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Tseng WC, Wang YF, Chen HS, Wang TG, Hsiao MY. Spot sign score is associated with hematoma expansion and longer hospital stay but not functional outcomes in primary intracerebral hemorrhage survivors. Jpn J Radiol 2024; 42:1130-1137. [PMID: 38833105 DOI: 10.1007/s11604-024-01597-1] [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: 01/03/2024] [Accepted: 05/16/2024] [Indexed: 06/06/2024]
Abstract
PURPOSE The computed tomography angiography (CTA) spot sign is a validated predictor of 30-day mortality in intracerebral hemorrhage (ICH). However, its role in predicting unfavorable functional outcomes remains unclear. This study explores the frequency of the spot sign and its association with functional outcomes, hematoma expansion, and length of hospital stay among survivors of ICH. MATERIALS AND METHODS This was a retrospective analysis of consecutive patients with primary ICH who received CTA within 24 h of admission to two medical centers between January 2007 and August 2022. Patients who died before discharge and those referred from other hospitals were excluded. Spot signs were assessed by an experienced neuroradiologist. Functional outcomes were determined by modified Rankin Scale (mRS) scores and the Barthel Index (BI). RESULTS In total, 98 patients were included; 14 (13.64%) had a spot sign. No significant differences were observed in the baseline characteristics between the patients with and without a spot sign. Higher spot sign scores were associated with higher odds of experiencing hematoma expansion (p = 0.013, 95% CI = 1.16-3.55), undergoing surgery (p = 0.012, 95% CI = 0.19-1.55), and having longer hospital stay (p = 0.02, 95% CI = 1.22-13.92). However, higher spot sign scores were not associated with unfavorable functional outcomes (p = 0.918 for BI, and p = 0.782 for mRS). CONCLUSION Spot signs are common findings among patients with ICH, and higher spot sign scores were associated with subsequent hematoma expansion and longer hospital stays but not unfavorable functional outcomes.
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Affiliation(s)
- Wen-Che Tseng
- Department of Physical Medicine and Rehabilitation, Yunlin Rd, National Taiwan University Hospital Yunlin Branch, Yunlin County, Sec. 2, 579, Douliu City, Taiwan
| | - Yu-Fen Wang
- Department of Medical Imaging, National Taiwan University Hospital, 7, Zhongshan S. Rd, Taipei, Taiwan
| | - Hsin-Shui Chen
- Department of Physical Medicine and Rehabilitation, Yunlin Rd, National Taiwan University Hospital Yunlin Branch, Yunlin County, Sec. 2, 579, Douliu City, Taiwan
| | - Tyng-Guey Wang
- Department of Physical Medicine and Rehabilitation, National Taiwan University Hospital, 7, Zhongshan S. Rd, Taipei, Taiwan
- Department of Physical Medicine and Rehabilitation, College of Medicine, National Taiwan University, 7, Zhongshan S. Rd, Taipei, Taiwan
| | - Ming-Yen Hsiao
- Department of Physical Medicine and Rehabilitation, National Taiwan University Hospital, 7, Zhongshan S. Rd, Taipei, Taiwan.
- Department of Physical Medicine and Rehabilitation, College of Medicine, National Taiwan University, 7, Zhongshan S. Rd, Taipei, Taiwan.
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Chen Y, Zhou Z, Wang J, Li W, Huang T, Zhou Y, Tan Y, Zhou H, Zhong W, Guo D, Zhou X, Wu X. Swirl sign score system: a novel and practical tool for predicting hematoma expansion risk after spontaneous intracerebral haemorrhage. Br J Radiol 2024; 97:1261-1267. [PMID: 38724228 PMCID: PMC11186553 DOI: 10.1093/bjr/tqae090] [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: 03/07/2024] [Accepted: 04/29/2024] [Indexed: 06/21/2024] Open
Abstract
OBJECTIVE To methodically analyse the swirl sign and construct a scoring system to predict the risk of hematoma expansion (HE) after spontaneous intracerebral haemorrhage (sICH). METHODS We analysed 231 of 683 sICH patients with swirl signs on baseline noncontrast CT (NCCT) images. The characteristics of the swirl sign were analysed, including the number, maximum diameter, shape, boundary, minimum CT value of the swirl sign, and the minimum distance from the swirl sign to the edge of the hematoma. In the development cohort, univariate and multivariate analyses were used to identify independent predictors of HE, and logistic regression analysis was used to construct the swirl sign score system. The swirl sign score system was verified in the validation cohort. RESULTS The number and the minimum CT value of the swirl sign were independent predictors of HE. The swirl sign score system was constructed (2 points for the number of swirl signs >1 and 1 point for the minimum CT value ≤41 Hounsfield units). The area under the curve of the swirl sign score system in predicting HE was 0.773 and 0.770 in the development and validation groups, respectively. CONCLUSIONS The swirl sign score system is an easy-to-use radiological grading scale that requires only baseline NCCT images to effectively identify subjects at high risk of HE. ADVANCES IN KNOWLEDGE Our newly developed semiquantitative swirl sign score system greatly improves the ability of swirl sign to predict HE.
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Affiliation(s)
- Yuanyuan Chen
- Department of Radiology, The Second Affiliated Hospital of Chongqing Medical University, Chongqing 400010, China
| | - Zhiming Zhou
- Department of Radiology, The Second Affiliated Hospital of Chongqing Medical University, Chongqing 400010, China
| | - Jing Wang
- Department of Radiology, The Second Affiliated Hospital of Chongqing Medical University, Chongqing 400010, China
| | - Wenjie Li
- Department of Radiology, The Second Affiliated Hospital of Chongqing Medical University, Chongqing 400010, China
| | - Tianxing Huang
- Department of Radiology, The Second Affiliated Hospital of Chongqing Medical University, Chongqing 400010, China
| | - Yu Zhou
- Department of Radiology, The Second Affiliated Hospital of Chongqing Medical University, Chongqing 400010, China
| | - Yuanxin Tan
- Department of Radiology, The Second Affiliated Hospital of Chongqing Medical University, Chongqing 400010, China
| | - Hongli Zhou
- Department of Radiology, Nanchong Central Hospital, Nanchong 637000, China
| | - Weijia Zhong
- Department of Radiology, The Second Affiliated Hospital of Chongqing Medical University, Chongqing 400010, China
| | - Dajing Guo
- Department of Radiology, The Second Affiliated Hospital of Chongqing Medical University, Chongqing 400010, China
| | - Xi Zhou
- Department of Radiology, The Second Affiliated Hospital of Chongqing Medical University, Chongqing 400010, China
| | - Xiaojia Wu
- Department of Radiology, The Second Affiliated Hospital of Chongqing Medical University, Chongqing 400010, China
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Zhu W, Zhou J, Ma B, Fan C. Predictors of early neurological deterioration in patients with intracerebral hemorrhage: a systematic review and meta-analysis. J Neurol 2024; 271:2980-2991. [PMID: 38507074 DOI: 10.1007/s00415-024-12230-6] [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: 01/06/2024] [Revised: 01/26/2024] [Accepted: 01/27/2024] [Indexed: 03/22/2024]
Abstract
BACKGROUND Early neurological deterioration, a common complication in patients with intracerebral hemorrhage, is associated with poor outcomes. Despite the fact that the prevalence and predictors of early neurological impairment are widely addressed, few studies have consolidated these findings. This study aimed to systematically investigate the prevalence and predictors of early neurological deterioration. METHODS The PubMed, Embase, Cochrane Library, CIHNAL, and Web of Science databases were systematically searched for relevant studies from the inception to December 2023. The data were extracted using a predefined worksheet. Quality assessment was conducted using the Newcastle-Ottawa Scale. Two reviewers independently performed the study selection, data extraction, and quality appraisal. The pooled effect size and 95% confidence intervals were calculated using the STATA 17.0 software package. RESULTS In total, 32 studies and 5,014 patients were included in this meta-analysis. The prevalence of early neurological deterioration was 23% (95% CI 21-26%, p < 0.01). The initial NIHSS score (OR = 1.24, 95% CI 1.17, 1.30, p < 0.01), hematoma volume (OR = 1.07, 95% CI 1.06, 1.09, p < 0.01), intraventricular hemorrhage (OR = 3.50, 95% CI 1.64, 7.47, p < 0.01), intraventricular extension (OR = 3.95, 95% CI 1.96, 7.99, p < 0.01), hematoma expansion (OR = 9.77, 95% CI 4.43, 17.40, p < 0.01), and computed tomographic angiography spot sign (OR = 5.77, 95% CI 1.53, 20.23, p = 0.01) were predictors of early neurological deterioration. The funnel plot and Egger's test revealed significant publication bias (p < 0.001). CONCLUSIONS This meta-analysis revealed a pooled prevalence of early neurological deterioration of 23% in patients with intracerebral hemorrhage. The initial NIHSS score, hematoma volume, intraventricular hemorrhage, intraventricular expansion, hematoma expansion, and spot sign enhanced the probability of early neurological deterioration. These findings provide healthcare providers with an evidence-based basis for detecting and managing early neurological deterioration in patients with intracerebral hemorrhage.
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Affiliation(s)
- Wei Zhu
- Department of Neurosurgery, West China Hospital, Sichuan University/West China School of Nursing, Sichuan University, Chengdu, China
| | - Jiehong Zhou
- Department of Ultrasound, West China Hospital, Sichuan University, Chengdu, China
| | - Buyun Ma
- Department of Ultrasound, West China Hospital, Sichuan University, Chengdu, China
| | - Chaofeng Fan
- Department of Neurosurgery, West China Hospital, Sichuan University/West China School of Nursing, Sichuan University, Chengdu, China.
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Pradilla G, Ratcliff JJ, Hall AJ, Saville BR, Allen JW, Paulon G, McGlothlin A, Lewis RJ, Fitzgerald M, Caveney AF, Li XT, Bain M, Gomes J, Jankowitz B, Zenonos G, Molyneaux BJ, Davies J, Siddiqui A, Chicoine MR, Keyrouz SG, Grossberg JA, Shah MV, Singh R, Bohnstedt BN, Frankel M, Wright DW, Barrow DL. Trial of Early Minimally Invasive Removal of Intracerebral Hemorrhage. N Engl J Med 2024; 390:1277-1289. [PMID: 38598795 DOI: 10.1056/nejmoa2308440] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/12/2024]
Abstract
BACKGROUND Trials of surgical evacuation of supratentorial intracerebral hemorrhages have generally shown no functional benefit. Whether early minimally invasive surgical removal would result in better outcomes than medical management is not known. METHODS In this multicenter, randomized trial involving patients with an acute intracerebral hemorrhage, we assessed surgical removal of the hematoma as compared with medical management. Patients who had a lobar or anterior basal ganglia hemorrhage with a hematoma volume of 30 to 80 ml were assigned, in a 1:1 ratio, within 24 hours after the time that they were last known to be well, to minimally invasive surgical removal of the hematoma plus guideline-based medical management (surgery group) or to guideline-based medical management alone (control group). The primary efficacy end point was the mean score on the utility-weighted modified Rankin scale (range, 0 to 1, with higher scores indicating better outcomes, according to patients' assessment) at 180 days, with a prespecified threshold for posterior probability of superiority of 0.975 or higher. The trial included rules for adaptation of enrollment criteria on the basis of hemorrhage location. A primary safety end point was death within 30 days after enrollment. RESULTS A total of 300 patients were enrolled, of whom 30.7% had anterior basal ganglia hemorrhages and 69.3% had lobar hemorrhages. After 175 patients had been enrolled, an adaptation rule was triggered, and only persons with lobar hemorrhages were enrolled. The mean score on the utility-weighted modified Rankin scale at 180 days was 0.458 in the surgery group and 0.374 in the control group (difference, 0.084; 95% Bayesian credible interval, 0.005 to 0.163; posterior probability of superiority of surgery, 0.981). The mean between-group difference was 0.127 (95% Bayesian credible interval, 0.035 to 0.219) among patients with lobar hemorrhages and -0.013 (95% Bayesian credible interval, -0.147 to 0.116) among those with anterior basal ganglia hemorrhages. The percentage of patients who had died by 30 days was 9.3% in the surgery group and 18.0% in the control group. Five patients (3.3%) in the surgery group had postoperative rebleeding and neurologic deterioration. CONCLUSIONS Among patients in whom surgery could be performed within 24 hours after an acute intracerebral hemorrhage, minimally invasive hematoma evacuation resulted in better functional outcomes at 180 days than those with guideline-based medical management. The effect of surgery appeared to be attributable to intervention for lobar hemorrhages. (Funded by Nico; ENRICH ClinicalTrials.gov number, NCT02880878.).
