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Alqahtani MS, Asiri MA, Al-Ajlan FS. Rethinking Spontaneous Intracerebral Hemorrhage: Leveraging Innovation and Recent Data to Shape the Future of Care. World Neurosurg 2024:S1878-8750(24)01517-1. [PMID: 39332934 DOI: 10.1016/j.wneu.2024.08.148] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/29/2024]
Affiliation(s)
- Mohammed S Alqahtani
- Neuroscience Center, King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabia; Department of Medicine, Armed Forces Hospitals, Khamis Mushait, Southern Region, Saudi Arabia
| | - Muhannad A Asiri
- Neuroscience Center, King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabia
| | - Fahad S Al-Ajlan
- Neuroscience Center, King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabia; Alfaisal University, Riyadh, Saudi Arabia
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Łopatka P, Błaż M, Nowicki G, Undas A. Altered fibrin clot phenotype in young adults with intracerebral hemorrhage of unknown cause: A case-control study. Thromb Res 2024; 240:109062. [PMID: 38901058 DOI: 10.1016/j.thromres.2024.109062] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2023] [Revised: 05/13/2024] [Accepted: 06/05/2024] [Indexed: 06/22/2024]
Abstract
BACKGROUND Intracerebral hemorrhage (ICH) of undetermined etiology occurs infrequently in young and middle-aged adults. We hypothesized that slight decreases in coagulation factors and formation of less compact fibrin clots prone to faster lysis predispose to this type of ICH. METHODS We recruited 44 consecutive patients aged <50 years following ICH of unknown cause at least 3 months since the event. Subjects free of ICH (n = 47) matched for age, sex, BMI, and hypertension served as the control group. We assessed plasma fibrin clot permeability, turbidity and fibrinolytic capacity, along with thrombin generation, coagulation factors (F) II, FV, FVII, FVIII, FIX, FX, FXI, antithrombin, and fibrinolysis proteins. RESULTS ICH patients (median age 41 years, 45.5 % women) had 8.4 % lower FII (p = 0.0001) and 10.1 % lower FVII activity (p = 0.0003), 9.4 % higher antithrombin activity (p = 0.0004) and 13.5 % lower platelet count (p = 0.02). Other factors and thrombin generation did not differ between the two groups. The ICH survivors were characterized by impaired fibrin polymerization reflected by 10.1 % longer lag phase of the turbidimetry curve (p = 0.0002), decreased fiber density indicated by 11.8 % lower maximum absorbance (p = 0.004), as well as 11.1 % shorter clot lysis time (p = 0.014) and 10.0 % faster increase of maximal D-Dimer levels (p = 0.000001). CONCLUSIONS We demonstrated a prohemorrhagic fibrin clot phenotype, along with lower FII, FVII and higher antithrombin activity in adults below 50 years of age who suffered from ICH of unknown cause, which might indicate novel mechanisms contributing to ICH in younger individuals.
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Affiliation(s)
- Paweł Łopatka
- Department of Neurosurgery, John Paul II Hospital, Nowy Targ, Poland
| | - Michał Błaż
- Department of Neurology, John Paul II Hospital, Krakow, Poland
| | - Grzegorz Nowicki
- Department of Family and Geriatric Nursing, Faculty of Health Sciences, Medical University of Lublin, Poland
| | - Anetta Undas
- Department of Thromboembolic Diseases, Institute of Cardiology, Jagiellonian University Medical College, Krakow, Poland.
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Kumar A, Witsch J, Frontera J, Qureshi AI, Oermann E, Yaghi S, Melmed KR. Predicting hematoma expansion using machine learning: An exploratory analysis of the ATACH 2 trial. J Neurol Sci 2024; 461:123048. [PMID: 38749281 DOI: 10.1016/j.jns.2024.123048] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2023] [Revised: 05/07/2024] [Accepted: 05/10/2024] [Indexed: 06/13/2024]
Abstract
INTRODUCTION Hematoma expansion (HE) in patients with intracerebral hemorrhage (ICH) is a key predictor of poor prognosis and potentially amenable to treatment. This study aimed to build a classification model to predict HE in patients with ICH using deep learning algorithms without using advanced radiological features. METHODS Data from the ATACH-2 trial (Antihypertensive Treatment of Acute Cerebral Hemorrhage) was utilized. Variables included in the models were chosen as per literature consensus on salient variables associated with HE. HE was defined as increase in either >33% or 6 mL in hematoma volume in the first 24 h. Multiple machine learning algorithms were employed using iterative feature selection and outcome balancing methods. 70% of patients were used for training and 30% for internal validation. We compared the ML models to a logistic regression model and calculated AUC, accuracy, sensitivity and specificity for the internal validation models respective models. RESULTS Among 1000 patients included in the ATACH-2 trial, 924 had the complete parameters which were included in the analytical cohort. The median [interquartile range (IQR)] initial hematoma volume was 9.93.mm3 [5.03-18.17] and 25.2% had HE. The best performing model across all feature selection groups and sampling cohorts was using an artificial neural network (ANN) for HE in the testing cohort with AUC 0.702 [95% CI, 0.631-0.774] with 8 hidden layer nodes The traditional logistic regression yielded AUC 0.658 [95% CI, 0.641-0.675]. All other models performed with less accuracy and lower AUC. Initial hematoma volume, time to initial CT head, and initial SBP emerged as most relevant variables across all best performing models. CONCLUSION We developed multiple ML algorithms to predict HE with the ANN classifying the best without advanced radiographic features, although the AUC was only modestly better than other models. A larger, more heterogenous dataset is needed to further build and better generalize the models.
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Affiliation(s)
- Arooshi Kumar
- Rush University Medical Center, Department of Neurology, Chicago, IL 60612, United States of America.
| | - Jens Witsch
- Hospital of the University of Pennsylvania, Department of Neurology, Philadelphia, PA 19104, United States of America
| | - Jennifer Frontera
- NYU Langone Medical Center, Department of Neurology, New York, NY 10016, United States of America
| | - Adnan I Qureshi
- Zeenat Qureshi Stroke Institutes and Department of Neurology, University of Missouri, Columbia, MO 65201, United States of America
| | - Eric Oermann
- NYU Langone Medical Center, Department of Neurology, New York, NY 10016, United States of America
| | - Shadi Yaghi
- Warren Alpert Medical School of Brown University, Department of Neurology, Providence, RI 02903, United States of America
| | - Kara R Melmed
- NYU Langone Medical Center, Department of Neurology, New York, NY 10016, United States of America; NYU Langone Medical Center, Department of Neurosurgery, New York, NY 10016, United States of America
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Yassi N, Zhao H, Churilov L, Wu TY, Ma H, Nguyen HT, Cheung A, Meretoja A, Mai DT, Kleinig T, Jeng JS, Choi PMC, Duc PD, Brown H, Ranta A, Spratt N, Cloud GC, Wang HK, Grimley R, Mahawish K, Cho DY, Shah D, Nguyen TMP, Sharma G, Yogendrakumar V, Yan B, Harrison EL, Devlin M, Cordato D, Martinez-Majander N, Strbian D, Thijs V, Sanders LM, Anderson D, Parsons MW, Campbell BCV, Donnan GA, Davis SM. Tranexamic acid versus placebo in individuals with intracerebral haemorrhage treated within 2 h of symptom onset (STOP-MSU): an international, double-blind, randomised, phase 2 trial. Lancet Neurol 2024; 23:577-587. [PMID: 38648814 DOI: 10.1016/s1474-4422(24)00128-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2024] [Revised: 03/18/2024] [Accepted: 03/18/2024] [Indexed: 04/25/2024]
Abstract
BACKGROUND Tranexamic acid, an antifibrinolytic agent, might attenuate haematoma growth after an intracerebral haemorrhage. We aimed to determine whether treatment with intravenous tranexamic acid within 2 h of an intracerebral haemorrhage would reduce haematoma growth compared with placebo. METHODS STOP-MSU was an investigator-led, double-blind, randomised, phase 2 trial conducted at 24 hospitals and one mobile stroke unit in Australia, Finland, New Zealand, Taiwan, and Viet Nam. Eligible participants had acute spontaneous intracerebral haemorrhage confirmed on non-contrast CT, were aged 18 years or older, and could be treated with the investigational product within 2 h of stroke onset. Using randomly permuted blocks (block size of 4) and a concealed pre-randomised assignment procedure, participants were randomly assigned (1:1) to receive intravenous tranexamic acid (1 g over 10 min followed by 1 g over 8 h) or placebo (saline; matched dosing regimen) commencing within 2 h of symptom onset. Participants, investigators, and treating teams were masked to group assignment. The primary outcome was haematoma growth, defined as either at least 33% relative growth or at least 6 mL absolute growth on CT at 24 h (target range 18-30 h) from the baseline CT. The analysis was conducted within the estimand framework with primary analyses adhering to the intention-to-treat principle. The primary endpoint and secondary safety endpoints (mortality at days 7 and 90 and major thromboembolic events at day 90) were assessed in all participants randomly assigned to treatment groups who did not withdraw consent to use any data. This study was registered with ClinicalTrials.gov, NCT03385928, and the trial is now complete. FINDINGS Between March 19, 2018, and Feb 27, 2023, 202 participants were recruited, of whom one withdrew consent for any data use. The remaining 201 participants were randomly assigned to either placebo (n=98) or tranexamic acid (n=103; intention-to-treat population). Median age was 66 years (IQR 55-77), and 82 (41%) were female and 119 (59%) were male; no data on race or ethnicity were collected. CT scans at baseline or follow-up were missing or of inadequate quality in three participants (one in the placebo group and two in the tranexamic acid group), and were considered missing at random. Haematoma growth occurred in 37 (38%) of 97 assessable participants in the placebo group and 43 (43%) of 101 assessable participants in the tranexamic acid group (adjusted odds ratio [aOR] 1·31 [95% CI 0·72 to 2·40], p=0·37). Major thromboembolic events occurred in one (1%) of 98 participants in the placebo group and three (3%) of 103 in the tranexamic acid group (risk difference 0·02 [95% CI -0·02 to 0·06]). By 7 days, eight (8%) participants in the placebo group and eight (8%) in the tranexamic acid group had died (aOR 1·08 [95% CI 0·35 to 3·35]) and by 90 days, 15 (15%) participants in the placebo group and 19 (18%) in the tranexamic acid group had died (aOR 1·61 [95% CI 0·65 to 3·98]). INTERPRETATION Intravenous tranexamic acid did not reduce haematoma growth when administered within 2 h of intracerebral haemorrhage symptom onset. There were no observed effects on other imaging endpoints, functional outcome, or safety. Based on our results, tranexamic acid should not be used routinely in primary intracerebral haemorrhage, although results of ongoing phase 3 trials will add further context to these findings. FUNDING Australian Government Medical Research Future Fund.
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Affiliation(s)
- Nawaf Yassi
- Department of Medicine and Neurology, Melbourne Brain Centre at The Royal Melbourne Hospital, University of Melbourne, Parkville, VIC, Australia; Population Health and Immunity Division, The Walter and Eliza Hall Institute of Medical Research, Parkville, VIC, Australia.
| | - Henry Zhao
- Department of Medicine and Neurology, Melbourne Brain Centre at The Royal Melbourne Hospital, University of Melbourne, Parkville, VIC, Australia
| | - Leonid Churilov
- Department of Medicine and Neurology, Melbourne Brain Centre at The Royal Melbourne Hospital, University of Melbourne, Parkville, VIC, Australia; Melbourne Medical School, University of Melbourne, Parkville, VIC, Australia
| | - Teddy Y Wu
- Department of Neurology, Christchurch Hospital, Christchurch, New Zealand
| | - Henry Ma
- Department of Medicine, School of Clinical Sciences, Monash University, Melbourne, VIC, Australia
| | - Huy-Thang Nguyen
- Department of Cerebrovascular Disease, 115 Hospital, Ho Chi Minh City, Viet Nam
| | - Andrew Cheung
- Department of Interventional Neuroradiology, Liverpool Hospital, Liverpool, NSW, Australia
| | - Atte Meretoja
- Department of Neurology, Helsinki University Hospital, Helsinki, Finland
| | - Duy Ton Mai
- Stroke Center, Bach Mai Hospital, Hanoi Medical University, VNU University of Medicine and Pharmacy, Hanoi, Viet Nam
| | - Timothy Kleinig
- Department of Neurology, Royal Adelaide Hospital, Adelaide, SA, Australia
| | - Jiann-Shing Jeng
- Stroke Centre and Department of Neurology, National Taiwan University Hospital, Taipei, Taiwan
| | - Philip M C Choi
- Department of Neuroscience, Box Hill Hospital, Eastern Health, Eastern Health Clinical School, Monash University, Box Hill, VIC, Australia
| | - Phuc Dang Duc
- Stroke Department, 103 Military Hospital, Hanoi, Viet Nam
| | - Helen Brown
- Department of Neurology, Princess Alexandra Hospital, Woolloongabba, QLD, Australia
| | - Annemarei Ranta
- Department of Medicine, University of Otago, Wellington, New Zealand
| | - Neil Spratt
- Department of Neurology, John Hunter Hospital, and School of Biomedical Sciences and Pharmacy, University of Newcastle, Newcastle, NSW, Australia
| | - Geoffrey C Cloud
- Department of Neurology, Alfred Hospital, Melbourne, VIC, Australia
| | - Hao-Kuang Wang
- Department of Neurosurgery, E-Da Hospital, I-Shou University, Yanchao, Taiwan
| | - Rohan Grimley
- Department of Medicine, Sunshine Coast University Hospital, Birtinya, QLD, Australia
| | - Karim Mahawish
- Department of Internal Medicine, Palmerston North Hospital, Palmerston North, New Zealand
| | - Der-Yang Cho
- Department of Neurosurgery, China Medical University Hospital, Taichung, Taiwan
| | - Darshan Shah
- Department of Neurology, Gold Coast University Hospital, Southport, QLD, Australia
| | | | - Gagan Sharma
- Department of Medicine and Neurology, Melbourne Brain Centre at The Royal Melbourne Hospital, University of Melbourne, Parkville, VIC, Australia
| | - Vignan Yogendrakumar
- Department of Medicine and Neurology, Melbourne Brain Centre at The Royal Melbourne Hospital, University of Melbourne, Parkville, VIC, Australia
| | - Bernard Yan
- Department of Medicine and Neurology, Melbourne Brain Centre at The Royal Melbourne Hospital, University of Melbourne, Parkville, VIC, Australia
| | - Emma L Harrison
- Department of Neurology, Princess Alexandra Hospital, Woolloongabba, QLD, Australia
| | - Michael Devlin
- Department of Neurology, Princess Alexandra Hospital, Woolloongabba, QLD, Australia
| | - Dennis Cordato
- Department of Interventional Neuroradiology, Liverpool Hospital, Liverpool, NSW, Australia
| | - Nicolas Martinez-Majander
- Department of Neurology, Helsinki University Hospital, Helsinki, Finland; Department of Neurology, University of Helsinki, Helsinki, Finland
| | - Daniel Strbian
- Department of Neurology, Helsinki University Hospital, Helsinki, Finland; Department of Neurology, University of Helsinki, Helsinki, Finland
| | - Vincent Thijs
- The Florey, Stroke Theme, Heidelberg, VIC, Australia; Department of Neurology, Austin Hospital, Heidelberg, VIC, Australia; Department of Medicine, University of Melbourne, Heidelberg, VIC, Australia
| | - Lauren M Sanders
- Department of Neurosciences, St Vincent's Hospital, Melbourne, VIC, Australia
| | | | - Mark W Parsons
- Department of Neurology, Liverpool Hospital, Liverpool, NSW, Australia
| | - Bruce C V Campbell
- Department of Medicine and Neurology, Melbourne Brain Centre at The Royal Melbourne Hospital, University of Melbourne, Parkville, VIC, Australia
| | - Geoffrey A Donnan
- Department of Medicine and Neurology, Melbourne Brain Centre at The Royal Melbourne Hospital, University of Melbourne, Parkville, VIC, Australia
| | - Stephen M Davis
- Department of Medicine and Neurology, Melbourne Brain Centre at The Royal Melbourne Hospital, University of Melbourne, Parkville, VIC, Australia
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Ling Y, Tariq MB, Tang K, Aronowski J, Fann Y, Savitz SI, Jiang X, Kim Y. An interpretable framework to identify responsive subgroups from clinical trials regarding treatment effects: Application to treatment of intracerebral hemorrhage. PLOS DIGITAL HEALTH 2024; 3:e0000493. [PMID: 38713647 DOI: 10.1371/journal.pdig.0000493] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/22/2024] [Accepted: 03/26/2024] [Indexed: 05/09/2024]
Abstract
Randomized Clinical trials (RCT) suffer from a high failure rate which could be caused by heterogeneous responses to treatment. Despite many models being developed to estimate heterogeneous treatment effects (HTE), there remains a lack of interpretable methods to identify responsive subgroups. This work aims to develop a framework to identify subgroups based on treatment effects that prioritize model interpretability. The proposed framework leverages an ensemble uplift tree method to generate descriptive decision rules that separate samples given estimated responses to the treatment. Subsequently, we select a complementary set of these decision rules and rank them using a sparse linear model. To address the trial's limited sample size problem, we proposed a data augmentation strategy by borrowing control patients from external studies and generating synthetic data. We apply the proposed framework to a failed randomized clinical trial for investigating an intracerebral hemorrhage therapy plan. The Qini-scores show that the proposed data augmentation strategy plan can boost the model's performance and the framework achieves greater interpretability by selecting complementary descriptive rules without compromising estimation quality. Our model derives clinically meaningful subgroups. Specifically, we find those patients with Diastolic Blood Pressure≥70 mm hg and Systolic Blood Pressure<215 mm hg benefit more from intensive blood pressure reduction therapy. The proposed interpretable HTE analysis framework offers a promising potential for extracting meaningful insight from RCTs with neutral treatment effects. By identifying responsive subgroups, our framework can contribute to developing personalized treatment strategies for patients more efficiently.
