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Li CR, Yang MY, Cheng WY, Tseng HC, Lin YY, Liu YH, Shen CC, Yen CM. Urokinase administration for intraventricular hemorrhage in adults: A retrospective analysis of hemorrhage volume reduction and clinical outcomes. J Chin Med Assoc 2023; 86:930-934. [PMID: 37528523 DOI: 10.1097/jcma.0000000000000973] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 08/03/2023] Open
Abstract
BACKGROUND Intraventricular hemorrhage (IVH) is a type of ventricular bleeding that results in significant morbidity and mortality. Multiple studies have investigated the use of urokinase in IVH treatment. The use of urokinase may lead to higher rates of hematoma resolution and lower mortality rates. However, further studies are required to determine efficacy of urokinase administration. This study examined the association between urokinase use, IVH volume reduction, and clinical outcomes. METHODS In total, 94 adult patients with hypertensive intracerebral hemorrhage with ventricular extension or primary IVH were enrolled between 2015 and 2021. Participants were categorized into two groups: "EVD combined with fibrinolysis" and "EVD only." The primary objective was to assess the reduction of IVH severity. Additionally, the study evaluated the functional outcomes and shunt dependency rate as secondary outcomes. Non-contrast computed tomography scans were obtained to measure the severity of IVH using the mGRAEB score. The main outcomes were the association among urokinase administration, reduced IVH severity, and functional outcomes. RESULTS There were no significant differences in the reduction rate of mGRAEB scores within a 7-day period (-50.0 [-64.4 to -32.5] % vs -44.2 [-59.3 to -7.9] %; p = 0.489). In addition, investigation of the third and fourth ventricles showed similar findings between the two groups. Urokinase treatment was not associated with significant differences in the modified Rankin Scale (5.0 (4.0-5.0) vs. 4.5 (4.0-5.0), p = 0.674) or shunt dependency rate (33.3% vs 39.3%, p = 0.58). CONCLUSION This study found that intraventricular urokinase use in patients with IVH was not associated with reduced IVH severity. In addition, urokinase use was not associated with better functional outcomes or minor shunt dependency rates.
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Affiliation(s)
- Chi-Ruei Li
- Department of Neurosurgery, Neurological Institute, Taichung Veterans General Hospital, Taichung, Taiwan, ROC
| | - Meng-Yin Yang
- Department of Neurosurgery, Neurological Institute, Taichung Veterans General Hospital, Taichung, Taiwan, ROC
- Oncology Neurosurgery Division, Department of Neurosurgery, Neurological Institute, Taichung Veterans General Hospital, Taichung, Taiwan, ROC
- College of Nursing, Central Taiwan University of Science and Technology, Taichung, Taiwan, ROC
| | - Wen-Yu Cheng
- Department of Neurosurgery, Neurological Institute, Taichung Veterans General Hospital, Taichung, Taiwan, ROC
- Institute of Biomedical Sciences, National Chung Hsing University, Taichung, Taiwan, ROC
- Department of Physical Therapy, Hung Kuang University, Taichung, Taiwan, ROC
| | - Huan-Chin Tseng
- School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan, ROC
- Department of Medical Research, Taipei Veterans General Hospital, Taipei, Taiwan, ROC
| | - Yi-Ying Lin
- School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan, ROC
- Department of Medical Research, Taipei Veterans General Hospital, Taipei, Taiwan, ROC
| | - Yu-Hao Liu
- School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan, ROC
- Department of Medical Research, Taipei Veterans General Hospital, Taipei, Taiwan, ROC