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Affiliation(s)
- Gustavo Pradilla
- From the Departments of Neurosurgery (G. Pradilla, J.A.G., D.L.B.), Emergency Medicine (J.J.R., A.J.H., D.W.W.), Neurology (J.J.R., J.W.A., M. Frankel), and Radiology (J.W.A., X.T.L.), Emory University School of Medicine, and the Marcus Stroke and Neuroscience Center, Grady Memorial Hospital (G. Pradilla, J.J.R., A.J.H., J.A.G., M. Frankel, D.W.W.) - both in Atlanta; Berry Consultants, Austin, TX (B.R.S., G. Paulon, A.M., R.J.L., M. Fitzgerald); the Department of Biostatistics, Vanderbilt University School of Medicine, Nashville (B.R.S.); the Department of Emergency Medicine, Harbor-UCLA Medical Center, Torrance, CA (R.J.L.); the Department of Psychiatry, University of Michigan, Ann Arbor (A.F.C.); the Cerebrovascular Center, Cleveland Clinic, Cleveland (M.B., J.G.); the Department of Neurosurgery, University of Pennsylvania, Philadelphia (B.J.); the Department of Neurological Surgery, University of Pittsburgh, Pittsburgh (G.Z.); the Department of Neurology, Brigham and Women's Hospital, Boston (B.J.M.); the Department of Neurosurgery, State University of New York at Buffalo, Buffalo (J.D., A.S.); the Department of Neurosurgery, University of Missouri, Columbia (M.R.C.), and the Department of Neurology, Washington University, St. Louis (S.G.K.); and the Departments of Neurosurgery (M.V.S., B.N.B.) and Pulmonary and Critical Care Medicine (R.S.), Indiana University, Indianapolis
| | - Jonathan J Ratcliff
- From the Departments of Neurosurgery (G. Pradilla, J.A.G., D.L.B.), Emergency Medicine (J.J.R., A.J.H., D.W.W.), Neurology (J.J.R., J.W.A., M. Frankel), and Radiology (J.W.A., X.T.L.), Emory University School of Medicine, and the Marcus Stroke and Neuroscience Center, Grady Memorial Hospital (G. Pradilla, J.J.R., A.J.H., J.A.G., M. Frankel, D.W.W.) - both in Atlanta; Berry Consultants, Austin, TX (B.R.S., G. Paulon, A.M., R.J.L., M. Fitzgerald); the Department of Biostatistics, Vanderbilt University School of Medicine, Nashville (B.R.S.); the Department of Emergency Medicine, Harbor-UCLA Medical Center, Torrance, CA (R.J.L.); the Department of Psychiatry, University of Michigan, Ann Arbor (A.F.C.); the Cerebrovascular Center, Cleveland Clinic, Cleveland (M.B., J.G.); the Department of Neurosurgery, University of Pennsylvania, Philadelphia (B.J.); the Department of Neurological Surgery, University of Pittsburgh, Pittsburgh (G.Z.); the Department of Neurology, Brigham and Women's Hospital, Boston (B.J.M.); the Department of Neurosurgery, State University of New York at Buffalo, Buffalo (J.D., A.S.); the Department of Neurosurgery, University of Missouri, Columbia (M.R.C.), and the Department of Neurology, Washington University, St. Louis (S.G.K.); and the Departments of Neurosurgery (M.V.S., B.N.B.) and Pulmonary and Critical Care Medicine (R.S.), Indiana University, Indianapolis
| | - Alex J Hall
- From the Departments of Neurosurgery (G. Pradilla, J.A.G., D.L.B.), Emergency Medicine (J.J.R., A.J.H., D.W.W.), Neurology (J.J.R., J.W.A., M. Frankel), and Radiology (J.W.A., X.T.L.), Emory University School of Medicine, and the Marcus Stroke and Neuroscience Center, Grady Memorial Hospital (G. Pradilla, J.J.R., A.J.H., J.A.G., M. Frankel, D.W.W.) - both in Atlanta; Berry Consultants, Austin, TX (B.R.S., G. Paulon, A.M., R.J.L., M. Fitzgerald); the Department of Biostatistics, Vanderbilt University School of Medicine, Nashville (B.R.S.); the Department of Emergency Medicine, Harbor-UCLA Medical Center, Torrance, CA (R.J.L.); the Department of Psychiatry, University of Michigan, Ann Arbor (A.F.C.); the Cerebrovascular Center, Cleveland Clinic, Cleveland (M.B., J.G.); the Department of Neurosurgery, University of Pennsylvania, Philadelphia (B.J.); the Department of Neurological Surgery, University of Pittsburgh, Pittsburgh (G.Z.); the Department of Neurology, Brigham and Women's Hospital, Boston (B.J.M.); the Department of Neurosurgery, State University of New York at Buffalo, Buffalo (J.D., A.S.); the Department of Neurosurgery, University of Missouri, Columbia (M.R.C.), and the Department of Neurology, Washington University, St. Louis (S.G.K.); and the Departments of Neurosurgery (M.V.S., B.N.B.) and Pulmonary and Critical Care Medicine (R.S.), Indiana University, Indianapolis
| | - Benjamin R Saville
- From the Departments of Neurosurgery (G. Pradilla, J.A.G., D.L.B.), Emergency Medicine (J.J.R., A.J.H., D.W.W.), Neurology (J.J.R., J.W.A., M. Frankel), and Radiology (J.W.A., X.T.L.), Emory University School of Medicine, and the Marcus Stroke and Neuroscience Center, Grady Memorial Hospital (G. Pradilla, J.J.R., A.J.H., J.A.G., M. Frankel, D.W.W.) - both in Atlanta; Berry Consultants, Austin, TX (B.R.S., G. Paulon, A.M., R.J.L., M. Fitzgerald); the Department of Biostatistics, Vanderbilt University School of Medicine, Nashville (B.R.S.); the Department of Emergency Medicine, Harbor-UCLA Medical Center, Torrance, CA (R.J.L.); the Department of Psychiatry, University of Michigan, Ann Arbor (A.F.C.); the Cerebrovascular Center, Cleveland Clinic, Cleveland (M.B., J.G.); the Department of Neurosurgery, University of Pennsylvania, Philadelphia (B.J.); the Department of Neurological Surgery, University of Pittsburgh, Pittsburgh (G.Z.); the Department of Neurology, Brigham and Women's Hospital, Boston (B.J.M.); the Department of Neurosurgery, State University of New York at Buffalo, Buffalo (J.D., A.S.); the Department of Neurosurgery, University of Missouri, Columbia (M.R.C.), and the Department of Neurology, Washington University, St. Louis (S.G.K.); and the Departments of Neurosurgery (M.V.S., B.N.B.) and Pulmonary and Critical Care Medicine (R.S.), Indiana University, Indianapolis
| | - Jason W Allen
- From the Departments of Neurosurgery (G. Pradilla, J.A.G., D.L.B.), Emergency Medicine (J.J.R., A.J.H., D.W.W.), Neurology (J.J.R., J.W.A., M. Frankel), and Radiology (J.W.A., X.T.L.), Emory University School of Medicine, and the Marcus Stroke and Neuroscience Center, Grady Memorial Hospital (G. Pradilla, J.J.R., A.J.H., J.A.G., M. Frankel, D.W.W.) - both in Atlanta; Berry Consultants, Austin, TX (B.R.S., G. Paulon, A.M., R.J.L., M. Fitzgerald); the Department of Biostatistics, Vanderbilt University School of Medicine, Nashville (B.R.S.); the Department of Emergency Medicine, Harbor-UCLA Medical Center, Torrance, CA (R.J.L.); the Department of Psychiatry, University of Michigan, Ann Arbor (A.F.C.); the Cerebrovascular Center, Cleveland Clinic, Cleveland (M.B., J.G.); the Department of Neurosurgery, University of Pennsylvania, Philadelphia (B.J.); the Department of Neurological Surgery, University of Pittsburgh, Pittsburgh (G.Z.); the Department of Neurology, Brigham and Women's Hospital, Boston (B.J.M.); the Department of Neurosurgery, State University of New York at Buffalo, Buffalo (J.D., A.S.); the Department of Neurosurgery, University of Missouri, Columbia (M.R.C.), and the Department of Neurology, Washington University, St. Louis (S.G.K.); and the Departments of Neurosurgery (M.V.S., B.N.B.) and Pulmonary and Critical Care Medicine (R.S.), Indiana University, Indianapolis
| | - Giorgio Paulon
- From the Departments of Neurosurgery (G. Pradilla, J.A.G., D.L.B.), Emergency Medicine (J.J.R., A.J.H., D.W.W.), Neurology (J.J.R., J.W.A., M. Frankel), and Radiology (J.W.A., X.T.L.), Emory University School of Medicine, and the Marcus Stroke and Neuroscience Center, Grady Memorial Hospital (G. Pradilla, J.J.R., A.J.H., J.A.G., M. Frankel, D.W.W.) - both in Atlanta; Berry Consultants, Austin, TX (B.R.S., G. Paulon, A.M., R.J.L., M. Fitzgerald); the Department of Biostatistics, Vanderbilt University School of Medicine, Nashville (B.R.S.); the Department of Emergency Medicine, Harbor-UCLA Medical Center, Torrance, CA (R.J.L.); the Department of Psychiatry, University of Michigan, Ann Arbor (A.F.C.); the Cerebrovascular Center, Cleveland Clinic, Cleveland (M.B., J.G.); the Department of Neurosurgery, University of Pennsylvania, Philadelphia (B.J.); the Department of Neurological Surgery, University of Pittsburgh, Pittsburgh (G.Z.); the Department of Neurology, Brigham and Women's Hospital, Boston (B.J.M.); the Department of Neurosurgery, State University of New York at Buffalo, Buffalo (J.D., A.S.); the Department of Neurosurgery, University of Missouri, Columbia (M.R.C.), and the Department of Neurology, Washington University, St. Louis (S.G.K.); and the Departments of Neurosurgery (M.V.S., B.N.B.) and Pulmonary and Critical Care Medicine (R.S.), Indiana University, Indianapolis
| | - Anna McGlothlin
- From the Departments of Neurosurgery (G. Pradilla, J.A.G., D.L.B.), Emergency Medicine (J.J.R., A.J.H., D.W.W.), Neurology (J.J.R., J.W.A., M. Frankel), and Radiology (J.W.A., X.T.L.), Emory University School of Medicine, and the Marcus Stroke and Neuroscience Center, Grady Memorial Hospital (G. Pradilla, J.J.R., A.J.H., J.A.G., M. Frankel, D.W.W.) - both in Atlanta; Berry Consultants, Austin, TX (B.R.S., G. Paulon, A.M., R.J.L., M. Fitzgerald); the Department of Biostatistics, Vanderbilt University School of Medicine, Nashville (B.R.S.); the Department of Emergency Medicine, Harbor-UCLA Medical Center, Torrance, CA (R.J.L.); the Department of Psychiatry, University of Michigan, Ann Arbor (A.F.C.); the Cerebrovascular Center, Cleveland Clinic, Cleveland (M.B., J.G.); the Department of Neurosurgery, University of Pennsylvania, Philadelphia (B.J.); the Department of Neurological Surgery, University of Pittsburgh, Pittsburgh (G.Z.); the Department of Neurology, Brigham and Women's Hospital, Boston (B.J.M.); the Department of Neurosurgery, State University of New York at Buffalo, Buffalo (J.D., A.S.); the Department of Neurosurgery, University of Missouri, Columbia (M.R.C.), and the Department of Neurology, Washington University, St. Louis (S.G.K.); and the Departments of Neurosurgery (M.V.S., B.N.B.) and Pulmonary and Critical Care Medicine (R.S.), Indiana University, Indianapolis
| | - Roger J Lewis
- From the Departments of Neurosurgery (G. Pradilla, J.A.G., D.L.B.), Emergency Medicine (J.J.R., A.J.H., D.W.W.), Neurology (J.J.R., J.W.A., M. Frankel), and Radiology (J.W.A., X.T.L.), Emory University School of Medicine, and the Marcus Stroke and Neuroscience Center, Grady Memorial Hospital (G. Pradilla, J.J.R., A.J.H., J.A.G., M. Frankel, D.W.W.) - both in Atlanta; Berry Consultants, Austin, TX (B.R.S., G. Paulon, A.M., R.J.L., M. Fitzgerald); the Department of Biostatistics, Vanderbilt University School of Medicine, Nashville (B.R.S.); the Department of Emergency Medicine, Harbor-UCLA Medical Center, Torrance, CA (R.J.L.); the Department of Psychiatry, University of Michigan, Ann Arbor (A.F.C.); the Cerebrovascular Center, Cleveland Clinic, Cleveland (M.B., J.G.); the Department of Neurosurgery, University of Pennsylvania, Philadelphia (B.J.); the Department of Neurological Surgery, University of Pittsburgh, Pittsburgh (G.Z.); the Department of Neurology, Brigham and Women's Hospital, Boston (B.J.M.); the Department of Neurosurgery, State University of New York at Buffalo, Buffalo (J.D., A.S.); the Department of Neurosurgery, University of Missouri, Columbia (M.R.C.), and the Department of Neurology, Washington University, St. Louis (S.G.K.); and the Departments of Neurosurgery (M.V.S., B.N.B.) and Pulmonary and Critical Care Medicine (R.S.), Indiana University, Indianapolis
