Hematoma Expansion Predictors: Laboratory and Radiological Risk Factors in Patients with Acute Intracerebral Hemorrhage: A Prospective Observational Study

Hybrid clinical-radiomics model based on fully automatic segmentation for predicting the early expansion of spontaneous intracerebral hemorrhage: A multi-center study

BACKGROUND

Early prediction of hematoma expansion (HE) is important for the development of therapeutic strategies for spontaneous intracerebral hemorrhage (sICH). Radiomics can help to predict early hematoma expansion in intracerebral hemorrhage. However, complex image processing procedures, especially hematoma segmentation, are time-consuming and dependent on assessor experience. We provide a fully automated hematoma segmentation method, and construct a hybrid predictive model for risk stratification of hematoma expansion.

PURPOSE

To propose an automatic approach for predicting early hemorrhage expansion after spontaneous intracerebral hemorrhage using deep-learning and radiomics methods.

METHODS

A total of 258 patients with sICH were retrospectively enrolled for model construction and internal validation, while another two cohorts (n=87, 149) were employed for independent validation. For hemorrhage segmentation, an iterative segmentation procedure was performed to delineate the area using an nnU-Net framework. Radiomics models of intra-hemorrhage and multiscale peri-hemorrhage were established and evaluated, and the best discriminative-scale peri-hemorrhage radiomics model was selected for further analysis. Combining clinical factors and intra- and peri-hemorrhage radiomics signatures, a hybrid nomogram was constructed for the early HE prediction using multivariate logistic regression. For model validation, the receiver operating characteristic (ROC) curve analyses and DeLong test were used to evaluate the performances of the constructed models, and the calibration curve and decision curve analysis were performed for clinical application.

RESULTS

Our iterative auto-segmentation model showed satisfactory results for hematoma segmentation in all four cohorts. The Dice similarity coefficient of this hematoma segmentation model reached 0.90, showing an expert-level accuracy in hematoma segmentation. The consumed time of the efficient delineation was significantly decreased, from 18 min to less than 2 min, with the assistance of the auto-segmentation model. The radiomics model of 2-mm peri-hemorrhage had a preferable area under ROC curve (AUC) of 0.840 (95 % confidence interval [CI]: 0.768, 0.912) compared with the original (0-mm dilatation) model with an AUC of 0.796 (95 % CI: 0.717, 0.875). The clinical-radiomics hybrid model showed better performances for HE prediction, with AUC of 0.853, 0.852, 0.772, and 0.818 in the training, internal validation, and independent validation cohorts 1 and 2, respectively.

CONCLUSIONS

The fully automatic clinical-radiomics model based on deep learning and radiomics exhibits a good ability for hematoma segmentation and a favorable performance in stratifying HE risks.

Low LDL-C/HDL-C Ratio is Associated with Poor Clinical Outcome After Intracerebral Hemorrhage: A Retrospective Analysis of Multicenter, Prospective Cohort Data in China

BACKGROUND

The association between low-density lipoprotein cholesterol (LDL-C)/high-density lipoprotein cholesterol (HDL-C) ratio and the clinical outcomes of acute intracranial hemorrhage (ICH) remains unclear. In this study, we attempt to investigate whether low LDL-C/HDL-C ratio is associated with poor clinical outcomes in patients with ICH.

METHODS

The database was collected from a multicenter, prospective, observational cohort study, conducted in 13 hospitals in Beijing from January 2014 to September 2016. A total of 1,964 patients with ICH were initially screened in our database. Next, we selected patients with admission serum lipid information for retrospective analysis. Patients were categorized into four groups based on LDL-C/HDL-C ratio quartiles. The main outcomes were 30-day and 90-day poor functional outcome, which is defined as modified Rankin Scale score of 3 to 6, and 90-day all-cause death. Logistic regression was used to assess the association between LDL-C/HDL-C ratio and 30-day or 90-day poor functional outcome. Kaplan-Meier survival analysis and Cox regression were used to assess the association between LDL-C/HDL-C ratio and 90-day all-cause death. Restricted cubic splines were used to explore the nonlinear association between LDL-C/HDL-C ratio and the outcome of patients with ICH.

RESULTS

A total of 491 patients with spontaneous ICH were finally enrolled in our study. The mean age was 57.6 years old, and 72.1% (357/491) were men. After adjustment for confounders, patients in the lowest LDL-C/HDL-C quartile (< 1.74) had a significantly higher risk of 30-day and 90-day poor functional outcome compared with those in the highest quartile (> 3.16; 30-day: adjusted odds ratio 3.61, 95% confidence interval 1.68-7.72; 90-day: adjusted odds ratio 2.82, 95% confidence interval 1.33-5.95). Restricted cubic splines depicted a nonlinear association between LDL-C/HDL-C ratio and 90-day poor functional outcomes, indicating LDL-C/HDL-C ratio of 3.1-3.5 was correlated with better 90-day functional outcome. However, no significant correlation was found between low LDL-C/HDL-C ratio and 90-day all-cause death.

