Contrast extravasation on CT angiography predicts hematoma expansion in intracerebral hemorrhage

The spot sign score in primary intracerebral hemorrhage identifies patients at highest risk of in-hospital mortality and poor outcome among survivors

BACKGROUND AND PURPOSE

The spot sign score is a potent predictor of hematoma expansion in patients with primary intracerebral hemorrhage (ICH). We aim to determine the accuracy of this scoring system for the prediction of in-hospital mortality and poor outcome among survivors in patients with primary ICH.

METHODS

Three neuroradiologists retrospectively reviewed CT angiograms (CTAs) performed in 573 consecutive patients who presented to our Emergency Department with primary ICH over a 9-year period to determine the presence and scoring of spot signs according to strict criteria. Baseline ICH and intraventricular hemorrhage volumes were independently determined by computer-assisted volumetric analysis. Medical records were independently reviewed for baseline clinical characteristics and modified Rankin Scale (mRS) at hospital discharge and 3-month follow-up. Poor outcome among survivors was defined as a mRS > or =4 at 3-month follow-up.

RESULTS

We identified spot signs in 133 of 573 CTAs (23.2%), 11 of which were delayed spot signs (8.3%). The presence of any spot sign increased the risk of in-hospital mortality (55.6%, OR 4.0, 95% CI 2.6 to 5.9, P<0.0001) and poor outcome among survivors at 3-month follow-up (50.8%, OR 2.5, 95% CI 1.4 to 4.3, P<0.0014). The spot sign score successfully predicted an escalating risk of both outcome measures. In multivariate analysis, the spot sign score was an independent predictor of in-hospital mortality (OR 1.5, 95% CI 1.2 to 1.9, P<0.0002) and poor outcome among survivors at 3-month follow-up (OR 1.6, 95% CI 1.1 to 2.1, P<0.0065).

CONCLUSIONS

The spot sign score is an independent predictor of in-hospital mortality and poor outcome among survivors in primary ICH.

Options to restrict hematoma expansion after spontaneous intracerebral hemorrhage

BACKGROUND AND PURPOSE

Secondary expansion of hematoma after spontaneous intracerebral hemorrhage occurs frequently and early with the potential sequelae of functional deterioration or death. The aim of this topical review is to give a summary of current evidence- and experience-based options to avoid or attenuate hematoma expansion.

METHOD

We reviewed the literature of the past 10 years on efforts to restrict spontaneous intracerebral hemorrhage expansion by searching Medline and adding related articles known to us. Based on evidence, current guidelines, and our own clinical practice, we have collected consistent and inconsistent pieces of data. These were differentiated according to surgical versus medical approaches, weighed and discussed with regard to expectable benefit, potential risk, and practicability. Finally, we have outlined promising future approaches.

RESULTS

Although consistent evidence on the topic is generally limited, some important studies have provided data on risk factors predicting spontaneous intracerebral hemorrhage expansion implying ways of directing therapy toward these risk factors. Large trials have shed light on 4 major efforts to avoid hematoma expansion: surgical hematoma treatment, reduction of hypertension, reversal of coagulopathies or anticoagulants, and hemostatic therapy. The results were largely disappointing but provide insights for new trials. Future strategies include the combination of surgical and medical treatment and the use of neuroprotectants.

CONCLUSIONS

Early restriction of intracerebral hemorrhage is of paramount importance because secondary volume expansion leads to outcome deterioration and death. Although there appear to be few indications for neurosurgical measures, nonsurgical measures such as reduction of hypertension and normalization of altered coagulation seem to be beneficial. However, the routine use of coagulation factors outside of warfarin-associated spontaneous intracerebral hemorrhage cannot generally be recommended at present. The same applies for future approaches such as combined medical-surgical approaches and neuroprotective therapies at this point.

Stroke. 'Spotting' patients at the highest risk of hematoma growth

Clinical trials aimed at preventing hematoma expansion in patients with intraparenchymal hemorrhage have failed to show benefit from experimental intervention. novel methods for identifying those patients at the highest risk of hemorrhage growth might enable better patient selection and, hence, increase the chance of demonstrating an improvement in clinical outcome.

Clinical predictors of significant findings on head computed tomographic angiography

BACKGROUND

Although head computed tomographic angiography (CTA) is a sensitive tool for the evaluation of neurological symptoms in the emergency department (ED), little is known about which clinical signs predict significant CTA findings.