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Affiliation(s)
- Yaobin Ling
- D.Bradley Mc.Williams School of Biomedical Informatics, UTHealth at Houston, Houston, Texas, United States of America
| | - Muhammad Bilal Tariq
- Department of Neurology, University of California, Los Angeles, Los Angeles, California, United States of America
| | - Kaichen Tang
- D.Bradley Mc.Williams School of Biomedical Informatics, UTHealth at Houston, Houston, Texas, United States of America
| | - Jaroslaw Aronowski
- Institute for Stroke and Cerebrovascular Disease, UTHealth at Houston, Houston, Texas, United States of America
| | - Yang Fann
- Intramural Research Program, National Institute of Neurological Disorders and Stroke, National Institutes of Health, Bethesda, Maryland, United States of America
| | - Sean I Savitz
- Institute for Stroke and Cerebrovascular Disease, UTHealth at Houston, Houston, Texas, United States of America
| | - Xiaoqian Jiang
- D.Bradley Mc.Williams School of Biomedical Informatics, UTHealth at Houston, Houston, Texas, United States of America
| | - Yejin Kim
- D.Bradley Mc.Williams School of Biomedical Informatics, UTHealth at Houston, Houston, Texas, United States of America
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Li Q, Yakhkind A, Alexandrov AW, Alexandrov AV, Anderson CS, Dowlatshahi D, Frontera JA, Hemphill JC, Ganti L, Kellner C, May C, Morotti A, Parry-Jones A, Sheth KN, Steiner T, Ziai W, Goldstein JN, Mayer SA. Code ICH: A Call to Action. Stroke 2024; 55:494-505. [PMID: 38099439 DOI: 10.1161/strokeaha.123.043033] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2024]
Abstract
Intracerebral hemorrhage is the most serious type of stroke, leading to high rates of severe disability and mortality. Hematoma expansion is an independent predictor of poor functional outcome and is a compelling target for intervention. For decades, randomized trials aimed at decreasing hematoma expansion through single interventions have failed to meet their primary outcomes of statistically significant improvement in neurological outcomes. A wide range of evidence suggests that ultra-early bundled care, with multiple simultaneous interventions in the acute phase, offers the best hope of limiting hematoma expansion and improving functional recovery. Patients with intracerebral hemorrhage who fail to receive early aggressive care have worse outcomes, suggesting that an important treatment opportunity exists. This consensus statement puts forth a call to action to establish a protocol for Code ICH, similar to current strategies used for the management of acute ischemic stroke, through which early intervention, bundled care, and time-based metrics have substantially improved neurological outcomes. Based on current evidence, we advocate for the widespread adoption of an early bundle of care for patients with intracerebral hemorrhage focused on time-based metrics for blood pressure control and emergency reversal of anticoagulation, with the goal of optimizing the benefit of these already widely used interventions. We hope Code ICH will endure as a structural platform for continued innovation, standardization of best practices, and ongoing quality improvement for years to come.
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Affiliation(s)
- Qi Li
- The Second Affiliated Hospital of Anhui Medical University, Hefei, China (Q.L.)
| | | | | | | | - Craig S Anderson
- The George Institute for Global Heath, University of New South Wales, Sydney, Australia (C.S.A.)
| | - Dar Dowlatshahi
- University of Ottawa and Ottawa Hospital Research Institute, Canada (D.D.)
| | | | | | - Latha Ganti
- University of Central Florida College of Medicine, Orlando (L.G.)
| | | | - Casey May
- The Ohio State University College of Pharmacy, Columbus (C.M.)
| | | | | | - Kevin N Sheth
- Yale University School of Medicine, New Haven, CT (K.N.S.)
| | | | - Wendy Ziai
- John Hopkins University School of Medicine, Baltimore, MD (W.Z.)
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Xing Y, Cheng H, Yang C, Xiao Z, Yan C, Chen F, Li J, Zhang Y, Cui C, Li J, Liu C. Evaluation of skin sympathetic nervous activity for classification of intracerebral hemorrhage and outcome prediction. Comput Biol Med 2023; 166:107397. [PMID: 37804780 DOI: 10.1016/j.compbiomed.2023.107397] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2023] [Revised: 08/02/2023] [Accepted: 08/26/2023] [Indexed: 10/09/2023]
Abstract
Classification and outcome prediction of intracerebral hemorrhage (ICH) is critical for improving the survival rate of patients. Early or delayed neurological deterioration is common in ICH patients, which may lead to changes in the autonomic nervous system (ANS). Therefore, we proposed a new framework for ICH classification and outcome prediction based on skin sympathetic nervous activity (SKNA) signals. A customized measurement device presented in our previous papers was used to collect data. 117 subjects (50 healthy control subjects and 67 ICH patients) were recruited for this study to obtain their 5-min electrocardiogram (ECG) and SKNA signals. We extracted the signal's time-domain, frequency-domain, and nonlinear features and analyzed their differences between healthy control subjects and ICH patients. Subsequently, we established the ICH classification and outcome evaluation model based on the eXtreme Gradient Boosting (XGBoost). In addition, heart rate variability (HRV) as an ANS assessment method was also included as a comparison method in this study. The results showed significant differences in most features of the SKNA signal between healthy control subjects and ICH patients. The ICH patients with good outcomes have a higher change rate and complexity of SKNA signal than those with bad outcomes. In addition, the accuracy of the model for ICH classification and outcome prediction based on the SKNA signal was more than 91% and 83%, respectively. The ICH classification and outcome prediction based on the SKNA signal proved to be a feasible method in this study. Furthermore, the features of change rate and complexity, such as entropy measures, can be used to characterize the difference in SKNA signals of different groups. The method can potentially provide a new tool for rapid classification and outcome prediction of ICH patients. Index Terms-intracerebral hemorrhage (ICH), skin sympathetic nervous activity (SKNA), classification, outcome prediction, cardiovascular and cerebrovascular diseases.
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Affiliation(s)
- Yantao Xing
- State Key Laboratory of Bioelectronics, School of Instrument Science and Engineering, Southeast University, Nanjing, 210096, China
| | - Hongyi Cheng
- Division of Cardiology, The First Affiliated Hospital of Nanjing Medical University, Nanjing, 210096, China
| | - Chenxi Yang
- State Key Laboratory of Bioelectronics, School of Instrument Science and Engineering, Southeast University, Nanjing, 210096, China
| | - Zhijun Xiao
- State Key Laboratory of Bioelectronics, School of Instrument Science and Engineering, Southeast University, Nanjing, 210096, China
| | - Chang Yan
- State Key Laboratory of Bioelectronics, School of Instrument Science and Engineering, Southeast University, Nanjing, 210096, China
| | - FeiFei Chen
- State Key Laboratory of Bioelectronics, School of Instrument Science and Engineering, Southeast University, Nanjing, 210096, China
| | - Jiayi Li
- State Key Laboratory of Bioelectronics, School of Instrument Science and Engineering, Southeast University, Nanjing, 210096, China
| | - Yike Zhang
- Division of Cardiology, The First Affiliated Hospital of Nanjing Medical University, Nanjing, 210096, China
| | - Chang Cui
- Division of Cardiology, The First Affiliated Hospital of Nanjing Medical University, Nanjing, 210096, China
| | - Jianqing Li
- State Key Laboratory of Bioelectronics, School of Instrument Science and Engineering, Southeast University, Nanjing, 210096, China.
| | - Chengyu Liu
- State Key Laboratory of Bioelectronics, School of Instrument Science and Engineering, Southeast University, Nanjing, 210096, China.
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8
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Xiao Z, Li P, Shen Y, Manaenko A, Yang W, Wang P, Li X, Liu F, Xie P, Li Q. Multi-time point metabolomics reveals key metabolic features from the ultra-early stage of intracerebral hemorrhage in mice. Exp Neurol 2023; 368:114507. [PMID: 37598880 DOI: 10.1016/j.expneurol.2023.114507] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2023] [Revised: 08/10/2023] [Accepted: 08/16/2023] [Indexed: 08/22/2023]
Abstract
Despite decades of intensive research, there are still very limited options for the effective treatment of intracerebral hemorrhage (ICH). Recently, mounting evidence has indicated that the ultra-early stage (<3 h), serving as the primary phase of ICH, plays a pivotal role and may even surpass other stages in terms of its significance. Therefore, uncovering the metabolic alterations induced by ICH in the ultra-early stage is of crucial importance. To investigate this, the collagenase ICH mouse model was employed in this study. ICH or sham-operated mice were euthanized at the ultra-early stage of 3 h and the acute stage of 24 h and 72 h after the operation. Then, the metabolic changes in the perihematomal tissues were detected by liquid chromatography coupled with tandem mass spectrometry. In total, alterations in the levels of 465 metabolites were detected. A total of 136 metabolites were significantly changed at 3 h. At 24 h and 72 h, the amounts were 132 and 126, respectively. Additionally, the key corresponding metabolic pathways for these time points were analyzed through KEGG. To gather additional information, quantitative real-time transcription polymerase chain reaction, enzyme-linked immunosorbent assay and Western blots were performed to validate the metabolic changes. Overall, ICH significantly alters important physiological functions such as cysteine metabolism, purine metabolism, synaptic alterations, the synaptic vesicle cycle, and the ATP-binding cassette transporter system. These might be the key pathologic mechanisms of the ultra-early stage induced by ICH.
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Affiliation(s)
- Zhongsong Xiao
- NHC Key Laboratory of Diagnosis and Treatment on Brain Functional Diseases, The First Affiliated Hospital of Chongqing Medical University, Chongqing 400016, China; Department of Neurology, The First Affiliated Hospital of Chongqing Medical University, Chongqing 400016, China
| | - Peizheng Li
- NHC Key Laboratory of Diagnosis and Treatment on Brain Functional Diseases, The First Affiliated Hospital of Chongqing Medical University, Chongqing 400016, China; Department of Neurology, The First Affiliated Hospital of Chongqing Medical University, Chongqing 400016, China
| | - Yiqing Shen
- NHC Key Laboratory of Diagnosis and Treatment on Brain Functional Diseases, The First Affiliated Hospital of Chongqing Medical University, Chongqing 400016, China; Department of Neurology, The First Affiliated Hospital of Chongqing Medical University, Chongqing 400016, China
| | - Anatol Manaenko
- NHC Key Laboratory of Diagnosis and Treatment on Brain Functional Diseases, The First Affiliated Hospital of Chongqing Medical University, Chongqing 400016, China; Department of Neurology, The First Affiliated Hospital of Chongqing Medical University, Chongqing 400016, China
| | - Wensong Yang
- NHC Key Laboratory of Diagnosis and Treatment on Brain Functional Diseases, The First Affiliated Hospital of Chongqing Medical University, Chongqing 400016, China; Department of Neurology, The First Affiliated Hospital of Chongqing Medical University, Chongqing 400016, China
| | - Peng Wang
- NHC Key Laboratory of Diagnosis and Treatment on Brain Functional Diseases, The First Affiliated Hospital of Chongqing Medical University, Chongqing 400016, China; Department of Neurology, The First Affiliated Hospital of Chongqing Medical University, Chongqing 400016, China
| | - Xinhui Li
- NHC Key Laboratory of Diagnosis and Treatment on Brain Functional Diseases, The First Affiliated Hospital of Chongqing Medical University, Chongqing 400016, China; Department of Neurology, The First Affiliated Hospital of Chongqing Medical University, Chongqing 400016, China
| | - Fangyu Liu
- NHC Key Laboratory of Diagnosis and Treatment on Brain Functional Diseases, The First Affiliated Hospital of Chongqing Medical University, Chongqing 400016, China; Department of Neurology, The First Affiliated Hospital of Chongqing Medical University, Chongqing 400016, China
| | - Peng Xie
- NHC Key Laboratory of Diagnosis and Treatment on Brain Functional Diseases, The First Affiliated Hospital of Chongqing Medical University, Chongqing 400016, China; Department of Neurology, The First Affiliated Hospital of Chongqing Medical University, Chongqing 400016, China.
| | - Qi Li
- NHC Key Laboratory of Diagnosis and Treatment on Brain Functional Diseases, The First Affiliated Hospital of Chongqing Medical University, Chongqing 400016, China; Department of Neurology, The First Affiliated Hospital of Chongqing Medical University, Chongqing 400016, China.
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Haupenthal D, Schwab S, Kuramatsu JB. Hematoma expansion in intracerebral hemorrhage - the right target? Neurol Res Pract 2023; 5:36. [PMID: 37496094 PMCID: PMC10373350 DOI: 10.1186/s42466-023-00256-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2023] [Accepted: 05/30/2023] [Indexed: 07/28/2023] Open
Abstract
BACKGROUND The avoidance of hematoma expansion is the most important therapeutic goal during acute care of patients with intracerebral hemorrhage. Hematoma expansion occurs in up to 20-40% of patients and leads to poorer patient outcome in one of the most severe sub-types of stroke. MAIN TEXT At current, randomized controlled trials have failed to provide evidence for interventions that effectively improve functional outcome in patients with intracerebral hemorrhage. Hence, hematoma expansion may serve as important surrogate target that appears causally linked with a poorer prognosis. Therefore, reduction of hematoma expansion rates will eventually translate to improved patient outcome overall. Recent years have shed light on the importance of early and aggressive treatment in order to reduce the risk for hematoma expansion in these patients. Time measures and imaging markers have been identified that may allow patient selection at very high risk for hematoma expansion. CONCLUSIONS Refinements in patient selection may increase chance for randomized trials to show true benefit. Therefore, this current review article will critically evaluate and discuss available evidence associated with hematoma expansion in patients with intracerebral hemorrhage.
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Affiliation(s)
- David Haupenthal
- Department of Neurology, University Hospital Erlangen, Friedrich-Alexander-University of Erlangen-Nuremberg (FAU), Schwabachanlage 6, 91054, Erlangen, Germany
| | - Stefan Schwab
- Department of Neurology, University Hospital Erlangen, Friedrich-Alexander-University of Erlangen-Nuremberg (FAU), Schwabachanlage 6, 91054, Erlangen, Germany
| | - Joji B Kuramatsu
- Department of Neurology, University Hospital Erlangen, Friedrich-Alexander-University of Erlangen-Nuremberg (FAU), Schwabachanlage 6, 91054, Erlangen, Germany.
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10
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Huang YW, Huang HL, Li ZP, Yin XS. Research advances in imaging markers for predicting hematoma expansion in intracerebral hemorrhage: a narrative review. Front Neurol 2023; 14:1176390. [PMID: 37181553 PMCID: PMC10166819 DOI: 10.3389/fneur.2023.1176390] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2023] [Accepted: 04/03/2023] [Indexed: 05/16/2023] Open
Abstract
Introduction Stroke is a major global health concern and is ranked as the second leading cause of death worldwide, with the third highest incidence of disability. Intracerebral hemorrhage (ICH) is a devastating form of stroke that is responsible for a significant proportion of stroke-related morbidity and mortality worldwide. Hematoma expansion (HE), which occurs in up to one-third of ICH patients, is a strong predictor of poor prognosis and can be potentially preventable if high-risk patients are identified early. In this review, we provide a comprehensive summary of previous research in this area and highlight the potential use of imaging markers for future research studies. Recent advances Imaging markers have been developed in recent years to aid in the early detection of HE and guide clinical decision-making. These markers have been found to be effective in predicting HE in ICH patients and include specific manifestations on Computed Tomography (CT) and CT Angiography (CTA), such as the spot sign, leakage sign, spot-tail sign, island sign, satellite sign, iodine sign, blend sign, swirl sign, black hole sign, and hypodensities. The use of imaging markers holds great promise for improving the management and outcomes of ICH patients. Conclusion The management of ICH presents a significant challenge, and identifying high-risk patients for HE is crucial to improving outcomes. The use of imaging markers for HE prediction can aid in the rapid identification of such patients and may serve as potential targets for anti-HE therapies in the acute phase of ICH. Therefore, further research is needed to establish the reliability and validity of these markers in identifying high-risk patients and guiding appropriate treatment decisions.
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Affiliation(s)
- Yong-Wei Huang
- Department of Neurosurgery, Mianyang Central Hospital, School of Medicine, University of Electronic Science and Technology of China, Mianyang, Sichuan, China
| | - Hai-Lin Huang
- Department of Neurosurgery, Mianyang Central Hospital, School of Medicine, University of Electronic Science and Technology of China, Mianyang, Sichuan, China
| | - Zong-Ping Li
- Department of Neurosurgery, Mianyang Central Hospital, School of Medicine, University of Electronic Science and Technology of China, Mianyang, Sichuan, China
| | - Xiao-Shuang Yin
- Department of Immunology, Mianyang Central Hospital, School of Medicine, University of Electronic Science and Technology of China, Mianyang, Sichuan, China
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11
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Al-Ajlan FS, Gladstone DJ, Song D, Thorpe KE, Swartz RH, Butcher KS, Del Campo M, Dowlatshahi D, Gensicke H, Lee GJ, Flaherty ML, Hill MD, Aviv RI, Demchuk AM. Time Course of Early Hematoma Expansion in Acute Spot-Sign Positive Intracerebral Hemorrhage: Prespecified Analysis of the SPOTLIGHT Randomized Clinical Trial. Stroke 2023; 54:715-721. [PMID: 36756899 DOI: 10.1161/strokeaha.121.038475] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/10/2023]
Abstract
BACKGROUND In the SPOTLIGHT trial (Spot Sign Selection of Intracerebral Hemorrhage to Guide Hemostatic Therapy), patients with a computed tomography (CT) angiography spot-sign positive acute intracerebral hemorrhage were randomized to rFVIIa (recombinant activated factor VIIa; 80 μg/kg) or placebo within 6 hours of onset, aiming to limit hematoma expansion. Administration of rFVIIa did not significantly reduce hematoma expansion. In this prespecified analysis, we aimed to investigate the impact of delays from baseline imaging to study drug administration on hematoma expansion. METHODS Hematoma volumes were measured on the baseline CT, early post-dose CT, and 24 hours CT scans. Total hematoma volume (intracerebral hemorrhage+intraventricular hemorrhage) change between the 3 scans was calculated as an estimate of how much hematoma expansion occurred before and after studying drug administration. RESULTS Of the 50 patients included in the trial, 44 had an early post-dose CT scan. Median time (interquartile range) from onset to baseline CT was 1.4 hours (1.2-2.6). Median time from baseline CT to study drug was 62.5 (55-80) minutes, and from study drug to early post-dose CT was 19 (14.5-30) minutes. Median (interquartile range) total hematoma volume increased from baseline CT to early post-dose CT by 10.0 mL (-0.7 to 18.5) in the rFVIIa arm and 5.4 mL (1.8-8.3) in the placebo arm (P=0.96). Median volume change between the early post-dose CT and follow-up scan was 0.6 mL (-2.6 to 8.3) in the rFVIIa arm and 0.7 mL (-1.6 to 2.1) in the placebo arm (P=0.98). Total hematoma volume decreased between the early post-dose CT and 24-hour scan in 44.2% of cases (rFVIIa 38.9% and placebo 48%). The adjusted hematoma growth in volume immediately post dose for FVIIa was 0.998 times that of placebo ([95% CI, 0.71-1.43]; P=0.99). The hourly growth in FFVIIa was 0.998 times that for placebo ([95% CI, 0.994-1.003]; P=0.50; Table 3). CONCLUSIONS In the SPOTLIGHT trial, the adjusted hematoma volume growth was not associated with Factor VIIa treatment. Most hematoma expansion occurred between the baseline CT and the early post-dose CT, limiting any potential treatment effect of hemostatic therapy. Future hemostatic trials must treat intracerebral hemorrhage patients earlier from onset, with minimal delay between baseline CT and drug administration. REGISTRATION URL: https://www. CLINICALTRIALS gov; Unique identifier: NCT01359202.
