorrhage (ICH) patients. The aims of this study are to develop a novel prediction model for haematoma expansion by applying deep learning model and validate its prediction accuracy.

Methods

Data of this study were obtained from a prospectively enrolled cohort of patients with primary supratentorial ICH from our centre. We developed a deep learning model to predict haematoma expansion and compared its performance with conventional non-contrast CT (NCCT) markers. To evaluate the predictability of this model, it was also compared with a logistic regression model based on haematoma volume or the BAT score.

Results

A total of 266 patients were finally included for analysis, and 74 (27.8%) of them experienced early haematoma expansion. The deep learning model exhibited highest C statistic as 0.80, compared with 0.64, 0.65, 0.51, 0.58 and 0.55 for hypodensities, black hole sign, blend sign, fluid level and irregular shape, respectively. While the C statistics for swirl sign (0.70; p=0.211) and heterogenous density (0.70; p=0.141) were not significantly higher than that of the deep learning model. Moreover, the predictive value for the deep learning model was significantly superior to that of the logistic model of haematoma volume (0.62; p=0.042) and the BAT score (0.65; p=0.042).

Conclusions

Compared with the conventional NCCT markers and BAT predictive model, the deep learning algorithm showed superiority for predicting early haematoma expansion in ICH patients.

Dual-Energy CT Angiography Improves Accuracy of Spot Sign for Predicting Hematoma Expansion in Intracerebral Hemorrhage

Background and Purpose

Spot sign (SS) on computed tomography angiography (CTA) is associated with hematoma expansion (HE) and poor outcome after intracerebral hemorrhage (ICH). However, its predictive performance varies across studies, possibly because differentiating hyperdense hemorrhage from contrast media is difficult. We investigated whether dual-energy-CTA (DE-CTA), which can separate hemorrhage from iodinated contrast, improves the diagnostic accuracy of SS for predicting HE.

Methods

Primary ICH patients undergoing DE-CTA (both arterial as well as delayed venous phase) and follow-up computed tomography were prospectively included between 2014 and 2019. SS was assessed on both arterial and delayed phase images of the different DE-CTA datasets, i.e., conventional-like mixed images, iodine images, and fusion images. Diagnostic accuracy of SS for prediction of HE was determined on all datasets. The association between SS and HE, and between SS and poor outcome (modified Rankin Scale at 3 months ≥3) was assessed with multivariable logistic regression, using the dataset with highest diagnostic accuracy.

Results

Of 139 included patients, 47 showed HE (33.8%). Sensitivity of SS for HE was 32% (accuracy 0.72) on conventional-like mixed arterial images which increased to 76% (accuracy 0.80) on delayed fusion images. Presence of SS on delayed fusion images was independently associated with HE (odds ratio [OR], 17.5; 95% confidence interval [CI], 6.14 to 49.82) and poor outcome (OR, 3.84; 95% CI, 1.16 to 12.73).

Conclusions

Presence of SS on DE-CTA, in particular on delayed phase fusion images, demonstrates higher diagnostic performance in predicting HE compared to conventional-like mixed imaging, and it is associated with poor outcome.

In spontaneous intracerebral hematoma patients, prediction of the hematoma expansion risk and mortality risk using radiological and clinical markers and a newly developed scale

Objective: In patients with spontaneous intracerebral hematoma (ICH), early-stage hematoma expansion has been associated with poor prognosis in literature. This study aimed to develop predictive parameter(s) as well as a new scale to define hematoma expansion and short-term prognosis in patients with ICH.Methods: In 46 patients with ICH, Glasgow Coma Scale (GCS) scores, non-contrast CT (NCCT) markers (hematoma volume on admission and follow-up, hypodensity, intraventricular hemorrhage, blend and island sign, BAT score), and modified Rankin Scale scores were evaluated for predicting the hematoma expansion risk and mortality risk. Furthermore, a newly developed scale called the 'HEMRICH scale' was constituted using the GCS score, hematoma volumes, and some NCCT markers.Results: Roc-Curve and Logistic Regression test results revealed that GCS score, initial hematoma volume value, hypodensity, intraventricular haemorrhage, BAT score, and HEMRICH scale score could be the best markers in predicting hematoma expansion risk whereas GCS score, intraventricular haemorrhage, BAT score, hematoma expansion, and HEMRICH scale score could be the best markers in predicting mortality risk (p = 0.01). Moreover, Factor analysis and Reliability test results showed that HEMRICH scale score could predict both hematoma expansion and mortality risks validly (Kaiser-Meyer-Olkin test value = 0.729) and reliably (Cronbach's alpha = 0.564).Conclusion: It was concluded that the GCS score, intraventricular haemorrhage, and BAT score could predict both hematoma expansion risk and mortality risk in the early stage in patients with ICH. Furthermore, it was suggested that the newly produced HEMRICH scale could be a valid and reliable scale for predicting both hematoma expansion and mortality risk.

Hemorrhagic stroke

Hemorrhagic stroke comprises about 20% of all strokes, with intracerebral hemorrhage (ICH) being the most common type. Frequency of ICH is increased where hypertension is untreated. ICH in particularly has a disproportionately high risk of early mortality and long-term disability. Until recently, there has been a paucity of randomized controlled trials (RCTs) to provide evidence for the efficacy of various commonly considered interventions in ICH, including acute blood pressure management, coagulopathy reversal, and surgical hematoma evacuation. Evidence-based guidelines do exist for ICH and these form the basis for a framework of care. Current approaches emphasize control of extremely high blood pressure in the acute phase, rapid reversal of vitamin K antagonists, and surgical evacuation of cerebellar hemorrhage. Lingering questions, many of which are the topic of ongoing clinical research, include optimizing individual blood pressure targets, reversal strategies for newer anticoagulant medications, and the role of minimally invasive surgery. Risk stratification models exist, which derive from findings on clinical exam and neuroimaging, but care should be taken to avoid a self-fulfilling prophecy of poor outcome from limiting treatment due to a presumed poor prognosis. Cerebral venous thrombosis is an additional subtype of hemorrhagic stroke that has a unique set of causes, natural history, and treatment and is discussed as well.