OBJECTIVES

To identify clinical factors that predict significant findings on head CTA in patients presenting to the ED with neurological complaints.

METHODS

Retrospective chart review of consecutive adult patients undergoing head CTA over a 6-month period in an urban, tertiary care ED with an annual volume of 76,000. Significant head CTA findings were defined as clinically significant neurological abnormalities undetected by previous imaging studies. Demographics, chief complaint, results of the neurological examinations (NE), and head non-contrast computed tomography (CT) results were used as predictors of significant head CTA. All predictors with a univariate p < 0.2 using Pearson's chi-squared were entered stepwise into a multivariable logistic regression including odds ratios (OR), with inclusion restricted to p < 0.05.

RESULTS

Chart review yielded 456 cases; 215 (47%) were male. Mean age was 62 (SD 20) years. There were 189 patients (41%) with abnormal CTAs. Multivariable logistic regression indicated five variables that predicted a clinically significant CTA: abnormal CT (OR 3.72), chief complaint of subarachnoid hemorrhage-type headache (OR 2.30), and motor deficit (OR 2.23), visual deficit (OR 2.23), and other focal deficit (OR 2.18) on NE. A chief complaint of trauma (OR 0.23) predicted a normal CTA.

CONCLUSIONS

Specific historical and focal neurological findings are useful for predicting clinically significant findings on head CTA.

Haemostatic drug therapies for acute spontaneous intracerebral haemorrhage

BACKGROUND

Because spontaneous (non-traumatic) intracerebral haemorrhage (ICH) volume influences its outcome and a third of ICHs enlarge by a third within 24 hours of onset, early haemostatic drug therapy might improve outcome. This is an update of a Cochrane review first published in 2006.

OBJECTIVES

To examine the clinical effectiveness and safety of haemostatic drug therapies for acute ICH in a randomised controlled trial (RCT) design.

SEARCH STRATEGY

I searched the Cochrane Stroke Group Trials Register (last searched 26 June 2009), the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library Issue 2, 2009), MEDLINE (1966 to June 2009) and EMBASE (1980 to June 2009). In an effort to identify further published, ongoing and unpublished studies I scanned bibliographies of relevant articles, searched international registers of clinical trials and research, and contacted authors and pharmaceutical companies.

SELECTION CRITERIA

I sought RCTs of any haemostatic drug therapy for acute ICH, compared against placebo or open control, with relevant clinical outcome measures.

DATA COLLECTION AND ANALYSIS

Two authors independently applied the inclusion criteria, reviewed the relevant studies, and extracted data.

MAIN RESULTS

I found five phase II RCTs and one phase III RCT, involving 1398 adults aged 18 years or over, within four hours of ICH onset: 423 participants received placebo and 975 participants received haemostatic drugs (two received epsilon-aminocaproic acid (EACA) and 973 received recombinant activated factor VII (rFVIIa)). Haemostatic drugs did not significantly reduce 90-day case fatality after ICH (risk ratio (RR) 0.85, 95% confidence interval (CI) 0.58 to 1.25), and rFVIIa did not significantly reduce death or dependence on the modified Rankin Scale (grades 4 to 6) within 90 days of ICH (RR 0.91, 95% CI 0.72 to 1.15). There was a trend towards more participants on rFVIIa experiencing thromboembolic serious adverse events (RR 1.37, 95% CI 0.74 to 2.55)

AUTHORS' CONCLUSIONS

Haemostatic drugs cannot be recommended for the treatment of acute spontaneous ICH in clinical practice, but a large RCT would be justified.

Systematic characterization of the computed tomography angiography spot sign in primary intracerebral hemorrhage identifies patients at highest risk for hematoma expansion: the spot sign score

BACKGROUND AND PURPOSE

The presence of active contrast extravasation (the spot sign) on computed tomography (CT) angiography has been recognized as a predictor of hematoma expansion in patients with intracerebral hemorrhage. We aim to systematically characterize the spot sign to identify features that are most predictive of hematoma expansion and construct a spot sign scoring system.

METHODS

We retrospectively reviewed CT angiograms performed in all patients who presented to our emergency department over a 9-year period with primary intracerebral hemorrhage and had a follow-up noncontrast head CT within 48 hours of the baseline CT angiogram. Three neuroradiologists reviewed the CT angiograms and determined the presence and characteristics of spot signs according to strict radiological criteria. Baseline and follow-up intracerebral hemorrhage volumes were determined by computer-assisted volumetric analysis.