| | - Mark Fitzgerald
- From the Departments of Neurosurgery (G. Pradilla, J.A.G., D.L.B.), Emergency Medicine (J.J.R., A.J.H., D.W.W.), Neurology (J.J.R., J.W.A., M. Frankel), and Radiology (J.W.A., X.T.L.), Emory University School of Medicine, and the Marcus Stroke and Neuroscience Center, Grady Memorial Hospital (G. Pradilla, J.J.R., A.J.H., J.A.G., M. Frankel, D.W.W.) - both in Atlanta; Berry Consultants, Austin, TX (B.R.S., G. Paulon, A.M., R.J.L., M. Fitzgerald); the Department of Biostatistics, Vanderbilt University School of Medicine, Nashville (B.R.S.); the Department of Emergency Medicine, Harbor-UCLA Medical Center, Torrance, CA (R.J.L.); the Department of Psychiatry, University of Michigan, Ann Arbor (A.F.C.); the Cerebrovascular Center, Cleveland Clinic, Cleveland (M.B., J.G.); the Department of Neurosurgery, University of Pennsylvania, Philadelphia (B.J.); the Department of Neurological Surgery, University of Pittsburgh, Pittsburgh (G.Z.); the Department of Neurology, Brigham and Women's Hospital, Boston (B.J.M.); the Department of Neurosurgery, State University of New York at Buffalo, Buffalo (J.D., A.S.); the Department of Neurosurgery, University of Missouri, Columbia (M.R.C.), and the Department of Neurology, Washington University, St. Louis (S.G.K.); and the Departments of Neurosurgery (M.V.S., B.N.B.) and Pulmonary and Critical Care Medicine (R.S.), Indiana University, Indianapolis
| | - Angela F Caveney
- From the Departments of Neurosurgery (G. Pradilla, J.A.G., D.L.B.), Emergency Medicine (J.J.R., A.J.H., D.W.W.), Neurology (J.J.R., J.W.A., M. Frankel), and Radiology (J.W.A., X.T.L.), Emory University School of Medicine, and the Marcus Stroke and Neuroscience Center, Grady Memorial Hospital (G. Pradilla, J.J.R., A.J.H., J.A.G., M. Frankel, D.W.W.) - both in Atlanta; Berry Consultants, Austin, TX (B.R.S., G. Paulon, A.M., R.J.L., M. Fitzgerald); the Department of Biostatistics, Vanderbilt University School of Medicine, Nashville (B.R.S.); the Department of Emergency Medicine, Harbor-UCLA Medical Center, Torrance, CA (R.J.L.); the Department of Psychiatry, University of Michigan, Ann Arbor (A.F.C.); the Cerebrovascular Center, Cleveland Clinic, Cleveland (M.B., J.G.); the Department of Neurosurgery, University of Pennsylvania, Philadelphia (B.J.); the Department of Neurological Surgery, University of Pittsburgh, Pittsburgh (G.Z.); the Department of Neurology, Brigham and Women's Hospital, Boston (B.J.M.); the Department of Neurosurgery, State University of New York at Buffalo, Buffalo (J.D., A.S.); the Department of Neurosurgery, University of Missouri, Columbia (M.R.C.), and the Department of Neurology, Washington University, St. Louis (S.G.K.); and the Departments of Neurosurgery (M.V.S., B.N.B.) and Pulmonary and Critical Care Medicine (R.S.), Indiana University, Indianapolis
| | - Xiao T Li
- From the Departments of Neurosurgery (G. Pradilla, J.A.G., D.L.B.), Emergency Medicine (J.J.R., A.J.H., D.W.W.), Neurology (J.J.R., J.W.A., M. Frankel), and Radiology (J.W.A., X.T.L.), Emory University School of Medicine, and the Marcus Stroke and Neuroscience Center, Grady Memorial Hospital (G. Pradilla, J.J.R., A.J.H., J.A.G., M. Frankel, D.W.W.) - both in Atlanta; Berry Consultants, Austin, TX (B.R.S., G. Paulon, A.M., R.J.L., M. Fitzgerald); the Department of Biostatistics, Vanderbilt University School of Medicine, Nashville (B.R.S.); the Department of Emergency Medicine, Harbor-UCLA Medical Center, Torrance, CA (R.J.L.); the Department of Psychiatry, University of Michigan, Ann Arbor (A.F.C.); the Cerebrovascular Center, Cleveland Clinic, Cleveland (M.B., J.G.); the Department of Neurosurgery, University of Pennsylvania, Philadelphia (B.J.); the Department of Neurological Surgery, University of Pittsburgh, Pittsburgh (G.Z.); the Department of Neurology, Brigham and Women's Hospital, Boston (B.J.M.); the Department of Neurosurgery, State University of New York at Buffalo, Buffalo (J.D., A.S.); the Department of Neurosurgery, University of Missouri, Columbia (M.R.C.), and the Department of Neurology, Washington University, St. Louis (S.G.K.); and the Departments of Neurosurgery (M.V.S., B.N.B.) and Pulmonary and Critical Care Medicine (R.S.), Indiana University, Indianapolis
| | - Mark Bain
- From the Departments of Neurosurgery (G. Pradilla, J.A.G., D.L.B.), Emergency Medicine (J.J.R., A.J.H., D.W.W.), Neurology (J.J.R., J.W.A., M. Frankel), and Radiology (J.W.A., X.T.L.), Emory University School of Medicine, and the Marcus Stroke and Neuroscience Center, Grady Memorial Hospital (G. Pradilla, J.J.R., A.J.H., J.A.G., M. Frankel, D.W.W.) - both in Atlanta; Berry Consultants, Austin, TX (B.R.S., G. Paulon, A.M., R.J.L., M. Fitzgerald); the Department of Biostatistics, Vanderbilt University School of Medicine, Nashville (B.R.S.); the Department of Emergency Medicine, Harbor-UCLA Medical Center, Torrance, CA (R.J.L.); the Department of Psychiatry, University of Michigan, Ann Arbor (A.F.C.); the Cerebrovascular Center, Cleveland Clinic, Cleveland (M.B., J.G.); the Department of Neurosurgery, University of Pennsylvania, Philadelphia (B.J.); the Department of Neurological Surgery, University of Pittsburgh, Pittsburgh (G.Z.); the Department of Neurology, Brigham and Women's Hospital, Boston (B.J.M.); the Department of Neurosurgery, State University of New York at Buffalo, Buffalo (J.D., A.S.); the Department of Neurosurgery, University of Missouri, Columbia (M.R.C.), and the Department of Neurology, Washington University, St. Louis (S.G.K.); and the Departments of Neurosurgery (M.V.S., B.N.B.) and Pulmonary and Critical Care Medicine (R.S.), Indiana University, Indianapolis
| | - Joao Gomes
- From the Departments of Neurosurgery (G. Pradilla, J.A.G., D.L.B.), Emergency Medicine (J.J.R., A.J.H., D.W.W.), Neurology (J.J.R., J.W.A., M. Frankel), and Radiology (J.W.A., X.T.L.), Emory University School of Medicine, and the Marcus Stroke and Neuroscience Center, Grady Memorial Hospital (G. Pradilla, J.J.R., A.J.H., J.A.G., M. Frankel, D.W.W.) - both in Atlanta; Berry Consultants, Austin, TX (B.R.S., G. Paulon, A.M., R.J.L., M. Fitzgerald); the Department of Biostatistics, Vanderbilt University School of Medicine, Nashville (B.R.S.); the Department of Emergency Medicine, Harbor-UCLA Medical Center, Torrance, CA (R.J.L.); the Department of Psychiatry, University of Michigan, Ann Arbor (A.F.C.); the Cerebrovascular Center, Cleveland Clinic, Cleveland (M.B., J.G.); the Department of Neurosurgery, University of Pennsylvania, Philadelphia (B.J.); the Department of Neurological Surgery, University of Pittsburgh, Pittsburgh (G.Z.); the Department of Neurology, Brigham and Women's Hospital, Boston (B.J.M.); the Department of Neurosurgery, State University of New York at Buffalo, Buffalo (J.D., A.S.); the Department of Neurosurgery, University of Missouri, Columbia (M.R.C.), and the Department of Neurology, Washington University, St. Louis (S.G.K.); and the Departments of Neurosurgery (M.V.S., B.N.B.) and Pulmonary and Critical Care Medicine (R.S.), Indiana University, Indianapolis
| | - Brain Jankowitz
- From the Departments of Neurosurgery (G. Pradilla, J.A.G., D.L.B.), Emergency Medicine (J.J.R., A.J.H., D.W.W.), Neurology (J.J.R., J.W.A., M. Frankel), and Radiology (J.W.A., X.T.L.), Emory University School of Medicine, and the Marcus Stroke and Neuroscience Center, Grady Memorial Hospital (G. Pradilla, J.J.R., A.J.H., J.A.G., M. Frankel, D.W.W.) - both in Atlanta; Berry Consultants, Austin, TX (B.R.S., G. Paulon, A.M., R.J.L., M. Fitzgerald); the Department of Biostatistics, Vanderbilt University School of Medicine, Nashville (B.R.S.); the Department of Emergency Medicine, Harbor-UCLA Medical Center, Torrance, CA (R.J.L.); the Department of Psychiatry, University of Michigan, Ann Arbor (A.F.C.); the Cerebrovascular Center, Cleveland Clinic, Cleveland (M.B., J.G.); the Department of Neurosurgery, University of Pennsylvania, Philadelphia (B.J.); the Department of Neurological Surgery, University of Pittsburgh, Pittsburgh (G.Z.); the Department of Neurology, Brigham and Women's Hospital, Boston (B.J.M.); the Department of Neurosurgery, State University of New York at Buffalo, Buffalo (J.D., A.S.); the Department of Neurosurgery, University of Missouri, Columbia (M.R.C.), and the Department of Neurology, Washington University, St. Louis (S.G.K.); and the Departments of Neurosurgery (M.V.S., B.N.B.) and Pulmonary and Critical Care Medicine (R.S.), Indiana University, Indianapolis
| | - Georgios Zenonos
- From the Departments of Neurosurgery (G. Pradilla, J.A.G., D.L.B.), Emergency Medicine (J.J.R., A.J.H., D.W.W.), Neurology (J.J.R., J.W.A., M. Frankel), and Radiology (J.W.A., X.T.L.), Emory University School of Medicine, and the Marcus Stroke and Neuroscience Center, Grady Memorial Hospital (G. Pradilla, J.J.R., A.J.H., J.A.G., M. Frankel, D.W.W.) - both in Atlanta; Berry Consultants, Austin, TX (B.R.S., G. Paulon, A.M., R.J.L., M. Fitzgerald); the Department of Biostatistics, Vanderbilt University School of Medicine, Nashville (B.R.S.); the Department of Emergency Medicine, Harbor-UCLA Medical Center, Torrance, CA (R.J.L.); the Department of Psychiatry, University of Michigan, Ann Arbor (A.F.C.); the Cerebrovascular Center, Cleveland Clinic, Cleveland (M.B., J.G.); the Department of Neurosurgery, University of Pennsylvania, Philadelphia (B.J.); the Department of Neurological Surgery, University of Pittsburgh, Pittsburgh (G.Z.); the Department of Neurology, Brigham and Women's Hospital, Boston (B.J.M.); the Department of Neurosurgery, State University of New York at Buffalo, Buffalo (J.D., A.S.); the Department of Neurosurgery, University of Missouri, Columbia (M.R.C.), and the Department of Neurology, Washington University, St. Louis (S.G.K.); and the Departments of Neurosurgery (M.V.S., B.N.B.) and Pulmonary and Critical Care Medicine (R.S.), Indiana University, Indianapolis
| | - Bradley J Molyneaux
- From the Departments of Neurosurgery (G. Pradilla, J.A.G., D.L.B.), Emergency Medicine (J.J.R., A.J.H., D.W.W.), Neurology (J.J.R., J.W.A., M. Frankel), and Radiology (J.W.A., X.T.L.), Emory University School of Medicine, and the Marcus Stroke and Neuroscience Center, Grady Memorial Hospital (G. Pradilla, J.J.R., A.J.H., J.A.G., M. Frankel, D.W.W.) - both in Atlanta; Berry Consultants, Austin, TX (B.R.S., G. Paulon, A.M., R.J.L., M. Fitzgerald); the Department of Biostatistics, Vanderbilt University School of Medicine, Nashville (B.R.S.); the Department of Emergency Medicine, Harbor-UCLA Medical Center, Torrance, CA (R.J.L.); the Department of Psychiatry, University of Michigan, Ann Arbor (A.F.C.); the Cerebrovascular Center, Cleveland Clinic, Cleveland (M.B., J.G.); the Department of Neurosurgery, University of Pennsylvania, Philadelphia (B.J.); the Department of Neurological Surgery, University of Pittsburgh, Pittsburgh (G.Z.); the Department of Neurology, Brigham and Women's Hospital, Boston (B.J.M.); the Department of Neurosurgery, State University of New York at Buffalo, Buffalo (J.D., A.S.); the Department of Neurosurgery, University of Missouri, Columbia (M.R.C.), and the Department of Neurology, Washington University, St. Louis (S.G.K.); and the Departments of Neurosurgery (M.V.S., B.N.B.) and Pulmonary and Critical Care Medicine (R.S.), Indiana University, Indianapolis