CONCLUSIONS

Lower LDL-C/HDL-C ratio (< 1.74) is independently associated with an increased risk of poor functional outcome in patients with ICH. In the population of patients whom we studied, there is a nonlinear association between LDL-C/HDL-C ratio and 90-day poor functional outcome, and patients with an LDL-C/HDL-C ratio of 3.1 to 3.5 tend to have the lowest risk of 90-day poor functional outcome.

Blood-Based Biomarkers in Intracerebral Hemorrhage

Intracerebral hemorrhage (ICH) is one of the most lethal subtypes of stroke, associated with high morbidity and mortality. Prevention of hematoma growth and perihematomal edema expansion are promising therapeutic targets currently under investigation. Despite recent improvements in the management of ICH, the ideal treatments are still to be determined. Early stratification and triage of ICH patients enable the adjustment of the standard of care in keeping with the personalized medicine principles. In recent years, research efforts have been concentrated on the development and validation of blood-based biomarkers. The benefit of looking for blood candidate markers is obvious because of their acceptance in terms of sample collection by the general population compared to any other body fluid. Given their ease of accessibility in clinical practice, blood-based biomarkers have been widely used as potential diagnostic, predictive, and prognostic markers. This review identifies some relevant and potentially promising blood biomarkers for ICH. These blood-based markers are summarized by their roles in clinical practice. Well-designed and large-scale studies are required to validate the use of all these biomarkers in the future.

Role of LDL-C level alteration in increased mortality risks in spontaneous intracerebral hemorrhage patients: Systematic review and meta-analysis

Background

Current studies indicate a contradictory relationship between decreased mortality risks of spontaneous intracerebral hemorrhage (sICH) and elevated low-density lipoprotein cholesterol (LDL-C) levels. Thus, this meta-analysis was designed to examine the involvement of high LDL-C levels in a lower mortality risk of sICH patients.

Methods

PubMed, Cochrane, and Embase databases were searched up to the date of August 3rd, 2022. Pooled odds ratio (OR) with a 95% confidence interval (CI) was estimated for the higher vs. lower serum LDL-C level groups. Subgroup and sensitivity analyses were also carried out. Egger's test was applied to detect any potential publication bias.

Results

Of 629 citations reviewed, 8 eligible cohort studies involving 83,013 patients were enrolled in this meta-analysis. Compared with lower serum LDL-C levels containing patients, higher serum LDL-C patients exhibited significantly decreased risks of 3-month mortality (OR: 0.51; 95%CI: 0.33-0.78; I² = 47.8%); however, the LDL-C level change wasn't significantly associated with in-hospital mortality risks (OR: 0.92; 95%CI: 0.63-1.33; I² = 91.4%) among sICH subjects. All studies included were classified as high-quality investigations.

Conclusions

This meta-analysis suggests a higher LDL-C level may decrease the mortality risk in sICH patients. LDL-C level increase is inversely associated with the 3-month mortality risks in these patients but not significantly correlated with the in-hospital mortality risks. Further well-designed prospective studies with extended follow-up periods are needed to confirm these findings and explore underlying cross-talks.

Systematic review registration

https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42022318318, identifier: PROSPERO 2022 CRD42022318318.

Red Cell Microparticles Suppress Hematoma Growth Following Intracerebral Hemorrhage in Chronic Nicotine-Exposed Rats

Spontaneous intracerebral hemorrhage (sICH) is a disabling stroke sub-type, and tobacco use is a prominent risk factor for sICH. We showed that chronic nicotine exposure enhances bleeding post-sICH. Reduction of hematoma growth is a promising effective therapy for sICH in smoking subjects. Red-blood-cell-derived microparticles (RMPs) are hemostatic agents that limit hematoma expansion following sICH in naïve rats. Considering the importance of testing the efficacy of experimental drugs in animal models with a risk factor for a disease, we tested RMP efficacy and the therapeutic time window in limiting hematoma growth post-sICH in rats exposed to nicotine. Young rats were chronically treated with nicotine using osmotic pumps. sICH was induced in rats using an injection of collagenase in the right striatum. Vehicle/RMPs were administered intravenously. Hematoma volume and neurological impairment were quantified ≈24 h after sICH. Hematoma volumes in male and female nicotine-exposed rats that were treated with RMPs at 2 h post-sICH were significantly lower by 26 and 31% when compared to their respective control groups. RMP therapy was able to limit hematoma volume when administered up to 4.5 h post-sICH in animals of both sexes. Therefore, RMPs may limit hematoma growth in sICH patients exposed to tobacco use.