Management of Intracerebral Hemorrhage: JACC Focus Seminar

Intracerebral hemorrhage (ICH) accounts for a disproportionate amount of stroke-related morbidity and mortality. Although chronic hypertension and cerebral amyloid angiopathy are the underlying cerebral vasculopathies accounting for the majority of ICH, there are a broad range of potential causes, and effective management requires accurate identification and treatment of the underlying mechanism of hemorrhage. Magnetic resonance imaging and vascular imaging techniques play a critical role in identifying disease mechanisms. Modern treatment of ICH focuses on rapid stabilization, often requiring urgent treatment of mass effect, aggressive blood pressure reduction and correction of contributing coagulopathies to achieve hemostasis. We discuss management of patients with ICH who continue to require long-term anticoagulation, the interaction of ICH with neurodegenerative diseases, and our approach to prognostication after ICH. We close this review with a discussion of novel medical and surgical approaches to ICH treatment that are being tested in clinical trials.

A Meta-analysis of the Predictive Significance of the Island Sign for Hematoma Expansion in Intracerebral Hemorrhage

BACKGROUND

The island sign of non-contrast computed tomography is a risk factor for hematoma expansion (HE) after spontaneous intracerebral hemorrhage, but has inconsistent conclusions. A meta-analysis was performed to investigate the predictive accuracy of island sign for HE.

METHODS

A systematic review of published literature on island sign and hematoma expansion was conducted. The pooled sensitivity, specificity, and summary receiver operating characteristics curve (SROC) were generated. The publication bias was assessed by Deeks' funnel plot asymmetry test.

RESULTS

Nine studies with a total of 2939 patients were included in the present study. The pooled sensitivity and specificity of island sign for predicting hematoma expansion was 0.50 and 0.89, respectively. The area under the curve was 0.73 in the SROC curve. There was no significant publication bias.

CONCLUSIONS

This meta-analysis suggests that island sign of non-contrast computed tomography has a good predictive accuracy for hematoma enlargement in intracerebral hemorrhage.

Prevalence and the predictive performance of the dynamic CT-angiography spot sign in an observational cohort with intracerebral hemorrhage

The CT-angiography (CTA) spot sign is a predictor of hematoma expansion (HE). We have previously reported on the use of dynamic CTA (dCTA) to detect spot sign, and to study its formation over the acquisition period. In this study, we report the frequency of dCTA spot sign in acute intracerebral hemorrhage, its sensitivity and specificity to predict HE, and explore the rate of contrast extravasation in relation to hematoma growth.We enrolled consecutive patients presenting with primary intracerebral hemorrhage within 4.5 hours. All patients underwent a dCTA protocol acquired over 60 seconds following contrast injection. We calculated frequency of the dCTA spot sign, predictive performance, and rate of contrast extravasation. We compared extravasation rates to the dichotomous definition of significant HE (defined as 6 mL or 33% growth).In 78 eligible patients, dCTA spot sign frequency was 44.9%. In 61 patients available for expansion analysis, sensitivity and specificity of dCTA spot sign was 65.4% and 62.9%, respectively. Contrast extravasation rate did not significantly predict HE (Odds Ratio 15.6 for each mL/min [95% confidence interval 0.30-820.25], P = .17). Correlation between extravasation rate and HE was low (r = 0.297, P= .11). Patients with significant HE had a higher rate of extravasation as compared to those without (0.12 mL/min vs 0.04 mL/min, P = .03).Dynamic CTA results in a higher frequency of spot sign positivity, but with modest sensitivity and specificity to predict expansion. Extravasation rate is likely related to HE, but a single measurement may be insufficient to predict the magnitude of expansion.

Associations Between Levels of High-Sensitivity C-Reactive Protein and Outcome After Intracerebral Hemorrhage

Background: Patients with spontaneous intracerebral hemorrhage (ICH) have high mortality and morbidity rates; approximately one-third of patients with ICH experience hematoma expansion (HE). The spot sign is an established and validated imaging marker for HE. High-sensitivity C-reactive protein (hs-CRP) is an established laboratory marker for inflammation and secondary brain injury following ICH. Objective: To determine the association between the spot sign and hs-CRP, hematoma expansion, and clinical outcomes. Methods: Between December 2014 and September 2016, we prospectively recruited 1,964 patients with acute symptomatic ICH at 13 hospitals in Beijing, China. Next, we selected 92 patients within 24 h of the onset of symptoms from this cohort for the present study. ICH was diagnosed in the emergency room by non-contrast computed tomography (NCCT) scans. Follow-up scans were carried out within 48 h to evaluate patients for HE. Multidetector computed tomography angiography (MDCTA) was also used to identify spot signs. Blood samples were collected from each patient at admission in EDTA tubes (for plasma) or vacutainer tubes (for serum). hs-CRP values were determined by a particle-enhanced immunoturbidimetric assay in the laboratory at Beijing Tiantan Hospital, Capital Medical University. Patients were categorized into two groups according to their hs-CRP levels (hs-CRP <3 mg/L, hs-CRP ≥3 mg/L). Results: The incidences of spot sign and HE in our study cohort were 31.5 and 29.3%, respectively. Following the removal of potential confounding variables, stepwise-forward logistic regression analysis identified that an hs-CRP level ≥3 mg/L was not a significant indicator for either spot sign (p = 0.68) or HE (p = 0.07). However, an hs-CRP level ≥3 mg/L (odds ratio: 16.64, 95% confidence interval: 2.11-131.45, p = 0.008) was identified as an independent predictor of an unfavorable outcome 1 year after acute ICH. Conclusions: Our analyses identified that an hs-CRP level ≥3 mg/L was a significant indicator for an unfavorable outcome 1 year after acute ICH.