RESULTS

We identified spot signs in 71 of 367 CT angiograms (19%), 6 of which were delayed spot signs (8%). The presence of any spot sign increased the risk of significant hematoma expansion (69%, OR=92, P<0.0001). Among the spot sign characteristics examined, the presence of > or =3 spot signs, a maximum axial dimension > or =5 mm, and maximum attenuation > or =180 Hounsfield units were independent predictors of significant hematoma expansion, and these were subsequently used to construct the spot sign score. In multivariate analysis, the spot sign score was the strongest predictor of significant hematoma expansion, independent of time from ictus to CT angiogram evaluation.

CONCLUSIONS

The spot sign score predicts significant hematoma expansion in primary intracerebral hemorrhage. If validated in other data sets, it could be used to select patients for early hemostatic therapy.

CT angiography for intracerebral hemorrhage does not increase risk of acute nephropathy

BACKGROUND AND PURPOSE

CT angiography (CTA) is receiving increased attention in intracerebral hemorrhage (ICH) for its role in ruling out vascular abnormalities and potentially predicting ongoing bleeding. Its use is limited by the concern for contrast induced nephropathy (CIN); however, the magnitude of this risk is not known.

METHODS

We performed a retrospective analysis of a prospectively collected cohort of consecutive patients with ICH presenting to a single tertiary care hospital from 2002 to 2007. Demographic, clinical, and radiographic data were prospectively collected for all patients. Laboratory data and clinical course over the first 48 hours were retrospectively reviewed. Acute nephropathy was defined as any rise in creatinine of >25% or >0.5 mg/dL, such that the highest creatinine value was above 1.5 mg/dL.

RESULTS

539 patients presented during the study period and had at least 2 creatinine measurements. 348 (65%) received a CTA. Acute nephropathy developed in 6% of patients who received a CTA and in 10% of those who did not (P=0.1). Risk of nephropathy was 14% in those receiving no contrast (130 patients), 5% in those receiving 1 contrast study (124 patients), and 6% in those receiving >1 contrast study (244 patients). Neither CTA nor any use of contrast predicted nephropathy in univariate or multivariate analysis.

CONCLUSIONS

The risk of acute nephropathy after ICH was not increased by use of CTA. Studies of CIN that do not include a control group may overestimate the influence of contrast. Patients with ICH appear to have an 8% risk of developing "Hospital-Acquired Nephropathy."

Intracerebral haemorrhage

Intracerebral haemorrhage is an important public health problem leading to high rates of death and disability in adults. Although the number of hospital admissions for intracerebral haemorrhage has increased worldwide in the past 10 years, mortality has not fallen. Results of clinical trials and observational studies suggest that coordinated primary and specialty care is associated with lower mortality than is typical community practice. Development of treatment goals for critical care, and new sequences of care and specialty practice can improve outcome after intracerebral haemorrhage. Specific treatment approaches include early diagnosis and haemostasis, aggressive management of blood pressure, open surgical and minimally invasive surgical techniques to remove clot, techniques to remove intraventricular blood, and management of intracranial pressure. These approaches improve clinical management of patients with intracerebral haemorrhage and promise to reduce mortality and increase functional survival.

Density and Shape as CT Predictors of Intracerebral Hemorrhage Growth

Background and Purpose— Intracerebral hemorrhage (ICH) growth predicts mortality and functional outcome. We hypothesized that irregular hematoma shape and density heterogeneity, reflecting active, multifocal bleeding or a variable bleeding time course, would predict ICH growth.

Methods— Three raters examined baseline sub-3-hour CT brain scans of 90 patients in the placebo arm of a Phase IIb trial of recombinant activated Factor VII in ICH. Each rater, blinded to growth data, independently applied novel 5-point categorical scales of density and shape to randomly presented baseline CT images of ICH. Density and shape were defined as either homogeneous/regular (Category 1 to 2) or heterogeneous/irregular (Category 3 to 5). Within- and between-rater reliability was determined for these scales. Growth was assessed as a continuous variable and using 3 binary definitions: (1) any ICH growth; (2) ≥33% or ≥12.5 mL ICH growth; and (3) radial growth >1 mm between baseline and 24-hour CT scan. Patients were divided into tertiles of baseline ICH volume: “small” (0 to 10 mL), “medium” (10 to 25 mL), and “large” (25 to 106 mL).