Relationship between mean corpuscular volume and 30-day mortality in patients with intracerebral hemorrhage: Evidence from the MIMIC-III database

Previous studies have shown that mean corpuscular volume (MCV) levels are associated with the prognosis of patients with cardiovascular disease. However, the relationship between MCV levels and mortality in patients with intracerebral hemorrhage (ICH) remains unclear. Patients with ICH were extracted from the Medical Information Mart for Intensive Care-III database. The primary outcome measure was 30-day mortality. Multivariate Cox regression analysis was used to investigate the relationship between MCV at admission and 30-day mortality in ICH patients. We enrolled 1100 patients with ICH. After adjustment for potential confounders, we found that a 1 unit increase in MCV (fl) was associated with a 3% increase in 30-day mortality (HR = 1.03, 95% CI = 1.01-1.05, P = .0015). High MCV (MCV ≥ 92 fl) compared with the low MCV group (MCV < 87 fl) showed a 46% increase of 30-day mortality (HR = 1.46, 95% CI = 1.10-1.92 P = .008). In subgroups analysis's the results remained stable. We demonstrated that MCV at admission was positively associated with 30-day mortality. The Kaplan-Meier (KM) method was used to plot survival curves of three groups with different admission MCV levels.

Red cell distribution width and Glasgow coma scale score as predictors of in-hospital mortality in maintenance hemodialysis patients diagnosed with spontaneous intracerebral hemorrhage

Glasgow Coma Scale (GCS) score is being widely used as a useful predictor to investigate patients with head injury. High red cell distribution width (RDW) values have been independently associated with mortality and poor neurological outcome. However, there are few data available for Spontaneous Intracerebral Hemorrhage (SIH) in maintenance hemodialysis (MHD) patients. This study aimed to evaluate the prognostic value of the combined measurement of RDW and GCS score in MHD patients with SIH. We retrospectively studied 46 MHD patients who was admitted to our hospital for nontraumatic SIH from October 2014 to May 2020. Data including demographic information, cause of renal failure, comorbidities at ESRD, clinical and laboratory parameters at admission were collected from medical records. Univariate and multivariate Logistic regression analysis were performed to identify independent risk factors of the in-hospital Mortality in Hemodialysis Patients with SIH. The receiver operating characteristic curve (ROC) and areas under the curve (AUCs) were determined. The sensitivity and specificity of independent risk factors were calculated for a range of different cutoff points. A total of 46 patients were enrolled in the study. The in-hospital mortality rate was 69.57%. We divided subjects into 2 groups based on the clinical outcomes. Compared with survivors (n = 14), non-survivors (n = 32) had longer hemodialysis vintage (P = .017), lower GCS score (P < .001), higher hemoglobin (Hb) (P = .032) and RDW (P = .009). In multivariate logistic regression analysis, GCS score (OR 0.719, 95% CI 0.546-0.946; P = .018) and RDW (OR 4.549, 95% CI 1.243-0.946; P = .018) were independent risk factors of in-hospital mortality in MHD patients with SIH. The area under the ROC curve (AUC) for GCS score was 0.849 (95% CI 0.729-0.970) while that for RDW was 0.743 (95% CI 0.596-0.891). The AUC for the combined prediction was 0.916 (95% CI 0.828-1.000), with a sensitivity of 90.63% and a specificity of 88.46%. In conclusion, high RDW and low GCS score were useful and independent poor prognostic markers for in-hospital mortality of MHD patients with SIH.

Combined Association of Low-Density Lipoprotein Cholesterol Levels and Systolic Blood Pressure to the Outcome of Intracerebral Hemorrhage: Data from the China Stroke Center Alliance

Limited data were available about the combined impact of systolic blood pressure (SBP) and low-density lipoprotein cholesterol (LDL-C) levels on intracerebral hemorrhage (ICH) prognosis. The objective of this study is to explore whether the relationship between LDL-C and ICH outcomes was modified by SBP levels in a Chinese population. From August 1, 2015, to July 31, 2019, 75,443 ICH patients enrolled from the Chinese Stroke Center Alliance program were included in our study. Patients were divided into LDL-C levels of <70 mg/dL, 70-100 mg/dL, and ≥100 mmol/L. SBP was stratified as <140 mmHg, 140-180 mmHg, and ≥180 mmHg. The primary outcome was the occurrence of hematoma expansion (HE), and the second outcome was in-hospital mortality. Correlation between LDL-C levels and SBP on ICH outcomes were assessed by logistic regression. 6,116 (8.1%) and 1,576 (2.1%) patients suffered HE and in-hospital mortality. Compared with the ≥100 mg/dL group, patients with LDL-C concentrations under 70 mg/dL had a 19% and 24% increase in the relative risk of HE (crude OR 1.19, 95% CI 1.11-1.28) and in-hospital mortality (crude OR 1.24, 95% CI 1.08-1.42). When SBP was added as a stratification variable, the above-mentioned association was attenuated in patients under a threshold SBP of 140 mmHg (P > 0.05). However, no statistical interaction was detected between SBP and LDL-C levels. Lower LDL-C levels (<70 mg/dL) are related to a higher risk of HE and in-hospital mortality confined to ICH patients with elevated SBP (≥140 mmHg).