| | - Jason Davies
- From the Departments of Neurosurgery (G. Pradilla, J.A.G., D.L.B.), Emergency Medicine (J.J.R., A.J.H., D.W.W.), Neurology (J.J.R., J.W.A., M. Frankel), and Radiology (J.W.A., X.T.L.), Emory University School of Medicine, and the Marcus Stroke and Neuroscience Center, Grady Memorial Hospital (G. Pradilla, J.J.R., A.J.H., J.A.G., M. Frankel, D.W.W.) - both in Atlanta; Berry Consultants, Austin, TX (B.R.S., G. Paulon, A.M., R.J.L., M. Fitzgerald); the Department of Biostatistics, Vanderbilt University School of Medicine, Nashville (B.R.S.); the Department of Emergency Medicine, Harbor-UCLA Medical Center, Torrance, CA (R.J.L.); the Department of Psychiatry, University of Michigan, Ann Arbor (A.F.C.); the Cerebrovascular Center, Cleveland Clinic, Cleveland (M.B., J.G.); the Department of Neurosurgery, University of Pennsylvania, Philadelphia (B.J.); the Department of Neurological Surgery, University of Pittsburgh, Pittsburgh (G.Z.); the Department of Neurology, Brigham and Women's Hospital, Boston (B.J.M.); the Department of Neurosurgery, State University of New York at Buffalo, Buffalo (J.D., A.S.); the Department of Neurosurgery, University of Missouri, Columbia (M.R.C.), and the Department of Neurology, Washington University, St. Louis (S.G.K.); and the Departments of Neurosurgery (M.V.S., B.N.B.) and Pulmonary and Critical Care Medicine (R.S.), Indiana University, Indianapolis
| | - Adnan Siddiqui
- From the Departments of Neurosurgery (G. Pradilla, J.A.G., D.L.B.), Emergency Medicine (J.J.R., A.J.H., D.W.W.), Neurology (J.J.R., J.W.A., M. Frankel), and Radiology (J.W.A., X.T.L.), Emory University School of Medicine, and the Marcus Stroke and Neuroscience Center, Grady Memorial Hospital (G. Pradilla, J.J.R., A.J.H., J.A.G., M. Frankel, D.W.W.) - both in Atlanta; Berry Consultants, Austin, TX (B.R.S., G. Paulon, A.M., R.J.L., M. Fitzgerald); the Department of Biostatistics, Vanderbilt University School of Medicine, Nashville (B.R.S.); the Department of Emergency Medicine, Harbor-UCLA Medical Center, Torrance, CA (R.J.L.); the Department of Psychiatry, University of Michigan, Ann Arbor (A.F.C.); the Cerebrovascular Center, Cleveland Clinic, Cleveland (M.B., J.G.); the Department of Neurosurgery, University of Pennsylvania, Philadelphia (B.J.); the Department of Neurological Surgery, University of Pittsburgh, Pittsburgh (G.Z.); the Department of Neurology, Brigham and Women's Hospital, Boston (B.J.M.); the Department of Neurosurgery, State University of New York at Buffalo, Buffalo (J.D., A.S.); the Department of Neurosurgery, University of Missouri, Columbia (M.R.C.), and the Department of Neurology, Washington University, St. Louis (S.G.K.); and the Departments of Neurosurgery (M.V.S., B.N.B.) and Pulmonary and Critical Care Medicine (R.S.), Indiana University, Indianapolis
| | - Michael R Chicoine
- From the Departments of Neurosurgery (G. Pradilla, J.A.G., D.L.B.), Emergency Medicine (J.J.R., A.J.H., D.W.W.), Neurology (J.J.R., J.W.A., M. Frankel), and Radiology (J.W.A., X.T.L.), Emory University School of Medicine, and the Marcus Stroke and Neuroscience Center, Grady Memorial Hospital (G. Pradilla, J.J.R., A.J.H., J.A.G., M. Frankel, D.W.W.) - both in Atlanta; Berry Consultants, Austin, TX (B.R.S., G. Paulon, A.M., R.J.L., M. Fitzgerald); the Department of Biostatistics, Vanderbilt University School of Medicine, Nashville (B.R.S.); the Department of Emergency Medicine, Harbor-UCLA Medical Center, Torrance, CA (R.J.L.); the Department of Psychiatry, University of Michigan, Ann Arbor (A.F.C.); the Cerebrovascular Center, Cleveland Clinic, Cleveland (M.B., J.G.); the Department of Neurosurgery, University of Pennsylvania, Philadelphia (B.J.); the Department of Neurological Surgery, University of Pittsburgh, Pittsburgh (G.Z.); the Department of Neurology, Brigham and Women's Hospital, Boston (B.J.M.); the Department of Neurosurgery, State University of New York at Buffalo, Buffalo (J.D., A.S.); the Department of Neurosurgery, University of Missouri, Columbia (M.R.C.), and the Department of Neurology, Washington University, St. Louis (S.G.K.); and the Departments of Neurosurgery (M.V.S., B.N.B.) and Pulmonary and Critical Care Medicine (R.S.), Indiana University, Indianapolis
| | - Salah G Keyrouz
- From the Departments of Neurosurgery (G. Pradilla, J.A.G., D.L.B.), Emergency Medicine (J.J.R., A.J.H., D.W.W.), Neurology (J.J.R., J.W.A., M. Frankel), and Radiology (J.W.A., X.T.L.), Emory University School of Medicine, and the Marcus Stroke and Neuroscience Center, Grady Memorial Hospital (G. Pradilla, J.J.R., A.J.H., J.A.G., M. Frankel, D.W.W.) - both in Atlanta; Berry Consultants, Austin, TX (B.R.S., G. Paulon, A.M., R.J.L., M. Fitzgerald); the Department of Biostatistics, Vanderbilt University School of Medicine, Nashville (B.R.S.); the Department of Emergency Medicine, Harbor-UCLA Medical Center, Torrance, CA (R.J.L.); the Department of Psychiatry, University of Michigan, Ann Arbor (A.F.C.); the Cerebrovascular Center, Cleveland Clinic, Cleveland (M.B., J.G.); the Department of Neurosurgery, University of Pennsylvania, Philadelphia (B.J.); the Department of Neurological Surgery, University of Pittsburgh, Pittsburgh (G.Z.); the Department of Neurology, Brigham and Women's Hospital, Boston (B.J.M.); the Department of Neurosurgery, State University of New York at Buffalo, Buffalo (J.D., A.S.); the Department of Neurosurgery, University of Missouri, Columbia (M.R.C.), and the Department of Neurology, Washington University, St. Louis (S.G.K.); and the Departments of Neurosurgery (M.V.S., B.N.B.) and Pulmonary and Critical Care Medicine (R.S.), Indiana University, Indianapolis
| | - Jonathan A Grossberg
- From the Departments of Neurosurgery (G. Pradilla, J.A.G., D.L.B.), Emergency Medicine (J.J.R., A.J.H., D.W.W.), Neurology (J.J.R., J.W.A., M. Frankel), and Radiology (J.W.A., X.T.L.), Emory University School of Medicine, and the Marcus Stroke and Neuroscience Center, Grady Memorial Hospital (G. Pradilla, J.J.R., A.J.H., J.A.G., M. Frankel, D.W.W.) - both in Atlanta; Berry Consultants, Austin, TX (B.R.S., G. Paulon, A.M., R.J.L., M. Fitzgerald); the Department of Biostatistics, Vanderbilt University School of Medicine, Nashville (B.R.S.); the Department of Emergency Medicine, Harbor-UCLA Medical Center, Torrance, CA (R.J.L.); the Department of Psychiatry, University of Michigan, Ann Arbor (A.F.C.); the Cerebrovascular Center, Cleveland Clinic, Cleveland (M.B., J.G.); the Department of Neurosurgery, University of Pennsylvania, Philadelphia (B.J.); the Department of Neurological Surgery, University of Pittsburgh, Pittsburgh (G.Z.); the Department of Neurology, Brigham and Women's Hospital, Boston (B.J.M.); the Department of Neurosurgery, State University of New York at Buffalo, Buffalo (J.D., A.S.); the Department of Neurosurgery, University of Missouri, Columbia (M.R.C.), and the Department of Neurology, Washington University, St. Louis (S.G.K.); and the Departments of Neurosurgery (M.V.S., B.N.B.) and Pulmonary and Critical Care Medicine (R.S.), Indiana University, Indianapolis
| | - Mitesh V Shah
- From the Departments of Neurosurgery (G. Pradilla, J.A.G., D.L.B.), Emergency Medicine (J.J.R., A.J.H., D.W.W.), Neurology (J.J.R., J.W.A., M. Frankel), and Radiology (J.W.A., X.T.L.), Emory University School of Medicine, and the Marcus Stroke and Neuroscience Center, Grady Memorial Hospital (G. Pradilla, J.J.R., A.J.H., J.A.G., M. Frankel, D.W.W.) - both in Atlanta; Berry Consultants, Austin, TX (B.R.S., G. Paulon, A.M., R.J.L., M. Fitzgerald); the Department of Biostatistics, Vanderbilt University School of Medicine, Nashville (B.R.S.); the Department of Emergency Medicine, Harbor-UCLA Medical Center, Torrance, CA (R.J.L.); the Department of Psychiatry, University of Michigan, Ann Arbor (A.F.C.); the Cerebrovascular Center, Cleveland Clinic, Cleveland (M.B., J.G.); the Department of Neurosurgery, University of Pennsylvania, Philadelphia (B.J.); the Department of Neurological Surgery, University of Pittsburgh, Pittsburgh (G.Z.); the Department of Neurology, Brigham and Women's Hospital, Boston (B.J.M.); the Department of Neurosurgery, State University of New York at Buffalo, Buffalo (J.D., A.S.); the Department of Neurosurgery, University of Missouri, Columbia (M.R.C.), and the Department of Neurology, Washington University, St. Louis (S.G.K.); and the Departments of Neurosurgery (M.V.S., B.N.B.) and Pulmonary and Critical Care Medicine (R.S.), Indiana University, Indianapolis
| | - Ranjeet Singh
- From the Departments of Neurosurgery (G. Pradilla, J.A.G., D.L.B.), Emergency Medicine (J.J.R., A.J.H., D.W.W.), Neurology (J.J.R., J.W.A., M. Frankel), and Radiology (J.W.A., X.T.L.), Emory University School of Medicine, and the Marcus Stroke and Neuroscience Center, Grady Memorial Hospital (G. Pradilla, J.J.R., A.J.H., J.A.G., M. Frankel, D.W.W.) - both in Atlanta; Berry Consultants, Austin, TX (B.R.S., G. Paulon, A.M., R.J.L., M. Fitzgerald); the Department of Biostatistics, Vanderbilt University School of Medicine, Nashville (B.R.S.); the Department of Emergency Medicine, Harbor-UCLA Medical Center, Torrance, CA (R.J.L.); the Department of Psychiatry, University of Michigan, Ann Arbor (A.F.C.); the Cerebrovascular Center, Cleveland Clinic, Cleveland (M.B., J.G.); the Department of Neurosurgery, University of Pennsylvania, Philadelphia (B.J.); the Department of Neurological Surgery, University of Pittsburgh, Pittsburgh (G.Z.); the Department of Neurology, Brigham and Women's Hospital, Boston (B.J.M.); the Department of Neurosurgery, State University of New York at Buffalo, Buffalo (J.D., A.S.); the Department of Neurosurgery, University of Missouri, Columbia (M.R.C.), and the Department of Neurology, Washington University, St. Louis (S.G.K.); and the Departments of Neurosurgery (M.V.S., B.N.B.) and Pulmonary and Critical Care Medicine (R.S.), Indiana University, Indianapolis
| | - Bradley N Bohnstedt
- From the Departments of Neurosurgery (G. Pradilla, J.A.G., D.L.B.), Emergency Medicine (J.J.R., A.J.H., D.W.W.), Neurology (J.J.R., J.W.A., M. Frankel), and Radiology (J.W.A., X.T.L.), Emory University School of Medicine, and the Marcus Stroke and Neuroscience Center, Grady Memorial Hospital (G. Pradilla, J.J.R., A.J.H., J.A.G., M. Frankel, D.W.W.) - both in Atlanta; Berry Consultants, Austin, TX (B.R.S., G. Paulon, A.M., R.J.L., M. Fitzgerald); the Department of Biostatistics, Vanderbilt University School of Medicine, Nashville (B.R.S.); the Department of Emergency Medicine, Harbor-UCLA Medical Center, Torrance, CA (R.J.L.); the Department of Psychiatry, University of Michigan, Ann Arbor (A.F.C.); the Cerebrovascular Center, Cleveland Clinic, Cleveland (M.B., J.G.); the Department of Neurosurgery, University of Pennsylvania, Philadelphia (B.J.); the Department of Neurological Surgery, University of Pittsburgh, Pittsburgh (G.Z.); the Department of Neurology, Brigham and Women's Hospital, Boston (B.J.M.); the Department of Neurosurgery, State University of New York at Buffalo, Buffalo (J.D., A.S.); the Department of Neurosurgery, University of Missouri, Columbia (M.R.C.), and the Department of Neurology, Washington University, St. Louis (S.G.K.); and the Departments of Neurosurgery (M.V.S., B.N.B.) and Pulmonary and Critical Care Medicine (R.S.), Indiana University, Indianapolis