Results— Inter- and intrarater agreements for the novel scales exceeded 85% (±1 category). Median growth was significantly higher in the large-volume group compared with the small group ( P <0.001) and in heterogeneous compared with homogeneous ICH ( P =0.008). Median growth trended higher in irregular ICHs compared with regular ICHs ( P =0.084). Small ICHs were more regularly shaped (43%) than medium (17%) and large (3%) ICHs ( P <0.001). Small ICHs were more homogeneous (73%) compared with medium (37%) and large (17%) ICHs ( P <0.001). Adjusting for baseline ICH volume and time to scan, density heterogeneity, but not shape irregularity, independently predicted ICH growth ( P =0.046) on a continuous growth scale.

Conclusions— Large ICHs were significantly more irregular in shape, heterogeneous in density, and had greater growth. Density heterogeneity independently predicted ICH growth using some definitions.

Postcontrast CT extravasation is associated with hematoma expansion in CTA spot negative patients

BACKGROUND AND PURPOSE

The purpose of this study was to assess the effect of postcontrast CT (PCCT) leakage (PCL) on hematoma growth in CTA spot negative patients.

METHODS

A retrospective study of 61 patients presenting within 6 hours of primary ICH onset imaged with CT angiography (CTA) and PCCT. Presence of CTA spot sign and PCL were documented. PCL was defined as the presence of contrast extravasation on the PCCT study at a location remote from the CTA spot sign if present. Hematoma expansion was defined as >6 mL or 30% hematoma enlargement. Patients were dichotomized by CTA spot sign presence and PCL and compared for baseline demographic data, hematoma size, and growth using the unpaired t test and Mann-Whitney test for continuous and categorical data, respectively. A probability value <0.05 was considered significant.

RESULTS

PCL was present in 11/61 patients (18%), occurring in 5 without a spot sign (45%). Spot negative PCL patients demonstrated larger absolute (P=0.02) and percentage hematoma growth (P=0.02) compared to those without PCL. The mean volume and percent increase was 6.7 mL and 26%, respectively. Inclusion of PCL together with CTA spot sign as risk factor for hematoma expansion increased sensitivity from 0.78 (95% CI; 0.52 to 0.94) to 0.94 (95% CI; 0.72 to 1.00) and NPV from 0.90 (95% CI; 0.76 to 0.97) to 0.97 (95% CI; 0.85 to 1.00).

CONCLUSIONS

Inclusion of PCCT in the investigation of ICH patients allows detection of PCL which, together with the CTA spot sign, increases sensitivity and negative predictive value for predicting hematoma expansion. This finding should be validated in larger studies.

Can a Subset of Intracerebral Hemorrhage Patients Benefit From Hemostatic Therapy With Recombinant Activated Factor VII?

Background and Purpose— In the Factor Seven for Acute Hemorrhagic Stroke (FAST) trial, 80 μg/kg of recombinant activated factor VII (rFVIIa) significantly reduced intracerebral hemorrhage (ICH) expansion when given within 4 hours of onset. However, in contrast to an earlier Phase 2b study, rFVIIa did not improve survival or functional outcome. In this exploratory analysis, we hypothesized that earlier treatment and exclusion of patients with a poor prognosis at baseline might enhance the benefit of rFVIIa treatment.

Methods— Using the FAST data set, the impact of rFVIIa (80 μg/kg) on poor outcome at 3 months (modified Rankin Score of 5 or 6) was systematically evaluated within subgroups using clinically meaningful cut points in onset-to-treatment time, age, and baseline ICH and intraventricular hemorrhage volume. The effect of treatment on outcome was analyzed using logistic regression, and ICH volume was analyzed with linear mixed models.

Results— A subgroup (n=160, 19% of the FAST population) was identified comprising patients ≤70 years with baseline ICH volume <60 mL, intraventricular hemorrhage volume <5 mL, and time from onset-to-treatment ≤2.5 hours. The adjusted ORs for poor outcome with rFVIIa treatment was 0.28 (95% CI, 0.08 to 1.06), whereas the reduction in ICH growth was almost doubled (7.3±3.2 versus 3.8±1.5 mL, P =0.02). The improved effect was confirmed in an analysis of similar Phase 2 patients.

Conclusions— A prospective trial would be needed to determine whether younger patients with ICH without extensive bleeding at baseline can benefit from 80 μg/kg of rFVIIa given within 2.5 hours of symptom onset.