| | - Chiung-Chyi Shen
- Department of Neurosurgery, Neurological Institute, Taichung Veterans General Hospital, Taichung, Taiwan, ROC
- Department of Physical Therapy, Hung Kuang University, Taichung, Taiwan, ROC
- Basic Medical Education, Central Taiwan University of Science and Technology, Taichung, Taiwan, ROC
| | - Chun-Ming Yen
- Department of Neurosurgery, Neurological Institute, Taichung Veterans General Hospital, Taichung, Taiwan, ROC
- School of Medicine, National Defense Medical Center, Taipei, Taiwan, ROC
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MacIntosh BJ, Liu Q, Schellhorn T, Beyer MK, Groote IR, Morberg PC, Poulin JM, Selseth MN, Bakke RC, Naqvi A, Hillal A, Ullberg T, Wassélius J, Rønning OM, Selnes P, Kristoffersen ES, Emblem KE, Skogen K, Sandset EC, Bjørnerud A. Radiological features of brain hemorrhage through automated segmentation from computed tomography in stroke and traumatic brain injury. Front Neurol 2023; 14:1244672. [PMID: 37840934 PMCID: PMC10568013 DOI: 10.3389/fneur.2023.1244672] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2023] [Accepted: 09/05/2023] [Indexed: 10/17/2023] Open
Abstract
Introduction Radiological assessment is necessary to diagnose spontaneous intracerebral hemorrhage (ICH) and traumatic brain injury intracranial hemorrhage (TBI-bleed). Artificial intelligence (AI) deep learning tools provide a means for decision support. This study evaluates the hemorrhage segmentations produced from three-dimensional deep learning AI model that was developed using non-contrast computed tomography (CT) imaging data external to the current study. Methods Non-contrast CT imaging data from 1263 patients were accessed across seven data sources (referred to as sites) in Norway and Sweden. Patients were included based on ICH, TBI-bleed, or mild TBI diagnosis. Initial non-contrast CT images were available for all participants. Hemorrhage location frequency maps were generated. The number of estimated haematoma clusters was correlated with the total haematoma volume. Ground truth expert annotations were available for one ICH site; hence, a comparison was made with the estimated haematoma volumes. Segmentation volume estimates were used in a receiver operator characteristics (ROC) analysis for all samples (i.e., bleed detected) and then specifically for one site with few TBI-bleed cases. Results The hemorrhage frequency maps showed spatial patterns of estimated lesions consistent with ICH or TBI-bleed presentations. There was a positive correlation between the estimated number of clusters and total haematoma volume for each site (correlation range: 0.45-0.74; each p-value < 0.01) and evidence of ICH between-site differences. Relative to hand-drawn annotations for one ICH site, the VIOLA-AI segmentation mask achieved a median Dice Similarity Coefficient of 0.82 (interquartile range: 0.78 and 0.83), resulting in a small overestimate in the haematoma volume by a median of 0.47 mL (interquartile range: 0.04 and 1.75 mL). The bleed detection ROC analysis for the whole sample gave a high area-under-the-curve (AUC) of 0.92 (with sensitivity and specificity of 83.28% and 95.41%); however, when considering only the mild head injury site, the TBI-bleed detection gave an AUC of 0.70. Discussion An open-source segmentation tool was used to visualize hemorrhage locations across multiple data sources and revealed quantitative hemorrhage site differences. The automated total hemorrhage volume estimate correlated with a per-participant hemorrhage cluster count. ROC results were moderate-to-high. The VIOLA-AI tool had promising results and might be useful for various types of intracranial hemorrhage.