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Affiliation(s)
- Fahad S Al-Ajlan
- Department of Neurosciences (Neurology), King Faisal Specialist Hospital and Research Center, Alfaisal University, Riyadh, Saudi Arabia (F.S.A.-A.)
| | - David J Gladstone
- Sunnybrook Research Institute, Hurvitz Brain Sciences Program and Department of Medicine, Sunnybrook Health Sciences Centre (D.J.G., R.H.S.).,Department of Medicine (Neurology), University of Toronto, Canada (D.J.G., R.H.S., M.D.C.)
| | - Dongbeom Song
- Calgary Stroke Program, Department of Clinical Neurosciences, Department of Radiology, Hotchkiss Brain Institute, Cumming School of Medicine, University of Calgary, Canada (D.S., G.J.L., M.D.H., A.M.D.)
| | - Kevin E Thorpe
- Applied Health Research Centre, Li Ka Shing Knowledge Institute, St. Michael's Hospital, Dalla Lana School of Public Health, University of Toronto, Canada (K.E.T.)
| | - Rick H Swartz
- Sunnybrook Research Institute, Hurvitz Brain Sciences Program and Department of Medicine, Sunnybrook Health Sciences Centre (D.J.G., R.H.S.).,Department of Medicine (Neurology), University of Toronto, Canada (D.J.G., R.H.S., M.D.C.)
| | - Kenneth S Butcher
- Prince of Wales Clinical School, University of New South Wales, Sydney, AustraliaDepartment of Medicine (Neurology), University of Alberta, Edmonton, Canada (K.S.B.)
| | - Martin Del Campo
- Department of Medicine (Neurology), University of Toronto, Canada (D.J.G., R.H.S., M.D.C.)
| | - Dar Dowlatshahi
- Department of Medicine (Neurology), University of Ottawa and Ottawa Hospital Research Institute, Canada (D.D.)
| | - Henrik Gensicke
- Stroke Center and Neurology, University Hospital Basel, Switzerland (H.G.)
| | - Gloria Jooyoung Lee
- Calgary Stroke Program, Department of Clinical Neurosciences, Department of Radiology, Hotchkiss Brain Institute, Cumming School of Medicine, University of Calgary, Canada (D.S., G.J.L., M.D.H., A.M.D.)
| | - Matthew L Flaherty
- Department of Neurology, University of Cincinnati, OH (M.L.F., R.I.A.). Division of Neuroradiology and Department of Medical Imaging, Sunnybrook Health Sciences Centre, University of Toronto, Canada
| | - Michael D Hill
- Calgary Stroke Program, Department of Clinical Neurosciences, Department of Radiology, Hotchkiss Brain Institute, Cumming School of Medicine, University of Calgary, Canada (D.S., G.J.L., M.D.H., A.M.D.)
| | - Richard I Aviv
- Department of Neurology, University of Cincinnati, OH (M.L.F., R.I.A.). Division of Neuroradiology and Department of Medical Imaging, Sunnybrook Health Sciences Centre, University of Toronto, Canada
| | - Andrew M Demchuk
- Calgary Stroke Program, Department of Clinical Neurosciences, Department of Radiology, Hotchkiss Brain Institute, Cumming School of Medicine, University of Calgary, Canada (D.S., G.J.L., M.D.H., A.M.D.)
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12
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Naidech AM, Grotta J, Elm J, Janis S, Dowlatshahi D, Toyoda K, Steiner T, Mayer SA, Khanolkar P, Denlinger J, Audebert HJ, Molina C, Khatri P, Sprigg N, Vagal A, Broderick JP. Recombinant factor VIIa for hemorrhagic stroke treatment at earliest possible time (FASTEST): Protocol for a phase III, double-blind, randomized, placebo-controlled trial. Int J Stroke 2022; 17:806-809. [PMID: 34427473 PMCID: PMC9933458 DOI: 10.1177/17474930211042700] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
INTRODUCTION Intracerebral hemorrhage is the deadliest form of stroke. Hematoma expansion, growth of the hematoma between the baseline computed tomography scan and a follow-up computed tomography scan at 24 ± 6 h, predicts long-term disability or death. Recombinant factor VIIa (rFVIIa) has reduced hematoma expansion in previous clinical trials with a variable effect on clinical outcomes, with the greatest impact on hematoma expansion and potential benefit when administered within 2 h of symptom onset. METHODS Factor VIIa for Hemorrhagic Stroke Treatment at Earliest Possible Time (FASTEST, NCT03496883) is a randomized controlled trial that will enroll 860 patients at ∼100 emergency departments and mobile stroke units in five countries. Patients are eligible for enrollment if they have acute intracerebral hemorrhage within 2 h of symptom onset confirmed by computed tomography, a hematoma volume of 2 to 60 mL, no or small volumes of intraventricular hemorrhage, do not take anticoagulant medications or concurrent heparin/heparinoids (antiplatelet medications are permissible), and are not deeply comatose. Enrolled patients will receive rFVIIa 80 µg/kg or placebo intravenously over 2 min. The primary outcome measure is the distribution of the ordinal modified Rankin Scale at 180 days. FASTEST is monitored by a Data Safety Monitoring Board. Safety endpoints include thrombotic events (e.g. myocardial infarction). Human subjects research is monitored by an external Institutional Review Board in participating countries. DISCUSSION In the US, FASTEST will be first NIH StrokeNet Trial with an Exception from Informed Consent which allows enrollment of non-communicative patients without an immediately identifiable proxy.
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Affiliation(s)
| | | | - Jordan Elm
- Medical University of South Carolina, Charleston, SC, USA
| | - Scott Janis
- National Institute of Neurological Diseases and Stroke, Bethesda, MD, USA
| | | | - Kazunori Toyoda
- National Cerebral and Cardiovascular Center, Suita, Osaka, Japan
| | - Thorsten Steiner
- National Cerebral and Cardiovascular Center, Suita, Osaka, Japan
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13
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Yu M, Zhu D, Luo Z, Pan Z, Yang Y, Xu H. Moderate-Severe White Matter Lesion Predicts Delayed Intraventricular Hemorrhage in Intracerebral Hemorrhage. Neurocrit Care 2022; 37:714-723. [PMID: 35799090 DOI: 10.1007/s12028-022-01543-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2022] [Accepted: 06/01/2022] [Indexed: 10/17/2022]
Abstract
BACKGROUND Most existing studies have focused on the correlation between white matter lesion (WML) and baseline intraventricular hemorrhage (IVH) in patients with intracerebral hemorrhage (ICH), whereas few studies have investigated the relationship between WML severity and delayed IVH after admission. This study aimed to investigate the correlation between WML severity and delayed IVH and to verify the association between WML and baseline IVH. METHODS A total of 480 patients with spontaneous ICH from February 2018 to October 2020 were selected. WML was scored using the Van Swieten Scale, with scores of 0-2 representing nonslight WML and scores of 3-4 representing moderate-severe WML. We determined the presence of IVH on baseline (< 6 h) and follow-up computed tomography (< 72 h) images. Univariate analysis and multiple logistic regression were used to analyze the influencing factors of baseline and delayed IVH. RESULTS Among 480 patients with ICH, 172 (35.8%) had baseline IVH, and there was a higher proportion of moderate-severe WML in patients with baseline IVH (20.3%) than in those without baseline IVH (12.7%) (P = 0.025). Among 308 patients without baseline IVH, delayed IVH was found in 40 patients (12.9%), whose proportion of moderate-severe WML (25.0%) was higher than that in patients without delayed IVH (10.8%) (P = 0.012). Multiple logistic regression results showed that moderate-severe WML was independently correlated with baseline IVH (P = 0.006, odds ratio = 2.266, 95% confidence interval = 1.270-4.042) and delayed IVH (P = 0.002, odds ratio = 7.009, 95% confidence interval = 12.086-23.552). CONCLUSIONS Moderate-severe WML was an independent risk factor for delayed IVH as well as baseline IVH.
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Affiliation(s)
- Mengying Yu
- Department of Radiology, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, Zhejiang, China
| | - Dongqin Zhu
- Department of Radiology, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, Zhejiang, China
| | - Zhixian Luo
- Department of Radiology, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, Zhejiang, China
| | - Zhifang Pan
- The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, Zhejiang, China
| | - Yunjun Yang
- Department of Radiology, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, Zhejiang, China
| | - Haoli Xu
- Department of Radiology, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, Zhejiang, China. .,Medical College of Soochow University, Suzhou, Jiangsu, China.
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14
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Greenberg SM, Ziai WC, Cordonnier C, Dowlatshahi D, Francis B, Goldstein JN, Hemphill JC, Johnson R, Keigher KM, Mack WJ, Mocco J, Newton EJ, Ruff IM, Sansing LH, Schulman S, Selim MH, Sheth KN, Sprigg N, Sunnerhagen KS. 2022 Guideline for the Management of Patients With Spontaneous Intracerebral Hemorrhage: A Guideline From the American Heart Association/American Stroke Association. Stroke 2022; 53:e282-e361. [PMID: 35579034 DOI: 10.1161/str.0000000000000407] [Citation(s) in RCA: 404] [Impact Index Per Article: 202.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
| | | | | | | | | | | | | | | | | | - William J Mack
- AHA Stroke Council Scientific Statement Oversight Committee on Clinical Practice Guideline liaison
| | | | | | - Ilana M Ruff
- AHA Stroke Council Stroke Performance Measures Oversight Committee liaison
| | | | | | | | - Kevin N Sheth
- AHA Stroke Council Scientific Statement Oversight Committee on Clinical Practice Guideline liaison.,AAN representative
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15
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Randhawa AS, Pariona-Vargas F, Starkman S, Sanossian N, Liebeskind DS, Avila G, Stratton S, Gornbein J, Sharma L, Restrepo-Jimenez L, Valdes-Sueiras M, Kim-Tenser M, Villablanca P, Conwit R, Hamilton S, Saver JL. Beyond the Golden Hour: Treating Acute Stroke in the Platinum 30 Minutes. Stroke 2022; 53:2426-2434. [PMID: 35545939 PMCID: PMC9329219 DOI: 10.1161/strokeaha.121.036993] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND To emphasize treatment speed for time-sensitive conditions, emergency medicine has developed not only the concept of the golden hour, but also the platinum half-hour. Patients with acute stroke treated within the first half-hour of onset have not been previously characterized. METHODS In this cohort study, we analyzed patients enrolled in the FAST-MAG (Field Administration of Stroke Therapy-Magnesium) trial, testing paramedic prehospital start of neuroprotective agent ≤2 hours of onset. The features of all acute cerebral ischemia, and intracranial hemorrhage patients with treatment starting at ≤30 m of last known well were compared with later-treated patients. RESULTS Among 1680 patients, 203 (12.1%) received study agents within 30 minutes of last known well. Among platinum half-hour patients, median onset-to-treatment time was 28 minutes (interquartile range, 25-30), and final diagnoses were acute cerebral ischemia in 71.8% (ischemic stroke, 61.5%, TIA 10.3%); intracranial hemorrhage in 26.1%; and mimic in 2.5%. Clinical features among platinum half-hour patients were largely similar to later-treated patients and included age 69 (interquartile range, 57-79), 44.8% women, prehospital Los Angeles Motor Scale median 4 (3-5), and early-postarrival National Institutes of Health Stroke Scale deficit 8 (interquartile range, 3-18). Platinum half-hour acute cerebral ischemia patients did have more severe prehospital motor deficits and younger age; platinum half-hour intracranial hemorrhage patients had more severe motor deficits, were more often female, and less often of Hispanic ethnicity. Outcomes at 3 m in platinum half-hour patients were comparable to later-treated patients and included freedom-from-disability (modified Rankin Scale score, 0-1) in 35.5%, functional independence (modified Rankin Scale score, 0-2) in 53.2%, and mortality in 17.7%. CONCLUSIONS Prehospital initiation permits treatment start within the platinum half-hour after last known well in a substantial proportion of acute ischemic and hemorrhagic stroke patients, accounting for more than 1 in 10 enrolled in a multicenter trial. Hyperacute platinum half-hour patients were largely similar to later-treated patients and are an attainable target for treatment in prehospital stroke trials.
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Affiliation(s)
- Anantbir S Randhawa
- California University of Science and Medicine, School of Medicine, Colton (A.S.R.)
| | | | - Sidney Starkman
- Departments of Emergency Medicine and Neurology, University of California Los Angeles David Geffen School of Medicine. (S.S., S.S.)
| | - Nerses Sanossian
- Department of Neurology University of Southern California, Los Angeles (N.S., M.K.-T.)
| | - David S Liebeskind
- Department of Neurology, University of California Los Angeles David Geffen School of Medicine. (D.S.L., G.A., L.S., L.R.-J., M.V.-S., J.L.S.)
| | - Gilda Avila
- Department of Neurology, University of California Los Angeles David Geffen School of Medicine. (D.S.L., G.A., L.S., L.R.-J., M.V.-S., J.L.S.)
| | - Samuel Stratton
- Departments of Emergency Medicine and Neurology, University of California Los Angeles David Geffen School of Medicine. (S.S., S.S.)
| | - Jeffrey Gornbein
- Department of Computational Medicine, University of California, Los Angeles (J.G.)
| | - Latisha Sharma
- Department of Neurology, University of California Los Angeles David Geffen School of Medicine. (D.S.L., G.A., L.S., L.R.-J., M.V.-S., J.L.S.)
| | - Lucas Restrepo-Jimenez
- Department of Neurology, University of California Los Angeles David Geffen School of Medicine. (D.S.L., G.A., L.S., L.R.-J., M.V.-S., J.L.S.)
| | - Miguel Valdes-Sueiras
- Department of Neurology, University of California Los Angeles David Geffen School of Medicine. (D.S.L., G.A., L.S., L.R.-J., M.V.-S., J.L.S.)
| | - May Kim-Tenser
- Department of Neurology University of Southern California, Los Angeles (N.S., M.K.-T.)
| | - Pablo Villablanca
- Department of Neuroradiology, University of California Los Angeles David Geffen School of Medicine. (P.V.)
| | - Robin Conwit
- National Institute of Neurological Disorders and Stroke, National Institutes of Health, Neuroscience Center, Bethesda, MD (R.C.)
| | - Scott Hamilton
- Department of Neurology, Stanford University, Palo Alto, CA (S.H.)
| | - Jeffrey L Saver
- Department of Neurology, University of California Los Angeles David Geffen School of Medicine. (D.S.L., G.A., L.S., L.R.-J., M.V.-S., J.L.S.)
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16
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Chen Y, Cao D, Guo ZQ, Ma XL, Ou YB, He Y, Chen X, Chen J. The Attenuation Value Within the Non-hypodense Region on Non-contrast Computed Tomography of Spontaneous Cerebral Hemorrhage: A Long-Neglected Predictor of Hematoma Expansion. Front Neurol 2022; 13:785670. [PMID: 35463149 PMCID: PMC9024072 DOI: 10.3389/fneur.2022.785670] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2021] [Accepted: 03/08/2022] [Indexed: 11/25/2022] Open
Abstract
Background and Purpose The ability of attenuation value of the non-hypodense region of hematoma in non-contrast computed tomography (NCCT) for predicting hematoma expansion (HE) remains unclear. Our purpose is to explore this relationship. Methods Two cohorts of patients were collected for analysis. The region where we measured hematoma attenuation values was limited to the non-hypodense region that was not adjacent to the normal brain tissue on NCCT. The critical attenuation value was derived via receiver operating characteristic (ROC) curve analysis in the derivation cohort and its predictive ability was validated in the validation cohort. Independent relationships between predictors, such as critical attenuation value of the non-hypodense region and HE were analyzed using the least absolute shrinkage and selection operator (LASSO) regression and multivariate logistic analysis. Results The results showed that the attenuation value <64 Hounsfield units (HU) was independently associated with HE [odds ratio (OR), 4.118; 95% confidential interval (CI), 1.897–9.129, p < 0.001] and the sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), positive likelihood ratio (PLR), negative likelihood ratio (NLR), and area under the curve (AUC) for predicting HE were 36.11%, 81.71%, 1.97, 0.78, 44.8%, 75.7%, and 0.589, respectively. Conclusions Our research explored and validated the relationship between the attenuation value of the non-hypodense region of hematoma and HE. The attenuation value < 64 HU was an appropriate indicator of early HE.
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Affiliation(s)
- Yong Chen
- Department of Neurosurgery, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Dan Cao
- Department of Neurosurgery, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Zheng-Qian Guo
- Department of Neurosurgery, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Xiao-Ling Ma
- Department of Radiology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Yi-Bo Ou
- Department of Neurosurgery, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Yue He
- Department of Neurosurgery, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Xu Chen
- Department of Neurosurgery, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Jian Chen
- Department of Neurosurgery, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
- *Correspondence: Jian Chen
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17
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Guo DC, Gu J, He J, Chu HR, Dong N, Zheng YF. External validation study on the value of deep learning algorithm for the prediction of hematoma expansion from noncontrast CT scans. BMC Med Imaging 2022; 22:45. [PMID: 35287616 PMCID: PMC8922885 DOI: 10.1186/s12880-022-00772-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2021] [Accepted: 03/07/2022] [Indexed: 11/23/2022] Open
Abstract
Background Hematoma expansion is an independent predictor of patient outcome and mortality. The early diagnosis of hematoma expansion is crucial for selecting clinical treatment options. This study aims to explore the value of a deep learning algorithm for the prediction of hematoma expansion from non-contrast computed tomography (NCCT) scan through external validation. Methods 102 NCCT images of hypertensive intracerebral hemorrhage (HICH) patients diagnosed in our hospital were retrospectively reviewed. The initial computed tomography (CT) scan images were evaluated by a commercial Artificial Intelligence (AI) software using deep learning algorithm and radiologists respectively to predict hematoma expansion and the corresponding sensitivity, specificity and accuracy of the two groups were calculated and compared. Comparisons were also conducted among gold standard hematoma expansion diagnosis time, AI software diagnosis time and doctors’ reading time. Results Among 102 HICH patients, the sensitivity, specificity, and accuracy of hematoma expansion prediction in the AI group were higher than those in the doctor group(80.0% vs 66.7%, 73.6% vs 58.3%, 75.5% vs 60.8%), with statistically significant difference (p < 0.05). The AI diagnosis time (2.8 ± 0.3 s) and the doctors’ diagnosis time (11.7 ± 0.3 s) were both significantly shorter than the gold standard diagnosis time (14.5 ± 8.8 h) (p < 0.05), AI diagnosis time was significantly shorter than that of doctors (p < 0.05). Conclusions Deep learning algorithm could effectively predict hematoma expansion at an early stage from the initial CT scan images of HICH patients after onset with high sensitivity and specificity and greatly shortened diagnosis time, which provides a new, accurate, easy-to-use and fast method for the early prediction of hematoma expansion.
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Affiliation(s)
- Dong Chuang Guo
- Department of Radiology, Huzhou Central Hospital, Affiliated Central Hospital of Huzhou University, Huzhou, 313000, Zhejiang Province, China
| | - Jun Gu
- Institute of Clinical Research, Biomind Technology, Beijing, 100050, China
| | - Jian He
- Department of Radiology, Huzhou Central Hospital, Affiliated Central Hospital of Huzhou University, Huzhou, 313000, Zhejiang Province, China
| | - Hai Rui Chu
- Department of Radiology, Huzhou Central Hospital, Affiliated Central Hospital of Huzhou University, Huzhou, 313000, Zhejiang Province, China
| | - Na Dong
- Institute of Clinical Research, Biomind Technology, Beijing, 100050, China
| | - Yi Feng Zheng
- Department of Radiology, Huzhou Central Hospital, Affiliated Central Hospital of Huzhou University, Huzhou, 313000, Zhejiang Province, China.