Various effects of nutritional status on clinical outcomes after intracerebral hemorrhage

Although the assessment of nutrition is essential for stroke patients, detailed associations between nutritional status at admission, subsequent complications, and clinical outcomes in patients with acute intracerebral hemorrhage (ICH) are unclear. We aimed to elucidate these associations using the Controlling Nutritional Status (CONUT) score. Consecutive patients with acute ICH were investigated. Nutritional status was evaluated using the CONUT score, calculated from the serum albumin level, lymphocyte count, and total cholesterol level. Subsequent complications, such as hemorrhage expansion (HE) during the acute stage and aspiration pneumonia during hospitalization, were evaluated. Poor outcome was defined as a modified Rankin Scale score of ≥ 3 at 3 months. Of the 721 patients, 49 had HE, 111 had aspiration pneumonia, and 409 had poor outcomes. Patients with HE had significantly lower total cholesterol levels than those without HE. Patients with aspiration pneumonia had significantly lower albumin levels, lower lymphocyte counts, and higher CONUT scores than those without aspiration pneumonia. Patients with poor outcomes had significantly lower albumin levels, lower lymphocyte counts, lower total cholesterol levels, and higher CONUT scores than those with good outcomes. Multivariable logistic analysis showed that higher CONUT scores were independently associated with poor outcome (odds ratio, 1.28; 95% confidence interval, 1.09-1.49; P = 0.002) after adjusting for baseline characteristics, HE, and aspiration pneumonia. Each component of CONUT was a useful predictor of subsequent complications. Malnutrition, determined using the CONUT score, was independently associated with poor outcomes in patients with ICH after adjusting for these complications.

Chronic Nicotine Exposure Increases Hematoma Expansion Following Collagenase-Induced Intracerebral Hemorrhage in Rats

Spontaneous intracerebral hemorrhage (sICH) is a deadly stroke subtype, and tobacco use increases sICH risk. However epidemiological studies show that, there are no confirmatory studies showing the effect of tobacco use on sICH outcome. Therefore, we evaluated the effect of chronic nicotine exposure (as a surrogate for tobacco use) on outcomes following sICH. Young male and female rats were randomly assigned to either nicotine (4.5 mg/kg b.w. per day) or vehicle (saline) treatment (2–3 weeks) groups. sICH was induced by injecting collagenase into the right striatum. Neurological score and hematoma volume were determined 24 h post-sICH. The hematoma volumes in nicotine-treated male and female rats were significantly higher by 42% and 48% when compared to vehicle-treated male and female rats, respectively. Neurological deficits measured in terms of neurological score for the nicotine-treated male and female groups were significantly higher when compared to the respective vehicle-treated male and female groups. Our results show that chronic nicotine exposure increases hematoma volume post-sICH in rats of both sexes. Identifying the mechanism of nicotine-dependent increase in hematoma growth post-sICH will be crucial to understanding the detrimental effect of tobacco use on the severity of bleeding following intracerebral hemorrhage.

Low-Density Lipoprotein Cholesterol and Mortality in Patients With Intracerebral Hemorrhage in Taiwan

Objective: Lower serum low-density lipoprotein cholesterol (LDL-C) levels are associated with increased intracerebral hemorrhage (ICH) risk. However, reverse causality and residual confounding has not attracted public attention. Therefore, we assessed whether people with LDL-C have increased risk of mortality adjusting for potential confounders using two large Taiwan cohorts.

Methods: The Mei-Jhao (MJ) cohort has 414,372 adults participating in a medical screening program with 378 ICH deaths within 15 years of follow-up (1994–2008). Cox proportional hazards regressions estimated hazard death ratios according to LDL-C levels. We identified 4,606 ICH patients from the Taiwan Stroke Registry (TSR) and analyzed the impact of LDL-C on 3-month mortality.

Results: Low cholesterol (LDL-C <100 mg/dL), found in 1/4 of the MJ cohort, was highly prevalent (36%) among young adults (age 20–39). There was a graded relationship between cholesterol and mortality for ICH [Hazard ratio, 1.56; 95% confidence interval (CI), 1.13–2.16]. Compared with patients with an LDL-C of 110–129 mg/dL in TSR, the risk for mortality was 1.84 (95% CI, 1.28–2.63) with an LDL-C of <100 mg/dL.