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Affiliation(s)
- Bradley J. MacIntosh
- Computational Radiology & Artificial Intelligence Unit, Department of Physics and Computational Radiology, Clinic for Radiology and Nuclear Medicine, Oslo University Hospital, Oslo, Norway
- Department of Medical Biophysics, Faculty of Medicine, University of Toronto, Toronto, ON, Canada
- Hurvitz Brain Sciences, Sandra Black Centre for Brain Resilience & Recovery, Physical Sciences Platform, Sunnybrook Research Institute, Toronto, Oslo, Norway
| | - Qinghui Liu
- Computational Radiology & Artificial Intelligence Unit, Department of Physics and Computational Radiology, Clinic for Radiology and Nuclear Medicine, Oslo University Hospital, Oslo, Norway
| | - Till Schellhorn
- Computational Radiology & Artificial Intelligence Unit, Department of Physics and Computational Radiology, Clinic for Radiology and Nuclear Medicine, Oslo University Hospital, Oslo, Norway
- Division of Radiology and Nuclear Medicine, Oslo University Hospital, Oslo, Norway
| | - Mona K. Beyer
- Division of Radiology and Nuclear Medicine, Oslo University Hospital, Oslo, Norway
| | - Inge Rasmus Groote
- Computational Radiology & Artificial Intelligence Unit, Department of Physics and Computational Radiology, Clinic for Radiology and Nuclear Medicine, Oslo University Hospital, Oslo, Norway
- Department of Radiology, Vestfold Hospital Trust, Tønsberg, Norway
| | - Pål C. Morberg
- Computational Radiology & Artificial Intelligence Unit, Department of Physics and Computational Radiology, Clinic for Radiology and Nuclear Medicine, Oslo University Hospital, Oslo, Norway
- Department of Radiology and Department of Surgery, Vestfold Hospital Trust, Tønsberg, Norway
| | - Joshua M. Poulin
- Hurvitz Brain Sciences, Sandra Black Centre for Brain Resilience & Recovery, Physical Sciences Platform, Sunnybrook Research Institute, Toronto, Oslo, Norway
| | - Maiken N. Selseth
- Department of Neurology, Akershus University Hospital, Lørenskog, Norway
- Department of Diagnostic Imaging, Akershus University Hospital, Lørenskog, Norway
| | - Ragnhild C. Bakke
- Division of Radiology and Nuclear Medicine, Oslo University Hospital, Oslo, Norway
| | - Aina Naqvi
- Division of Radiology and Nuclear Medicine, Oslo University Hospital, Oslo, Norway
| | - Amir Hillal
- Department of Diagnostic Radiology, Neuroradiology, Skåne University Hospital, Lund, Sweden
| | - Teresa Ullberg
- Department of Diagnostic Radiology, Neuroradiology, Skåne University Hospital, Lund, Sweden
- Department of Medical Imaging and Physiology, Skåne University Hospital, Lund, Sweden
| | - Johan Wassélius
- Department of Diagnostic Radiology, Neuroradiology, Skåne University Hospital, Lund, Sweden
- Department of Clinical Sciences, Faculty of Medicine, Lund University, Lund, Sweden
| | - Ole M. Rønning
- Department of Neurology, Akershus University Hospital, Lørenskog, Norway
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - Per Selnes
- Department of Neurology, Akershus University Hospital, Lørenskog, Norway
| | - Espen S. Kristoffersen
- Department of Neurology, Akershus University Hospital, Lørenskog, Norway
- Department of General Practice, Institute of Health and Society, Faculty of Medicine, University of Oslo, Oslo, Norway
| | - Kyrre Eeg Emblem
- Department of Physics and Computational Radiology, Clinic for Radiology and Nuclear Medicine, Oslo University Hospital, Oslo, Norway
| | - Karoline Skogen
- Computational Radiology & Artificial Intelligence Unit, Department of Physics and Computational Radiology, Clinic for Radiology and Nuclear Medicine, Oslo University Hospital, Oslo, Norway
- Division of Radiology and Nuclear Medicine, Oslo University Hospital, Oslo, Norway
| | - Else C. Sandset
- Department of Neurology, Oslo University Hospital, Oslo, Norway
| | - Atle Bjørnerud
- Computational Radiology & Artificial Intelligence Unit, Department of Physics and Computational Radiology, Clinic for Radiology and Nuclear Medicine, Oslo University Hospital, Oslo, Norway
- Department of Physics, University of Oslo, Oslo, Norway