Tranexamic acid in patients with intracerebral haemorrhage (STOP-AUST): a multicentre, randomised, placebo-controlled, phase 2 trial

BACKGROUND

Despite intracerebral haemorrhage causing 5% of deaths worldwide, few evidence-based therapeutic strategies other than stroke unit care exist. Tranexamic acid decreases haemorrhage in conditions such as acute trauma and menorrhoea. We aimed to assess whether tranexamic acid reduces intracerebral haemorrhage growth in patients with acute intracerebral haemorrhage.

METHODS

We did a prospective, double-blind, randomised, placebo-controlled, investigator-led, phase 2 trial at 13 stroke centres in Australia, Finland, and Taiwan. Patients were eligible if they were aged 18 years or older, had an acute intracerebral haemorrhage fulfilling clinical criteria (eg, Glasgow Coma Scale score of >7, intracerebral haemorrhage volume <70 mL, no identified or suspected secondary cause of intracerebral haemorrhage, no thrombotic events within the previous 12 months, no planned surgery in the next 24 h, and no use of anticoagulation), had contrast extravasation on CT angiography (the so-called spot sign), and were treatable within 4·5 h of symptom onset and within 1 h of CT angiography. Patients were randomly assigned (1:1) to receive either 1 g of intravenous tranexamic acid over 10 min followed by 1 g over 8 h or matching placebo, started within 4·5 h of symptom onset. Randomisation was done using a centralised web-based procedure with randomly permuted blocks of varying size. All patients, investigators, and staff involved in patient management were masked to treatment. The primary outcome was intracerebral haemorrhage growth (>33% relative or >6 mL absolute) at 24 h. The primary and safety analyses were done in the intention-to-treat population. The trial is registered at ClinicalTrials.gov (NCT01702636).

FINDINGS

Between March 1, 2013, and Aug 13, 2019, we enrolled and randomly assigned 100 participants to the tranexamic acid group (n=50) or the placebo group (n=50). Median age was 71 years (IQR 57-79) and median intracerebral haemorrhage volume was 14·6 mL (7·9-32·7) at baseline. The primary outcome was not different between the two groups: 26 (52%) patients in the placebo group and 22 (44%) in the tranexamic acid group had intracerebral haemorrhage growth (odds ratio [OR] 0·72 [95% CI 0·32-1·59], p=0·41). There was no evidence of a difference in the proportions of patients who died or had thromboembolic complications between the groups: eight (16%) in the placebo group vs 13 (26%) in the tranexamic acid group died and two (4%) vs one (2%) had thromboembolic complications. None of the deaths was considered related to study medication.

INTERPRETATION

Our study does not provide evidence that tranexamic acid prevents intracerebral haemorrhage growth, although the treatment was safe with no increase in thromboembolic complications. Larger trials of tranexamic acid, with simpler recruitment methods and an earlier treatment window, are justified.

FUNDING

National Health and Medical Research Council, Royal Melbourne Hospital Foundation.

Noncontrast Computed Tomography-Based Radiomics Analysis in Discriminating Early Hematoma Expansion after Spontaneous Intracerebral Hemorrhage

Objective

To determine whether noncontrast computed tomography (NCCT) models based on multivariable, radiomics features, and machine learning (ML) algorithms could further improve the discrimination of early hematoma expansion (HE) in patients with spontaneous intracerebral hemorrhage (sICH).

Materials and Methods

We retrospectively reviewed 261 patients with sICH who underwent initial NCCT within 6 hours of ictus and follow-up CT within 24 hours after initial NCCT, between April 2011 and March 2019. The clinical characteristics, imaging signs and radiomics features extracted from the initial NCCT images were used to construct models to discriminate early HE. A clinical-radiologic model was constructed using a multivariate logistic regression (LR) analysis. Radiomics models, a radiomics-radiologic model, and a combined model were constructed in the training cohort (n = 182) and independently verified in the validation cohort (n = 79). Receiver operating characteristic analysis and the area under the curve (AUC) were used to evaluate the discriminative power.

Results

The AUC of the clinical-radiologic model for discriminating early HE was 0.766. The AUCs of the radiomics model for discriminating early HE built using the LR algorithm in the training and validation cohorts were 0.926 and 0.850, respectively. The AUCs of the radiomics-radiologic model in the training and validation cohorts were 0.946 and 0.867, respectively. The AUCs of the combined model in the training and validation cohorts were 0.960 and 0.867, respectively.

Conclusion

NCCT models based on multivariable, radiomics features and ML algorithm could improve the discrimination of early HE. The combined model was the best recommended model to identify sICH patients at risk of early HE.

An East Coast Perspective on Artificial Intelligence and Machine Learning: Part 1: Hemorrhagic Stroke Imaging and Triage

Hemorrhagic stroke is a medical emergency. Artificial intelligence techniques and algorithms may be used to automatically detect and quantitate intracranial hemorrhage in a semiautomated fashion. This article reviews the use of deep learning convolutional neural networks for managing hemorrhagic stroke. Such a capability may be used to alert appropriate care teams, make decisions about patient transport from a primary care center to a comprehensive stroke center, and assist in treatment selection. This article reviews artificial intelligence algorithms for intracranial hemorrhage detection, quantification, and prognostication. Multiple algorithms currently being explored are described and illustrated with the help of examples.

An East Coast Perspective on Artificial Intelligence and Machine Learning: Part 2: Ischemic Stroke Imaging and Triage

Acute ischemic stroke constitutes approximately 85% of strokes. Most strokes occur in community settings; thus, automatic algorithms techniques are attractive for managing these cases. This article reviews the use of deep learning convolutional neural networks in the management of ischemic stroke. Artificial intelligence-based algorithms may be used in patient triage to detect and sound the alarm based on early imaging, alert care teams, and assist in treatment selection. This article reviews algorithms for artificial intelligence techniques that may be used to detect and localize acute ischemic stroke. We describe artificial intelligence algorithms for these tasks and illustrate them with examples.