Conclusion: Lower serum LDL-C level independently predicts higher mortality after acute ICH. While its causative role may vary, low cholesterol may pose potential harms in Taiwan.

Red blood cell distribution width in glioblastoma

INTRODUCTION

Glioblastoma (GBM) is the most common and deadly adult brain tumor. Red blood cell distribution width (RDW) has been found in non-central nervous system neoplasms to be associated with survival. This study aims to assess the prognostic value of pre-operative RDW and trends in RDW over time during the disease course.

METHODS

This single-institution retrospective cohort study identified patients ≥ 18 years old with pathology-proved glioblastoma treated between April 2003-May 2017 from an institutional database. A Cox proportional hazards model was developed using known prognostic clinical variables to predict overall survival time; a second model incorporating continuously valued RDW was then created. The additional prognostic value of RDW was assessed with a joint model F-test. The variation of RDW-CV over time was evaluated with linear mixed model of RDW. A post-hoc exploratory analysis was performed to assess the trend in RDW lab value leading up to time of death.

RESULTS

346 adult GBM patients were identified; complete survival data was available for all patients. The addition of RDW to the multivariable Cox proportional hazards model did not increase prognostic value. There was an upward trend in RDW throughout the post-operative disease course. In a post-hoc analysis, there was an upward trend in RDW leading up to the time of death.

CONCLUSION

Although RDW has been prognostic of survival for many inflammatory, prothrombotic, and neoplastic diseases, pre-operative RDW was not associated with overall survival in GBM patients. RDW trended upwards throughout the disease course, suggesting possible systemic inflammatory effects of either glioblastoma or treatment.

Noncontrast Computed Tomography Markers of Cerebral Hemorrhage Expansion: Diagnostic Accuracy Meta-Analysis

BACKGROUND AND PURPOSE

Assess the diagnostic accuracy of noncontrast computed tomography (NCCT) markers of hematoma expansion in patients with primary intracerebral hemorrhage.

METHODS

We performed a meta-analysis of observational studies and randomized controlled trials with available data for calculation of sensitivity and specificity of NCCT markers for hematoma expansion (absolute growth >6 or 12.5 mL and/or relative growth >33%). The following NCCT markers were analyzed: irregular shape, island sign (shape-related features); hypodensity, heterogeneous density, blend sign, black hole sign, and swirl sign (density-related features). Pooled accuracy values for each marker were derived from hierarchical logistic regression models.

RESULTS

A total of 10,363 subjects from 23 eligible studies were included. Significant risk of bias of included studies was noted. Hematoma expansion frequency ranged from 7% to 40%, mean intracerebral hemorrhage volume from 9 to 27.8 ml, presence of NCCT markers from 9% (island sign) to 82% (irregular shape). Among shape features, sensitivity ranged from 0.32 (95%CI = 0.20-0.47) for island sign to 0.68 (95%CI = 0.57-0.77) for irregular shape, specificity ranged from 0.47 (95%CI = 0.36-0.59) for irregular shape to 0.92 (95%CI = 0.85-0.96) for island sign; among density features sensitivity ranged from 0.28 (95%CI = 0.21-0.35) for black hole sign to 0.63 (95%CI = 0.44-0.78) for hypodensity, specificity ranged from 0.65 (95%CI = 0.56-0.73) for heterogeneous density to 0.89 (95%CI = 0.85-0.92) for blend sign.

CONCLUSION

Diagnostic accuracy of NCCT markers remains suboptimal for implementation in clinical trials although density features performed better than shape-related features. This analysis may help in better tailoring patients' selection for hematoma expansion targeted trials.

Lower low-density lipoprotein cholesterol levels are associated with an increased risk of hematoma expansion and ensuing mortality in acute ICH patients

BACKGROUND AND PURPOSE

The relationship between lipid levels and the prognosis of acute intracerebral hemorrhage (ICH) remains controversial. Thus, we aimed to investigate whether lower low-density lipoprotein cholesterol (LDL-C) levels increased the risk of adverse outcomes, as well as the current situation of statin treatment in acute ICH patients with premorbid lipid-lowering therapy.

METHODS

From August 1, 2015, to July 31, 2019, a total of 73,098 ICH patients were included in our study from the Chinese Stroke Center Alliance program. Patients were grouped by LDL-C levels of < 1.4 mmol/L, 1.4-1.8 mmol/L, 1.8-2.6 mmol/L, and > 2.6 mmol/L. Logistic regression was used to assess the association between LDL-C levels and the composite risk of hematoma expansion (HE) or in-hospital death. Moreover, statin treatment in ICH patients with cardio-cerebrovascular diseases was analyzed.