Blood-brain barrier function in intracerebral hemorrhage

In this paper, we review current knowledge on blood-brain barrier (BBB) dysfunction following intracerebral hemorrhage (ICH). BBB disruption is a hallmark of ICH-induced brain injury. Such disruption contributes to edema formation, the influx of leukocytes, and the entry of potentially neuroactive agents into the perihematomal brain, all of which may contribute to brain injury. A range of factors have been implicated in inducing BBB disruption, including inflammatory mediators (e.g., cytokines and chemokines), thrombin, hemoglobin breakdown products, oxidative stress, complement, and matrix metalloproteinases. While there is interaction between some of these mediators, it is probable that prevention of ICH-induced BBB disruption will involve blocking multiple pathways or blocking a common end pathway (e.g., by stabilizing tight junction structure). While the effects of ICH on BBB passive permeability have been extensively examined, effects on other 'barrier' properties (metabolic and transport functions) have been less well-studied. However, recent data suggests that ICH can affect transport and that this may help protect the BBB and the brain. Indeed, it is possible in small bleeds that BBB disruption may be beneficial, and it is only in the presence of larger bleeds that disruption has detrimental effects.

Accuracy of CT angiography for the diagnosis of vascular abnormalities causing intraparenchymal hemorrhage in young patients

The objective of this study is to measure the accuracy of multidetector CT angiography (MD CTA) in the detection of vascular abnormalities in patients <or=40 years with spontaneous intraparenchymal hemorrhage (IPH) presenting to the emergency department. After institutional review board approval, a retrospective study was performed of 43 consecutive patients <or=40 years, who presented to our emergency department with IPH and that were evaluated with MD CTA. MD CTA images were reviewed by a neuroradiologist to determine IPH location, presence of a vascular abnormality, and associated extraparenchymal hemorrhage. Diagnostic accuracy was measured comparing it to the available reference standards, which included conventional catheter angiogram (CCA), surgical macroscopic findings, and pathology results. Medical records were reviewed for risk factors and correlation with final diagnosis. MD CTA demonstrated an accuracy of 97.7%, with a sensitivity of 96.4% (95% CI 0.79-0.99) and a specificity of 100% (95% CI 0.74-0.99) for the detection of vascular abnormalities in young patients with IPH. Additionally, MD CTA had a PPV of 100%, and the NPV 93.8% in this population. Of the 43 patients included in the study, 28 patients (65%) had a causative vascular etiology for the IPH. Among the 28 patients with vascular etiologies for the IPH, 11 had an AVM (39.2%), nine a ruptured aneurysm (32.14%), seven dural venous sinus thrombosis (25%), and one had vasculitis (3.57%). MD CTA is highly accurate in the detection of vascular abnormalities in the setting of IPH, which as a group represents the most frequent etiology of IPH among patients age <or=40 years. MD CTA performed in the Emergency Department provides accurate, rapid and critical presurgical and premedical treatment information in young patients with IPH.

Prior antiplatelet use does not affect hemorrhage growth or outcome after ICH

OBJECTIVE

To examine whether antiplatelet medication use at onset of intracerebral hemorrhage (ICH) is associated with hemorrhage growth and outcome after spontaneous ICH using a large, prospectively collected database from a recent clinical trial.

METHODS

The Cerebral Hemorrhage and NXY-059 Treatment trial was a randomized, placebo-controlled trial of NXY-059 after spontaneous ICH. We analyzed patients in the placebo arm, and correlated antiplatelet medication use at the time of ICH with initial ICH volumes, ICH growth in the first 72 hours, and modified Rankin Score at 90 days. Patients on oral anticoagulation were excluded.

RESULTS

There were 282 patients included in this analysis, including 70 (24.8%) who were taking antiplatelet medications at ICH onset. Use of antiplatelet medications at ICH onset had no association with the volume of ICH at presentation, growth of ICH at 72 hours, initial edema volume, or edema growth. In multivariable analysis, there was no association of use of antiplatelet medications with any hemorrhage expansion (relative risk [RR] 0.85 [upper limit of confidence interval (UCI) 1.03], p = 0.16), hemorrhage expansion greater than 33% (RR 0.77 [UCI 1.18], p = 0.32), or clinical outcome at 90 days (odds ratio 0.67, 95% confidence interval 0.39-1.14, p = 0.14).