Surgical strategy for patients with supratentorial spontaneous intracerebral hemorrhage: minimally invasive surgery and conventional surgery

Objective

The role of surgery in spontaneous intracerebral hemorrhage (sICH) is still controversial. We aimed to investigate the effectiveness of minimally invasive surgery (MIS) compared to conventional surgery (CS) for supratentorial sICH.

Methods

The medical data of 70 patients with surgically treated supratentorial sICH were retrospectively reviewed. MIS was performed in 35 patients, and CS was performed in 35 patients. The surgical technique was selected based on the neurological status and radiological findings, such as hematoma volume, neurological status and spot signs on computed tomographic angiography. Treatment outcomes, prognostic factors and the usefulness of the spot sign were analyzed.

Results

Clinical states in both groups were statistically similar, preoperatively, and in 1 and 3 months after surgery. Both groups showed significant progressive improvement till 3 months after surgery. Better preoperative neurological status, more hematoma removal and intensive care unit (ICU) stay ≤7 days were the significant prognostic factors for favorable 3-month clinical outcomes (odds ratio [OR] 0.31, 95% confidence interval [CI] 0.10–0.96, p=0.04; OR 1.04, 95% CI 1.01–1.08, p=0.02; OR 26.31, 95% CI 2.46–280.95, p=0.01, respectively). Initial hematoma volume and MIS were significant prognostic factors for a short ICU stay (≤7 days; OR 0.95; 95% CI 0.91–0.99; p=0.01; OR 3.91, 95% CI 1.03–14.82, p=0.045, respectively). No patients in the MIS group experienced hematoma expansion before surgery or postoperative rebleeding.

Conclusions

MIS was not inferior to CS in terms of clinical outcomes. The spot sign seems to be an effective radiological marker for predicting hematoma expansion and determining the surgical technique.

Rationale and Design of a Randomized, Double-Blind Trial Evaluating the Efficacy of Tranexamic Acid on Hematoma Expansion and Peri-hematomal Edema in Patients with Spontaneous Intracerebral Hemorrhage within 4.5 h after Symptom Onset: The THE-ICH Trial Protocol

BACKGROUND

Hematoma expansion (HE) and peri-hematomal edema (PHE) are associated with adverse outcomes of patients with acute spontaneous intracerebral hemorrhage (sICH). Due to a lack of proven treatments, it is critical to explore novel treatments for HE and PHE to improve functional recovery after sICH.

METHODS

This is a prospective, multicenter, placebo-controlled, double-blind, and randomized clinical study of approximately 2400 patients with sICH. Patients within 4.5 h of sICH onset that fulfilling the clinical criteria for diagnosis (e.g. age more than 18 years old, the Glasgow Coma Scal>7, and no planned surgery) will randomly receive either intravenous tranexamic acid (TXA) 1 g 10-min bolus followed by 1 g eight-hour infusion or placebo (sodium chloride 0.9%). Clinical data including the ICH score and the Glasgow Coma Scale score will be collected on admission. After assessment of HE and PHE expansion, follow-up will be conducted with enrolled patients for 90 days.

RESULTS

Primary outcome metrics are HE (defined as either >33% or >6 ml increase from baseline) and PHE expansion rate at 24 ± 3 h and 72 ± 3 h post-sICH. Secondary outcome metrics include mortality and the modified Rankin Scale on day 90 after sICH. Appropriate statistic methods will be used to evaluate the efficacy of TXA on patients with sICH within 4.5 h of symptom onset.

CONCLUSIONS

HE usually occurs within the first few hours after onset of symptoms. It is essential to evaluate the efficacy of TXA on HE within a narrow window of time. This will be the first trial to evaluate the efficacy of TXA on HE and PHE expansion in sICH patients within 4.5 h after symptom onset. This trial is registered as ChiCTR1900027065 at http://www.chictr.org.cn.

Clinico-radiological related to early brain death factors

OBJECTIVE

To identify clinical and radiological factors associated to early evolution to brain death (BD), defined as occurring within the first 24 hours.

DESIGN

A retrospective cohort study was made covering the period 2015-2017.

SETTING

An adult Intensive Care Unit (ICU).

PATIENTS/METHODS

Epidemiological, clinical and imaging (CT scan) parameters upon admission to the ICU in patients evolving to BD.

RESULTS

A total of 166 patients with BD (86 males, mean age 62.7 years) were analyzed. Primary cause: intracerebral hemorrhage 42.8%, subarachnoid hemorrhage 18.7%, traumatic brain injury 17.5%, anoxia 9%, stroke 7.8%, other causes 4.2%. Epidemiological data: arterial hypertension 50%, dyslipidemia 34%, smoking 33%, antiplatelet medication 21%, alcoholism 19%, anticoagulant therapy 15%, diabetes 15%. The Glasgow Coma Score (GCS) upon admission was 3 in 68.8% of the cases in early BD versus in 38.2% of the cases in BD occurring after 24 h (p = 0.0001). Eighty-five patients presented supratentorial hematomas with a volume of 90.9 ml in early BD versus 82.7 ml in BD >24 h (p = 0.54). The mean midline shift was 10.7 mm in early BD versus 7.8 mm in BD >24 h (p = 0.045). Ninety-one patients presented ventriculomegaly and 38 additionally ependymal transudation (p = 0.021). Thirty-six patients with early BD versus 24 with BD >24 h presented complete effacement of basal cisterns (p = 0.005), sulcular effacement (p = 0.013), loss of cortico-subcortical differentiation (p = 0.0001) and effacement of the suprasellar cistern (p = 0.005). The optic nerve sheath measurements showed no significant differences between groups.