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Witsch J, Roh D, Oh S, Iadecola C, Diaz-Arrastia R, Kasner SE, Mayer SA, Murthy SB. Association Between Soluble Intercellular Adhesion Molecule-1 and Intracerebral Hemorrhage Outcomes in the FAST Trial. Stroke 2023; 54:1726-1734. [PMID: 37226773 PMCID: PMC10330250 DOI: 10.1161/strokeaha.123.042466] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2023] [Accepted: 04/20/2023] [Indexed: 05/26/2023]
Abstract
BACKGROUND Neutrophil-mediated inflammation in the acute phase of intracerebral hemorrhage (ICH) worsens outcome in preclinical studies. sICAM-1 (soluble intercellular adhesion molecule-1), an inducible ligand for integrins and cell-cell adhesion molecules, is critical for neutrophil extravasation. We aimed to determine whether serum levels of sICAM-1 are associated with worse outcomes after ICH. METHODS We conducted a post hoc secondary analysis of an observational cohort using data from the FAST trial (Factor-VII for Acute Hemorrhagic Stroke Treatment). The study exposure was the admission serum level of sICAM-1. The coprimary outcomes were mortality and poor outcome (modified Rankin Scale score 4-6) at 90 days. Secondary radiological outcomes were hematoma expansion at 24 hours and perihematomal edema expansion at 72 hours. We used multiple linear and logistic regression analyses to test for associations between sICAM-1 and outcomes, after adjustment for demographics, ICH severity characteristics, change in the systolic blood pressure in the first 24 hours, treatment randomization arm, and the time from symptom onset to study drug administration. RESULTS Of 841 patients, we included 507 (60%) with complete data. Hematoma expansion occurred in 169 (33%), while 242 (48%) had a poor outcome. In multivariable analyses, sICAM-1 was associated with mortality (odds ratio, 1.53 per SD increase [95% CI, 1.15-2.03]) and poor outcome (odds ratio, 1.34 per SD increase [CI, 1.06-1.69]). In multivariable analyses of secondary outcomes, sICAM-1 was associated with hematoma expansion (odds ratio, 1.35 per SD increase [CI, 1.11-1.66]), but was not associated with log-transformed perihematomal edema expansion at 72 hours. In additional analyses stratified by treatment assignment, similar results were noted in the recombinant activated factor-VII arm, but not in the placebo arm. CONCLUSIONS Admission serum levels of sICAM-1 were associated with mortality, poor outcome, and hematoma expansion. Given the possibility of a biological interaction between recombinant activated factor-VII and sICAM-1, these findings highlight the need to further explore the role of sICAM-1 as a potential marker of poor ICH outcomes.
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Affiliation(s)
- Jens Witsch
- Department of Neurology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - David Roh
- Vagelos College of Physicians and Surgeons, Department of Neurology, Columbia University, New York, NY
| | - Stephanie Oh
- Clinical and Translational Neuroscience Unit, Feil Family Brain and Mind Research Institute and Department of Neurology, Weill Cornell Medicine, New York, NY
| | - Costantino Iadecola
- Clinical and Translational Neuroscience Unit, Feil Family Brain and Mind Research Institute and Department of Neurology, Weill Cornell Medicine, New York, NY
| | - Ramon Diaz-Arrastia
- Department of Neurology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Scott E. Kasner
- Department of Neurology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Stephan A. Mayer
- Departments of Neurology and Neurosurgery, New York Medical College, Valhalla, NY
| | - Santosh B. Murthy
- Clinical and Translational Neuroscience Unit, Feil Family Brain and Mind Research Institute and Department of Neurology, Weill Cornell Medicine, New York, NY
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Abulhasan YB, Teitelbaum J, Al-Ramadhani K, Morrison KT, Angle MR. Functional Outcomes and Mortality in Patients With Intracerebral Hemorrhage After Intensive Medical and Surgical Support. Neurology 2023; 100:e1985-e1995. [PMID: 36927881 PMCID: PMC10186215 DOI: 10.1212/wnl.0000000000207132] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2022] [Accepted: 01/17/2023] [Indexed: 03/18/2023] Open
Abstract