CONCLUSIONS

Use of antiplatelet medications at intracerebral hemorrhage (ICH) onset is not associated with increased hemorrhage volumes, hemorrhage expansion, or clinical outcome at 90 days. These findings suggest that attempts to reverse antiplatelet medications after ICH may not be warranted.

Management of spontaneous intracerebral hemorrhage

Spontaneous intracerebral hemorrhage (ICH) has the highest mortality of all cerebrovascular events. Thirty-day mortality approaches 50%, and only 20% of survivors achieve meaningful functional recovery at 6 months. Many clinicians believe that effective therapies are lacking; however, this is changing because of new data on the pathophysiology and treatment of ICH, particularly research establishing the role of medical therapies to promote hematoma stabilization. This article provides updates to a recent publication discussing basic principles of ICH management, including initial stabilization, the prevention of hematoma growth, treatment of complications, and identification of the underlying etiology. Minimally invasive surgery (MIS) to reduce clot size is also discussed, with the goal of preserving neurologic function through reduction in parenchymal damage from edema formation.

Eligibility for the surgical trial in intracerebral hemorrhage II study in a population-based cohort

INTRODUCTION

No proven treatments exist for intracerebral hemorrhage (ICH). Carefully selected patients may benefit from surgery, and an international multicenter trial is ongoing. We sought to determine how many patients in a population-based ICH cohort would have been eligible for surgery using the Surgical Trial in Intracerebral Hemorrhage II (STICH II) criteria.

METHODS

We identified all patients aged > or =18 years residing in the five-county Greater Cincinnati region who were hospitalized with first-ever nontraumatic ICH in 2005. STICH II trial criteria were used to determine eligibility for treatment and reasons for exclusion.

RESULTS

During 2005, 286 ICH patients were identified (103 lobar, 126 deep cerebral, 23 brainstem, 28 cerebellar, and 6 IVH). Non-lobar hemorrhages are not eligible for STICH II. Among patients with lobar hemorrhage, 22 had no exclusions. The most common (not mutually exclusive) reasons for exclusion were volume <10 cc or >100 cc (n = 46) and presence of IVH (n = 27). No significant age, gender or racial differences existed between eligible and ineligible patients with lobar ICH. Only one (4.5%) of the 22 STICH II eligible patients in our population had surgery, compared with eight of 81 (9.9%) ineligible lobar ICH patients (P = 0.43). Mortality at 180 days in STICH II eligible patients was 36% vs. 49% for ineligible lobar ICH patients (P = 0.19).

CONCLUSIONS

In this population-based ICH cohort, 7.7% (22 of 286) of ICH patients would have qualified for STICH II enrollment. Other treatment options need to be explored for most ICH patients.

Clinical review: Critical care management of spontaneous intracerebral hemorrhage

Intracerebral hemorrhage is by far the most destructive form of stroke. The clinical presentation is characterized by a rapidly deteriorating neurological exam coupled with signs and symptoms of elevated intracranial pressure. The diagnosis is easily established by the use of computed tomography or magnetic resonance imaging. Ventilatory support, blood pressure control, reversal of any preexisting coagulopathy, intracranial pressure monitoring, osmotherapy, fever control, seizure prophylaxis, treatment of hyerglycemia, and nutritional supplementation are the cornerstones of supportive care in the intensive care unit. Dexamethasone and other glucocorticoids should be avoided. Ventricular drainage should be performed urgently in all stuporous or comatose patients with intraventricular blood and acute hydrocephalus. Emergent surgical evacuation or hemicraniectomy should be considered for patients with large (>3 cm) cerebellar hemorrhages, and in those with large lobar hemorrhages, significant mass effect, and a deteriorating neurological exam. Apart from management in a specialized stroke or neurological intensive care unit, no specific medical therapies have been shown to consistently improve outcome after intracerebral hemorrhage.

Management of spontaneous intracerebral hemorrhage

Spontaneous intracerebral hemorrhage (ICH) has the highest mortality of all cerebrovascular events. Thirty-day mortality approaches 50%, and only 20% of survivors achieve meaningful functional recovery at 6 months. Many clinicians believe that effective therapies are lacking; however, this is changing because of new data on the pathophysiology and treatment of ICH, particularly research establishing the role of medical therapies to promote hematoma stabilization. This article provides updates to a recent publication discussing basic principles of ICH management, including initial stabilization, the prevention of hematoma growth, treatment of complications, and identification of the underlying etiology. Minimally invasive surgery (MIS) to reduce clot size is also discussed, with the goal of preserving neurologic function through reduction in parenchymal damage from edema formation.