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18
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Picard JM, Schmidt C, Sheth KN, Bösel J. Critical Care of the Patient With Acute Stroke. Stroke 2022. [DOI: 10.1016/b978-0-323-69424-7.00056-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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19
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Ren X, Huang Q, Qu Q, Cai X, Fu H, Mo X, Wang Y, Zheng Y, Jiang E, Ye Y, Luo Y, Chen S, Yang T, Zhang Y, Han W, Tang F, Mo W, Wang S, Li F, Liu D, Zhang X, Zhang Y, Feng S, Gao F, Yuan H, Wang D, Wan D, Chen H, Chen Y, Wang J, Chen Y, Wang Y, Xu K, Lang T, Wang X, Meng H, Li L, Wang Z, Fan Y, Chang Y, Xu L, Huang X, Zhang X. Predicting mortality from intracranial hemorrhage in patients who undergo allogeneic hematopoietic stem cell transplantation. Blood Adv 2021; 5:4910-4921. [PMID: 34448835 PMCID: PMC9153001 DOI: 10.1182/bloodadvances.2021004349] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2021] [Accepted: 05/04/2021] [Indexed: 02/07/2023] Open
Abstract
Intracranial hemorrhage (ICH) is a rare but fatal central nervous system complication of allogeneic hematopoietic stem cell transplantation (allo-HSCT). However, factors that are predictive of early mortality in patients who develop ICH after undergoing allo-HSCT have not been systemically investigated. From January 2008 to June 2020, a total of 70 allo-HSCT patients with an ICH diagnosis formed the derivation cohort. Forty-one allo-HSCT patients with an ICH diagnosis were collected from 12 other medical centers during the same period, and they comprised the external validation cohort. These 2 cohorts were used to develop and validate a grading scale that enables the prediction of 30-day mortality from ICH in all-HSCT patients. Four predictors (lactate dehydrogenase level, albumin level, white blood cell count, and disease status) were retained in the multivariable logistic regression model, and a simplified grading scale (termed the LAWS score) was developed. The LAWS score was adequately calibrated (Hosmer-Lemeshow test, P > .05) in both cohorts. It had good discrimination power in both the derivation cohort (C-statistic, 0.859; 95% confidence interval, 0.776-0.945) and the external validation cohort (C-statistic, 0.795; 95% confidence interval, 0.645-0.945). The LAWS score is the first scoring system capable of predicting 30-day mortality from ICH in allo-HSCT patients. It showed good performance in identifying allo-HSCT patients at increased risk of early mortality after ICH diagnosis. We anticipate that it would help risk stratify allo-HSCT patients with ICH and facilitate future studies on developing individualized and novel interventions for patients within different LAWS risk groups.
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Affiliation(s)
- Xiying Ren
- Peking University People’s Hospital, Peking University Institute of Hematology, Beijing, China
- National Clinical Research Center for Hematologic Disease, Beijing, China
| | - Qiusha Huang
- Peking University People’s Hospital, Peking University Institute of Hematology, Beijing, China
- National Clinical Research Center for Hematologic Disease, Beijing, China
| | - Qingyuan Qu
- Peking University People’s Hospital, Peking University Institute of Hematology, Beijing, China
- National Clinical Research Center for Hematologic Disease, Beijing, China
| | - Xuan Cai
- Peking University People’s Hospital, Peking University Institute of Hematology, Beijing, China
- National Clinical Research Center for Hematologic Disease, Beijing, China
| | - Haixia Fu
- Peking University People’s Hospital, Peking University Institute of Hematology, Beijing, China
- National Clinical Research Center for Hematologic Disease, Beijing, China
| | - Xiaodong Mo
- Peking University People’s Hospital, Peking University Institute of Hematology, Beijing, China
- National Clinical Research Center for Hematologic Disease, Beijing, China
| | - Yu Wang
- Peking University People’s Hospital, Peking University Institute of Hematology, Beijing, China
- National Clinical Research Center for Hematologic Disease, Beijing, China
| | - Yawei Zheng
- Center of Hematopoietic Stem Cell Transplantation, Institute of Hematology and Blood Diseases Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Tianjin, China
| | - Erlie Jiang
- Center of Hematopoietic Stem Cell Transplantation, Institute of Hematology and Blood Diseases Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Tianjin, China
| | - Yishan Ye
- Bone Marrow Transplantation Center, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Yi Luo
- Bone Marrow Transplantation Center, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Shaozhen Chen
- Department of Hematology, Fujian Institute of Hematology, Fujian Provincial Key Laboratory of Hematology, Fujian Medical University Union Hospital, Fuzhou, China
| | - Ting Yang
- Department of Hematology, Fujian Institute of Hematology, Fujian Provincial Key Laboratory of Hematology, Fujian Medical University Union Hospital, Fuzhou, China
| | - Yuanyuan Zhang
- Peking University People’s Hospital, Peking University Institute of Hematology, Beijing, China
- National Clinical Research Center for Hematologic Disease, Beijing, China
| | - Wei Han
- Peking University People’s Hospital, Peking University Institute of Hematology, Beijing, China
- National Clinical Research Center for Hematologic Disease, Beijing, China
| | - Feifei Tang
- Peking University People’s Hospital, Peking University Institute of Hematology, Beijing, China
- National Clinical Research Center for Hematologic Disease, Beijing, China
| | - Wenjian Mo
- Department of Hematology, Guangzhou First People’s Hospital, School of Medicine, South China University of Technology, Guangzhou, China
| | - Shunqing Wang
- Department of Hematology, Guangzhou First People’s Hospital, School of Medicine, South China University of Technology, Guangzhou, China
| | - Fei Li
- Department of Hematology, Chinese PLA General Hospital, Beijing, China
| | - Daihong Liu
- Department of Hematology, Chinese PLA General Hospital, Beijing, China
| | - Xiaoying Zhang
- Department of Hematology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Yicheng Zhang
- Department of Hematology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Shuqing Feng
- Department of Hematology, North China University of Science and Technology Affiliated Hospital, Tangshan, China
| | - Feng Gao
- Department of Hematology, North China University of Science and Technology Affiliated Hospital, Tangshan, China
| | - Hailong Yuan
- Hematology Center, The First Affiliated Hospital of Xinjiang Medical University, Urumqi, China
| | | | - Dingming Wan
- Department of Hematology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Huan Chen
- Peking University People’s Hospital, Peking University Institute of Hematology, Beijing, China
- National Clinical Research Center for Hematologic Disease, Beijing, China
| | - Yao Chen
- Peking University People’s Hospital, Peking University Institute of Hematology, Beijing, China
- National Clinical Research Center for Hematologic Disease, Beijing, China
| | - Jingzhi Wang
- Peking University People’s Hospital, Peking University Institute of Hematology, Beijing, China
- National Clinical Research Center for Hematologic Disease, Beijing, China
| | - Yuhong Chen
- Peking University People’s Hospital, Peking University Institute of Hematology, Beijing, China
- National Clinical Research Center for Hematologic Disease, Beijing, China
| | - Ying Wang
- Department of Hematology, The Affiliated Hospital of Xuzhou Medical University, Xuzhou, China
| | - Kailin Xu
- Department of Hematology, The Affiliated Hospital of Xuzhou Medical University, Xuzhou, China
| | - Tao Lang
- Department of Hematology, People’s Hospital of Xinjiang Uygur Autonomous Region, Urumqi, China
| | - Xiaomin Wang
- Department of Hematology, People’s Hospital of Xinjiang Uygur Autonomous Region, Urumqi, China
| | - Hongbin Meng
- Department of Hematology, The First Affiliated Hospital, Harbin Medical University, Harbin, China; and
| | - Limin Li
- Department of Hematology, The First Affiliated Hospital, Harbin Medical University, Harbin, China; and
| | - Zhiguo Wang
- Bone Marrow Transplantation Department, Harbin Institute of Hematology and Oncology, Harbin, China
| | - Yanling Fan
- Bone Marrow Transplantation Department, Harbin Institute of Hematology and Oncology, Harbin, China
| | - Yingjun Chang
- Peking University People’s Hospital, Peking University Institute of Hematology, Beijing, China
- National Clinical Research Center for Hematologic Disease, Beijing, China
| | - Lanping Xu
- Peking University People’s Hospital, Peking University Institute of Hematology, Beijing, China
- National Clinical Research Center for Hematologic Disease, Beijing, China
| | - Xiaojun Huang
- Peking University People’s Hospital, Peking University Institute of Hematology, Beijing, China
- National Clinical Research Center for Hematologic Disease, Beijing, China
| | - Xiaohui Zhang
- Peking University People’s Hospital, Peking University Institute of Hematology, Beijing, China
- National Clinical Research Center for Hematologic Disease, Beijing, China
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20
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Tang M, Shin HJ, Metcalf-Doetsch W, Luo Y, Lindholm PF, Kwaan H, Naidech AM. Antiplatelet Medications and Biomarkers of Hemostasis May Explain the Association of Hematoma Appearance and Subsequent Hematoma Expansion After Intracerebral Hemorrhage. Neurocrit Care 2021; 36:791-796. [PMID: 34708342 PMCID: PMC10084720 DOI: 10.1007/s12028-021-01369-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2021] [Accepted: 09/27/2021] [Indexed: 11/26/2022]
Abstract
BACKGROUND To test the hypothesis that appearances of intracranial hematomas on diagnostic computed tomography (CT) are not idiosyncratic and reflect a biologically plausible mechanism, we evaluated the association between hematoma appearance on CT, biomarkers of platelet activity, and antiplatelet or anticoagulant medication use prior to admission. METHODS We studied 330 consecutively identified patients from 2006 to 2019. Biomarkers of platelet activity (platelet aspirin assay) and medication history (aspirin, clopidogrel) were prospectively recorded on admission. A blinded interpreter recorded the presence of hematoma appearances from the diagnostic scan. Associations were tested with parametric or nonparametric statistics, as appropriate. RESULTS The black hole sign (101, 30%) was most prevalent, followed by the island sign (57, 17%) and blend sign (32, 10%). There was reduced platelet activity in patients with a black hole sign (511 [430-610] vs. 562 [472-628] aspirin reaction units, P = 0.01) or island sign (505 [434-574] vs. 559 [462-629] aspirin reaction units, P = 0.004). Clopidogrel use prior to admission was associated with the black hole sign (odds ratio 2.25, 95% confidence interval 1.02-4.98, P = 0.04). CONCLUSIONS In patients with acute intracerebral hemorrhage, hematoma appearances on CT are associated with biomarkers of platelet activity and clopidogrel use prior to admission. Appearances of intracranial hematomas on CT may reflect reduced hemostasis from antiplatelet medication use.
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Affiliation(s)
- Mengxuan Tang
- Department of Neurology, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | - Hye Jung Shin
- Institute for Public Health and Medicine, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | - William Metcalf-Doetsch
- Department of Neurosurgery, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | - Yuan Luo
- Division of Health and Biomedical Informatics, Department of Preventive Medicine, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | - Paul F Lindholm
- Department of Pathology, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | - Hau Kwaan
- Division of Hematology and Oncology, Department of Medicine, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | - Andrew M Naidech
- Department of Neurology, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA.
- Institute for Public Health and Medicine, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA.
- Division of Health and Biomedical Informatics, Department of Preventive Medicine, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA.
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21
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Tanaka K, Toyoda K. Clinical Strategies Against Early Hematoma Expansion Following Intracerebral Hemorrhage. Front Neurosci 2021; 15:677744. [PMID: 34526875 PMCID: PMC8435629 DOI: 10.3389/fnins.2021.677744] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2021] [Accepted: 08/05/2021] [Indexed: 02/01/2023] Open
Abstract
Hematoma volume is the strongest predictor of morbidity and mortality after intracerebral hemorrhage. Protection against early hematoma growth is therefore the mainstay of therapeutic intervention for acute intracerebral hemorrhage, but the current armamentarium is restricted to early blood pressure lowering and emergent reversal for anticoagulant agents. Although intensive lowering of systolic blood pressure to <140 mmHg appears likely to prevent hematoma growth, two recent randomized trials, INTERACT-2 and ATACH-2, demonstrated non-significant trends of reduced hematoma enlargement by intensive blood pressure control, with only a small magnitude of benefit or no benefit for clinical outcomes. While oral anticoagulants can be immediately reversed by prothrombin complex concentrate, or the newly developed idarucizumab for direct thrombin inhibitor or andexanet for factor Xa inhibitors, the situation regarding reversal of antiplatelet agents is not yet quite as advanced. However, considering at most the approximately 10% rate of anticoagulant use among patients with intracerebral hemorrhage, what is most essential for patients with intracerebral hemorrhage in general is early hemostatic therapy. Tranexamic acid may safely reduce hematoma expansion, but its hemostatic effect was insufficient to be translated into improved functional outcomes in the TICH-2 randomized trial with 2,325 participants. In this context, recombinant activated factor VII (rFVIIa) is a candidate to be added to the armory against hematoma enlargement. The FAST, a phase 3 trial that compared doses of 80 and 20 μg/kg rFVIIa with placebo in 841 patients within 4 h after the stroke onset, showed a significant reduction in hematoma growth with rFVIIa treatment, but demonstrated no significant difference in the proportion of patients with severe disability or death. However, a post hoc analysis of the FAST trial suggested a benefit of rFVIIa in a target subgroup of younger patients without extensive bleeding at baseline when treated earlier after stroke onset. The FASTEST trial is now being prepared to determine this potential benefit of rFVIIa, reflecting the pressing need to develop therapeutic strategies against hematoma enlargement, a powerful but modifiable prognostic factor in patients with intracerebral hemorrhage.
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Affiliation(s)
- Kanta Tanaka
- Department of Cerebrovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Kazunori Toyoda
- Department of Cerebrovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Japan
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22
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Mayer SA, Frontera JA, Jankowitz B, Kellner CP, Kuppermann N, Naik BI, Nishijima DK, Steiner T, Goldstein JN. Recommended Primary Outcomes for Clinical Trials Evaluating Hemostatic Agents in Patients With Intracranial Hemorrhage: A Consensus Statement. JAMA Netw Open 2021; 4:e2123629. [PMID: 34473266 DOI: 10.1001/jamanetworkopen.2021.23629] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
IMPORTANCE In patients with acute spontaneous or traumatic intracranial hemorrhage, early hemostasis is thought to be critical to minimize ongoing bleeding. However, research evaluating hemostatic therapies has been hampered by a lack of standardized clinical trial outcome measures. OBJECTIVE To identify appropriate primary outcomes for phase 2 and 3 clinical trials of therapies aimed at reducing acute intracranial bleeding. EVIDENCE REVIEW A comprehensive review of all previous clinical trials of hemostatic therapy for intracranial bleeding was performed, and studies measuring the frequency, risk factors, and association of intracranial bleeding with outcome of hemorrhage growth were included. FINDINGS A hierarchy of 3 outcome measures is recommended, with the first choice being a global patient-centered clinical outcome scale measured 30 to 180 days after the event; the second, a combined clinical and radiographic end point associating hemorrhage expansion with a poor patient-centered outcome at 24 hours or later; and the third, a radiographic measure of hemorrhage expansion at 24 hours alone. Additional recommendations stress the importance of separating various subtypes of bleeding when possible, early treatment within a standardized treatment window, and the routine use of computerized planimetry comparing continuous measures of absolute and relative hemorrhage growth as either a primary or secondary end point. CONCLUSIONS AND RELEVANCE Standardization of outcome measures in studies of intracranial bleeding and hemostatic therapy will support comparative effectiveness research and meta-analysis, with the goal of accelerating the translation of research into clinical practice. The 3 outcome measures proposed in this consensus statement could help this process.
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Affiliation(s)
- Stephan A Mayer
- Departments of Neurology and Neurosurgery, Westchester Medical Center Health, New York Medical College, Valhalla
| | | | - Brian Jankowitz
- Department of Neurosurgery, Cooper University Health Care, Camden, New Jersey
| | | | - Nathan Kuppermann
- Departments of Emergency Medicine and Pediatrics, University of California, Davis School of Medicine, UC Davis Health, Sacramento
| | - Bhiken I Naik
- Department of Anesthesiology and Neurological Surgery, University of Virginia, Charlottesville
| | - Daniel K Nishijima
- Department of Emergency Medicine, University of California, Davis School of Medicine, UC Davis Health, Sacramento
| | - Thorsten Steiner
- Department of Neurology, Klinikum Frankfurt Höchst, Frankfurt, Germany
- Department of Neurology, Heidelberg University Hospital, Heidelberg, Germany
| | - Joshua N Goldstein
- Department of Emergency Medicine, Massachusetts General Hospital, Boston
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23
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Early Administration of Desmopressin and Platelet Transfusion for Reducing Hematoma Expansion in Patients With Acute Antiplatelet Therapy Associated Intracerebral Hemorrhage. Crit Care Med 2021; 48:1009-1017. [PMID: 32304415 DOI: 10.1097/ccm.0000000000004348] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
OBJECTIVES To investigate the hemostatic efficacy of combined desmopressin (1-deamino-8-D-arginine vasopressin) and platelet transfusion in reducing hematoma expansion in acute, spontaneous intracerebral hemorrhage under antiplatelet treatment. DESIGN Single-center, nonrandomized study, performed between 2006 and 2014. SETTING Tertiary University Hospital of Tuebingen, Germany. PATIENTS Adult patients with intracerebral hemorrhage under antiplatelet treatment and follow-up CT at 24 ± 12 hours were included. Exclusion criteria included other intracerebral hemorrhage causes, anticoagulation, coagulopathy, or immediate surgery after baseline-CT. INTERVENTIONS Treatment with IV 1-deamino-8-D-arginine vasopressin (0.4 µg/kg) + platelet transfusion (2 U) within 60 minutes of intracerebral hemorrhage under antiplatelet treatment diagnosis on brain imaging. MEASUREMENTS AND MAIN RESULTS Primary outcome was relative hematoma expansion from baseline to follow-up CT. Secondary outcomes included secondary intraventricular hemorrhage or hydrocephalus upon follow-up CT, thromboembolic events before discharge, and the 3-month functional outcome (assessed by modified Rankin Scale). One-hundred forty patients were included, 72 treated versus 68 controls. Times of symptom-onset-to-baseline-CT (hr) (median [interquartile range]: 3 [4] vs 5 [5]; p = 0.468) and follow-up CT (26 [18] vs 19 [12]; p = 0.352) were similar between groups. No between-group differences of total intracerebral hematoma expansion (%) (median [interquartile range]: 8.5 [12.4] vs 9.1 [16.5]; p = 0.825), intraparenchymal (10.7 [23.1] vs 9.2 [20.7]; p = 0.900), and intraventricular hematoma expansion (14.5 [63.2] vs 6.1 [40.4]; p = 0.304) were noted. Among patients with hematoma expansion greater than or equal to 33% compared with baseline, 16 (52%) received treatment versus 15 (48%) controls. The occurrence of hematoma expansion greater than or equal to 33% was similar between groups (p = 0.981). Rates of secondary intraventricular hemorrhage, hydrocephalus, and thromboembolic events were similar between groups. Treatment with 1-deamino-8-D-arginine vasopressin + platelet transfusion was not associated with the 3-month functional outcome (adjusted odds ratio, 1.570; 95% CI, 0.721-3.419; p = 0.309). CONCLUSIONS In line with the randomized Platelet Transfusion Versus Standard Care After Acute Stroke Due to Spontaneous Cerebral Hemorrhage Associated With Antiplatelet Therapy trial, our results suggest no hemostatic efficacy of early platelet transfusion in intracerebral hemorrhage under antiplatelet treatment. Contrary to results of preclinical and clinical nonintracerebral hemorrhage studies, adjunct 1-deamino-8-D-arginine vasopressin showed no benefit in limiting hematoma expansion or improving functional outcome.