BACKGROUND AND OBJECTIVES Despite decades of increasingly sophisticated neurocritical care, patient outcomes after spontaneous intracerebral hemorrhage (ICH) remain dismal. Whether this reflects therapeutic nihilism or the effects of the primary injury has been questioned. In this contemporary cohort, we determined the 30- and 90-day mortality, cause-specific mortality, functional outcome, and the effect of surgical intervention in a culture of aggressive medical and surgical support. METHODS This was a retrospective cohort study of consecutive adult patients with spontaneous ICH admitted to a tertiary neurocritical care unit. Patients with secondary ICH and those subject to limitation of care before 72 hours were excluded. For each ICH score, mortality at 30- and 90-days, and the modified Rankin Scale (mRS) within 1-year were examined. The effect of craniotomy/craniectomy ± hematoma evacuation on the outcome of supratentorial ICH was determined using propensity score matching. Median patient follow-up after discharge was 2.2 (interquartile range [IQR] 0.4-4.4) years. RESULTS Among 319 patients with spontaneous ICH (median age was 69 [IQR 60-77] years, 60% male), 30- and 90-day mortality were 16% and 22%, respectively, and unfavorable functional outcome (mRS score 4-6) was 50% at a median 3.1 months after ICH. Admission predictors of mortality mirrored those of the original ICH score. Unfavorable outcomes for ICH scores 3 and 4 were 73% and 86%, respectively. The most common adjudicated primary causes of mortality were direct effect or progression of ICH (54%), refractory cerebral edema (21%), and medical complications (11%). In matched analyses, lifesaving surgery for supratentorial ICH did not significantly alter mortality or unfavorable functional outcome in patients overall. In subgroup analyses restricted to (1) surgery with hematoma evacuation and (2) ICH score 3 and 4 patients, the odds of 30-day mortality were reduced by 71% (odds ratio [OR] 0.29, 95% CI 0.09-0.9, p = 0.032) and 80% (OR 0.2, 95% CI 0.04-0.91, p = 0.038), respectively, but no difference was observed for 90-day mortality or unfavorable functional outcome. DISCUSSION This study demonstrates that poor outcomes after ICH prevail despite aggressive treatment. Unfavorable outcomes appear related to direct effects of the primary injury and not to premature care limitations. Lifesaving surgery for supratentorial lesions delayed mortality but did not alter functional outcomes.
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Affiliation(s)
- Yasser B Abulhasan
- From the Neurological Intensive Care Unit (Y.B.A., J.T., M.R.A.) and Department of Radiology (K.A.R.), Montreal Neurological Institute and Hospital, McGill University, Quebec, Canada; Faculty of Medicine (Y.B.A.), Health Sciences Center, Kuwait University; and Department of Epidemiology, Biostatistics and Occupational Health (K.T.M.), McGill University, Montreal, Quebec, Canada.
| | - Jeanne Teitelbaum
- From the Neurological Intensive Care Unit (Y.B.A., J.T., M.R.A.) and Department of Radiology (K.A.R.), Montreal Neurological Institute and Hospital, McGill University, Quebec, Canada; Faculty of Medicine (Y.B.A.), Health Sciences Center, Kuwait University; and Department of Epidemiology, Biostatistics and Occupational Health (K.T.M.), McGill University, Montreal, Quebec, Canada
| | - Khalsa Al-Ramadhani
- From the Neurological Intensive Care Unit (Y.B.A., J.T., M.R.A.) and Department of Radiology (K.A.R.), Montreal Neurological Institute and Hospital, McGill University, Quebec, Canada; Faculty of Medicine (Y.B.A.), Health Sciences Center, Kuwait University; and Department of Epidemiology, Biostatistics and Occupational Health (K.T.M.), McGill University, Montreal, Quebec, Canada
| | - Kathryn T Morrison
- From the Neurological Intensive Care Unit (Y.B.A., J.T., M.R.A.) and Department of Radiology (K.A.R.), Montreal Neurological Institute and Hospital, McGill University, Quebec, Canada; Faculty of Medicine (Y.B.A.), Health Sciences Center, Kuwait University; and Department of Epidemiology, Biostatistics and Occupational Health (K.T.M.), McGill University, Montreal, Quebec, Canada
| | - Mark R Angle
- From the Neurological Intensive Care Unit (Y.B.A., J.T., M.R.A.) and Department of Radiology (K.A.R.), Montreal Neurological Institute and Hospital, McGill University, Quebec, Canada; Faculty of Medicine (Y.B.A.), Health Sciences Center, Kuwait University; and Department of Epidemiology, Biostatistics and Occupational Health (K.T.M.), McGill University, Montreal, Quebec, Canada