Efficacy and safety of recombinant activated factor VII for acute intracerebral hemorrhage

BACKGROUND

Intracerebral hemorrhage is the least treatable form of stroke. We performed this phase 3 trial to confirm a previous study in which recombinant activated factor VII (rFVIIa) reduced growth of the hematoma and improved survival and functional outcomes.

METHODS

We randomly assigned 841 patients with intracerebral hemorrhage to receive placebo (268 patients), 20 microg of rFVIIa per kilogram of body weight (276 patients), or 80 microg of rFVIIa per kilogram (297 patients) within 4 hours after the onset of stroke. The primary end point was poor outcome, defined as severe disability or death according to the modified Rankin scale 90 days after the stroke.

RESULTS

Treatment with 80 microg of rFVIIa per kilogram resulted in a significant reduction in growth in volume of the hemorrhage. The mean estimated increase in volume of the intracerebral hemorrhage at 24 hours was 26% in the placebo group, as compared with 18% in the group receiving 20 microg of rFVIIa per kilogram (P=0.09) and 11% in the group receiving 80 microg (P<0.001). The growth in volume of intracerebral hemorrhage was reduced by 2.6 ml (95% confidence interval [CI], -0.3 to 5.5; P=0.08) in the group receiving 20 microg of rFVIIa per kilogram and by 3.8 ml (95% CI, 0.9 to 6.7; P=0.009) in the group receiving 80 microg, as compared with the placebo group. Despite this reduction in bleeding, there was no significant difference among the three groups in the proportion of patients with poor clinical outcome (24% in the placebo group, 26% in the group receiving 20 microg of rFVIIa per kilogram, and 29% in the group receiving 80 microg). The overall frequency of thromboembolic serious adverse events was similar in the three groups; however, arterial events were more frequent in the group receiving 80 microg of rFVIIa than in the placebo group (9% vs. 4%, P=0.04).

CONCLUSIONS

Hemostatic therapy with rFVIIa reduced growth of the hematoma but did not improve survival or functional outcome after intracerebral hemorrhage. (ClinicalTrials.gov number, NCT00127283 [ClinicalTrials.gov].).

Management of warfarin-related intracerebral hemorrhage

Warfarin-related intracerebral hemorrhage (WICH) is a medical and neurosurgical emergency with a 1-month mortality of approximately 50%. Warfarin is commonly is used in patients with atrial fibrillation to prevent ischemic stroke and to prevent progression of deep vein thrombosis to pulmonary embolism. Owing to the ageing population, and increased incidence of atrial fibrillation with age and warfarin use, the incidence of WICH is expected to rise in the future. When WICH occurs, immediate discontinuation of warfarin with rapid warfarin reversal remains the first-line intervention, often with neurosurgical intervention. The optimal agent for rapid warfarin anticoagulation reversal remains to be defined owing to the lack of prospective randomized trials. We review current literature and prospects for future research for this devastating neurologic emergency.

Multiphase CT angiography versus single-phase CT angiography: comparison of image quality and radiation dose

BACKGROUND AND PURPOSE

Conventional CT angiography (CTA) is acquired during only a short interval in the arterial phase, which limits its ability to evaluate the cerebral circulation. Our aim was to compare the image quality and radiation dose of conventional single-phase CTA (SP-CTA) with a multiphase CTA (MP-CTA) algorithm reconstructed from a perfusion CT (PCT) dataset.

MATERIALS AND METHODS

Fifty consecutive patients undergoing head CTA and PCT in 1 examination were enrolled. The PCT dataset was obtained with 40.0-mm-detector coverage, 5.0-mm axial thickness, 80 kilovolt peak (kVp), 180 mA, and 30 mL of contrast medium. MP-CTA was reconstructed from the same PCT dataset with an axial thickness of 0.625 mm by using a new axial reconstruction algorithm. A conventional SP-CTA dataset was obtained with 0.625-mm axial thickness, 120 kVp, 350 mA, and 60 mL of contrast medium. We compared image quality, vascular enhancement, and radiation dose.