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24
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Ovesen C, Jakobsen JC, Gluud C, Steiner T, Law Z, Flaherty K, Dineen RA, Christensen LM, Overgaard K, Rasmussen RS, Bath PM, Sprigg N, Christensen H. Tranexamic Acid for Prevention of Hematoma Expansion in Intracerebral Hemorrhage Patients With or Without Spot Sign. Stroke 2021; 52:2629-2636. [PMID: 34000834 DOI: 10.1161/strokeaha.120.032426] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
BACKGROUND AND PURPOSE The computed tomography angiography or contrast-enhanced computed tomography based spot sign has been proposed as a biomarker for identifying on-going hematoma expansion in patients with acute intracerebral hemorrhage. We investigated, if spot-sign positive participants benefit more from tranexamic acid versus placebo as compared to spot-sign negative participants. METHODS TICH-2 trial (Tranexamic Acid for Hyperacute Primary Intracerebral Haemorrhage) was a randomized, placebo-controlled clinical trial recruiting acutely hospitalized participants with intracerebral hemorrhage within 8 hours after symptom onset. Local investigators randomized participants to 2 grams of intravenous tranexamic acid or matching placebo (1:1). All participants underwent computed tomography scan on admission and on day 2 (24±12 hours) after randomization. In this sub group analysis, we included all participants from the main trial population with imaging allowing adjudication of spot sign status. RESULTS Of the 2325 TICH-2 participants, 254 (10.9%) had imaging allowing for spot-sign adjudication. Of these participants, 64 (25.2%) were spot-sign positive. Median (interquartile range) time from symptom onset to administration of the intervention was 225.0 (169.0 to 310.0) minutes. The adjusted percent difference in absolute day-2 hematoma volume between participants allocated to tranexamic versus placebo was 3.7% (95% CI, -12.8% to 23.4%) for spot-sign positive and 1.7% (95% CI, -8.4% to 12.8%) for spot-sign negative participants (Pheterogenity=0.85). No difference was observed in significant hematoma progression (dichotomous composite outcome) between participants allocated to tranexamic versus placebo among spot-sign positive (odds ratio, 0.85 [95% CI, 0.29 to 2.46]) and negative (odds ratio, 0.77 [95% CI, 0.41 to 1.45]) participants (Pheterogenity=0.88). CONCLUSIONS Data from the TICH-2 trial do not support that admission spot sign status modifies the treatment effect of tranexamic acid versus placebo in patients with acute intracerebral hemorrhage. The results might have been affected by low statistical power as well as treatment delay. Registration: URL: http://www.controlled-trials.com; Unique identifier: ISRCTN93732214.
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Affiliation(s)
- Christian Ovesen
- Department of Neurology, Bispebjerg Hospital (C.O., L.M.C., H.C.), Copenhagen University Hospital, Copenhagen, Denmark.,The Copenhagen Trial Unit, Centre for Clinical Intervention Research, Rigshospitalet (C.O., J.C.J., C.G.), Copenhagen University Hospital, Copenhagen, Denmark
| | - Janus Christian Jakobsen
- The Copenhagen Trial Unit, Centre for Clinical Intervention Research, Rigshospitalet (C.O., J.C.J., C.G.), Copenhagen University Hospital, Copenhagen, Denmark.,Department of Regional Health Research, The Faculty of Heath Sciences, University of Southern Denmark, Odense (J.C.J.)
| | - Christian Gluud
- The Copenhagen Trial Unit, Centre for Clinical Intervention Research, Rigshospitalet (C.O., J.C.J., C.G.), Copenhagen University Hospital, Copenhagen, Denmark
| | - Thorsten Steiner
- Department of Neurology, Klinikum Frankfurt Höchst, Germany (T.S.).,Department of Neurology, Heidelberg University Hospital, Germany (T.S.)
| | - Zhe Law
- Stroke Trials Unit, Division of Clinical Neuroscience, University of Nottingham, City Hospital Campus, United Kingdom (Z.L., K.F., P.M.B., N.S.).,Stroke, Nottingham University Hospitals NHS Trust, United Kingdom (Z.L., P.M.B., N.S.).,Department of Medicine, National University of Malaysia, Malaysia (Z.L.)
| | - Katie Flaherty
- Stroke Trials Unit, Division of Clinical Neuroscience, University of Nottingham, City Hospital Campus, United Kingdom (Z.L., K.F., P.M.B., N.S.)
| | - Rob A Dineen
- Radiological Sciences, Division of Clinical Neuroscience, University of Nottingham, Queen's Medical Centre, United Kingdom (R.A.D.).,Sir Peter Mansfield Imaging Centre, University of Nottingham, United Kingdom (R.A.D.).,NIHR Nottingham Biomedical Research Centre, United Kingdom (R.A.D.)
| | - Louisa M Christensen
- Department of Neurology, Bispebjerg Hospital (C.O., L.M.C., H.C.), Copenhagen University Hospital, Copenhagen, Denmark
| | - Karsten Overgaard
- Department of Neurology, Herlev Hospital (K.O., R.S.R.), Copenhagen University Hospital, Copenhagen, Denmark
| | - Rune S Rasmussen
- Department of Neurology, Herlev Hospital (K.O., R.S.R.), Copenhagen University Hospital, Copenhagen, Denmark
| | - Philip M Bath
- Stroke Trials Unit, Division of Clinical Neuroscience, University of Nottingham, City Hospital Campus, United Kingdom (Z.L., K.F., P.M.B., N.S.).,Stroke, Nottingham University Hospitals NHS Trust, United Kingdom (Z.L., P.M.B., N.S.)
| | - Nikola Sprigg
- Stroke Trials Unit, Division of Clinical Neuroscience, University of Nottingham, City Hospital Campus, United Kingdom (Z.L., K.F., P.M.B., N.S.).,Stroke, Nottingham University Hospitals NHS Trust, United Kingdom (Z.L., P.M.B., N.S.)
| | - Hanne Christensen
- Department of Neurology, Bispebjerg Hospital (C.O., L.M.C., H.C.), Copenhagen University Hospital, Copenhagen, Denmark
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25
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Broderick JP, Grotta JC, Naidech AM, Steiner T, Sprigg N, Toyoda K, Dowlatshahi D, Demchuk AM, Selim M, Mocco J, Mayer S. The Story of Intracerebral Hemorrhage: From Recalcitrant to Treatable Disease. Stroke 2021; 52:1905-1914. [PMID: 33827245 PMCID: PMC8085038 DOI: 10.1161/strokeaha.121.033484] [Citation(s) in RCA: 34] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
This invited special report is based on an award presentation at the World Stroke Organization/European Stroke Organization Conference in November of 2020 outlining progress in the acute management of intracerebral hemorrhage (ICH) over the past 35 years. ICH is the second most common and the deadliest type of stroke for which there is no scientifically proven medical or surgical treatment. Prospective studies from the 1990s onward have demonstrated that most growth of spontaneous ICH occurs within the first 2 to 3 hours and that growth of ICH and resulting volumes of ICH and intraventricular hemorrhage are modifiable factors that can improve outcome. Trials focusing on early treatment of elevated blood pressure have suggested a target systolic blood pressure of 140 mm Hg, but none of the trials were positive by their primary end point. Hemostatic agents to decrease bleeding in spontaneous ICH have included desmopressin, tranexamic acid, and rFVIIa (recombinant factor VIIa) without clear benefit, and platelet infusions which were associated with harm. Hemostatic agents delivered within the first several hours have the greatest impact on growth of ICH and potentially on outcome. No large Phase III surgical ICH trial has been positive by primary end point, but pooled analyses suggest that earlier ICH removal is more likely to be beneficial. Recent trials emphasize maximization of clot removal and minimizing brain injury from the surgical approach. The future of ICH therapy must focus on delivery of medical and surgical therapies as soon as possible if we are to improve outcomes.
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Affiliation(s)
- Joseph P. Broderick
- University of Cincinnati Gardner Neuroscience Institute, Cincinnati, Ohio, USA
| | - James C. Grotta
- Memorial Hermann Hospital-Texas Medical Center, Houston, Texas, USA
| | - Andrew M. Naidech
- Department of Neurology, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
| | - Thorsten Steiner
- Department of Neurology, Klinikum Frankfurt Höchst, Frankfurt, Germany and Department of Neurology, Heidelberg University Hospital, Heidelberg, Germany
| | - Nikola Sprigg
- Stroke Trials Unit, Division of Clinical Neuroscience, University of Nottingham, City Hospital Campus, Nottingham, England
| | - Kazunori Toyoda
- Department of Cerebrovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Osaka, Japan
| | - Dar Dowlatshahi
- University of Ottawa and Ottawa Hospital Research Institute, Ottawa, Canada
| | - Andrew M. Demchuk
- Calgary Stroke Program, Depts of Clinical Neurosciences and Radiology, Hotchkiss Brain Institute, Cumming School of Medicine,, University of Calgary, Calgary, Alberta, Canada
| | - Magdy Selim
- Beth Israel Deaconess Medical Center, Boston, MA, USA; Harvard Medical School, Boston, MA, USA
| | - J Mocco
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York City, New York, USA
| | - Stephan Mayer
- Westchester Medical Center Health Network, Departments of Neurology and Neurosurgery, New York Medical College, Valhalla, New York, USA
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26
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Amoo M, Henry J, Alabi PO, Husien MB. The 'swirl sign' as a marker for haematoma expansion and outcome in intra-cranial haemorrhage: A meta-analysis. J Clin Neurosci 2021; 87:103-111. [PMID: 33863516 DOI: 10.1016/j.jocn.2021.02.028] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2020] [Revised: 02/04/2021] [Accepted: 02/25/2021] [Indexed: 11/27/2022]
Abstract
The 'swirl sign' is a CT imaging finding associated with haematoma expansion and poor prognosis. We performed a systematic review and meta-analysis to determine its prognostic value. PubMed/MEDLINE and EMBASE were searched until 16/12/2020 for related articles. Articles detailing the relationship between the swirl sign and any of haematoma expansion (HE), neurological outcome in the form of Glasgow Outcome Score (GOS) or mortality were included. A meta-analysis was performed and the pooled sensitivity, specificity, positive likelihood ratio (PLR) and negative likelihood ratio (NLR) were calculated for each of HE, GOS and mortality. 15 papers were assessed. Nine papers related to HE, for which the pooled sensitivity was 50% (95% CI 30-71), specificity was 77% (95%CI 67-85) and PLR was 2.16 (95%CI 1.89-2.42). There was significant heterogeneity (I2 = 70%, Q = 26.9). Three papers related to GOS, for which the pooled sensitivity was 45% (95%CI 20-74), specificity was 78.3% (95%CI 40-95.2) and PLR was 1.77 (95%CI 1.04-2.62). Three papers related to mortality, for which the pooled sensitivity was 65% (95% CI 32-88), specificity was 75% (95%CI 42-92) and pooled PLR was 2.64 (95%CI 1.60-4.13). Our findings indicated that the swirl sign is a useful prognostic marker in the radiological evaluation of intracranial haemorrhage. However, more research is needed to assess its independence from other risk factors for haematoma expansion.
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Affiliation(s)
- Michael Amoo
- Royal College of Surgeons Ireland, Dublin, Ireland; National Neurosurgical Centre, Beaumont Hospital, Dublin 9, Ireland.
| | - Jack Henry
- National Neurosurgical Centre, Beaumont Hospital, Dublin 9, Ireland; School of Medicine, University College Dublin, Dublin 4, Belfield, Ireland
| | | | - Mohammed Ben Husien
- Royal College of Surgeons Ireland, Dublin, Ireland; National Neurosurgical Centre, Beaumont Hospital, Dublin 9, Ireland
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Lv XN, Deng L, Yang WS, Wei X, Li Q. Computed Tomography Imaging Predictors of Intracerebral Hemorrhage Expansion. Curr Neurol Neurosci Rep 2021; 21:22. [PMID: 33710468 DOI: 10.1007/s11910-021-01108-z] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/23/2021] [Indexed: 12/14/2022]
Abstract
PURPOSE OF REVIEW Hematoma expansion (HE) is strongly associated with poor clinical outcome and is a compelling target for improving outcome after intracerebral hemorrhage (ICH). Non-contrast computed tomography (NCCT) is widely used in clinical practice due to its faster acquisition at the presence of acute stroke. Recently, imaging markers on NCCT are increasingly used for predicting HE. We comprehensively review the current evidence on HE prediction using NCCT and provide a summary for assessment of these markers in future research studies. RECENT FINDINGS Predictors of HE on NCCT have been described in reports of several studies. The proposed markers, including swirl sign, blend sign, black hole sign, island sign, satellite sign, and subarachnoid extension, were all significantly associated with HE and poor outcome in their small sample studies after ICH. In summary, the optimal management of ICH remains a therapeutic dilemma. Therefore, using NCCT markers to select patients at high risk of HE is urgently needed. These markers may allow rapid identification and provide potential targets for anti-HE treatments in patients with acute ICH.
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Affiliation(s)
- Xin-Ni Lv
- Department of Neurology, The First Affiliated Hospital of Chongqing Medical University, Chongqing, 400016, China
| | - Lan Deng
- Department of Neurology, The First Affiliated Hospital of Chongqing Medical University, Chongqing, 400016, China
| | - Wen-Song Yang
- Department of Neurology, The First Affiliated Hospital of Chongqing Medical University, Chongqing, 400016, China
| | - Xiao Wei
- Department of Traditional Chinese Medicine, Chongqing Medical and Pharmaceutical College, Chongqing, 401331, China.
| | - Qi Li
- Department of Neurology, The First Affiliated Hospital of Chongqing Medical University, Chongqing, 400016, China.
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Warrier AR, Bhatia R, Garg A, Padma Srivastava M, Dash D, Tripathi M, Singh MB, Singh V, Vishnubhatla S, Prasad K. Do Imaging Markers of Cerebral Small Vessel Disease Predict Hematoma Volume and Outcome in Acute Intracerebral Hemorrhage? Ann Indian Acad Neurol 2021; 24:204-210. [PMID: 34220064 PMCID: PMC8232507 DOI: 10.4103/aian.aian_183_20] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2020] [Revised: 04/09/2020] [Accepted: 05/08/2020] [Indexed: 11/04/2022] Open
Abstract
BACKGROUND AND PURPOSE Cerebral small vessel disease (CSVD) markers have not been widely studied in relation to hematoma volume and growth in hypertensive intracerebral hemorrhage (ICH). The objectives to assess the relationship of white matter hyperintense lesions (WMHL), microbleeds (MBs), and cortical siderosis (CSS) with hematoma volume, hematoma expansion (HE), and 3 months outcome in patients with hypertensive ICH. METHODS All consecutive acute hypertensive supratentorial ICH presenting to the emergency were prospectively recruited. Baseline and 24 hours computed tomography (CT) to assess hematoma volume and magnetic resonance imaging (MRI) for CSVD markers were performed in all subjects. WMHL (graded using Fazekas's scale), MBs, and CSS were assessed and compared with baseline variables and outcomes. All the images were assessed by an experienced stroke neurologist/neuroradiologist. RESULTS One hundred and fifty-seven patients were screened and 60 were included. Mean age was 54.08 ± 11.57 years and 47 (78%) were males. Of 60, 19 (28.1%) had HE, 31 (51.6%) had major bleed (>30 ml), and 28 (47.46%) had poor 3 month outcome (mRS 4-6). On univariate analysis, high grade WMHL was associated with greater HE [odds ratio (OR): 2.65, confidence interval (CI) 1.48-4.72, P = 0.001), greater proportion with volume >30 ml (OR: 7.16, CI: 1.09-47.13, P = 0.001) and poor outcome (OR: 2.1, CI: 0.05-3.27, P = 0.001). MBs were associated with poor outcome (P = 0.029) but not with HE/volume. CSS was related to HE (P = 0.031), a large volume bleed (P = 0.023), and poor outcome (P = 0.021). On multivariate model, only WMHL independently predicted HE (P = 0.034), greater proportion with bleed volume >30 ml (P = 0.041), and poor outcome (P = 0.042). CONCLUSIONS WMHL in MRI serves as a predictor of hematoma expansion, a large volume bleed, and poor outcome in hypertensive ICH and may be incorporated into existing prediction models.
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Affiliation(s)
- Anand R. Warrier
- Department of Neurology, All India Institute of Medical Sciences, New Delhi, India
| | - Rohit Bhatia
- Department of Neurology, All India Institute of Medical Sciences, New Delhi, India
| | - Ajay Garg
- Department of Neuroimaging and Interventional Neuroradiology, All India Institute of Medical Sciences, New Delhi, India
| | | | - Deepa Dash
- Department of Neurology, All India Institute of Medical Sciences, New Delhi, India
| | - Manjari Tripathi
- Department of Neurology, All India Institute of Medical Sciences, New Delhi, India
| | - Mamta Bhushan Singh
- Department of Neurology, All India Institute of Medical Sciences, New Delhi, India
| | - Vishwajeet Singh
- Department of Biostatistics, All India Institute of Medical Sciences, New Delhi, India
| | | | - Kameshwar Prasad
- Department of Neurology, All India Institute of Medical Sciences, New Delhi, India
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Hall AN, Weaver B, Liotta E, Maas MB, Faigle R, Mroczek DK, Naidech AM. Identifying Modifiable Predictors of Patient Outcomes After Intracerebral Hemorrhage with Machine Learning. Neurocrit Care 2021; 34:73-84. [PMID: 32385834 PMCID: PMC7648730 DOI: 10.1007/s12028-020-00982-8] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND/OBJECTIVE Demonstrating a benefit of acute treatment to patients with intracerebral hemorrhage (ICH) requires identifying which patients have a potentially modifiable outcome, where treatment could favorably shift a patient's expected outcome. A decision rule for which patients have a modifiable outcome could improve the targeting of treatments. We sought to determine which patients with ICH have a modifiable outcome. METHODS Patients with ICH were prospectively identified at two institutions. Data on hematoma volumes, medication histories, and other variables of interest were collected. ICH outcomes were evaluated using the modified Rankin Scale (mRS), assessed at 14 days and 3 months after ICH, with "good outcome" defined as 0-3 (independence or better) and "poor outcome" defined as 4-6 (dependence or worse). Supervised machine learning models identified the best predictors of good versus poor outcomes at Institution 1. Models were validated using repeated fivefold cross-validation as well as testing on the entirely independent sample at Institution 2. Model fit was assessed with area under the ROC curve (AUC). RESULTS Model performance at Institution 1 was strong for both 14-day (AUC of 0.79 [0.77, 0.81] for decision tree, 0.85 [0.84, 0.87] for random forest) and 3 month (AUC of 0.75 [0.73, 0.77] for decision tree, 0.82 [0.80, 0.84] for random forest) outcomes. Independent predictors of functional outcome selected by the algorithms as important included hematoma volume at hospital admission, hematoma expansion, intraventricular hemorrhage, overall ICH Score, and Glasgow Coma Scale. Hematoma expansion was the only potentially modifiable independent predictor of outcome and was compatible with "good" or "poor" outcome in a subset of patients with low hematoma volumes, good Glasgow Coma scale and premorbid modified Rankin Scale scores. Models trained on harmonized data also predicted patient outcomes well at Institution 2 using decision tree (AUC 0.69 [0.63, 0.75]) and random forests (AUC 0.78 [0.72, 0.84]). CONCLUSIONS Patient outcomes are predictable to a high level in patients with ICH, and hematoma expansion is the sole-modifiable predictor of these outcomes across two outcome types and modeling approaches. According to decision tree analyses predicting outcome at 3 months, patients with a high Glasgow Coma Scale score, less than 44.5 mL hematoma volume at admission, and relatively low premorbid modified Rankin Score in particular have a modifiable outcome and appear to be candidates for future interventions to improve outcomes after ICH.