| | - Michael Frankel
- From the Departments of Neurosurgery (G. Pradilla, J.A.G., D.L.B.), Emergency Medicine (J.J.R., A.J.H., D.W.W.), Neurology (J.J.R., J.W.A., M. Frankel), and Radiology (J.W.A., X.T.L.), Emory University School of Medicine, and the Marcus Stroke and Neuroscience Center, Grady Memorial Hospital (G. Pradilla, J.J.R., A.J.H., J.A.G., M. Frankel, D.W.W.) - both in Atlanta; Berry Consultants, Austin, TX (B.R.S., G. Paulon, A.M., R.J.L., M. Fitzgerald); the Department of Biostatistics, Vanderbilt University School of Medicine, Nashville (B.R.S.); the Department of Emergency Medicine, Harbor-UCLA Medical Center, Torrance, CA (R.J.L.); the Department of Psychiatry, University of Michigan, Ann Arbor (A.F.C.); the Cerebrovascular Center, Cleveland Clinic, Cleveland (M.B., J.G.); the Department of Neurosurgery, University of Pennsylvania, Philadelphia (B.J.); the Department of Neurological Surgery, University of Pittsburgh, Pittsburgh (G.Z.); the Department of Neurology, Brigham and Women's Hospital, Boston (B.J.M.); the Department of Neurosurgery, State University of New York at Buffalo, Buffalo (J.D., A.S.); the Department of Neurosurgery, University of Missouri, Columbia (M.R.C.), and the Department of Neurology, Washington University, St. Louis (S.G.K.); and the Departments of Neurosurgery (M.V.S., B.N.B.) and Pulmonary and Critical Care Medicine (R.S.), Indiana University, Indianapolis
| | - David W Wright
- From the Departments of Neurosurgery (G. Pradilla, J.A.G., D.L.B.), Emergency Medicine (J.J.R., A.J.H., D.W.W.), Neurology (J.J.R., J.W.A., M. Frankel), and Radiology (J.W.A., X.T.L.), Emory University School of Medicine, and the Marcus Stroke and Neuroscience Center, Grady Memorial Hospital (G. Pradilla, J.J.R., A.J.H., J.A.G., M. Frankel, D.W.W.) - both in Atlanta; Berry Consultants, Austin, TX (B.R.S., G. Paulon, A.M., R.J.L., M. Fitzgerald); the Department of Biostatistics, Vanderbilt University School of Medicine, Nashville (B.R.S.); the Department of Emergency Medicine, Harbor-UCLA Medical Center, Torrance, CA (R.J.L.); the Department of Psychiatry, University of Michigan, Ann Arbor (A.F.C.); the Cerebrovascular Center, Cleveland Clinic, Cleveland (M.B., J.G.); the Department of Neurosurgery, University of Pennsylvania, Philadelphia (B.J.); the Department of Neurological Surgery, University of Pittsburgh, Pittsburgh (G.Z.); the Department of Neurology, Brigham and Women's Hospital, Boston (B.J.M.); the Department of Neurosurgery, State University of New York at Buffalo, Buffalo (J.D., A.S.); the Department of Neurosurgery, University of Missouri, Columbia (M.R.C.), and the Department of Neurology, Washington University, St. Louis (S.G.K.); and the Departments of Neurosurgery (M.V.S., B.N.B.) and Pulmonary and Critical Care Medicine (R.S.), Indiana University, Indianapolis
| | - Daniel L Barrow
- From the Departments of Neurosurgery (G. Pradilla, J.A.G., D.L.B.), Emergency Medicine (J.J.R., A.J.H., D.W.W.), Neurology (J.J.R., J.W.A., M. Frankel), and Radiology (J.W.A., X.T.L.), Emory University School of Medicine, and the Marcus Stroke and Neuroscience Center, Grady Memorial Hospital (G. Pradilla, J.J.R., A.J.H., J.A.G., M. Frankel, D.W.W.) - both in Atlanta; Berry Consultants, Austin, TX (B.R.S., G. Paulon, A.M., R.J.L., M. Fitzgerald); the Department of Biostatistics, Vanderbilt University School of Medicine, Nashville (B.R.S.); the Department of Emergency Medicine, Harbor-UCLA Medical Center, Torrance, CA (R.J.L.); the Department of Psychiatry, University of Michigan, Ann Arbor (A.F.C.); the Cerebrovascular Center, Cleveland Clinic, Cleveland (M.B., J.G.); the Department of Neurosurgery, University of Pennsylvania, Philadelphia (B.J.); the Department of Neurological Surgery, University of Pittsburgh, Pittsburgh (G.Z.); the Department of Neurology, Brigham and Women's Hospital, Boston (B.J.M.); the Department of Neurosurgery, State University of New York at Buffalo, Buffalo (J.D., A.S.); the Department of Neurosurgery, University of Missouri, Columbia (M.R.C.), and the Department of Neurology, Washington University, St. Louis (S.G.K.); and the Departments of Neurosurgery (M.V.S., B.N.B.) and Pulmonary and Critical Care Medicine (R.S.), Indiana University, Indianapolis
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Zhang D, Zhuang D, Li T, Liu X, Zhang Z, Zhu L, Tian F, Chen X, Li K, Chen W, Sheng J. An analysis of neutrophil-to-lymphocyte ratios and monocyte-to-lymphocyte ratios with six-month prognosis after cerebral contusions. Front Immunol 2024; 15:1336862. [PMID: 38545111 PMCID: PMC10967015 DOI: 10.3389/fimmu.2024.1336862] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2023] [Accepted: 02/27/2024] [Indexed: 04/10/2024] Open
Abstract
Background and purpose Neutrophil-to-lymphocyte ratio (NLR) and monocyte-to-lymphocyte ratio (MLR) have been identified as potential prognostic markers in various conditions, including cancer, cardiovascular disease, and stroke. This study aims to investigate the dynamic changes of NLR and MLR following cerebral contusion and their associations with six-month outcomes. Methods Retrospective data were collected from January 2016 to April 2020, including patients diagnosed with cerebral contusion and discharged from two teaching-oriented tertiary hospitals in Southern China. Patient demographics, clinical manifestations, laboratory test results (neutrophil, monocyte, and lymphocyte counts) obtained at admission, 24 hours, and one week after cerebral contusion, as well as outcomes, were analyzed. An unfavorable outcome was defined as a Glasgow Outcome Score (GOS) of 0-3 at six months. Logistic regression analysis was performed to identify independent predictors of prognosis, while receiver characteristic curve analysis was used to determine the optimal cutoff values for NLR and MLR. Results A total of 552 patients (mean age 47.40, SD 17.09) were included, with 73.19% being male. Higher NLR at one-week post-cerebral contusion (adjusted OR = 4.19, 95%CI, 1.16 - 15.16, P = 0.029) and higher MLR at admission and at 24 h (5.80, 1.40 - 24.02, P = 0.015; 9.06, 1.45 - 56.54, P = 0.018, respectively) were significantly associated with a 6-month unfavorable prognosis after adjustment for other risk factors by multiple logistic regression. The NLR at admission and 24 hours, as well as the MLR at one week, were not significant predictors for a 6-month unfavorable prognosis. Based on receiver operating characteristic curve analysis, the optimal thresholds of NLR at 1 week and MLR at admission after cerebral contusion that best discriminated a unfavorable outcome at 6-month were 6.39 (81.60% sensitivity and 70.73% specificity) and 0.76 (55.47% sensitivity and 78.26% specificity), respectively. Conclusion NLR measured one week after cerebral contusion and MLR measured at admission may serve as predictive markers for a 6-month unfavorable prognosis. These ratios hold potential as parameters for risk stratification in patients with cerebral contusion, complementing established biomarkers in diagnosis and treatment. However, further prospective studies with larger cohorts are needed to validate these findings.
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Affiliation(s)
- Dangui Zhang
- Research Center of Translational Medicine, Second Affiliated Hospital of Shantou University Medical College, Shantou, Guangdong, China
| | - Dongzhou Zhuang
- Department of Neurosurgery, First Affiliated Hospital of Shantou University Medical College, Shantou, Guangdong, China
| | - Tian Li
- Department of Microbiology and Immunology and Guangdong Provincial Key Laboratory of Infectious Disease and Molecular Immunopathology, Shantou University Medical College, Shantou, Guangdong, China
| | - Xueer Liu
- Department of Microbiology and Immunology and Guangdong Provincial Key Laboratory of Infectious Disease and Molecular Immunopathology, Shantou University Medical College, Shantou, Guangdong, China
| | - Zelin Zhang
- Department of Microbiology and Immunology and Guangdong Provincial Key Laboratory of Infectious Disease and Molecular Immunopathology, Shantou University Medical College, Shantou, Guangdong, China
| | - Lihong Zhu
- Department of Microbiology and Immunology and Guangdong Provincial Key Laboratory of Infectious Disease and Molecular Immunopathology, Shantou University Medical College, Shantou, Guangdong, China
| | - Fei Tian
- Department of Neurosurgery, Second Affiliated Hospital of Shantou University Medical College, Shantou, Guangdong, China
| | - Xiaoxuan Chen
- Department of Microbiology and Immunology and Guangdong Provincial Key Laboratory of Infectious Disease and Molecular Immunopathology, Shantou University Medical College, Shantou, Guangdong, China
| | - Kangsheng Li
- Department of Microbiology and Immunology and Guangdong Provincial Key Laboratory of Infectious Disease and Molecular Immunopathology, Shantou University Medical College, Shantou, Guangdong, China
| | - Weiqiang Chen
- Department of Neurosurgery, First Affiliated Hospital of Shantou University Medical College, Shantou, Guangdong, China
| | - Jiangtao Sheng
- Department of Microbiology and Immunology and Guangdong Provincial Key Laboratory of Infectious Disease and Molecular Immunopathology, Shantou University Medical College, Shantou, Guangdong, China
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Albakr A, Almatar A, AlFajri A, Zafar A, Nazish S, Shahid R, AlJaafari D, Soltan N, Alarfaj Z, Al Ghamdi O, Alfilw S, Abdelhady A, Albaker W. Important Factors to Expect the Outcome After Intracerebral Hemorrhage: An Observational Study From a University Hospital in Saudi Arabia. Neurologist 2023; 28:310-315. [PMID: 37027177 DOI: 10.1097/nrl.0000000000000491] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/08/2023]
Abstract
BACKGROUND Intracerebral hemorrhage (ICH) has worse clinical outcomes than other stroke types. The risk factors contributing to ICH outcomes are not entirely understood, and published literature from Saudi Arabia on ICH outcomes is limited. Our goal was to study the specific clinical and imaging determinants of ICH outcomes. METHODS We retrospectively retrieved all patients with spontaneous ICH (SICH) from a prospective King Fahd Hospital University registry between 2017 and 2019. The clinical characteristics of ICH events and data on clinical outcomes (6 to 12 mo) were recorded. Groups of patients with a favorable modified Rankin Scale of 0 to 2 and nonfavorable outcomes of a modified Rankin Scale of 3 to 6 were investigated. The relationship between the clinical characteristics of the SICH event and its outcomes was assessed using linear and logistic regression analyses. RESULTS A total of 148 patients with a mean age of 60.3 years (±15.2) and a median follow-up of 9 months were included. Unfavorable outcomes were reported in 98 patients (66.2%). The ICH event variables associated with unfavorable outcomes were impaired renal function, Glasgow Coma Score <8, hematoma volume, hematoma expansion, and intraventricular extension (IVE). CONCLUSIONS Our study demonstrated important clinical and radiologic features in patients with ICH that may affect their clinical long-term functional outcomes. A larger multicenter study is required to validate our results and evaluate the methods to improve health care in patients with SICH.