RESULTS

SP-CTA and MP-CTA of 50 patients (male/female ratio, 31/19; mean age, 59.25 years) were analyzed. MP-CTA was significantly better than SP-CTA in vascular enhancement (P = .002), in the absence of venous contamination (P = .006), and was significantly higher in image noise (P < .001). MP-CTA used less contrast medium than SP-CTA and could demonstrate hemodynamic information. The effective dose of MP-CTA was 5.73 mSv, which was equal to that in conventional PCT, and it was 3.57 mSv in SP-CTA.

CONCLUSION

It is feasible that MP-CTA may provide both CTA and PCT results. Compared with SP-CTA, MP-CTA provides comparable image quality, better vascular enhancement, hemodynamic information, and more noise with less detail visibility with a lower tube voltage. The radiation dose of MP-CTA is higher than that of SP-CTA, but the dose can be reduced by altering the sampling interval.

Contrast extravasation on CT predicts mortality in primary intracerebral hemorrhage

BACKGROUND AND PURPOSE

Recent studies of intracerebral hemorrhage (ICH) treatments have highlighted the need to identify reliable predictors of hematoma expansion. The goal of this study was to determine whether contrast extravasation on multisection CT angiography (CTA) and/or contrast-enhanced CT (CECT) of the brain is associated with hematoma expansion and increased mortality in patients with primary ICH.

MATERIALS AND METHODS

All patients with primary ICH who underwent CTA and CECT, as well as follow-up noncontrast CT (NCCT) before discharge/death from January 1, 2003, to September 30, 2005, were retrospectively identified. One neuroradiologist reviewed admission and follow-up NCCT for hematoma size and growth. A second neuroradiologist independently reviewed CTA and CECT for active contrast extravasation. Univariate and multivariate logistic regression analyses were performed to evaluate the significance of clinical and radiologic variables in predicting 30-day mortality, designated as the primary outcome. Hematoma growth was considered as a secondary outcome.

RESULTS

Of 56 patients, contrast extravasation was seen in 17.9% of patients on initial CTA and in 23.2% of patients on initial CECT following CTA. Univariate analysis showed that the presence of extravasation on CT, large initial hematoma size (>30 mL), the presence of "swirl sign" on NCCT, the Glasgow Coma Scale and ICH scores, and international normalized ratio were associated with increased mortality. On multivariate analysis, only contrast extravasation on CT (P = .017) independently predicted mortality. Contrast extravasation on CT (P < .001) was also an independent predictor of hematoma growth on multivariate analysis.

CONCLUSION

Active contrast extravasation on CT in patients with primary ICH independently predicts mortality and hematoma growth.

Vascular and nonvascular mimics of the CT angiography "spot sign" in patients with secondary intracerebral hemorrhage

BACKGROUND AND PURPOSE

The newly-described computed tomography angiography (CTA) Spot Sign is present in about one third of patients with acute primary intracerebral hemorrhage (PICH) and predicts hematoma expansion. This sign has not been systematically evaluated in patients with secondary causes of ICH, and mimics have not been characterized. The purpose of this study was to assess for the presence of the Spot Sign in secondary ICH and to document potential mimics of the Spot Sign and their distinguishing features.

METHODS

We performed a retrospective chart review of consecutive patients presenting with ICH to our regional stroke center between January 2002 and May 2007. Ninety-six ICH patients underwent a CT stroke protocol including CTA. CTA documented a secondary cause for hemorrhage in 30 patients (31%). Each patient was assessed for the presence or absence of the CTA Spot Sign or a mimic by 2 blinded neuroradiologists. Clinical and radiological features of PICH and secondary ICH were compared.

RESULTS

No patients with secondary ICH had a true CTA Spot Sign, but several Spot Sign mimics were identified including: micro AVM, posterior communicating artery aneurysm, Moya Moya, and neoplasm-associated calcification. The secondary ICH group was younger (P=0.0001) and less likely to be hypertensive at presentation (P=0.0114). Significant hematoma expansion (>33% increase from baseline volume) occurred in 20% of secondary ICH patients and 28% of PICH patients (P=0.2463).

CONCLUSIONS

This study describes mimics of the CTA Spot Sign and classifies them as vascular (microAVM, aneurysm, Moya Moya) or nonvascular (tumor and choroid plexus calcification). Evaluation of the noncontrast CT together with the CTA source images is an essential part of the evaluation for the Spot Sign. Vessels entering the hematoma from the periphery are indicative of an underlying vascular lesion. Our findings suggest that the Spot Sign may be rare in secondary ICH and most specific for PICH.