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Hillal A, Ullberg T, Ramgren B, Wassélius J. Computed tomography in acute intracerebral hemorrhage: neuroimaging predictors of hematoma expansion and outcome. Insights Imaging 2022; 13:180. [DOI: 10.1186/s13244-022-01309-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2022] [Accepted: 09/24/2022] [Indexed: 11/24/2022] Open
Abstract
AbstractIntracerebral hemorrhage (ICH) accounts for 10–20% of all strokes worldwide and is associated with serious outcomes, including a 30-day mortality rate of up to 40%. Neuroimaging is pivotal in diagnosing ICH as early detection and determination of underlying cause, and risk for expansion/rebleeding is essential in providing the correct treatment. Non-contrast computed tomography (NCCT) is the most used modality for detection of ICH, identification of prognostic markers and measurements of hematoma volume, all of which are of major importance to predict outcome. The strongest predictors of 30-day mortality and functional outcome for ICH patients are baseline hematoma volume and hematoma expansion. Even so, exact hematoma measurement is rare in clinical routine practice, primarily due to a lack of tools available for fast, effective, and reliable volumetric tools. In this educational review, we discuss neuroimaging findings for ICH from NCCT images, and their prognostic value, as well as the use of semi-automatic and fully automated hematoma volumetric methods and assessment of hematoma expansion in prognostic studies.
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Witsch J, Roh DJ, Avadhani R, Merkler AE, Kamel H, Awad I, Hanley DF, Ziai WC, Murthy SB. Association Between Intraventricular Alteplase Use and Parenchymal Hematoma Volume in Patients With Spontaneous Intracerebral Hemorrhage and Intraventricular Hemorrhage. JAMA Netw Open 2021; 4:e2135773. [PMID: 34860246 PMCID: PMC8642781 DOI: 10.1001/jamanetworkopen.2021.35773] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
IMPORTANCE Intraventricular thrombolysis reduces intraventricular hemorrhage (IVH) volume in patients with spontaneous intracerebral hemorrhage (ICH), but it is unclear if a similar association with parenchymal ICH volume exists. OBJECTIVE To evaluate the association between intraventricular alteplase use and ICH volume as well as the association between a change in parenchymal ICH volume and long-term functional outcomes. DESIGN, SETTING, AND PARTICIPANTS This cohort study was a post hoc exploratory analysis of data from the Clot Lysis: Evaluating Accelerated Resolution of Intraventricular Hemorrhage phase 3 randomized clinical trial with blinded outcome assessments. Between September 1, 2009, and January 31, 2015, patients with ICH and IVH were randomized to receive either intraventricular alteplase or normal saline via an external ventricular drain. Participants with primary IVH were excluded. Data analyses were performed between January 1 and June 30, 2021. EXPOSURE Randomization to receive intraventricular alteplase. MAIN OUTCOMES AND MEASURES The primary outcome was the change in parenchymal ICH volume between the hematoma stability and end-of-treatment computed tomography scans. Secondary outcomes were a modified Rankin Scale score higher than 3 and mortality, both of which were assessed at 6 months. The association between alteplase and change in parenchymal ICH volume was assessed using multiple linear regression, whereas the associations between change in parenchymal ICH volume and 6-month outcomes were assessed using multiple logistic regression. Prespecified subgroup analyses were performed for baseline IVH volume, admission ICH volume, and ICH location. RESULTS A total of 454 patients (254 men [55.9%]; mean [SD] age, 59 [11] years) were included in the study. Of these patients, 230 (50.7%) were randomized to receive alteplase and 224 (49.3%) to receive normal saline. The alteplase group had a greater mean (SD) reduction in parenchymal ICH volume compared with the saline group (1.8 [0.2] mL vs 0.4 [0.1] mL; P < .001). In the primary analysis, alteplase use was associated with a change in the parenchymal ICH volume in the unadjusted analysis per 1-mL change (β, 1.37; 95% CI, 0.92-1.81; P < .001) and in multivariable linear regression analysis that was adjusted for demographic