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Affiliation(s)
| | | | | | | | | | | | | | | | | | | | - Suad Alfilw
- Department of Neurology, College of Nursing, Imam Abdulrahman Bin Faisal University, Dammam, Eastern Province, Saudi Arabia
| | - Ahmed Abdelhady
- Department of critical care, College of Medicine, Alexandria University, Egypt
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7
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Choi JH, Yoon WK, Kim JH, Kwon TH, Byun J. Predictor of the Postoperative Swelling After Craniotomy for Spontaneous Intracerebral Hemorrhage: Sphericity Index as a Novel Parameter. Korean J Neurotrauma 2023; 19:333-347. [PMID: 37840614 PMCID: PMC10567521 DOI: 10.13004/kjnt.2023.19.e41] [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: 07/19/2023] [Revised: 08/17/2023] [Accepted: 08/21/2023] [Indexed: 10/17/2023] Open
Abstract
Objective Spontaneous intracerebral hemorrhage is a serious type of stroke with high mortality and disability rates. Surgical treatment options vary; however, predicting edema aggravation is crucial when choosing the optimal approach. We propose using the sphericity index, a measure of roundness, to predict the aggravation of edema and guide surgical decisions. Methods We analyzed 56 cases of craniotomy and hematoma evacuation to investigate the correlation between the sphericity index and patient outcomes, including the need for salvage decompressive craniectomy (DC). Results The patients included 35 (62.5%) men and 21 (37.5%) women, with a median age of 62.5 years. The basal ganglia was the most common location of hemorrhage (50.0%). The mean hematoma volume was 86.3 cc, with 10 (17.9%) instances of hematoma expansion. Cerebral herniation was observed in 44 (78.6%) patients, intraventricular hemorrhage in 34 (60.7%), and spot signs in 9 (16.1%). Salvage DC was performed in 13 (23.6%) patients to relieve intracranial pressure. The median follow-up duration was 6 months, with a mortality rate of 12.5%. The sphericity index was significantly correlated with delayed swelling and hematoma expansion but not salvage DC. Conclusions The sphericity index is a promising predictor of delayed swelling and hematoma expansion that may aid in the development of surgical guidelines and medication strategies. Further large-scale studies are required to explore these aspects and establish comprehensive guidelines.
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Affiliation(s)
- Jae Hoon Choi
- Department of Neurosurgery, Korea University Guro Hospital, Korea University College of Medicine, Seoul, Korea
| | - Won Ki Yoon
- Department of Neurosurgery, Korea University Guro Hospital, Korea University College of Medicine, Seoul, Korea
| | - Jong Hyun Kim
- Department of Neurosurgery, Korea University Guro Hospital, Korea University College of Medicine, Seoul, Korea
| | - Taek Hyun Kwon
- Department of Neurosurgery, Korea University Guro Hospital, Korea University College of Medicine, Seoul, Korea
| | - Joonho Byun
- Department of Neurosurgery, Korea University Guro Hospital, Korea University College of Medicine, Seoul, Korea
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8
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Romero JM, Rojas-Serrano LF. Current Evaluation of Intracerebral Hemorrhage. Radiol Clin North Am 2023; 61:479-490. [PMID: 36931764 DOI: 10.1016/j.rcl.2023.01.005] [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] [Indexed: 02/22/2023]
Abstract
Advanced imaging is currently critical in diagnosing, predicting, and managing intracerebral hemorrhage. MD CT angiography has occupied the first line of evaluating patients with a clinical diagnosis of a stroke, given its rapid acquisition time, high resolution of vascular structures, and sensitivity for secondary causes of ICH.
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Affiliation(s)
- Javier M Romero
- Radiology Department, Massachusetts General Hospital, Harvard Medical School, 55 Fruit Street, Gray Building, 241G, MA 02114, USA.
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9
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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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10
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Yu L, Zhao M, Lin Y, Zeng J, He Q, Zheng Y, Ma K, Lin F, Kang D. Noncontrast Computed Tomography Markers Associated with Hematoma Expansion: Analysis of a Multicenter Retrospective Study. Brain Sci 2023; 13:brainsci13040608. [PMID: 37190573 DOI: 10.3390/brainsci13040608] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2023] [Revised: 03/19/2023] [Accepted: 03/24/2023] [Indexed: 05/17/2023] Open
Abstract
BACKGROUND Hematoma expansion (HE) is a significant predictor of poor outcomes in patients with intracerebral hemorrhage (ICH). Non-contrast computed tomography (NCCT) markers in ICH are promising predictors of HE. We aimed to determine the association of the NCCT markers with HE by using different temporal HE definitions. METHODS We utilized Risa-MIS-ICH trial data (risk stratification and minimally invasive surgery in acute intracerebral hemorrhage). We defined four HE types based on the time to baseline CT (BCT) and the time to follow-up CT (FCT). Hematoma volume was measured by software with a semi-automatic edge detection tool. HE was defined as a follow-up CT hematoma volume increase of >6 mL or a 33% hematoma volume increase relative to the baseline CT. Multivariable regression analyses were used to determine the HE parameters. The prediction potential of indicators for HE was evaluated using receiver-operating characteristic analysis. RESULTS The study enrolled 158 patients in total. The time to baseline CT was independently associated with HE in one type (odds ratio (OR) 0.234, 95% confidence interval (CI) 0.077-0.712, p = 0.011), and the blend sign was independently associated with HE in two types (OR, 6.203-6.985, both p < 0.05). Heterogeneous density was independently associated with HE in all types (OR, 6.465-88.445, all p < 0.05) and was the optimal type for prediction, with an area under the curve of 0.674 (p = 0.004), a sensitivity of 38.9%, and specificity of 96.0%. CONCLUSION In specific subtypes, the time to baseline CT, blend sign, and heterogeneous density were independently associated with HE. The association between NCCT markers and HE is influenced by the temporal definition of HE. Heterogeneous density is a stable and robust predictor of HE in different subtypes of hematoma expansion.
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Affiliation(s)
- Lianghong Yu
- Department of Neurosurgery, Neurosurgery Research Institute, The First Affiliated Hospital, Fujian Medical University, Fuzhou 350005, China
- Department of Neurosurgery, Binhai Branch of National Regional Medical Center, The First Affiliated Hospital, Fujian Medical University, Fuzhou 350005, China
- Fujian Institute for Brain Disorders and Brain Science, The First Affiliated Hospital, Fujian Medical University, Fuzhou 350005, China
- Fujian Provincial Clinical Research Center for Neurological Diseases, The First Affiliated Hospital, Fujian Medical University, Fuzhou 350005, China
| | - Mingpei Zhao
- Department of Neurosurgery, Neurosurgery Research Institute, The First Affiliated Hospital, Fujian Medical University, Fuzhou 350005, China
- Department of Neurosurgery, Binhai Branch of National Regional Medical Center, The First Affiliated Hospital, Fujian Medical University, Fuzhou 350005, China
| | - Yuanxiang Lin
- Department of Neurosurgery, Neurosurgery Research Institute, The First Affiliated Hospital, Fujian Medical University, Fuzhou 350005, China
- Department of Neurosurgery, Binhai Branch of National Regional Medical Center, The First Affiliated Hospital, Fujian Medical University, Fuzhou 350005, China
- Fujian Institute for Brain Disorders and Brain Science, The First Affiliated Hospital, Fujian Medical University, Fuzhou 350005, China
- Fujian Provincial Clinical Research Center for Neurological Diseases, The First Affiliated Hospital, Fujian Medical University, Fuzhou 350005, China
| | - Jiateng Zeng
- Department of Neurosurgery, Neurosurgery Research Institute, The First Affiliated Hospital, Fujian Medical University, Fuzhou 350005, China
- Department of Neurosurgery, Binhai Branch of National Regional Medical Center, The First Affiliated Hospital, Fujian Medical University, Fuzhou 350005, China
| | - Qiu He
- Department of Neurosurgery, Neurosurgery Research Institute, The First Affiliated Hospital, Fujian Medical University, Fuzhou 350005, China
- Department of Neurosurgery, Binhai Branch of National Regional Medical Center, The First Affiliated Hospital, Fujian Medical University, Fuzhou 350005, China
| | - Yan Zheng
- Department of Neurosurgery, Neurosurgery Research Institute, The First Affiliated Hospital, Fujian Medical University, Fuzhou 350005, China
- Department of Neurosurgery, Binhai Branch of National Regional Medical Center, The First Affiliated Hospital, Fujian Medical University, Fuzhou 350005, China
| | - Ke Ma
- Clinical Research and Translation Center, The First Affiliated Hospital, Fujian Medical University, Fuzhou 350005, China
| | - Fuxin Lin
- Department of Neurosurgery, Neurosurgery Research Institute, The First Affiliated Hospital, Fujian Medical University, Fuzhou 350005, China
- Department of Neurosurgery, Binhai Branch of National Regional Medical Center, The First Affiliated Hospital, Fujian Medical University, Fuzhou 350005, China
- Fujian Institute for Brain Disorders and Brain Science, The First Affiliated Hospital, Fujian Medical University, Fuzhou 350005, China
- Fujian Provincial Clinical Research Center for Neurological Diseases, The First Affiliated Hospital, Fujian Medical University, Fuzhou 350005, China
- Clinical Research and Translation Center, The First Affiliated Hospital, Fujian Medical University, Fuzhou 350005, China
| | - Dezhi Kang
- Department of Neurosurgery, Neurosurgery Research Institute, The First Affiliated Hospital, Fujian Medical University, Fuzhou 350005, China
- Department of Neurosurgery, Binhai Branch of National Regional Medical Center, The First Affiliated Hospital, Fujian Medical University, Fuzhou 350005, China
- Fujian Institute for Brain Disorders and Brain Science, The First Affiliated Hospital, Fujian Medical University, Fuzhou 350005, China
- Fujian Provincial Clinical Research Center for Neurological Diseases, The First Affiliated Hospital, Fujian Medical University, Fuzhou 350005, China
- Clinical Research and Translation Center, The First Affiliated Hospital, Fujian Medical University, Fuzhou 350005, China
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Wu TC, Liu YL, Chen JH, Ho CH, Zhang Y, Su MY. Prediction of poor outcome in stroke patients using radiomics analysis of intraparenchymal and intraventricular hemorrhage and clinical factors. Neurol Sci 2023; 44:1289-1300. [PMID: 36445541 DOI: 10.1007/s10072-022-06528-4] [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: 05/11/2022] [Accepted: 11/23/2022] [Indexed: 11/30/2022]
Abstract
PURPOSE To build three prognostic models using radiomics analysis of the hemorrhagic lesions, clinical variables, and their combination, to predict the outcome of stroke patients with spontaneous intracerebral hemorrhage (sICH). MATERIALS AND METHODS Eighty-three sICH patients were included. Among them, 40 patients (48.2%) had poor prognosis with modified Rankin scale (mRS) of 5 and 6 at discharge, and the prognostic model was built to differentiate mRS ≤ 4 vs. 5 + 6. The region of interest (ROI) of intraparenchymal hemorrhage (IPH) and intraventricular hemorrhage (IVH) were separately segmented. Features were extracted using PyRadiomics, and the support vector machine was applied to select features and build radiomics models based on IPH and IPH + IVH. The clinical models were built using multivariate logistic regression, and then the radiomics scores were combined with clinical variables to build the combined model. RESULTS When using IPH, the AUC for radiomics, clinical, and combined model was 0.78, 0.82, and 0.87, respectively. When using IPH + IVH, the AUC was increased to 0.80, 0.84, and 0.90, respectively. The combined model had a significantly improved AUC compared to the radiomics by DeLong test. A clinical prognostic model based on the ICH score of 0-1 only achieved AUC of 0.71. CONCLUSIONS The combined model using the radiomics score derived from IPH + IVH and the clinical factors could achieve a high accuracy in prediction of sICH patients with poor outcome, which may be used to assist in making the decision about the optimal care.
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Affiliation(s)
- Te-Chang Wu
- Department of Medical Imaging, Chi-Mei Medical Center, Tainan, Taiwan.
- Department of Medical Sciences Industry, Chang Jung Christian University, Tainan, Taiwan.
| | - Yan-Lin Liu
- Center for Functional Onco-Imaging of Radiological Sciences, School of Medicine, University of California, Irvine, CA, USA
| | - Jeon-Hor Chen
- Center for Functional Onco-Imaging of Radiological Sciences, School of Medicine, University of California, Irvine, CA, USA
- Department of Radiology, E-DA Hospital, E-DA Cancer Hospital, I-Shou University, Kaohsiung, Taiwan
| | - Chung-Han Ho
- Department of Medical Research, Chi Mei Medical Center, Tainan, Taiwan
- Department of Information Management, Southern Taiwan University of Science and Technology, Tainan, Taiwan
| | - Yang Zhang
- Center for Functional Onco-Imaging of Radiological Sciences, School of Medicine, University of California, Irvine, CA, USA
- Department of Radiation Oncology, Rutgers-Cancer Institute of New Jersey, Robert Wood Johnson Medical School, New Brunswick, NJ, USA
| | - Min-Ying Su
- Center for Functional Onco-Imaging of Radiological Sciences, School of Medicine, University of California, Irvine, CA, USA
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Chu H, Huang C, Zhou Z, Tang Y, Dong Q, Guo Q. Inflammatory score predicts early hematoma expansion and poor outcomes in patients with intracerebral hemorrhage. Int J Surg 2023; 109:266-276. [PMID: 37093070 PMCID: PMC10389560 DOI: 10.1097/js9.0000000000000191] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2022] [Accepted: 11/20/2022] [Indexed: 04/25/2023]
Abstract
BACKGROUND This study aimed to develop a prediction score named inflammatory score based on proper integration of several inflammatory markers and investigate whether it was associated with hematoma expansion and poor outcomes in patients with intracerebral hemorrhage (ICH). METHODS This study involved a consecutive series of spontaneous ICH patients of two cohorts admitted within 24 hours after symptom onset. Inflammatory score (0-9) was developed with the combination of neutrophil-to-lymphocyte ratio, platelet-to-lymphocyte ratio, monocyte-to-lymphocyte ratio, systemic immune-inflammation index, lactate dehydrogenase, and C-reactive protein. The authors investigated the association between inflammatory score and hematoma expansion and poor outcomes by using univariate and multivariate logistic regression analyses. The optimal cutoff point of inflammatory score was determined by receiver operating characteristic analysis in the development cohort and then validated. RESULTS A total of 301 and 154 ICH patients were enrolled in the development and validation cohorts. Inflammatory score was significantly higher in patients with hematoma expansion and poor outcomes. The multivariate logistic regression analysis revealed inflammatory score was independently associated with hematoma expansion, secondary neurological deterioration within 48 hours, 30-day mortality, and 3-month poor modified Rankin scale (4-6). The diagnostic accuracy of inflammatory score exhibited by area under the curve showed numerically or statistically higher than most of the individual indicators. Moreover, inflammatory score greater than or equal to 5 was selected as the optimal cutoff point, which was further prospectively validated with high diagnostic accuracy. CONCLUSIONS The inflammatory score is a reliable predictor for early hematoma expansion and short-term and long-term poor outcomes with good diagnostic accuracies in ICH patients.