RESULTS

In total, 6368 (8.7%) patients were identified as a composite of HE or in-hospital death with a mean LDL-C level of 2.9 ± 1.7 mmol/L. In the univariate analysis, patients who achieved lower LDL-C concentrations under 1.4 mmol/L had a 36% higher risk of adverse outcomes compared with the ≥ 2.6 mmol/L group (OR 1.36, 95%CI 1.23-1.51). Similar results were obtained in multivariate analyses, especially for patients with GCS scores of 9-15. For acute ICH patients with concomitant atherosclerotic disease, statin treatment was discontinued in the majority of Chinese population.

CONCLUSIONS

Lower LDL-C levels (< 1.4 mmol/L) are associated with an increased risk of HE and ensuing mortality in acute ICH patients. Maintaining an optimal LDL-C range may have therapeutic potential against HE which merits further investigation.

Neutrophil to lymphocyte ratio predicts early growth of traumatic intracerebral haemorrhage

OBJECTIVE

The neutrophil to lymphocyte ratio (NLR) has been proposed to capture the inflammatory status of patients with various conditions involving the brain. This retrospective study aimed to explore the association between the NLR and the early growth of traumatic intracerebral haemorrhage (tICH) in patients with traumatic brain injury (TBI).

METHODS

A multicentre, observational cohort study was conducted. Patients with cerebral contusion undergoing baseline computed tomography for haematoma volume analysis within 6 h after primary injury and follow-up visits within 48 h were included. Routine blood tests were performed upon admission, and early growth of tICH was assessed. Prediction accuracies of the NLR for the early growth of tICH and subsequent surgical intervention in patients were analysed.

RESULTS

There were a total of 1077 patients who met the criteria included in the study cohort. Univariate analysis results showed that multiple risk factors were associated with the early growth of tICH and included in the following multivariate analysis models. The multivariate logistic regression analysis results revealed that the NLR was highly associated with the early growth of tICH (p < 0.001) while considering other risk factors in the same model. The prediction accuracy of the NLR for the early growth of tICH in patients is 82%.

INTERPRETATION

The NLR is easily calculated and might predict the early growth of tICH for patients suffering from TBI.

A nomogram to predict the risk of early postoperative ischemic events in patients with spontaneous intracranial hematoma

Spontaneous intracranial hematoma (ICH) is the second leading cause of stroke and has a high risk of postoperative ischemic events (PIEs). But, the evidence on PIEs in ICH patients still lacks. Therefore, a retrospective study was carried out to screen the risk factors for PIEs and construct a visual predictive model. This was a retrospective study whose population were divided into two groups based on the occurrence of PIEs. Univariate logistic regression analysis was used to determine factors associated with PIEs. Multifactorial logistic regression analysis was used to screen risk factors and construct the early PIEs risk nomogram. In addition, impact of PIEs on patient prognosis and surgery related costs was assessed. Out of 122 ICH patients, 24 (19.7%) were diagnosed with PIEs. Coronary heart disease history, ischemic stroke history, regular shaped hematoma and platelet number were identified as risk factors for early PIEs. Early PIEs risk nomogram showed good calibration and discrimination of the data with concordance index of 0.846 (95% confidence interval, 0.747-0.945) which was confirmed to be 0.827 through bootstrapping validation. In addition, there was statistical difference in discharged Glasgow Coma Scale score (P = 0.046) and surgery related costs (p = 0.031) between PIEs group and nPIEs group. These results showed the early PIEs risk nomogram was accurate for prediction risks of PIEs and the occurrence of PIEs affects prognosis of patients, and increases surgery related costs.

Development and validation of a nomogram for predicting hematoma expansion in intracerebral hemorrhage

BACKGROUND AND OBJECTIVE

To develop and validate a clinical nomogram for individualized predicting hematoma expansion (HE) in patients with Intracerebral Hemorrhage (ICH).

METHODS

A total of 1025 patients with ICH were retrospectively enrolled in the development cohort between 2010 and 2016. We identified and integrated significant factors for HE to build a nomogram. The model was subjected to validation with a separate cohort of 397 patients from the 2017-2019. The predictive accuracy and discriminative ability were measured by concordance index (C-index). The primary outcome was HE, defined as hematoma growth more than 6 mL or 33% increase in the volume.

RESULTS

A total of 1025 patients were included for univariable analysis. HE occurred in 180 patients (17.6%). The time to initial CT (≤6h vs. >6 h; p = 0.001), NIHSS score (0-4 vs. 5-14 vs. ≥15; p = 0.031), CTA spot sign (yes vs. no vs. absent; p = 0.018), hypodensities (p = 0.000), blend sign (p = 0.005), and INR (<1.2 vs. ≥1.2; p = 0.009) were identified and entered into the nomogram. The calibration curves for probability of HE showed optimal agreement between nomogram prediction and actual observation. The C-index was 0.751. The validation cohort consisted of 397 patients and HE occurred in 78 patients (19.6%). The C-index was 0.743.