CONCLUSIONS

Early BD (>24 h) was associated to GCS < 5, midline shift, effacement of the basal cisterns, cerebral sulci and suprasellar cistern, and ependymal transudation.

Not a String, not a Tangle, not an Aneurysm : Emerging Pattern of Large Parenchymal Bleeding in Younger Patients Associated with Abnormal Vessels on Imaging

PURPOSE

Intracerebral hemorrhage (ICH) accounts for up to 20% of all strokes, and there is a high rate of associated morbidity and mortality. Computed tomography (CT) findings, such as a spot sign have been shown to be an independent predictor of poor outcome. We have recently encountered a succession of ICH patients who presented with a peculiar imaging finding, which we term the spot on a string sign. This is a rare imaging finding, and interestingly, all these patients presented to our institution over the last few weeks.

METHODS

This was a single high-volume center series of patients who presented to our institution between 1 April and 21 May 2020. All patients underwent initial non-contrast CT brain and subsequent CT angiography (CTA). We also present laboratory and clinical data. Our primary measure was the presence of the spot on a string sign on the CTA. We also report the clinical course of these patients.

RESULTS

In this study seven large-volume ICH patients with this imaging sign were identified, with a median age of 48 years (range 30-68 years). All had tested negative for coronavirus disease 19 (COVID-19).

CONCLUSION

We have described an unusual imaging finding in a cohort of younger patients with large-volume ICH, all of whom presented in a 2-month period to a high-volume neurovascular unit. The cause of these ICH presentations and associated imaging findings are unclear, but we encourage other clinicians to be aware of and vigilant for this rare phenomenon, especially in younger patients with such a bleeding pattern.

Clinical Impact of Hematoma Expansion in Left Ventricular Assist Device Patients

BACKGROUND

Hematoma expansion (HE) is associated with poor outcome in patients with intracerebral hemorrhage (ICH), but the impact on patients with an left ventricular assist device (LVAD) is unknown. We aimed to define the occurrence of HE in the LVAD population and to determine the association between HE and mortality.

METHODS

We performed a retrospective cohort study of LVAD patients and intentionally matched anticoagulated controls without LVAD admitted to Columbia University Irving Medical Center with ICH between 2008 and 2019. We compared HE occurrence between patients with an LVAD and those without an LVAD using regression modeling, adjusting for factors known to influence HE. We evaluated pump thrombosis following anticoagulation reversal. We examined the association between HE and hospital mortality using Poisson regression modeling adjusting for factors associated with poor outcome.

RESULTS

Among 605 patients with an LVAD, we identified 28 patients with ICH meeting the study's inclusion criteria. Our LVAD ICH cohort was predominantly male (71%), with a mean age of 56 ± 10 years. The median baseline hematoma size was 20.1 mL³ (interquartile range [IQR], 8.6-46.9 mL³), and the median ICH score was 1 (IQR, 1-2). There was no significant difference in occurrence of HE in LVAD patients and matched non-LVAD patients (adjusted odds ratio [OR], 1.3; 95% confidence interval [CI], 0.4-4.2). There was an association between HE and in-hospital mortality in LVAD patients (adjusted OR, 4.8; 95% CI, 1.4-6.2).

CONCLUSIONS

HE occurrence appears to be similar in LVAD and non-LVAD patients. HE has a significant impact on LVAD ICH mortality, underscoring the importance of adequate coagulopathy reversal and blood pressure management in these patients.

Pseudoaneurysm Resulting in Rebleeding After Evacuation of Spontaneous Intracerebral Hemorrhage

BACKGROUND

Spontaneous intracerebral hemorrhage (ICH) is a devastating cerebrovascular disease with high morbidity and mortality. Branching pattern of the lenticulostriate arteries from the middle cerebral artery makes them susceptible to formation of microaneurysms, which have been implicated in hypertensive ICH. Recurrence of hematoma due to delayed development of pseudoaneurysm after initial surgical evacuation is uncommon.

CASE DESCRIPTION

Our patient is a 61-year-old gentleman who underwent primary evacuation of a spontaneous right-sided ICH. The initial vascular imaging was unremarkable for any underlying vascular malformation. After initial neurologic recovery, the patient developed another rebleeding in the hematoma cavity nearly 10 days after presentation. A formal angiogram showed the presence of a pseudoaneurysm that was treated via endovascular means.

CONCLUSIONS

The rates of rebleeding have ranged from 10%-40% in various studies and have been directly correlated with mortality. Since follow-up with angiograms are not a usual practice in spontaneous ICH management, such as pseudoaneurysmal rebleeds could go undiagnosed. This case report reinforces the need for a thorough angiographic evaluation in the event of a deviation from expected clinical course, rebleeding not in concordance with intraoperative findings and significantly delayed hematoma recurrence.

Accuracy of imaging markers on noncontrast computed tomography in predicting intracerebral hemorrhage expansion

Objectives Hematoma expansion (HE) is an important factor of unfavorable outcome in patients with intracerebral hemorrhage (ICH). Imaging markers on noncontrast computed tomography (NCCT) provide increasing value in the prediction of HE due to fast and easy-to-use advantages; however, the accuracy of NCCT-based prediction of intracerebral HE remains unclear. We aimed to investigate the predictive accuracy of NCCT markers for the evaluation of HE using a well-characterized ICH cohort. Methods We retrospectively analyzed 414 patients with spontaneous ICH, who underwent baseline CT within 6 h after symptom onset and follow-up CT within 24 h after ICH. Hematoma volumes were measured on baseline and follow-up CT images, and imaging features that predicted HE were analyzed. The test characteristics for the NCCT predictors were calculated. Results Of the 414 patients investigated, 63 presented blend sign, 45 showed black hole sign, 36 had island sign and 34 had swirl sign. In the 414 patients, 88 presented HE, the incidence was 21.26%. Of the 88 patients with HE, 22 presented blend sign, 11 showed black hole sign, 8 had swirl sign and 7 had island sign. The blend sign showed highest sensitivity (25.00%) and swirl sign showed the highest specificity (92.02%) among the four predictors. We noted excellent interobserver agreement for the identification of HE. Conclusion The four NCCT markers can predict HE with limited sensitivity, high specificity and good accuracy. This may be useful for prompt identification of patients at high risk of active bleeding, and prevention of over-treatment associated with HE. Abbreviations HE, hematoma expansion; ICH, intracerebral hemorrhage; NCCT, noncontrast computed tomography.