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Affiliation(s)
- Andrew N Hall
- Department of Psychology, Weinberg College of Arts and Sciences, Northwestern University, Evanston, IL, USA.
| | - Bradley Weaver
- Institute for Public Health and Medicine, Northwestern University Chicago, Chicago, IL, USA
| | - Eric Liotta
- Institute for Public Health and Medicine, Northwestern University Chicago, Chicago, IL, USA
| | - Matthew B Maas
- Institute for Public Health and Medicine, Northwestern University Chicago, Chicago, IL, USA
| | - Roland Faigle
- Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Daniel K Mroczek
- Department of Psychology, Weinberg College of Arts and Sciences, Northwestern University, Evanston, IL, USA
- Department of Medical Social Sciences, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | - Andrew M Naidech
- Institute for Public Health and Medicine, Northwestern University Chicago, Chicago, IL, USA
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Silva Blas Y, Diringer MN, Lo B, Masjuan J, Pérez de la Ossa N, Cardinal M, Yong F, Zhu T, Li G, Arkin S. Phase 1b Study to Evaluate Safety, Tolerability, and Maximum Tolerated Dose of PF-05230907 for Intracerebral Hemorrhage. Stroke 2020; 52:294-298. [PMID: 33272131 DOI: 10.1161/strokeaha.120.029789] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
BACKGROUND AND PURPOSE This study aimed to determine the maximum tolerated dose and to evaluate the overall safety and tolerability of single doses of PF-05230907 in subjects with acute intracerebral hemorrhage. METHODS Individuals presenting with intracerebral hemorrhage were enrolled in a phase 1, multicenter, open-label clinical trial. A Bayesian modified continual reassessment method design based on treatment-emergent thromboembolic or ischemic events was adopted. Sequential dosing, an external data monitoring committee, and prespecified stopping rules were incorporated as safeguards. RESULTS Twenty-one subjects received PF-05230907. The mean (±SD) age in years and intracerebral hemorrhage volume in mL at baseline were 62 (±9) and 18 (±11), respectively. Two treatment-emergent thromboembolic or ischemic events occurred (deep vein thrombosis and cerebral ischemia), in the 30 μg/kg dose group. There were no other clear drug-related toxicities at dose levels ranging from 5 to 30 μg/kg. At the time of study termination, the maximum tolerated dose was estimated to be 24 μg/kg, with a mean fitted dose-toxicity estimate of 11.9% (95% CI, 1.2%-27.4%). CONCLUSIONS Single doses of PF-05230907 appeared to be tolerated across a range of doses in the intracerebral hemorrhage population, with thrombotic events observed only at the highest dose level tested. Recruitment within the recommended therapeutic window of opportunity remains a challenge. Registration: URL: https://www.clinicaltrials.gov. Unique identifier: NCT02687191.
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Affiliation(s)
| | | | - Benjamin Lo
- Montreal Neurological Institute, Quebec, Canada (B.L.)
| | - Jaime Masjuan
- Hospital Universitario Ramón y Cajal, Madrid, Spain (J.M.)
| | | | | | | | - Tong Zhu
- Pfizer Inc, Cambridge, MA (M.C., F.Y., T.Z., S.A.)
| | - Gang Li
- Pfizer Inc, Collegeville, PA (G.L.)
| | - Steven Arkin
- Pfizer Inc, Cambridge, MA (M.C., F.Y., T.Z., S.A.)
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31
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Li Z, You M, Long C, Bi R, Xu H, He Q, Hu B. Hematoma Expansion in Intracerebral Hemorrhage: An Update on Prediction and Treatment. Front Neurol 2020; 11:702. [PMID: 32765408 PMCID: PMC7380105 DOI: 10.3389/fneur.2020.00702] [Citation(s) in RCA: 45] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2020] [Accepted: 06/09/2020] [Indexed: 12/15/2022] Open
Abstract
Intracerebral hemorrhage (ICH) is the most lethal type of stroke, but there is no specific treatment. After years of effort, neurologists have found that hematoma expansion (HE) is a vital predictor of poor prognosis in ICH patients, with a not uncommon incidence ranging widely from 13 to 38%. Herein, the progress of studies on HE after ICH in recent years is updated, and the topics of definition, prevalence, risk factors, prediction score models, mechanisms, treatment, and prospects of HE are covered in this review. The risk factors and prediction score models, including clinical, imaging, and laboratory characteristics, are elaborated in detail, but limited by sensitivity, specificity, and inconvenience to clinical practice. The management of HE is also discussed from bench work to bed practice. However, the upmost problem at present is that there is no treatment for HE proven to definitely improve clinical outcomes. Further studies are needed to identify more accurate predictors and effective treatment to reduce HE.
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Affiliation(s)
- Zhifang Li
- Department of Neurology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Mingfeng You
- Department of Neurology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Chunnan Long
- Department of Neurology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Rentang Bi
- Department of Neurology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Haoqiang Xu
- Department of Neurology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Quanwei He
- Department of Neurology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Bo Hu
- Department of Neurology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
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Li Q, Warren AD, Qureshi AI, Morotti A, Falcone GJ, Sheth KN, Shoamanesh A, Dowlatshahi D, Viswanathan A, Goldstein JN. Ultra-Early Blood Pressure Reduction Attenuates Hematoma Growth and Improves Outcome in Intracerebral Hemorrhage. Ann Neurol 2020; 88:388-395. [PMID: 32453453 DOI: 10.1002/ana.25793] [Citation(s) in RCA: 81] [Impact Index Per Article: 20.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/29/2020] [Revised: 05/13/2020] [Accepted: 05/17/2020] [Indexed: 11/06/2022]
Abstract
OBJECTIVE The aim was to investigate whether intensive blood pressure treatment is associated with less hematoma growth and better outcome in intracerebral hemorrhage (ICH) patients who received intravenous nicardipine treatment ≤2 hours after onset of symptoms. METHODS A post-hoc exploratory analysis of the Antihypertensive Treatment of Acute Cerebral Hemorrhage 2 (ATACH-2) trial was performed. This was a multicenter, international, open-label, randomized clinical trial, in which patients with primary ICH were allocated to intensive versus standard blood pressure treatment with nicardipine ≤4.5 hours after onset of symptoms. We have included 913 patients with complete imaging and follow-up data in the present analysis. RESULTS Among the 913 included patients, 354 (38.7%) had intravenous nicardipine treatment initiated within 2 hours. In this subgroup of patients treated within 2 hours, the frequency of ICH expansion was significantly lower in the intensive blood pressure reduction group compared with the standard treatment group (p = 0.02). Multivariable analysis showed that ultra-early intensive blood pressure treatment was associated with a decreased risk of hematoma growth (odds ratio, 0.56; 95% confidence interval [CI], 0.34-0.92; p = 0.02), higher rate of functional independence (odds ratio, 2.17; 95% CI, 1.28-3.68; p = 0.004), and good outcome (odds ratio, 1.68; 95% CI, 1.01-2.83; p = 0.048) at 90 days. Ultra-early intensive blood pressure reduction was associated with a favorable shift in modified Rankin Scale score distribution at 3 months (p = 0.04). INTERPRETATION In a subgroup of ICH patients with elevated blood pressure given intravenous nicardipine ≤2 hours after onset of symptoms, intensive blood pressure reduction was associated with reduced hematoma growth and improved functional outcome. ANN NEUROL 2020;88:388-395.
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Affiliation(s)
- Qi Li
- Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA.,Department of Neurology, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Andrew D Warren
- Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | | | - Andrea Morotti
- Department of Neurology and Neurorehabilitation, IRCCS Mondino Foundation, Pavia, Italy
| | - Guido J Falcone
- Department of Neurology, Yale School of Medicine, New Haven, CT, USA
| | - Kevin N Sheth
- Department of Neurology, Yale School of Medicine, New Haven, CT, USA
| | - Ashkan Shoamanesh
- Division of Neurology, McMaster University/Population Health Research Institute, Hamilton, Ontario, Canada
| | - Dar Dowlatshahi
- Department of Medicine (Neurology), Ottawa Hospital Research Institute, University of Ottawa, Ottawa, Ontario, Canada
| | - Anand Viswanathan
- Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Joshua N Goldstein
- Division of Neurocritical Care and Emergency Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
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Qureshi AI, Foster LD, Lobanova I, Huang W, Suarez JI. Intensive Blood Pressure Lowering in Patients with Moderate to Severe Grade Acute Cerebral Hemorrhage: Post Hoc Analysis of Antihypertensive Treatment of Acute Cerebral Hemorrhage (ATACH)-2 Trial. Cerebrovasc Dis 2020; 49:244-252. [PMID: 32585668 DOI: 10.1159/000506358] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2019] [Accepted: 02/04/2020] [Indexed: 11/19/2022] Open
Abstract
OBJECTIVE To study the effect of intensive blood pressure reduction in patients with moderate to severe intracerebral hemorrhage (ICH) within the subjects recruited in Antihypertensive Treatment of Acute Cerebral Hemorrhage 2 trial. DESIGN Randomized, multicenter, 2 group, open-label clinical trial. SETTING A total of 110 sites in the USA, Japan, China, Taiwan, South Korea, and Germany. PATIENTS A total of 1,000 patients underwent randomization from May 2011 till September 2015. INTERVENTIONS We analyzed the effect of intensive (goal 110-139 mm Hg) over standard (goal 140-179 mm Hg) systolic blood pressure (SBP) reduction using intravenous nicardipine within 4.5 h of symptom onset in moderate to severe grade subjects with ICH in a non-prespecified analysis. Moderate to severe grade was defined by Glasgow Coma Scale score <13 or baseline National Institutes of Health Stroke Scale score ≥10 or baseline intraparenchymal hemorrhage volume ≥30 mL or presence of intraventricular hemorrhage. The primary outcome was death or disability (score 4-6 on the modified Rankin scale) at 3 months after randomization ascertained by a blinded investigator. MEASUREMENTS AND MAIN RESULTS Of a total of 682 subjects who met the definition of moderate to severe grade (mean age 61.9 ± 13.1 years, 62.5% men) with a mean baseline SBP of 174.7 ± 24.8 mm Hg, the frequency of hematoma expansion was significantly lower among subjects randomized to intensive SBP reduction than among subjects randomized to standard SBP reduction (20.4 vs. 27.9%, relative risk [RR]: 0.7; 95% confidence interval [CI]: 0.55-0.96). The primary endpoint of death or disability was observed in 52.5% (170/324) of subjects receiving intensive SBP reduction and 48.9% (163/333) of subjects receiving standard SBP reduction (RR: 1.1; 95% CI: 0.9-1.2). CONCLUSIONS Intensive SBP lowering reduced the frequency of hematoma expansion but did not reduce the rate of death or disability in patients with moderate to severe grade ICH.
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Affiliation(s)
- Adnan I Qureshi
- Zeenet Qureshi Stroke Institute and Department of Neurology, University of Missouri, Columbia, Missouri, USA,
| | - Lydia D Foster
- Division of Biostatistics and Epidemiology, Department of Public Health Sciences, College of Medicine, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Iryna Lobanova
- Zeenet Qureshi Stroke Institute and Department of Neurology, University of Missouri, Columbia, Missouri, USA
| | - Wei Huang
- Zeenet Qureshi Stroke Institute and Department of Neurology, University of Missouri, Columbia, Missouri, USA
| | - Jose I Suarez
- Neurosciences Critical Care, Departments of Anesthesiology and Critical Care Medicine, Neurology, and Neurosurgery, Johns Hopkins University School of Medicine Baltimore, Baltimore, Maryland, USA
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From One-Size-Fits-All to Mechanism-Guided Treatment for Intracranial Hemorrhage. Crit Care Med 2020; 47:1815-1816. [PMID: 31738253 DOI: 10.1097/ccm.0000000000004055] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Hvas CL, Lauridsen SV, Pedersen ES, Gyldenholm T, Hvas AM. Ex vivo effect of hemostatic therapy in subarachnoid and intracerebral hemorrhage. Thromb Res 2020; 189:42-47. [DOI: 10.1016/j.thromres.2020.02.012] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2019] [Revised: 01/25/2020] [Accepted: 02/14/2020] [Indexed: 11/30/2022]
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Association between Serum Lipid and Hematoma Expansion after Spontaneous Intracerebral Hemorrhage in Chinese Patients. J Stroke Cerebrovasc Dis 2020; 29:104793. [PMID: 32224203 DOI: 10.1016/j.jstrokecerebrovasdis.2020.104793] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2020] [Revised: 02/22/2020] [Accepted: 02/26/2020] [Indexed: 01/05/2023] Open
Abstract
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.
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Leasure AC, Qureshi AI, Murthy SB, Kamel H, Goldstein JN, Woo D, Ziai WC, Hanley DF, Al-Shahi Salman R, Matouk CC, Sansing LH, Sheth KN, Falcone GJ. Association of Intensive Blood Pressure Reduction With Risk of Hematoma Expansion in Patients With Deep Intracerebral Hemorrhage. JAMA Neurol 2019; 76:949-955. [PMID: 31081862 DOI: 10.1001/jamaneurol.2019.1141] [Citation(s) in RCA: 38] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Importance Hypertension is the strongest risk factor for spontaneous intracerebral hemorrhage (ICH) involving deep brain regions, but it appears to be unknown if intensive blood pressure reduction in the acute care setting decreases hematoma expansion or improves outcomes in patients with deep ICH. Objective To determine whether intensive blood pressure reduction is associated with decreased risk of hematoma expansion and changes in 90-day modified Rankin Scale scores and if these associations are modified by the specific deep-brain nuclei involved. Design, Setting, and Participants This study is an exploratory analysis of the Antihypertensive Treatment of Acute Cerebral Hemorrhage-2 international, multicenter randomized clinical trial, which was conducted from May 2011 to September 2015, enrolled eligible patients with primary ICH, and followed up with them for 90 days. Patients who had ICH and complete neuroimaging data were included in the analysis. Data analysis was completed from July 2018 to December 2018. Exposures Participants were randomized to either intensive treatment (with a systolic blood pressure target of 110-139 mm Hg) or standard treatment (with a systolic blood pressure target of 140-179 mm Hg). Main Outcomes and Measures The main outcome was hematoma expansion, defined as an increase greater than 33% in hematoma volume between baseline and 24 hours. Functional outcome was evaluated 90 days after the ICH via the modified Rankin Scale. Results Of 1000 trial participants, 870 (87.0%) had deep ICH, of whom 780 (89.7%) had complete neuroimaging data (of 336 thalamic and 444 basal ganglia hemorrhages). The baseline characteristics of the intensive and standard treatment groups remained balanced in this subgroup of the original study. Intensive treatment was associated with a decreased risk of hematoma expansion in univariable analysis (odds ratio [OR], 0.62 [95% CI, 0.43-0.87]; P = .006) and multivariable analysis (OR, 0.61 [95% CI, 0.42-0.88]; P = .009). This association was modified by the specific deep location of the ICH (OR, 0.44 [95% CI, 0.22-0.96]; interaction P = .02), with stratified analyses showing a reduction in risk of hematoma expansion with intensive vs standard treatment among basal ganglia ICH (OR, 0.44 [95% CI, 0.27-0.72]; P = .001) but not thalamic ICH (OR, 0.91 [95% CI, 0.51-0.64]; P = .76). Intensive treatment was not associated with an improvement in the modified Rankin Scale score distribution. Conclusions and Relevance Compared with standard treatment, intensive blood pressure treatment was associated with reduced hematoma expansion in deep ICH, specifically among basal ganglia hemorrhages.
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Affiliation(s)
- Audrey C Leasure
- Department of Neurology, Yale School of Medicine, New Haven, Connecticut
| | | | - Santosh B Murthy
- Department of Neurology, Weill Cornell Medicine, New York, New York
| | - Hooman Kamel
- Department of Neurology, Weill Cornell Medicine, New York, New York
| | - Joshua N Goldstein
- Department of Emergency Medicine, Massachusetts General Hospital, Harvard Medical School, Boston
| | - Daniel Woo
- Department of Neurology and Rehabilitation Medicine, University of Cincinnati, Cincinnati, Ohio
| | - Wendy C Ziai
- Department of Neurology, Johns Hopkins University, Baltimore, Maryland
| | - Daniel F Hanley
- Department of Neurology, Johns Hopkins University, Baltimore, Maryland
| | | | - Charles C Matouk
- Department of Neurosurgery, Yale School of Medicine, New Haven, Connecticut
| | - Lauren H Sansing
- Department of Neurology, Yale School of Medicine, New Haven, Connecticut
| | - Kevin N Sheth
- Department of Neurology, Yale School of Medicine, New Haven, Connecticut
| | - Guido J Falcone
- Department of Neurology, Yale School of Medicine, New Haven, Connecticut
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He Q, Zhou Y, Wang F, Li B, Cheng Y, Xie ZY. Blood Type O Predicts Hematoma Expansion in Patients with Intracerebral Hemorrhage. J Stroke Cerebrovasc Dis 2019; 28:2311-2317. [PMID: 31171459 DOI: 10.1016/j.jstrokecerebrovasdis.2019.05.022] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2019] [Revised: 04/12/2019] [Accepted: 05/21/2019] [Indexed: 11/30/2022] Open
Abstract
BACKGROUND Hematoma expansion after acute spontaneous intracerebral hemorrhage (ICH) is well established to result in poor prognosis. Recent studies have demonstrated that the ABO blood type system has potential implications on hemostatic properties. The purpose of this study was to explore the potential association of blood type O with hematoma expansion in patients with ICH and validate the usefulness in predicting early hematoma expansion. METHODS We retrospectively enrolled consecutive patients with ICH who underwent baseline computed tomographic (CT) scan within 6 hours after onset of symptoms. The follow-up CT scan was available within 48 hours after the baseline CT scan. Hematoma expansion was defined as total volume increase more than 33% or more than 6 mL. We performed univariate and multivariate logistic regression analyses to investigate the relationship between the different types of blood (type O versus other types) and hematoma expansion. RESULTS A total of 210 patients were included in the study. Among them, 72 patients (34.3%) carried blood type O. Hematoma expansion was more common in patients with blood type O (41.7%) than those with other blood types (18.1%; P < .001). Furthermore, the time to baseline CT scan, blood type O, and admission Glasgow Coma Scale score were demonstrated to be independent predictors of hematoma expansion in multivariate logistic regression analysis model. The sensitivity, specificity, positive, and negative predictive values of blood type O for predicting hematoma expansion were 54.5%, 72.9%, 41.6%, and 81.9%, respectively. CONCLUSIONS Our findings suggest that blood type O represents an independent predictor of hematoma expansion after ICH. Hemostasis seems to be involved in expansion and may represent an important treatment target.