characteristics, stability ICH and IVH volumes, ICH location, and time to first dose of study drug per 1-mL change (β, 1.20; 95% CI, 0.79-1.62; P < .001). In the secondary analyses, no association was found between change in parenchymal ICH volume and poor outcome (odds ratio [OR], 0.97; 95% CI 0.87-1.10; P = .64) or mortality (OR, 0.97; 95% CI 0.99-1.08; P = .59). Similar results were observed in the subgroup analyses. CONCLUSIONS AND RELEVANCE This study found that intraventricular alteplase use in patients with a large IVH was associated with a small reduction in parenchymal ICH volume, but this association did not translate into improved functional outcomes or mortality. Intraventricular thrombolysis should be examined in patients with moderate to large ICH with IVH, especially in a thalamic location.
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Affiliation(s)
- Jens Witsch
- Clinical and Translational Neuroscience Unit and Department of Neurology, Feil Family Brain and Mind Research Institute, Weill Cornell Medicine, New York, New York
- Department of Neurology, University of Pennsylvania School of Medicine, Philadelphia
| | - David J. Roh
- Department of Neurology, Vagelos College of Physicians and Surgeons, Columbia University, New York, New York
| | - Radhika Avadhani
- Brain Injury Outcomes Division, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Alexander E. Merkler
- Clinical and Translational Neuroscience Unit and Department of Neurology, Feil Family Brain and Mind Research Institute, Weill Cornell Medicine, New York, New York
| | - Hooman Kamel
- Clinical and Translational Neuroscience Unit and Department of Neurology, Feil Family Brain and Mind Research Institute, Weill Cornell Medicine, New York, New York
| | - Issam Awad
- Department of Neurological Surgery, University of Chicago School of Medicine, Chicago, Illinois
| | - Daniel F. Hanley
- Brain Injury Outcomes Division, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Wendy C. Ziai
- Brain Injury Outcomes Division, Johns Hopkins University School of Medicine, Baltimore, Maryland
- Division of Neurosciences Critical Care, Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Santosh B. Murthy
- Clinical and Translational Neuroscience Unit and Department of Neurology, Feil Family Brain and Mind Research Institute, Weill Cornell Medicine, New York, New York
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Radioimaging and Demographic Profiles of Patients with Spontaneous Intracerebral Hemorrhage: A Need for the Pragmatic Referral System. ADVANCES IN EXPERIMENTAL MEDICINE AND BIOLOGY 2021; 1374:105-112. [PMID: 34773632 DOI: 10.1007/5584_2021_662] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
Referring patients with severe medical conditions, like brain stroke, from small or rural hospitals to tertiary care centers is often overexploited leading to a kind of defensive medicine. The issue of a patient referral system remains unaddressed in Nepal. In this article, we investigated the legitimacy of referring patients with spontaneous intracranial hemorrhage (ICH) from country peripheral hospitals to the leading tertiary neurological center in Nepal. We found that 81 out of the 130 ICH patients reviewed in the study were referred. We further show that the classifiers to be considered most in the decision-making on the patient referral are as follows: hematoma volume, midline shift found in radioimaging, ventricular extension of bleeding, and appearance of hydrocephalus. An improper referral of the patient to the tertiary care center decreases limited resources of healthcare services in low-income countries. We believe the study reflects a prevailing belief among healthcare professionals that the current referral system could be improved with the inception of the "hub and spoke" model of healthcare. In this model, a network of secondary health institutions, capable of offering limited treatment, would refer ICH patients to an anchor tertiary institution, respecting the proper dichotomization of patients based on the clinical classifiers. We conclude that the use of the "hub and spoke" model, legitimizing the patient referral system, is posed to offer medical benefits for patients hit by a stroke and would be economically viable for both patients and healthcare services.