Assessment of the Patient With Intracerebral Hemorrhage: A Review of the Literature

Spontaneous nontraumatic intracerebral hemorrhage is associated with high morbidity and mortality. Given the risk of rapid neurological deterioration, early identification with rapid neuroimaging is vital. Predictors of outcome, such as spot sign and intracerebral hemorrhage score, can help guide management goals. Management should be aimed at prevention of hematoma expansion, treatment of increased intracranial pressure, and prevention of secondary brain injury and medical complications.

Hematoma Expansion in Intracerebral Hemorrhage: An Update on Prediction and Treatment

Intracerebral hemorrhage (ICH) is the most lethal type of stroke, but there is no specific treatment. After years of effort, neurologists have found that hematoma expansion (HE) is a vital predictor of poor prognosis in ICH patients, with a not uncommon incidence ranging widely from 13 to 38%. Herein, the progress of studies on HE after ICH in recent years is updated, and the topics of definition, prevalence, risk factors, prediction score models, mechanisms, treatment, and prospects of HE are covered in this review. The risk factors and prediction score models, including clinical, imaging, and laboratory characteristics, are elaborated in detail, but limited by sensitivity, specificity, and inconvenience to clinical practice. The management of HE is also discussed from bench work to bed practice. However, the upmost problem at present is that there is no treatment for HE proven to definitely improve clinical outcomes. Further studies are needed to identify more accurate predictors and effective treatment to reduce HE.

The extravasation of contrast as a predictor of cerebral hemorrhagic contusion expansion, poor neurological outcome and mortality after traumatic brain injury: A systematic review and meta-analysis

Background

The active extravasation of contrast on CT angiography (CTA) in primary intracerebral hemorrhages (ICH) is recognized as a predictive factor for ICH expansion, unfavorable outcomes and mortality. However, few studies have been conducted on the setting of traumatic brain injury (TBI).

Purpose

To perform a literature systematic review and meta-analysis of the association of contrast extravasation on cerebral hemorrhagic contusion expansion, neurological outcomes and mortality.

Data sources

The PubMed, Cochrane Library, Medline, Scielo, VHL and IBECS databases up to September 21, 2019, were searched for eligible studies.

Study selection

A total of 505 individual titles and abstracts were identified and screened. A total of 36 were selected for full text analysis, out of which 4 fulfilled all inclusion and exclusion criteria.

Data analysis

All 4 studies yielded point estimates suggestive of higher risk for hematoma expansion with contrast extravasation and the summary RR was 5.75 (95%CI 2.74–10.47, p<0.001). Contrast extravasation was also associated with worse neurological outcomes (RR 3.25, 95%CI 2.24–4.73, p<0.001) and higher mortality (RR 2.77, 95%CI 1.03–7.47, p = 0.04).

Data synthesis

This study is a Systematic Review and Meta-Analysis revealed the extravasation of contrast is a useful imaging sign to predict hematoma expansion, worse neurological outcomes and higher mortality.

Limitations

Only four articles were selected.

Conclusions

The extravasation of contrast in the setting of TBI is a useful imaging sign to predict hematoma expansion, worse neurological outcomes and higher mortality.

A Patient with a Distal Medial Lenticulostriate Artery Aneurysm and Intraventricular Hemorrhage Treated by Endovascular Treatment

Objective

A patient with a ruptured distal medial lenticulostriate artery (mLSA) aneurysm presenting with intraventricular hemorrhage was successfully treated using endovascular treatment.

Case Presentation

A 60-year-old woman presented with impaired consciousness. Radiological examination revealed intraventricular hemorrhage caused by a rupture of a distal mLSA aneurysm. Using endovascular technique, approaching contralaterally through the anterior communicating artery (AComA), complete occlusion of the aneurysm was achieved by N-butyl-2-cyanoacrylate (NBCA) injection. The postoperative course was uneventful.

Conclusion

Intraventricular aneurysms at a distal site of the perforating arteries are rare. Although there have been reports on patients with distal mLSA aneurysms treated by open surgery or conservative therapy, endovascular therapy should also be considered as a treatment option.

Blend Sign Is a Strong Predictor of the Extent of Early Hematoma Expansion in Spontaneous Intracerebral Hemorrhage

Background and Purpose: It is unclear which imaging marker is optimal for predicting the extent of hematoma expansion (EHE). We aimed to compare the usefulness of the blend sign (BS) with that of other non-contrast computed tomography (NCCT) markers for predicting the EHE in patients with spontaneous intracerebral hemorrhage (sICH). Methods: Patients with sICH admitted to our Neurology Emergency Department between September 2013 and January 2019 were enrolled. The EHE was calculated as the absolute increase in hematoma volume between baseline and follow-up CT (within 72 h). The EHE was categorized into four groups: "no growth," "minimal change" (≤5.1 ml), "moderate change" (5.1-12.5 ml), and "massive change" (>12.5 ml). Univariate and multivariate analyses were performed to investigate the relationship between the NCCT markers [BS, black hole sign (BHS), satellite sign, and island sign] and the EHE. Results: A total of 1,111 sICH patients were included (median age: 60 years; 66.5% males). Multiple linear regression analysis showed that the presence of the BS and BHS was independently associated with the EHE, after adjusting for confounders (P < 0.001 and P = 0.003, respectively). The presence of the BS and BHS was positively correlated with growth category (r = 0.285 and r = 0.199, both Ps < 0.001). The BS demonstrated a better predictive performance for the EHE than did the BHS [area under the curve (AUC): 0.67 vs. 0.57; both Ps < 0.001]. Conclusions: In patients with acute sICH, the BS showed a better performance in predicting the EHE compared with other NCCT markers. This imaging marker may help identify patients at a high risk of significant hematoma expansion and may facilitate its early management.