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Affiliation(s)
- Heling Chu
- Department of Gerontology, Shanghai Sixth People's Hospital Affiliated to Shanghai Jiao Tong University School of Medicine
| | - Chuyi Huang
- Health Management Center, School of Medicine, Renji Hospital, School of Medicine, Shanghai Jiaotong University
| | - Zaiying Zhou
- Center for Statistical Science of Tsinghua University, Beijing, China
| | - Yuping Tang
- Department of Neurology, Huashan Hospital, State Key Laboratory of Medical Neurobiology, Fudan University, Shanghai
| | - Qiang Dong
- Center for Statistical Science of Tsinghua University, Beijing, China
| | - Qihao Guo
- Department of Gerontology, Shanghai Sixth People's Hospital Affiliated to Shanghai Jiao Tong University School of Medicine
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Multi-Energy CT Applications. Radiol Clin North Am 2023; 61:1-21. [DOI: 10.1016/j.rcl.2022.08.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
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Wu TC, Liu YL, Chen JH, Zhang Y, Chen TY, Ko CC, Su MY. The Added Value of Intraventricular Hemorrhage on the Radiomics Analysis for the Prediction of Hematoma Expansion of Spontaneous Intracerebral Hemorrhage. Diagnostics (Basel) 2022; 12:diagnostics12112755. [PMID: 36428815 PMCID: PMC9689620 DOI: 10.3390/diagnostics12112755] [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: 09/19/2022] [Revised: 10/29/2022] [Accepted: 11/08/2022] [Indexed: 11/12/2022] Open
Abstract
Background: Among patients undergoing head computed tomography (CT) scans within 3 h of spontaneous intracerebral hemorrhage (sICH), 28% to 38% have hematoma expansion (HE) on follow-up CT. This study aimed to predict HE using radiomics analysis and investigate the impact of intraventricular hemorrhage (IVH) compared with the conventional approach based on intraparenchymal hemorrhage (IPH) alone. Methods: This retrospective study enrolled 127 patients with baseline and follow-up non-contrast CT (NCCT) within 4~72 h of sICH. IPH and IVH were outlined separately for performing radiomics analysis. HE was defined as an absolute hematoma growth > 6 mL or percentage growth > 33% of either IPH (HEP) or a combination of IPH and IVH (HEP+V) at follow-up. Radiomic features were extracted using PyRadiomics, and then the support vector machine (SVM) was used to build the classification model. For each case, a radiomics score was generated to indicate the probability of HE. Results: There were 57 (44.9%) HEP and 70 (55.1%) non-HEP based on IPH alone, and 58 (45.7%) HEP+V and 69 (54.3%) non-HEP+V based on IPH + IVH. The majority (>94%) of HE patients had poor early outcomes (death or modified Rankin Scale > 3 at discharge). The radiomics model built using baseline IPH to predict HEP (RMP) showed 76.4% accuracy and 0.73 area under the ROC curve (AUC). The other model using IPH + IVH to predict HEP+V (RMP+V) had higher accuracy (81.9%) with AUC = 0.80, and this model could predict poor outcomes. The sensitivity/specificity of RMP and RMP+V for HE prediction were 71.9%/80.0% and 79.3%/84.1%, respectively. Conclusion: The proposed radiomics approach with additional IVH information can improve the accuracy in prediction of HE, which is associated with poor clinical outcomes. A reliable radiomics model may provide a robust tool to help manage ICH patients and to enroll high-risk ICH cases into anti-expansion or neuroprotection drug trials.
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Affiliation(s)
- Te-Chang Wu
- Department of Medical Imaging, Chi-Mei Medical Center, Tainan 71004, Taiwan
- Department of Medical Sciences Industry, Chang Jung Christian University, Tainan 71101, Taiwan
- Correspondence: (T.-C.W.); (J.-H.C.); Tel.: +886-62812811 (ext. 53752) (T.-C.W.)
| | - Yan-Lin Liu
- Department of Radiological Sciences, University of California, Irvine, CA 92521, USA
| | - Jeon-Hor Chen
- Department of Radiological Sciences, University of California, Irvine, CA 92521, USA
- Department of Radiology, E-DA Hospital, I-Shou University, Kaohsiung 84001, Taiwan
- Correspondence: (T.-C.W.); (J.-H.C.); Tel.: +886-62812811 (ext. 53752) (T.-C.W.)
| | - Yang Zhang
- Department of Radiological Sciences, University of California, Irvine, CA 92521, USA
- Department of Radiation Oncology, Rutgers-Cancer Institute of New Jersey, Robert Wood Johnson Medical School, New Brunswick, NJ 08901, USA
| | - Tai-Yuan Chen
- Department of Medical Imaging, Chi-Mei Medical Center, Tainan 71004, Taiwan
- Graduate Institute of Medical Sciences, Chang Jung Christian University, Tainan 71101, Taiwan
| | - Ching-Chung Ko
- Department of Medical Imaging, Chi-Mei Medical Center, Tainan 71004, Taiwan
- Center of General Education, Chia Nan University of Pharmacy and Science, Tainan 71710, Taiwan
| | - Min-Ying Su
- Department of Radiological Sciences, University of California, Irvine, CA 92521, USA
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Xu W, Guo H, Li H, Dai Q, Song K, Li F, Zhou J, Yao J, Wang Z, Liu X. A non-contrast computed tomography-based radiomics nomogram for the prediction of hematoma expansion in patients with deep ganglionic intracerebral hemorrhage. Front Neurol 2022; 13:974183. [DOI: 10.3389/fneur.2022.974183] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2022] [Accepted: 09/15/2022] [Indexed: 11/13/2022] Open
Abstract
Background and purposeHematoma expansion (HE) is a critical event following acute intracerebral hemorrhage (ICH). We aimed to construct a non-contrast computed tomography (NCCT) model combining clinical characteristics, radiological signs, and radiomics features to predict HE in patients with spontaneous ICH and to develop a nomogram to assess the risk of early HE.Materials and methodsWe retrospectively reviewed 388 patients with ICH who underwent initial NCCT within 6 h after onset and follow-up CT within 24 h after initial NCCT, between January 2015 and December 2021. Using the LASSO algorithm or stepwise logistic regression analysis, five models (clinical model, radiological model, clinical-radiological model, radiomics model, and combined model) were developed to predict HE in the training cohort (n = 235) and independently verified in the test cohort (n = 153). The Akaike information criterion (AIC) and the likelihood ratio test (LRT) were used for comparing the goodness of fit of the five models, and the AUC was used to evaluate their ability in discriminating HE. A nomogram was developed based on the model with the best performance.ResultsThe combined model (AIC = 202.599, χ2 = 80.6) was the best fitting model with the lowest AIC and the highest LRT chi-square value compared to the clinical model (AIC = 232.263, χ2 = 46.940), radiological model (AIC = 227.932, χ2 = 51.270), clinical-radiological model (AIC = 212.711, χ2 = 55.490) or radiomics model (AIC = 217.647, χ2 = 57.550). In both cohorts, the nomogram derived from the combined model showed satisfactory discrimination and calibration for predicting HE (AUC = 0.900, sensitivity = 83.87%; AUC = 0.850, sensitivity = 80.10%, respectively).ConclusionThe NCCT-based model combining clinical characteristics, radiological signs, and radiomics features could efficiently discriminate early HE, and the nomogram derived from the combined model, as a non-invasive tool, exhibited satisfactory performance in stratifying HE risks.
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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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Machine learning prediction of hematoma expansion in acute intracerebral hemorrhage. Sci Rep 2022; 12:12452. [PMID: 35864139 PMCID: PMC9304401 DOI: 10.1038/s41598-022-15400-6] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2022] [Accepted: 06/23/2022] [Indexed: 12/28/2022] Open
Abstract
To examine whether machine learning (ML) approach can be used to predict hematoma expansion in acute intracerebral hemorrhage (ICH) with accuracy and widespread applicability, we applied ML algorithms to multicenter clinical data and CT findings on admission. Patients with acute ICH from three hospitals (n = 351) and those from another hospital (n = 71) were retrospectively assigned to the development and validation cohorts, respectively. To develop ML predictive models, the k-nearest neighbors (k-NN) algorithm, logistic regression, support vector machines (SVMs), random forests, and XGBoost were applied to the patient data in the development cohort. The models were evaluated for their performance on the patient data in the validation cohort, which was compared with previous scoring methods, the BAT, BRAIN, and 9-point scores. The k-NN algorithm achieved the highest area under the receiver operating characteristic curve (AUC) of 0.790 among all ML models, and the sensitivity, specificity, and accuracy were 0.846, 0.733, and 0.775, respectively. The BRAIN score achieved the highest AUC of 0.676 among all previous scoring methods, which was lower than the k-NN algorithm (p = 0.016). We developed and validated ML predictive models of hematoma expansion in acute ICH. The models demonstrated good predictive ability, showing better performance than the previous scoring methods.
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18
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The Spot Sign and Intraventricular Hemorrhage are Associated with Baseline Coagulopathy and Outcome in Intracerebral Hemorrhage. Neurocrit Care 2022; 37:660-669. [PMID: 35761128 DOI: 10.1007/s12028-022-01537-9] [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: 12/02/2021] [Accepted: 05/18/2022] [Indexed: 10/17/2022]
Abstract
BACKGROUND Spontaneous intracerebral hemorrhage (ICH) is the second most prevalent subtype of stroke and has high mortality and morbidity. The utility of radiographic features to predict secondary brain injury related to hematoma expansion (HE) or increased intracranial pressure has been highlighted in patients with ICH, including the computed tomographic angiography (CTA) spot sign and intraventricular hemorrhage (IVH). Understanding the pathophysiology of spot sign and IVH may help identify optimal therapeutic strategies. We examined factors related to the spot sign and IVH, including coagulation status, hematoma size, and location, and evaluated their prognostic value in patients with ICH. METHODS Prospectively collected data from a single center between 2012 and 2015 were analyzed. Patients who underwent thromboelastography within 24 h of symptom onset and completed follow-up brain imaging and CTA within 48 h after onset were included for analysis. Multivariate logistic regression analyses were performed to identify determinants of the spot sign and IVH and their predictive value for HE, early neurological deterioration (END), in-hospital mortality, and functional outcome at discharge. RESULTS Of 161 patients, 50 (31.1%) had a spot sign and 93 (57.8%) had IVH. In multivariable analysis, the spot sign was associated with greater hematoma volume (odds ratio [OR] 1.02; 95% confidence interval [CI] 1.00-1.03), decreased white blood cell count (OR 0.88; 95% CI 0.79-0.98), and prolonged activated partial thromboplastin time (OR 1.14; 95% CI 1.06-1.23). IVH was associated with greater hematoma volume (OR 1.02; 95% CI 1.01-1.04) and nonlobar location of hematoma (OR 0.23; 95% CI 0.09-0.61). The spot sign was associated with greater risk of all adverse outcomes. IVH was associated with an increased risk of END and reduced HE, without significant impact on mortality or functional outcome. CONCLUSIONS The spot sign and IVH are associated with specific hematoma characteristics, such as size and location, but are related differently to coagulation status and clinical course. A combined analysis of the spot sign and IVH can improve the understanding of pathophysiology and risk stratification after ICH.