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Affiliation(s)
- Qiuguang He
- Department of Neurosurgery, the Second Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - You Zhou
- Department of Critical Care Medicine, the Second Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Feng Wang
- Department of Neurosurgery, the Second Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Bin Li
- Department of Radiology, the Second Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Yuan Cheng
- Department of Neurosurgery, the Second Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Zong-Yi Xie
- Department of Neurosurgery, the Second Affiliated Hospital of Chongqing Medical University, Chongqing, China.
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Reyes R, Viswanathan M, Aiyagari V. An update on neurocritical care for intracerebral hemorrhage. Expert Rev Neurother 2019; 19:557-578. [PMID: 31092052 DOI: 10.1080/14737175.2019.1618709] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Introduction: Intracerebral hemorrhage remains one of the leading causes of death and disability worldwide with few established interventions that improve neurologic outcome. Research dedicated to better understanding and treating hemorrhagic strokes has multiplied in the past decade. Areas Covered: This review aims to discuss the current landscape of management of intracerebral hemorrhage in a critical care setting and provide updates regarding developments in therapeutic interventions and targets. PubMed was utilized to review recent literature, with a focus on large trials and meta-analyses, which have shaped current practice. Published committee guidelines were also included. A focus was placed on research published after 2015 in an effort to supplement previous reviews included in this publication. Expert Opinion: Literature pertaining to ICH management has allowed for a greater understanding of ineffective strategies as opposed to those of benefit. Despite this, mortality has improved worldwide, which may be the result of growing research efforts. Areas of future research that will impact mortality and improve neurologic outcomes include prevention of hematoma expansion, optimization of blood pressure targets, effective coagulopathy reversal, and minimally invasive surgical techniques to reduce hematoma burden.
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Affiliation(s)
- Ranier Reyes
- a Neurological Surgery & Neurology and Neurotherapeutics , The University of Texas Southwestern Medical Center , Dallas , TX , USA
| | - Meera Viswanathan
- a Neurological Surgery & Neurology and Neurotherapeutics , The University of Texas Southwestern Medical Center , Dallas , TX , USA
| | - Venkatesh Aiyagari
- a Neurological Surgery & Neurology and Neurotherapeutics , The University of Texas Southwestern Medical Center , Dallas , TX , USA
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Tan CO, Lam S, Kuppens D, Bergmans RHJ, Parameswaran BK, Forghani R, Hu R, Daftari Besheli L, Goldstein JN, Thrall J, Lev M, Romero JM, Gupta R. Spot and Diffuse Signs: Quantitative Markers of Intracranial Hematoma Expansion at Dual-Energy CT. Radiology 2018; 290:179-186. [PMID: 30375929 DOI: 10.1148/radiol.2018180322] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Purpose To compare dual-energy CT with iodine quantification to single-energy CT for evaluation of the spot sign for intracranial hematoma expansion. Materials and Methods In this retrospective study, 42 patients (mean age, 66 years ± 15 [standard deviation]; 19 women) were referred for dual-energy CT assessment of intracranial hemorrhage from October 2014 to January 2017. A machine learning approach (naive Bayes classifier) was used to identify iodine markers of extravasation for risk of hematoma expansion. Specificity and sensitivity of these markers were then independently validated in 65 new patients from February 2017 to February 2018. Results Analysis of dual-energy CT images identified two features of iodine extravasation: total iodine concentration within the hematoma (Ih) and focal iodine concentration in the brightest spot in the hematoma (Ibs) as predictors of expansion. The I2 score derived from these features provided a measure of expansion probability. Optimal classification threshold was an I2 score of 20 (95% confidence interval [CI]: 18, 23), leading to correct identification of 39 of 46 (85%; 95% CI: 71%, 94%) of the hematomas on the training set (sensitivity of 79% [11 of 14; 95% CI: 57%, 100%] and specificity of 88% [28 of 32; 95% CI: 76%, 99%]), and 62 of 70 (89%; 95% CI: 79%, 95%) of the hematomas on the validation set (sensitivity of 71% [10 of 14; 95% CI: 48%, 95%] and specificity of 93% [52 of 56; 95% CI: 86%, 100%]). Sensitivity, specificity, and accuracy of conventional spot sign were, respectively, 57% (eight of 14), 90% (29 of 32), and 80% (37 of 46) on the training set and 57% (eight of 14), 83% (47 of 56), and 75% (53 of 70) on the validation set. Conclusion This study identified two quantitative markers of intracranial hemorrhage expansion at dual-energy CT of the brain. The I2 score derived from these markers highlights the utility of dual-energy CT measurements of iodine content for high sensitivity risk assessment. © RSNA, 2018 Online supplemental material is available for this article.
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Affiliation(s)
- Can Ozan Tan
- From the Cerebrovascular Research Laboratory, Spaulding Rehabilitation Hospital, 1575 Cambridge St, Boston, MA 02138 (C.O.T.); Departments of Radiology (C.O.T., S.L., D.K., R.H.J.B., L.D.B., J.T., M.L., J.M.R., R.G.) and Emergency Medicine (J.N.G.), Massachusetts General Hospital, Boston, Mass; Departments of Physical Medicine and Rehabilitation (C.O.T.), Radiology (S.L., L.D.B., J.T., M.L., J.M.R., R.G.), and Emergency Medicine (J.N.G.), Harvard Medical School, Boston, Mass; Department of Technical Medicine, University of Twente, Enschede, the Netherlands (D.K., R.H.J.B.); Imaging Associates, Box Hill, Victoria, Australia (B.K.P.); Department of Radiology, Jewish General Hospital and McGill University, Montreal, Canada (R.F.); and Department of Radiology and Imaging Sciences, Emory University, Atlanta, Ga (R.H.)
| | - Stephanie Lam
- From the Cerebrovascular Research Laboratory, Spaulding Rehabilitation Hospital, 1575 Cambridge St, Boston, MA 02138 (C.O.T.); Departments of Radiology (C.O.T., S.L., D.K., R.H.J.B., L.D.B., J.T., M.L., J.M.R., R.G.) and Emergency Medicine (J.N.G.), Massachusetts General Hospital, Boston, Mass; Departments of Physical Medicine and Rehabilitation (C.O.T.), Radiology (S.L., L.D.B., J.T., M.L., J.M.R., R.G.), and Emergency Medicine (J.N.G.), Harvard Medical School, Boston, Mass; Department of Technical Medicine, University of Twente, Enschede, the Netherlands (D.K., R.H.J.B.); Imaging Associates, Box Hill, Victoria, Australia (B.K.P.); Department of Radiology, Jewish General Hospital and McGill University, Montreal, Canada (R.F.); and Department of Radiology and Imaging Sciences, Emory University, Atlanta, Ga (R.H.)
| | - Daan Kuppens
- From the Cerebrovascular Research Laboratory, Spaulding Rehabilitation Hospital, 1575 Cambridge St, Boston, MA 02138 (C.O.T.); Departments of Radiology (C.O.T., S.L., D.K., R.H.J.B., L.D.B., J.T., M.L., J.M.R., R.G.) and Emergency Medicine (J.N.G.), Massachusetts General Hospital, Boston, Mass; Departments of Physical Medicine and Rehabilitation (C.O.T.), Radiology (S.L., L.D.B., J.T., M.L., J.M.R., R.G.), and Emergency Medicine (J.N.G.), Harvard Medical School, Boston, Mass; Department of Technical Medicine, University of Twente, Enschede, the Netherlands (D.K., R.H.J.B.); Imaging Associates, Box Hill, Victoria, Australia (B.K.P.); Department of Radiology, Jewish General Hospital and McGill University, Montreal, Canada (R.F.); and Department of Radiology and Imaging Sciences, Emory University, Atlanta, Ga (R.H.)
| | - Rick H J Bergmans
- From the Cerebrovascular Research Laboratory, Spaulding Rehabilitation Hospital, 1575 Cambridge St, Boston, MA 02138 (C.O.T.); Departments of Radiology (C.O.T., S.L., D.K., R.H.J.B., L.D.B., J.T., M.L., J.M.R., R.G.) and Emergency Medicine (J.N.G.), Massachusetts General Hospital, Boston, Mass; Departments of Physical Medicine and Rehabilitation (C.O.T.), Radiology (S.L., L.D.B., J.T., M.L., J.M.R., R.G.), and Emergency Medicine (J.N.G.), Harvard Medical School, Boston, Mass; Department of Technical Medicine, University of Twente, Enschede, the Netherlands (D.K., R.H.J.B.); Imaging Associates, Box Hill, Victoria, Australia (B.K.P.); Department of Radiology, Jewish General Hospital and McGill University, Montreal, Canada (R.F.); and Department of Radiology and Imaging Sciences, Emory University, Atlanta, Ga (R.H.)
| | - Bimal Kumar Parameswaran
- From the Cerebrovascular Research Laboratory, Spaulding Rehabilitation Hospital, 1575 Cambridge St, Boston, MA 02138 (C.O.T.); Departments of Radiology (C.O.T., S.L., D.K., R.H.J.B., L.D.B., J.T., M.L., J.M.R., R.G.) and Emergency Medicine (J.N.G.), Massachusetts General Hospital, Boston, Mass; Departments of Physical Medicine and Rehabilitation (C.O.T.), Radiology (S.L., L.D.B., J.T., M.L., J.M.R., R.G.), and Emergency Medicine (J.N.G.), Harvard Medical School, Boston, Mass; Department of Technical Medicine, University of Twente, Enschede, the Netherlands (D.K., R.H.J.B.); Imaging Associates, Box Hill, Victoria, Australia (B.K.P.); Department of Radiology, Jewish General Hospital and McGill University, Montreal, Canada (R.F.); and Department of Radiology and Imaging Sciences, Emory University, Atlanta, Ga (R.H.)
| | - Reza Forghani
- From the Cerebrovascular Research Laboratory, Spaulding Rehabilitation Hospital, 1575 Cambridge St, Boston, MA 02138 (C.O.T.); Departments of Radiology (C.O.T., S.L., D.K., R.H.J.B., L.D.B., J.T., M.L., J.M.R., R.G.) and Emergency Medicine (J.N.G.), Massachusetts General Hospital, Boston, Mass; Departments of Physical Medicine and Rehabilitation (C.O.T.), Radiology (S.L., L.D.B., J.T., M.L., J.M.R., R.G.), and Emergency Medicine (J.N.G.), Harvard Medical School, Boston, Mass; Department of Technical Medicine, University of Twente, Enschede, the Netherlands (D.K., R.H.J.B.); Imaging Associates, Box Hill, Victoria, Australia (B.K.P.); Department of Radiology, Jewish General Hospital and McGill University, Montreal, Canada (R.F.); and Department of Radiology and Imaging Sciences, Emory University, Atlanta, Ga (R.H.)
| | - Ranliang Hu
- From the Cerebrovascular Research Laboratory, Spaulding Rehabilitation Hospital, 1575 Cambridge St, Boston, MA 02138 (C.O.T.); Departments of Radiology (C.O.T., S.L., D.K., R.H.J.B., L.D.B., J.T., M.L., J.M.R., R.G.) and Emergency Medicine (J.N.G.), Massachusetts General Hospital, Boston, Mass; Departments of Physical Medicine and Rehabilitation (C.O.T.), Radiology (S.L., L.D.B., J.T., M.L., J.M.R., R.G.), and Emergency Medicine (J.N.G.), Harvard Medical School, Boston, Mass; Department of Technical Medicine, University of Twente, Enschede, the Netherlands (D.K., R.H.J.B.); Imaging Associates, Box Hill, Victoria, Australia (B.K.P.); Department of Radiology, Jewish General Hospital and McGill University, Montreal, Canada (R.F.); and Department of Radiology and Imaging Sciences, Emory University, Atlanta, Ga (R.H.)
| | - Laleh Daftari Besheli
- From the Cerebrovascular Research Laboratory, Spaulding Rehabilitation Hospital, 1575 Cambridge St, Boston, MA 02138 (C.O.T.); Departments of Radiology (C.O.T., S.L., D.K., R.H.J.B., L.D.B., J.T., M.L., J.M.R., R.G.) and Emergency Medicine (J.N.G.), Massachusetts General Hospital, Boston, Mass; Departments of Physical Medicine and Rehabilitation (C.O.T.), Radiology (S.L., L.D.B., J.T., M.L., J.M.R., R.G.), and Emergency Medicine (J.N.G.), Harvard Medical School, Boston, Mass; Department of Technical Medicine, University of Twente, Enschede, the Netherlands (D.K., R.H.J.B.); Imaging Associates, Box Hill, Victoria, Australia (B.K.P.); Department of Radiology, Jewish General Hospital and McGill University, Montreal, Canada (R.F.); and Department of Radiology and Imaging Sciences, Emory University, Atlanta, Ga (R.H.)
| | - Joshua N Goldstein
- From the Cerebrovascular Research Laboratory, Spaulding Rehabilitation Hospital, 1575 Cambridge St, Boston, MA 02138 (C.O.T.); Departments of Radiology (C.O.T., S.L., D.K., R.H.J.B., L.D.B., J.T., M.L., J.M.R., R.G.) and Emergency Medicine (J.N.G.), Massachusetts General Hospital, Boston, Mass; Departments of Physical Medicine and Rehabilitation (C.O.T.), Radiology (S.L., L.D.B., J.T., M.L., J.M.R., R.G.), and Emergency Medicine (J.N.G.), Harvard Medical School, Boston, Mass; Department of Technical Medicine, University of Twente, Enschede, the Netherlands (D.K., R.H.J.B.); Imaging Associates, Box Hill, Victoria, Australia (B.K.P.); Department of Radiology, Jewish General Hospital and McGill University, Montreal, Canada (R.F.); and Department of Radiology and Imaging Sciences, Emory University, Atlanta, Ga (R.H.)
| | - James Thrall
- From the Cerebrovascular Research Laboratory, Spaulding Rehabilitation Hospital, 1575 Cambridge St, Boston, MA 02138 (C.O.T.); Departments of Radiology (C.O.T., S.L., D.K., R.H.J.B., L.D.B., J.T., M.L., J.M.R., R.G.) and Emergency Medicine (J.N.G.), Massachusetts General Hospital, Boston, Mass; Departments of Physical Medicine and Rehabilitation (C.O.T.), Radiology (S.L., L.D.B., J.T., M.L., J.M.R., R.G.), and Emergency Medicine (J.N.G.), Harvard Medical School, Boston, Mass; Department of Technical Medicine, University of Twente, Enschede, the Netherlands (D.K., R.H.J.B.); Imaging Associates, Box Hill, Victoria, Australia (B.K.P.); Department of Radiology, Jewish General Hospital and McGill University, Montreal, Canada (R.F.); and Department of Radiology and Imaging Sciences, Emory University, Atlanta, Ga (R.H.)
| | - Michael Lev
- From the Cerebrovascular Research Laboratory, Spaulding Rehabilitation Hospital, 1575 Cambridge St, Boston, MA 02138 (C.O.T.); Departments of Radiology (C.O.T., S.L., D.K., R.H.J.B., L.D.B., J.T., M.L., J.M.R., R.G.) and Emergency Medicine (J.N.G.), Massachusetts General Hospital, Boston, Mass; Departments of Physical Medicine and Rehabilitation (C.O.T.), Radiology (S.L., L.D.B., J.T., M.L., J.M.R., R.G.), and Emergency Medicine (J.N.G.), Harvard Medical School, Boston, Mass; Department of Technical Medicine, University of Twente, Enschede, the Netherlands (D.K., R.H.J.B.); Imaging Associates, Box Hill, Victoria, Australia (B.K.P.); Department of Radiology, Jewish General Hospital and McGill University, Montreal, Canada (R.F.); and Department of Radiology and Imaging Sciences, Emory University, Atlanta, Ga (R.H.)
| | - Javier M Romero
- From the Cerebrovascular Research Laboratory, Spaulding Rehabilitation Hospital, 1575 Cambridge St, Boston, MA 02138 (C.O.T.); Departments of Radiology (C.O.T., S.L., D.K., R.H.J.B., L.D.B., J.T., M.L., J.M.R., R.G.) and Emergency Medicine (J.N.G.), Massachusetts General Hospital, Boston, Mass; Departments of Physical Medicine and Rehabilitation (C.O.T.), Radiology (S.L., L.D.B., J.T., M.L., J.M.R., R.G.), and Emergency Medicine (J.N.G.), Harvard Medical School, Boston, Mass; Department of Technical Medicine, University of Twente, Enschede, the Netherlands (D.K., R.H.J.B.); Imaging Associates, Box Hill, Victoria, Australia (B.K.P.); Department of Radiology, Jewish General Hospital and McGill University, Montreal, Canada (R.F.); and Department of Radiology and Imaging Sciences, Emory University, Atlanta, Ga (R.H.)
| | - Rajiv Gupta
- From the Cerebrovascular Research Laboratory, Spaulding Rehabilitation Hospital, 1575 Cambridge St, Boston, MA 02138 (C.O.T.); Departments of Radiology (C.O.T., S.L., D.K., R.H.J.B., L.D.B., J.T., M.L., J.M.R., R.G.) and Emergency Medicine (J.N.G.), Massachusetts General Hospital, Boston, Mass; Departments of Physical Medicine and Rehabilitation (C.O.T.), Radiology (S.L., L.D.B., J.T., M.L., J.M.R., R.G.), and Emergency Medicine (J.N.G.), Harvard Medical School, Boston, Mass; Department of Technical Medicine, University of Twente, Enschede, the Netherlands (D.K., R.H.J.B.); Imaging Associates, Box Hill, Victoria, Australia (B.K.P.); Department of Radiology, Jewish General Hospital and McGill University, Montreal, Canada (R.F.); and Department of Radiology and Imaging Sciences, Emory University, Atlanta, Ga (R.H.)