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Witsch J, Siegerink B, Nolte CH, Sprügel M, Steiner T, Endres M, Huttner HB. Prognostication after intracerebral hemorrhage: a review. Neurol Res Pract 2021; 3:22. [PMID: 33934715 PMCID: PMC8091769 DOI: 10.1186/s42466-021-00120-5] [Citation(s) in RCA: 22] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2021] [Accepted: 03/19/2021] [Indexed: 12/11/2022] Open
Abstract
Background Approximately half of patients with spontaneous intracerebral hemorrhage (ICH) die within 1 year. Prognostication in this context is of great importance, to guide goals of care discussions, clinical decision-making, and risk stratification. However, available prognostic scores are hardly used in clinical practice. The purpose of this review article is to identify existing outcome prediction scores for spontaneous intracerebral hemorrhage (ICH) discuss their shortcomings, and to suggest how to create and validate more useful scores. Main text Through a literature review this article identifies existing ICH outcome prediction models. Using the Essen-ICH-score as an example, we demonstrate a complete score validation including discrimination, calibration and net benefit calculations. Score performance is illustrated in the Erlangen UKER-ICH-cohort (NCT03183167). We identified 19 prediction scores, half of which used mortality as endpoint, the remainder used disability, typically the dichotomized modified Rankin score assessed at variable time points after the index ICH. Complete score validation by our criteria was only available for the max-ICH score. Our validation of the Essen-ICH-score regarding prediction of unfavorable outcome showed good discrimination (area under the curve 0.87), fair calibration (calibration intercept 1.0, slope 0.84), and an overall net benefit of using the score as a decision tool. We discuss methodological pitfalls of prediction scores, e.g. the withdrawal of care (WOC) bias, physiological predictor variables that are often neglected by authors of clinical scores, and incomplete score validation. Future scores need to integrate new predictor variables, patient-reported outcome measures, and reduce the WOC bias. Validation needs to be standardized and thorough. Lastly, we discuss the integration of current ICH scoring systems in clinical practice with the awareness of their shortcomings. Conclusion Presently available prognostic scores for ICH do not fulfill essential quality standards. Novel prognostic scores need to be developed to inform the design of research studies and improve clinical care in patients with ICH. Supplementary Information The online version contains supplementary material available at 10.1186/s42466-021-00120-5.
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Affiliation(s)
- Jens Witsch
- Department of Neurology, Weill Cornell Medicine, 525 East 68th Street, New York, NY, 10065, USA.
| | - Bob Siegerink
- Center for Stroke Research Berlin, Charité Universitätsmedizin, Berlin, Germany
| | - Christian H Nolte
- Center for Stroke Research Berlin, Charité Universitätsmedizin, Berlin, Germany.,Klinik und Hochschulambulanz für Neurologie, Charité Universitätsmedizin Berlin, Berlin, Germany
| | - Maximilian Sprügel
- Department of Neurology, Universitätsklinikum Erlangen, Erlangen, Germany
| | - Thorsten Steiner
- Department of Neurology, Klinikum Frankfurt Höchst, Frankfurt a. M., Germany.,Department of Neurology, Universität Heidelberg, Heidelberg, Germany
| | - Matthias Endres
- Center for Stroke Research Berlin, Charité Universitätsmedizin, Berlin, Germany.,Klinik und Hochschulambulanz für Neurologie, Charité Universitätsmedizin Berlin, Berlin, Germany.,German Center for Neurodegenerative Diseases (DZNE), Partner Site Berlin, Berlin, Germany.,German Centre for Cardiovascular Research (DZHK), Partner Site Berlin, Berlin, Germany
| | - Hagen B Huttner
- Department of Neurology, Universitätsklinikum Erlangen, Erlangen, Germany
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