CONCLUSIONS

We developed and validated a nomogram that can individually predict HE for ICH in Chinese populations. This practical prognostic nomogram may help clinicians make decision of clinical practice and design of clinical studies.

Association between electrolyte levels at presentation and hematoma expansion and outcome in spontaneous intracerebral hemorrhage: A systematic review

PURPOSE

To assess the association between specific electrolyte levels (sodium, potassium, calcium, magnesium, and phosphorus) on presentation and hematoma expansion (HE) and outcome in intracerebral hemorrhage (ICH).

METHODS

This review was conducted in accordance with the PRISMA statement recommendations. Three databases were searched (Pubmed, Scopus, and Cochrane). Risk of bias was computed using the Newcastle-Ottawa Scale tool.

RESULTS

18 full-text articles were included in this systematic review including 10,385 ICH patients. Hypocalcemia was associated with worse short-term outcome in four studies, and two other studies were neutral. All studies investigating HE in hypocalcemia (n = 5) reported an association between low calcium level and HE. Hyponatremia (Na < 135 mEq/L) was shown to correlate with worse short-term outcome in two studies, and worse long-term outcome in one. There was one report showing no association between sodium level and HE. Hypomagnesemia was shown to be associated with worse short-term outcome in one study, while other reports were neutral. Studies evaluating hypophosphatemia or hypokalemia in ICH were limited, with no demonstrable significant effect on outcome.

CONCLUSION

This review suggests a significant association between hypocalcemia, hyponatremia and, of lesser degree, hypomagnesemia on admission and HE or worse outcome in ICH.

Red Cell Distribution Width is Associated with 30-day Mortality in Patients with Spontaneous Intracerebral Hemorrhage

Background

Red cell distribution width (RDW) has been associated with mortality and outcome in a wide variety of non-neurological and neurological diseases, namely in myocardial infarction and acute ischemic stroke, and the reason for this is not completely understood. We aimed to investigate RDW as a potential prognostic marker in patients with intracerebral hemorrhage (ICH).

Methods

This is a retrospective study of consecutive patients with acute non-traumatic ICH admitted to a single center during a 4-year period. We reviewed individual clinical records to collect demographic and baseline information, including RDW at admission, 3-month functional status, and incidence of death during follow-up. Baseline computed tomography imaging was reviewed to classify the location of ICH, and to measure ICH volume and perihematomal edema volume. Patients were divided according to quartile distribution of RDW (RDW-Q1-4).

Results

The final study population consisted of 358 patients, median age 71 years (interquartile range [IQR] 60–80), 55% were male, and median Glasgow Coma Scale was 14 (IQR 10–15), with a mean follow-up of 17.6 months. Patients with higher RDW values were older (p = 0.003), more frequently presented with an active malignancy (p = 0.005), atrial fibrillation (p < 0.001), intraventricular hemorrhage (p = 0.048), and were anticoagulated (p < 0.001). Three-month functional independence was similar throughout RDW quartiles. RDW-Q4 was independently associated with increased 30-day mortality (adjusted odds ratio = 3.36, 95%CI = 1.48–7.62, p = 0.004), but not independently associated with increased mortality after 30 days (adjusted hazards ratio = 0.71, 95%CI = 0.29–1.73, p = 0.448).

Conclusions

RDW is a robust and independent predictor of 30-day mortality in non-traumatic ICH patients, and further studies to understand this association are warranted.

Electronic supplementary material

The online version of this article (10.1007/s12028-020-01103-1) contains supplementary material, which is available to authorized users.

Noncontrast CT markers of intracerebral hemorrhage expansion and poor outcome: A meta-analysis

OBJECTIVE

To provide precise estimates of the association between noncontrast CT (NCCT) markers, hematoma expansion (HE), and functional outcome in patients presenting with intracerebral hemorrhage (ICH) through a systematic review and meta-analysis.

METHODS

We searched PubMed for English-written observational studies or randomized controlled trials reporting data on NCCT markers of HE and outcome in spontaneous ICH including at least 50 subjects. The outcomes of interest were HE (hematoma growth >33%, >33% and/or >6 mL, >33% and/or >12.5 mL), poor functional outcome (modified Rankin Scale 3-6 or 4-6) at discharge or at 90 days, and mortality. We pooled data in random-effects models and extracted cumulative odds ratio (OR) for each NCCT marker.