Inter- and Intrarater Agreement of Spot Sign and Noncontrast CT Markers for Early Intracerebral Hemorrhage Expansion

Background: The aim of this study was to assess the inter- and intrarater reliability of noncontrast CT (NCCT) markers [Black Hole Sign (BH), Blend Sign (BS), Island Sign (IS), and Hypodensities (HD)] and Spot Sign (SS) on CTA in patients with spontaneous intracerebral hemorrhage (ICH). Methods: Patients with spontaneous ICH at three German tertiary stroke centers were retrospectively included. Each CT scan was rated for four NCCT markers and SS on CTA by two radiology residents. Raters were blind to all demographic and outcome data. Inter- and intrarater agreement was determined by Cohen’s kappa (κ) coefficient and percentage of agreement. Results: Interrater agreement was excellent in 473 included patients, ranging from 96% to 99%. Interrater κ ranged from 0.85 (95% CI [0.78–0.91]) to 0.97 (95% CI [0.94–0.99]) for NCCT markers and 0.93 (95% CI [0.88–0.98]) for SS, all p-values < 0.001. Intrarrater agreement ranged from 96% to 100%, with κ ranging from 0.85 (95% CI [0.78–0.91]) to 1.00 (95% CI [0.10–0.85]) for NCCT markers and 0.96 (95% CI [0.92–1.00]) for SS, all p-values < 0.001. Conclusions: NCCT imaging findings and SS on CTA have good-to-excellent inter- and intrarater reliabilities, with the highest agreement for BH and SS.

A Role for Endoplasmic Reticulum Stress in Intracerebral Hemorrhage

The endoplasmic reticulum (ER) is an intracellular organelle that performs multiple functions, such as lipid biosynthesis, protein folding, and maintaining intracellular calcium homeostasis. Thus, conditions wherein the ER is unable to fold proteins is defined as ER stress, and an inbuilt quality control mechanism, called the unfolded protein response (UPR), is activated during ER stress, which serves as a recovery system that inhibits protein synthesis. Further, based on the severity of ER stress, the response could involve both proapoptotic and antiapoptotic phases. Intracerebral hemorrhage (ICH) is the second most common subtype of cerebral stroke and many lines of evidence have suggested a role for the ER in major neurological disorders. The injury mechanism during ICH includes hematoma formation, which in turn leads to inflammation, elevated intracranial pressure, and edema. A proper understanding of the injury mechanism(s) is required to effectively treat ICH and closing the gap between our current understanding of ER stress mechanisms and ICH injury can lead to valuable advances in the clinical management of ICH.

Neuroimaging of Intracerebral Hemorrhage

Intracerebral hemorrhage (ICH) accounts for 10% to 20% of strokes worldwide and is associated with high morbidity and mortality rates. Neuroimaging is indispensable for rapid diagnosis of ICH and identification of the underlying etiology, thus facilitating triage and appropriate treatment of patients. The most common neuroimaging modalities include noncontrast computed tomography (CT), CT angiography (CTA), digital subtraction angiography, and magnetic resonance imaging (MRI). The strengths and disadvantages of each modality will be reviewed. Novel technologies such as dual-energy CT/CTA, rapid MRI techniques, near-infrared spectroscopy, and automated ICH detection hold promise for faster pre- and in-hospital ICH diagnosis that may impact patient management.

Expansion-Prone Hematoma: Defining a Population at High Risk of Hematoma Growth and Poor Outcome

BACKGROUND

Noncontrast computed tomography (CT) markers are increasingly used for predicting hematoma expansion. The aim of our study was to investigate the predictive value of expansion-prone hematoma in predicting hematoma expansion and outcome in patients with intracerebral hemorrhage (ICH).

METHODS

Between July 2011 and January 2017, ICH patients who underwent baseline CT scan within 6 h of symptoms onset and follow-up CT scan were recruited into the study. Expansion-prone hematoma was defined as the presence of one or more of the following imaging markers: blend sign, black hole sign, or island sign. The diagnostic performance of blend sign, black hole sign, island sign, and expansion-prone hematoma in predicting hematoma expansion was assessed. Predictors of hematoma growth and poor outcome were analyzed using multivariable logistical regression analysis.

RESULTS

A total of 282 patients were included in our final analysis. Of 88 patients with early hematoma growth, 69 (78.4%) had expansion-prone hematoma. Expansion-prone hematoma had a higher sensitivity and accuracy for predicting hematoma expansion and poor outcome when compared with any single imaging marker. After adjustment for potential confounders, expansion-prone hematoma independently predicted hematoma expansion (OR 28.33; 95% CI 12.95-61.98) and poor outcome (OR 5.67; 95% CI 2.82-11.40) in multivariable logistic model.

CONCLUSION

Expansion-prone hematoma seems to be a better predictor than any single noncontrast CT marker for predicting hematoma expansion and poor outcome. Considering the high risk of hematoma expansion in these patients, expansion-prone hematoma may be a potential therapeutic target for anti-expansion treatment in future clinical studies.

Combination of Ultraearly Hematoma Growth and Hypodensities for Outcome Prediction after Intracerebral Hemorrhage

BACKGROUND

Noncontrast computed tomography hypodensities (HD) and ultraearly hematoma growth (uHG) are reliable markers for outcome prediction in patients with spontaneous intracerebral hemorrhage (sICH). The present study aimed to assess whether the combination of these 2 markers could improve the prognostic value for sICH.