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Cordonnier C, Demchuk A, Ziai W, Anderson CS. Intracerebral haemorrhage: current approaches to acute management. Lancet 2018; 392:1257-1268. [PMID: 30319113 DOI: 10.1016/s0140-6736(18)31878-6] [Citation(s) in RCA: 385] [Impact Index Per Article: 64.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/26/2018] [Revised: 08/04/2018] [Accepted: 08/07/2018] [Indexed: 12/14/2022]
Abstract
Acute spontaneous intracerebral haemorrhage is a life-threatening illness of global importance, with a poor prognosis and few proven treatments. As a heterogeneous disease, certain clinical and imaging features help identify the cause, prognosis, and how to manage the disease. Survival and recovery from intracerebral haemorrhage are related to the site, mass effect, and intracranial pressure from the underlying haematoma, and by subsequent cerebral oedema from perihaematomal neurotoxicity or inflammation and complications from prolonged neurological dysfunction. A moderate level of evidence supports there being beneficial effects of active management goals with avoidance of early palliative care orders, well-coordinated specialist stroke unit care, targeted neurointensive and surgical interventions, early control of elevated blood pressure, and rapid reversal of abnormal coagulation.
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Affiliation(s)
- Charlotte Cordonnier
- University of Lille, Inserm U1171, Degenerative and Vascular Cognitive Disorders, Centre Hospitalier Universitaire Lille, Department of Neurology, Lille, France
| | - Andrew Demchuk
- Department of Clinical Neurosciences, University of Calgary, AB, Canada
| | - Wendy Ziai
- The Johns Hopkins University School of Medicine, Baltimore, MD, United States
| | - Craig S Anderson
- The George Institute for Global Health, University of New South Wales, Sydney, NSW, Australia; Neurology Department, Royal Prince Alfred Hospital, Sydney, NSW, Australia; The George Institute China at Peking University Health Science Center, Beijing, China.
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Qureshi AI, Qureshi MH. Acute hypertensive response in patients with intracerebral hemorrhage pathophysiology and treatment. J Cereb Blood Flow Metab 2018; 38:1551-1563. [PMID: 28812942 PMCID: PMC6125978 DOI: 10.1177/0271678x17725431] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
Acute hypertensive response is a common systemic response to occurrence of intracerebral hemorrhage which has gained unique prominence due to high prevalence and association with hematoma expansion and increased mortality. Presumably, the higher systemic blood pressure predisposes to continued intraparenchymal hemorrhage by transmission of higher pressure to the damaged small arteries and may interact with hemostatic and inflammatory pathways. Therefore, intensive reduction of systolic blood pressure has been evaluated in several clinical trials as a strategy to reduce hematoma expansion and subsequent death and disability. These trials have demonstrated either a small magnitude benefit (second intensive blood pressure reduction in acute cerebral hemorrhage trial and efficacy of nitric oxide in stroke trial) or no benefit (antihypertensive treatment of acute cerebral hemorrhage 2 trial) with intensive systolic blood pressure reduction compared with modest or standard blood pressure reduction. The differences may be explained by the variation in intensity of systolic blood pressure reduction between trials. A treatment threshold of systolic blood pressure of ≥180 mm with the target goal of systolic blood pressure reduction to values between 130 and 150 mm Hg within 6 h of symptom onset may be best supported by current evidence.
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Ovesen C, Jakobsen JC, Gluud C, Steiner T, Law Z, Flaherty K, Dineen RA, Bath PM, Sprigg N, Christensen H. Prevention of haematoma progression by tranexamic acid in intracerebral haemorrhage patients with and without spot sign on admission scan: a statistical analysis plan of a pre-specified sub-study of the TICH-2 trial. BMC Res Notes 2018; 11:379. [PMID: 29895329 PMCID: PMC5998558 DOI: 10.1186/s13104-018-3481-8] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2018] [Accepted: 06/05/2018] [Indexed: 12/12/2022] Open
Abstract
OBJECTIVE We present the statistical analysis plan of a prespecified Tranexamic Acid for Hyperacute Primary Intracerebral Haemorrhage (TICH)-2 sub-study aiming to investigate, if tranexamic acid has a different effect in intracerebral haemorrhage patients with the spot sign on admission compared to spot sign negative patients. The TICH-2 trial recruited above 2000 participants with intracerebral haemorrhage arriving in hospital within 8 h after symptom onset. They were included irrespective of radiological signs of on-going haematoma expansion. Participants were randomised to tranexamic acid versus matching placebo. In this subgroup analysis, we will include all participants in TICH-2 with a computed tomography angiography on admission allowing adjudication of the participants' spot sign status. RESULTS Primary outcome will be the ability of tranexamic acid to limit absolute haematoma volume on computed tomography at 24 h (± 12 h) after randomisation among spot sign positive and spot sign negative participants, respectively. Within all outcome measures, the effect of tranexamic acid in spot sign positive/negative participants will be compared using tests of interaction. This sub-study will investigate the important clinical hypothesis that spot sign positive patients might benefit more from administration of tranexamic acid compared to spot sign negative patients. Trial registration ISRCTN93732214 ( http://www.isrctn.com ).
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Affiliation(s)
- Christian Ovesen
- Department of Neurology, Bispebjerg Hospital, Copenhagen University Hospital, Bispebjerg bakke 23, 2400 Copenhagen, Denmark
- The Copenhagen Trial Unit, Centre for Clinical Intervention Research, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Janus Christian Jakobsen
- The Copenhagen Trial Unit, Centre for Clinical Intervention Research, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
- Department of Cardiology, Holbæk Hospital, Holbæk, Denmark
| | - Christian Gluud
- The Copenhagen Trial Unit, Centre for Clinical Intervention Research, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Thorsten Steiner
- Department of Neurology, Klinikum Frankfurt Höchst, Frankfurt, Germany
- Department of Neurology, Heidelberg University Hospital, Heidelberg, Germany
| | - Zhe Law
- Stroke Trials Unit, Division of Clinical Neuroscience, University of Nottingham, City Hospital Campus, Nottingham, NG5 1PB UK
- Department of Medicine, National University of Malaysia, 56000 Kuala Lumpur, Malaysia
| | - Katie Flaherty
- Stroke Trials Unit, Division of Clinical Neuroscience, University of Nottingham, City Hospital Campus, Nottingham, NG5 1PB UK
| | - Rob A. Dineen
- Radiological Sciences, Division of Clinical Neuroscience, Queen’s Medical Centre, University of Nottingham, Nottingham, NG7 2UH UK
- Sir Peter Mansfield Imaging Centre, University of Nottingham, Nottingham, NG7 2QX UK
- NIHR Nottingham Biomedical Research Centre, Nottingham, NG1 5DU UK
| | - Philip M. Bath
- Stroke Trials Unit, Division of Clinical Neuroscience, University of Nottingham, City Hospital Campus, Nottingham, NG5 1PB UK
| | - Nikola Sprigg
- Stroke Trials Unit, Division of Clinical Neuroscience, University of Nottingham, City Hospital Campus, Nottingham, NG5 1PB UK
| | - Hanne Christensen
- Department of Neurology, Bispebjerg Hospital, Copenhagen University Hospital, Bispebjerg bakke 23, 2400 Copenhagen, Denmark
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Zhang D, Chen J, Guo J, Jiang Y, Dong Y, Ping-Chi Chen B, Wang J, Hou L. Hematoma Heterogeneity on Noncontrast Computed Tomography Predicts Intracerebral Hematoma Expansion: A Meta-Analysis. World Neurosurg 2018; 114:e663-e676. [DOI: 10.1016/j.wneu.2018.03.048] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2018] [Revised: 03/04/2018] [Accepted: 03/06/2018] [Indexed: 10/17/2022]
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Lubnin AY. [The use of activated recombinant factor VII in neurosurgery]. ZHURNAL VOPROSY NEĬROKHIRURGII IMENI N. N. BURDENKO 2018; 82:112-119. [PMID: 29795095 DOI: 10.17116/oftalma2018822112-119] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Affiliation(s)
- A Yu Lubnin
- Burdenko Neurosurgical institute, 4-ya Tverskaya-Yamskaya str., 16, Moscow, Russia, 125047
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Affiliation(s)
- Joseph P Broderick
- Department of Neurology and Rehabilitation Medicine, University of Cincinnati Gardner Neuroscience Institute, University of Cincinnati, Cincinnati, OH 45219-0525, USA.
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Meta-Analysis of Predictive Significance of the Black Hole Sign for Hematoma Expansion in Intracerebral Hemorrhage. World Neurosurg 2018; 115:e711-e716. [PMID: 29709738 DOI: 10.1016/j.wneu.2018.04.140] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2018] [Revised: 04/18/2018] [Accepted: 04/19/2018] [Indexed: 02/05/2023]
Abstract
OBJECTIVE Hematoma expansion is related to unfavorable prognosis in intracerebral hemorrhage (ICH). The black hole sign is a novel marker on non-contrast computed tomography for predicting hematoma expansion. However, its predictive values are different in previous studies. Thus, this meta-analysis was conducted to evaluate the predictive significance of the black hole sign for hematoma expansion in ICH. METHODS A systematic literature search was performed. Original researches on the association between the black hole sign and hematoma expansion in ICH were included. Sensitivity and specificity were pooled to assess the predictive accuracy. Summary receiver operating characteristics curve (SROC) was developed. Deeks' funnel plot asymmetry test was used to assess the publication bias. RESULTS Five studies with a total of 1495 patients were included in this study. The pooled sensitivity and specificity of the black hole sign for predicting hematoma expansion were 0.30 and 0.91, respectively. The area under the curve was 0.78 in SROC curve. There was no significant publication bias. CONCLUSIONS This meta-analysis shows that the black hole sign is a helpful imaging marker for predicting hematoma expansion in ICH. Although the black hole sign has a relatively low sensitivity, its specificity is relatively high.
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Parry PV, Choi PA, Bauer JS, Panczykowski DM, Puccio AM, Okonkwo DO. Utility of the Aspirin and P2Y12 Response Assays to Determine the Effect of Antiplatelet Agents on Platelet Reactivity in Traumatic Brain Injury. Neurosurgery 2017; 80:92-96. [PMID: 28362884 DOI: 10.1227/neu.0000000000001406] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2015] [Accepted: 07/16/2016] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Premorbid antithrombotic medication may worsen intracranial injury and outcome after traumatic brain injury (TBI). Routine laboratory tests are insufficient to evaluate platelet activity. OBJECTIVE To profile the spectrum of platelet inhibition, as measured by aspirin and P2Y12 response unit assays, in a TBI population on antiplatelet therapy. METHODS This single-center, prospective cohort study included patients presenting to our institution between November 2010 and January 2015 with a clinical history of TBI. Serum platelet reactivity levels were determined immediately on admission and analyzed using the aspirin and P2Y12 response unit assays; test results were reported as aspirin response units and P2Y12 response units. We report congruence between assay results and clinical history as well as differences in assay results between types of antiplatelet therapy. RESULTS A sample of 317 patients was available for analysis, of which 87% had experienced mild TBI, 7% moderate, and 6% severe; the mean age was 71.5 years. The mean aspirin response units in patients with a history of any aspirin use was 456 ± 67 (range, 350-659), with 88% demonstrating therapeutic platelet inhibition. For clopidogrel, the mean P2Y12 response unit was 191 ± 70 (range, 51-351); 77% showed therapeutic response. CONCLUSION Rapid measurement of antiplatelet function using the aspirin and P2Y12 response assays indicated as many as one fourth of patients on antiplatelet therapy do not have platelet dysfunction. Further research is required to develop guidelines for the use of these assays to guide platelet transfusion in the setting of TBI.
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Affiliation(s)
- Phillip V Parry
- Department of Neurological Surgery, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Phillip A Choi
- University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Joshua S Bauer
- Department of Neurological Surgery, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - David M Panczykowski
- Department of Neurological Surgery, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Ava M Puccio
- Department of Neurological Surgery, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - David O Okonkwo
- Department of Neurological Surgery, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
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Abstract
PURPOSE OF REVIEW New therapies are needed to control bleeding in a range of clinical conditions. This review will discuss the biochemical properties of zymogen-like factor Xa, its preclinical assessment in different model systems, and future development prospects. RECENT FINDINGS Underlying many procoagulant therapeutic approaches is the rapid generation of thrombin to promote robust clot formation. Clinically tested prohemostatic agents (e.g., factor VIIa) can provide effective hemostasis to mitigate bleeding in hemophilia and other clinical situations. Over the past decade, we explored the possibility of using zymogen-like factor Xa variants to rapidly improve clot formation for the treatment of bleeding conditions. Compared to the wild-type enzyme, these variants adopt an altered, low activity, conformation which enables them to resist plasma protease inhibitors. However, zymogen-like factor Xa variants are conformationally dynamic and ligands such as its cofactor, factor Va, stabilize the molecule rescuing procoagulant activity. At the site of vascular injury, the variants in the presence of factor Va serve as effective prohemostatic agents. Preclinical data support their use to stop bleeding in a variety of clinical settings. Phase 1 studies suggest that zymogen-like factor Xa is safe and well tolerated, and a phase 1b is ongoing to assess safety in patients with intracerebral hemorrhage. SUMMARY Zymogen-like factor Xa is a unique prohemostatic agent for the treatment of a range of bleeding conditions.
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Affiliation(s)
- Nabil K Thalji
- Division of Hematology, Department of Pediatrics, The Raymond G. Perelman Center for Cellular and Molecular Therapeutics, The Children's Hospital of Philadelphia, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
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50
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Boulouis G, Morotti A, Brouwers HB, Charidimou A, Jessel MJ, Auriel E, Pontes-Neto O, Ayres A, Vashkevich A, Schwab KM, Rosand J, Viswanathan A, Gurol ME, Greenberg SM, Goldstein JN. Association Between Hypodensities Detected by Computed Tomography and Hematoma Expansion in Patients With Intracerebral Hemorrhage. JAMA Neurol 2017; 73:961-8. [PMID: 27323314 DOI: 10.1001/jamaneurol.2016.1218] [Citation(s) in RCA: 172] [Impact Index Per Article: 24.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
IMPORTANCE Hematoma expansion is a potentially modifiable predictor of poor outcome following an acute intracerebral hemorrhage (ICH). The ability to identify patients with ICH who are likeliest to experience hematoma expansion and therefore likeliest to benefit from expansion-targeted treatments remains an unmet need. Hypodensities within an ICH detected by noncontrast computed tomography (NCCT) have been suggested as a predictor of hematoma expansion. OBJECTIVE To determine whether hypodense regions, irrespective of their specific patterns, are associated with hematoma expansion in patients with ICH. DESIGN, SETTING, AND PARTICIPANTS We analyzed a large cohort of 784 patients with ICH (the development cohort; 55.6% female), examined NCCT findings for any hypodensity, and replicated our findings on a different cohort of patients (the replication cohort; 52.7% female). Baseline and follow-up NCCT data from consecutive patients with ICH presenting to a tertiary care hospital between 1994 and 2015 were retrospectively analyzed. Data analyses were performed between December 2015 and January 2016. MAIN OUTCOMES AND MEASURES Hypodensities were analyzed by 2 independent blinded raters. The association between hypodensities and hematoma expansion (>6 cm3 or 33% of baseline volume) was determined by multivariable logistic regression after controlling for other variables associated with hematoma expansion in univariate analyses with P ≤ .10. RESULTS A total of 1029 patients were included in the analysis. In the development and replication cohorts, 222 of 784 patients (28.3%) and 99 of 245 patients (40.4%; 321 of 1029 patients [31.2%]), respectively, had NCCT scans that demonstrated hypodensities at baseline (κ = 0.87 for interrater reliability). In univariate analyses, hypodensities were associated with hematoma expansion (86 of 163 patients with hematoma expansion had hypodensities [52.8%], whereas 136 of 621 patients without hematoma expansion had hypodensities [21.9%]; P < .001). The association between hypodensities and hematoma expansion remained significant (odds ratio, 3.42 [95% CI, 2.21-5.31]; P < .001) in a multivariable model; other independent predictors of hematoma expansion were a CT angiography spot sign, a shorter time to CT, warfarin use, and older age. The independent predictive value of hypodensities was again demonstrated in the replication cohort (odds ratio, 4.37 [95% CI, 2.05-9.62]; P < .001). CONCLUSION AND RELEVANCE Hypodensities within an acute ICH detected on an NCCT scan may predict hematoma expansion, independent of other clinical and imaging predictors. This novel marker may help clarify the mechanism of hematoma expansion and serve as a useful addition to clinical algorithms for determining the risk of and treatment stratification for hematoma expansion.
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Affiliation(s)
- Gregoire Boulouis
- Hemorrhagic Stroke Research Program, Department of Neurology, Massachusetts General Hospital Stroke Research Center, Harvard Medical School, Boston
| | - Andrea Morotti
- Hemorrhagic Stroke Research Program, Department of Neurology, Massachusetts General Hospital Stroke Research Center, Harvard Medical School, Boston
| | - H Bart Brouwers
- Hemorrhagic Stroke Research Program, Department of Neurology, Massachusetts General Hospital Stroke Research Center, Harvard Medical School, Boston2Department of Neurosurgery, Brain Center Rudolf Magnus, University Medical Center Utrecht, Utrecht Universi
| | - Andreas Charidimou
- Hemorrhagic Stroke Research Program, Department of Neurology, Massachusetts General Hospital Stroke Research Center, Harvard Medical School, Boston
| | - Michael J Jessel
- Hemorrhagic Stroke Research Program, Department of Neurology, Massachusetts General Hospital Stroke Research Center, Harvard Medical School, Boston
| | - Eitan Auriel
- Hemorrhagic Stroke Research Program, Department of Neurology, Massachusetts General Hospital Stroke Research Center, Harvard Medical School, Boston
| | - Octávio Pontes-Neto
- Hemorrhagic Stroke Research Program, Department of Neurology, Massachusetts General Hospital Stroke Research Center, Harvard Medical School, Boston
| | - Alison Ayres
- Hemorrhagic Stroke Research Program, Department of Neurology, Massachusetts General Hospital Stroke Research Center, Harvard Medical School, Boston
| | - Anastasia Vashkevich
- Hemorrhagic Stroke Research Program, Department of Neurology, Massachusetts General Hospital Stroke Research Center, Harvard Medical School, Boston
| | - Kristin M Schwab
- Hemorrhagic Stroke Research Program, Department of Neurology, Massachusetts General Hospital Stroke Research Center, Harvard Medical School, Boston
| | - Jonathan Rosand
- Hemorrhagic Stroke Research Program, Department of Neurology, Massachusetts General Hospital Stroke Research Center, Harvard Medical School, Boston3Division of Neurocritical Care and Emergency Neurology, Massachusetts General Hospital, Harvard Medical Sch
| | - Anand Viswanathan
- Hemorrhagic Stroke Research Program, Department of Neurology, Massachusetts General Hospital Stroke Research Center, Harvard Medical School, Boston
| | - Mahmut E Gurol
- Hemorrhagic Stroke Research Program, Department of Neurology, Massachusetts General Hospital Stroke Research Center, Harvard Medical School, Boston
| | - Steven M Greenberg
- Hemorrhagic Stroke Research Program, Department of Neurology, Massachusetts General Hospital Stroke Research Center, Harvard Medical School, Boston
| | - Joshua N Goldstein
- Hemorrhagic Stroke Research Program, Department of Neurology, Massachusetts General Hospital Stroke Research Center, Harvard Medical School, Boston3Division of Neurocritical Care and Emergency Neurology, Massachusetts General Hospital, Harvard Medical Sch
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