RESULTS

We included 25 eligible studies (n = 10,650). The following markers were associated with increased risk of HE and poor outcome, respectively: black hole sign (OR = 3.70, 95% confidence interval [CI] = 1.42-9.64 and OR = 5.26, 95% CI = 1.75-15.76), swirl sign (OR = 3.33, 95% CI = 2.42-4.60 and OR = 3.70; 95% CI = 2.47-5.55), heterogeneous density (OR = 2.74; 95% CI = 1.71-4.39 and OR = 2.80; 95% CI = 1.78-4.39), blend sign (OR = 3.49; 95% CI = 2.20-5.55 and OR = 2.21; 95% CI 1.16-4.18), hypodensities (OR = 3.47; 95% CI = 2.18-5.50 and OR = 2.94; 95% CI = 2.28-3.78), irregular shape (OR = 2.01, 95% CI = 1.27-3.19 and OR = 3.43; 95% CI = 2.33-5.03), and island sign (OR = 7.87, 95% CI = 2.17-28.47 and OR = 6.05, 95% CI = 4.44-8.24).

CONCLUSION

Our results suggest that multiple NCCT ICH shape and density features, with different effect size, are important markers for HE and clinical outcome and may provide useful information for future randomized controlled trials.

Red blood cell distribution width and mortality of spontaneous intracerebral hemorrhage patients

OBJECTIVES

Two studies have found an association between hematoma expansion and red blood cell distribution width (RDW) in the diagnosis of spontaneous intracerebral hemorrhage (SIH); however, its association with SIH mortality has been not reported. Thus, the objectives of this study were to determine whether RDW in patients with SIH could be associated with mortality and could be used as mortality biomarker.

PATIENTS AND METHODS

Observational and prospective study of patients with severe supratentorial SIH (Glasgow Coma Scale < 9) from Intensive Care Units of 6 Spanish hospitals. RDW was recorded at days 1, 4 and 8 of SIH. Thirty-day mortality was considered the end-point study.

RESULTS

Non-surviving patients (n = 54) compared to surviving patients (n = 63) had higher RDW (p ≤ 0.001) at days 1, 4 and 8 of SIH. The area under curve (95 % confidence interval) to predict 30-day mortality by RDW at days 1, 4, and 8 of SIH was 0.87 (0.79-0.92; p < 0.001), 0.74 (0.64-0.83; p < 0.001) and 0.79 (0.68-0.87; p < 0.001) respectively. In the regression analysis an association between RDW and 30-day mortality was found controlling for early evacuation of SIH, midline shift, ICH score and glycemia (Odds ratio = 1.159; 95 % CI = 1.046-1.284; p = 0.005).

CONCLUSIONS

The higher RDW during the first week of SIH in non-surviving than in surviving patients, and the potential role of RDW at any time during the first week as mortality biomarker are the main novelties of our study.

Association between Serum Lipid and Hematoma Expansion after Spontaneous Intracerebral Hemorrhage in Chinese Patients

OBJECTIVES

Although several studies have shown that interventions to lower blood lipid concentration may reduce the risk of coronary arterial disease and ischemic stroke, the correlation between serum lipid levels and hemorrhagic stroke remains controversial. To clarify any possible association between serum lipid and hematoma expansion, we examined various serum lipid indices in patients with and without early hematoma expansion.

METHODS

Data of 572 intracerebral hemorrhage (ICH) patients from the cerebral small vessel disease cohort of Peking Union Medical College Hospital were retrospectively analyzed. Patients who finished the baseline brain computed tomography (CT) examination within 6 h post-ictus and the follow-up CT within 48 h after initial CT were included in the study. Hematoma expansion was delimited as an enlargement of hemorrhage volume over 33% or 12.5 mL between baseline and subsequent CT. Both uni- and multivariate logistic regression analyses were conducted to explore the association between early hematoma growth and various serum lipid indices, including triglycerides, total cholesterol (TC), high-density lipoprotein cholesterol (HDL-C), low-density lipoprotein cholesterol (LDL-C), non-HDL-C, ratios of LDL-C/HDL-C and LDL-C/TC, as well as other demographic and clinical features.

RESULTS

Out of 157 patients included in the analysis, hematoma growth occurred in 45 (28.7%). Only higher baseline systolic blood pressure was found to be correlated with an increased risk of hematoma growth based on both univariate (odds ratio [OR] 1.014, 95% confidence interval [CI]: 1.002-1.026, P = .024) and multivariate logistic regression analyses (OR 1.022, 95%CI: 1.008-1.037, P = .003). No associations were detected between the various serum lipid indices examined and other clinical features with a likelihood of early hematoma growth between groups or within various subgroups defined by different characteristics including age, gender, baseline Glasgow Coma Scale score, systolic blood pressure, intraventricular extension, and hematoma location.

CONCLUSIONS

No association between various indices of serum lipid and hematoma growth was identified among patients and subgroups with spontaneous ICH in the Chinese population; these findings may help to guide lipid management after ICH. However, further multi-centered, larger scale studies are expected to verify our results.