METHODS

We recruited 242 patients with sICH who had been admitted within 6 hours from the onset of symptoms. HD was assessed by 2 independent blinded readers, and uHG was calculated as baseline ICH volume/onset-to-imaging time. We divided the study population into 4 groups: uHG(L) HD(-) (uHG <6.16 mL/hour and HD negative), uHG(L) HD(+) (uHG<6.16 mL/hour and HD positive), uHG(H) HD(-) (uHG ≥6.16 mL/hour and HD negative), and uHG(H) HD(+) (uHG ≥6.16 mL/h and HD positive). The outcome at 90 days was evaluated by the modified Rankin Scale (mRS) score and was dichotomized as good (mRS score 0-3) and poor (mRS score 4-6). The association between the combined indicators and unfavorable outcome was investigated using multivariable logistic regression models.

RESULTS

Patients with poor outcomes were more likely to have HD and higher uHG in univariate analysis. In multivariate logistic regression analysis, uHG(H) HD(+) had a higher risk of unfavorable outcomes compared with uHG(L) HD(-) (odds ratio [OR], 5.710; P < 0.001). In addition, the risk of unfavorable outcomes was increased in uHG(H) HD(-) (OR, 2.957, P = 0.044) and uHG(L) HD(+) (OR, 1.924; P = 0.232). The proportions of unfavorable prognoses were 32.6% in uHG(L) HD(-), 48.3% in uHG(L) HD(+), 72.2% in uHG(H) HD(-), and 87.5% in uHG(H) HD(+) (P < 0.001).

CONCLUSIONS

The combination of uHG and HD improves the stratification of unfavorable prognoses in patients with sICH.

The Role of digital subtraction angiography in the ventricular spot sign on the computed tomography angiography

Objective

The spot sign on computed tomography angiography is little known about the relationship between the spot sign and the results of cerebral angiography We retrospectively analyzed the spot sign, digital subtraction angiography results, and other factors.

Material and Methods

From December 2009 to May 2014, DSA was performed in 52 ICH patients with non-specific location or abnormalities on CTA findings. 26 of those patients, whose initial CTA showed the spot sign, were analyzed. Two groups, one with the spot sign in the ventricle (Group A) and others with the spot sign in another location (Group B) were statistically compared.

Results

The mean age of the study subjects was 46.9 years (range, 15 to 80 years) and the percentage of males was 53.8%. Thirteen of 26 patients had ICH without intraventricular hemorrhage, and 6 patients had co-existing IVH. In 17 cases, the DSA results were negative. Seven patients were diagnosed with pseudoaneurysms, and two cases showed developmental venous anomalies. Group A consisted of the 8 patients (30.8%) who showed the spot sign in a ventricle. The number of pseudoaneurysms was statistically significantly higher in Group A than in Group B (71.4% versus 28.6%; OR, 13.3; 95% CI, 1.7-103.8 P = 0.014). All three patients who underwent endovascular treatment were members of Group A (P = 0.022), whereas most (92.3%) of those in Group B underwent surgical evacuation. (P = 0.030).

Conclusion

When CTA shows the spot sign in a ventricle, it is a clue that an existing underlying vascular lesion requires endovascular treatment.

Correlation between Spot Sign and Intracranial Hemorrhage Expansion on Dual-Phase CT Angiography

Purpose: Expansion of intracranial hemorrhage (ICH) is an important predictor of poor clinical outcome. ICH expansion can be predicted with a spot sign on computed tomographic angiography (CTA). We aimed to evaluate the correlation between spot signs on CTA and ICH expansion on dual-phase CTA. Methods: Patients with spontaneous ICH between January 2017 and April 2019 who underwent an initial CT, dual-phase CTA, and a subsequent CT were retrospectively identified. ICH expansion was defined as volume growth of >33% or >6 mL. We analyzed the presence and change in size of the spot sign in the first phase and second phase CTA. Also, we divided the morphological status of the spot sign, such as a dot-like lesion or linear contrast extravasation, in the first and second phase CTA. Results: A total of 206 patients, including 38 (18.5%) with ICH expansion and 45 (21.8%) with a spot sign, qualified for analysis. Of patients with a spot sign, 26 (57.8%) had ICH expansion on subsequent CT. Increased size of a spot sign in second-phase CTA was more frequent in the ICH expansion group than in the no-expansion group (96.2% vs. 52.6%, p < 0.001). First visualization of a spot sign in the second phase was more common in the no-expansion group than in the ICH expansion group (47.4% vs. 3.8%, p < 0.001). The morphological patterns of a spot sign between the two groups were not significantly different. Conclusion: Spot signs on dual-phase CTA have different sizes and morphological patterns. Increased size of a spot sign in the second phase of CTA can help identify patients at risk for ICH expansion.

[Intensive care to facilitate organ donation. ONT-SEMICYUC recommendations]

Intensive care to facilitate organ donation (ICOD) is defined as the initiation or continuation of life-sustaining measures, such as mechanical ventilation, in patients with a devastating brain injury with high probability of evolving to brain death and in whom curative treatment has been completely dismissed and considered futile. ICOD incorporates the option to organ donation allowing a holistic approach to end-of-life care, consistent with the patients wills and values. Should the patient not evolve to brain death, life-supportive treatment must be withdrawal and controlled asystolia donation could be evaluated. ICOD is a legitimate practice, within the ethical and legal regulations that contributes increasing the accessibility of patients to transplantation, promoting health by increasing deceased donation by 24%, and with a mean of 2.3 organs transplanted per donor, and collaborating with the sustainability of health-care system. This ONT-SEMICYUC recommendations provide a guide to facilitate an ICOD harmonized practice in spanish ICUs.