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Blood Pressure and Spot Sign in Spontaneous Supratentorial Subcortical Intracerebral Hemorrhage. Neurocrit Care 2022; 37:246-254. [PMID: 35445934 PMCID: PMC9283165 DOI: 10.1007/s12028-022-01485-4] [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: 09/24/2021] [Accepted: 03/07/2022] [Indexed: 10/27/2022]
Abstract
BACKGROUND Spontaneous intracerebral hemorrhage is a potentially devastating cause of brain injury, often occurring secondary to hypertension. Contrast extravasation on computed tomography angiography (CTA), known as the spot sign, has been shown to predict hematoma expansion and worse outcomes. Although hypertension has been associated with an increased rate of the spot sign being present, the relationship between spot sign and blood pressure has not been fully explored. METHODS We retrospectively analyzed data from 134 patients (40 women and 94 men, mean age 62.3 ± 15.73 years) presenting to a tertiary academic medical center with spontaneous supratentorial subcortical intracerebral hemorrhage from 1/1/2018 to 1/4/2021. RESULTS A spot sign was demonstrated in images of 18 patients (13.43%) and correlated with a higher intracerebral hemorrhage score (2.61 ± 1.42 vs. 1.31 ± 1.25, p = 0.002), larger hematoma volume (53.49cm3 ± 32.08 vs. 23.45cm3 ± 25.65, p = 0.001), lower Glasgow Coma Scale on arrival (9.06 ± 4.56 vs. 11.74 ± 3.65, p = 0.027), increased risk of hematoma expansion (16.67% vs. 5.26%, p = 0.042), and need for surgical intervention (66.67% vs. 15.52%, p < 0.001). We did not see a correlation with age, sex, or underlying comorbidities. The presence of spot sign correlated with higher modified Rankin scores at discharge (4.94 ± 1.00 vs. 3.92 ± 1.64, p < 0.001). We saw significantly higher systolic blood pressure at the time of CTA in patients with a spot sign (184 mm Hg ± 43.11 vs. 153 mm Hg ± 36.99, p = 0.009) and the highest recorded blood pressure (p = 0.019), although not blood pressure on arrival (p = 0.081). Performing CTA early in the process of blood pressure lowering was associated with a spot sign (p < 0.001). CONCLUSIONS The presence of spot sign correlates with larger hematomas, worse outcomes, and increased surgical intervention. There is a significant association between spot sign and systolic blood pressure at the time of CTA, with the highest systolic blood pressure being recorded prior to CTA. Although the role of intensive blood pressure management in spontaneous intracerebral hemorrhage remains a subject of debate, patients with a spot sign may be a subgroup that could benefit from this.
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Sheng J, Chen W, Zhuang D, Li T, Yang J, Cai S, Chen X, Liu X, Tian F, Huang M, Li L, Li K. A Clinical Predictive Nomogram for Traumatic Brain Parenchyma Hematoma Progression. Neurol Ther 2022; 11:185-203. [PMID: 34855160 PMCID: PMC8857351 DOI: 10.1007/s40120-021-00306-8] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/10/2021] [Accepted: 11/22/2021] [Indexed: 02/05/2023] Open
Abstract
INTRODUCTION Acute traumatic intraparenchymal hematoma (tICH) expansion is a major cause of clinical deterioration after brain contusion. Here, an accurate prediction tool for acute tICH expansion is proposed. METHODS A multicenter hospital-based study for multivariable prediction model was conducted among patients (889 patients in a development dataset and 264 individuals in an external validation dataset) with initial and follow-up computed tomography (CT) imaging for tICH volume evaluation. Semi-automated software was employed to assess tICH expansion. Two multivariate predictive models for acute tICH expansion were developed and externally validated. RESULTS A total of 198 (22.27%) individuals had remarkable acute tICH expansion. The novel Traumatic Parenchymatous Hematoma Expansion Aid (TPHEA) model retained several variables, including age, coagulopathy, baseline tICH volume, time to baseline CT time, subdural hemorrhage, a novel imaging marker of multihematoma fuzzy sign, and an inflammatory index of monocyte-to-lymphocyte ratio. Compared with multihematoma fuzzy sign, monocyte-to-lymphocyte ratio, and the basic model, the TPHEA model exhibited optimal discrimination, calibration, and clinical net benefits for patients with acute tICH expansion. A TPHEA nomogram was subsequently introduced from this model to facilitate clinical application. In an external dataset, this device showed good predicting performance for acute tICH expansion. CONCLUSIONS The main predictive factors in the TPHEA nomogram are the monocyte-to-lymphocyte ratio, baseline tICH volume, and multihematoma fuzzy sign. This user-friendly tool can estimate acute tICH expansion and optimize personalized treatments for individuals with brain contusion.
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Affiliation(s)
- Jiangtao Sheng
- Department of Microbiology and Immunology, Guangdong Provincial Key Laboratory of Infectious Disease and Molecular Immunopathology, Shantou University Medical College, 22 Xinling Road, Shantou, 515041, Guangdong, Chin
| | - Weiqiang Chen
- Department of Neurosurgery, First Affiliated Hospital of Shantou University Medical College, 57 Changping Road, Shantou, 515041, Guangdong, China
| | - Dongzhou Zhuang
- Department of Neurosurgery, First Affiliated Hospital of Shantou University Medical College, 57 Changping Road, Shantou, 515041, Guangdong, China
| | - Tian Li
- Department of Microbiology and Immunology, Guangdong Provincial Key Laboratory of Infectious Disease and Molecular Immunopathology, Shantou University Medical College, 22 Xinling Road, Shantou, 515041, Guangdong, China
| | - Jinhua Yang
- Department of Neurosurgery, First Affiliated Hospital of Shantou University Medical College, 57 Changping Road, Shantou, 515041, Guangdong, China
| | - Shirong Cai
- Department of Neurosurgery, First Affiliated Hospital of Shantou University Medical College, 57 Changping Road, Shantou, 515041, Guangdong, China
| | - Xiaoxuan Chen
- Department of Microbiology and Immunology, Guangdong Provincial Key Laboratory of Infectious Disease and Molecular Immunopathology, Shantou University Medical College, 22 Xinling Road, Shantou, 515041, Guangdong, China
| | - Xueer Liu
- Department of Microbiology and Immunology, Guangdong Provincial Key Laboratory of Infectious Disease and Molecular Immunopathology, Shantou University Medical College, 22 Xinling Road, Shantou, 515041, Guangdong, China
| | - Fei Tian
- Department of Neurosurgery, Second Affiliated Hospital of Shantou University Medical College, Shantou, Guangdong, China
| | - Mindong Huang
- Department of Neurosurgery, Affiliated Jieyang Hospital of Sun Yat-Sen University, Jieyang, Guangdong, China
| | - Lianjie Li
- Department of Neurosurgery, Affiliated East Hospital of Xiamen University Medical College, Fuzhou, Fujian, China
| | - Kangsheng Li
- Department of Microbiology and Immunology, Guangdong Provincial Key Laboratory of Infectious Disease and Molecular Immunopathology, Shantou University Medical College, 22 Xinling Road, Shantou, 515041, Guangdong, China
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Falcone J, Chen JW. Early Minimally Invasive Parafascicular Surgery for Evacuation of Spontaneous Intracerebral Hemorrhage in the Setting of Computed Tomography Angiography Spot Sign: A Case Series. Oper Neurosurg (Hagerstown) 2022; 22:123-130. [PMID: 35030111 DOI: 10.1227/ons.0000000000000078] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2021] [Accepted: 10/03/2021] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Spontaneous intracerebral hemorrhage (sICH) is associated with high morbidity and mortality, and the role of surgery is uncertain. Spot sign on computed tomography angiography (CTA) has previously been seen as a contraindication for minimally invasive techniques. OBJECTIVE To demonstrate the use of minimally invasive parafascicular surgery (MIPS) for early evacuation of sICH in patients with spot sign on CTA. METHODS Retrospective review of patients presenting to a US tertiary academic medical center from 2018 to 2020 with sICH and CTA spot sign who were treated with MIPS within 6 h of arrival. RESULTS Seven patients (6 men and 1 woman, mean age 54.4 yr) were included in this study. There was a significant decrease between preoperative and postoperative intracerebral hemorrhage volumes (75.03 ± 39.00 cm3 vs 19.48 ± 17.81 cm3, P = .005) and intracerebral hemorrhage score (3.1 ± 0.9 vs 1.9 ± 0.9, P = .020). The mean time from arrival to surgery was 3.72 h (±1.22 h). The mean percentage of hematoma evacuation was 73.78% (±21.11%). The in-hospital mortality was 14.29%, and the mean modified Rankin score at discharge was 4.6 (±1.3). No complications related to the surgery were encountered in any of the cases, with no abnormal intraoperative bleeding and no pathology demonstrating occult vascular lesion. CONCLUSION Early intervention with MIPS appears to be a safe and effective means of hematoma evacuation despite the presence of CTA spot sign, and this finding should not delay early intervention when indicated. Intraoperative hemostasis may be facilitated by the direct visualization provided by a tubular retractor system.
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Affiliation(s)
- Joseph Falcone
- Department of Neurosurgery, University of California Irvine, Orange, California, USA
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Guo Y, Guo XM, Li RL, Zhao K, Bao QJ, Yang JC, Zhang Q, Yang MF. Tranexamic Acid for Acute Spontaneous Intracerebral Hemorrhage: A Meta-Analysis of Randomized Controlled Trials. Front Neurol 2022; 12:761185. [PMID: 34987465 PMCID: PMC8720763 DOI: 10.3389/fneur.2021.761185] [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: 08/19/2021] [Accepted: 11/25/2021] [Indexed: 11/13/2022] Open
Abstract
Background: The role of tranexamic acid (TXA) in preventing hematoma expansion (HE) in patients with acute spontaneous intracerebral hemorrhage (ICH) remains unclear. We aim to investigate the efficacy and safety of TXA in acute spontaneous ICH with a particular focus on subgroups. Methods: Randomized controlled trials (RCTs) were retrieved from CENTRAL, Clinicaltrials.gov, EMBASE, PubMed, and WHO ICTRP. The primary outcome measurement was HE. The secondary outcome measurements included 3-month poor functional outcome (PFO), 3-month mortality, and major thromboembolic events (MTE). We conducted subgroup analysis according to the CT markers of HE (standard-risk population and high-risk population) and the time from onset to randomization (>4.5 and ≤4.5 h). Results: We identified seven studies (representing five RCTs) involving 2,650 participants. Compared with placebo, TXA may reduce HE on subsequent imaging (odd ratio [OR] 0.825; 95% confidence interval [CI] 0.692–0.984; p = 0.033; I2 = 0%; GRADE: moderate certainty). TXA and placebo arms did not differ in the rates of 3-month PFO, 3-month mortality, and MTE. Subgroup analysis indicated that TXA reduced the risk of HE in the high-risk population with CT markers of HE (OR 0.646; 95% CI 0.503–0.829; p = 0.001; I2 = 0 %) and in patients who were treated within 4.5 h of symptom onset (OR 0.823; 95% CI 0.690–0.980; p = 0.029; I2 = 0%), but this protective effect was not observed in the standard-risk population and patients who were treated over 4.5 h of symptom onset. Conclusions: Tranexamic acid (TXA) may decrease the risk of HE in patients with acute spontaneous ICH. Importantly, the decreased risk was observed in patients who were treatable within 4.5 h and with a high risk of HE, but not in those who were treatable over 4.5 h and in standard-risk population. However, PFO or mortality at 3 months did not significantly differ between patients who received TXA and those who received placebo. TXA is safe for acute spontaneous ICH without increasing MTE.
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Affiliation(s)
- Yu Guo
- Graduate School, Qinghai University, Xining, China
| | - Xin-Mei Guo
- Biomedical Engineering Research Center, Kunming Medical University, Kunming, China
| | - Rui-Li Li
- Neurological Intensive Care Department, Shengli Oilfield Central Hospital, Dongying, China
| | - Kai Zhao
- Graduate School, Qinghai University, Xining, China
| | - Qiang-Ji Bao
- Graduate School, Qinghai University, Xining, China
| | - Jin-Cai Yang
- Graduate School, Qinghai University, Xining, China
| | - Qiang Zhang
- Department of Neurosurgery, Qinghai Provincial People's Hospital, Xining, China
| | - Ming-Fei Yang
- Department of Neurosurgery, Qinghai Provincial People's Hospital, Xining, China
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Chen D, Tang Y, Nie H, Zhang P, Wang W, Dong Q, Wu G, Xue M, Tang Y, Liu W, Pan C, Tang Z. Primary Brainstem Hemorrhage: A Review of Prognostic Factors and Surgical Management. Front Neurol 2021; 12:727962. [PMID: 34566872 PMCID: PMC8460873 DOI: 10.3389/fneur.2021.727962] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2021] [Accepted: 08/19/2021] [Indexed: 01/04/2023] Open
Abstract
Primary brainstem hemorrhage (PBSH) is the most fatal subtype of intracerebral hemorrhage and is invariably associated with poor prognosis. Several prognostic factors are involved, of which the two most predominant and consistent are the initial level of consciousness and hemorrhage size. Other predictors, such as age, hyperthermia, and hydrocephalus, are generally not dependable indicators for making prognoses. Scoring systems have now been developed that can predict mortality and functional outcomes in patients suffering from PBSH, which can thus guide treatment decision-making. A novel grading scale, entitled “the new primary pontine hemorrhage (PPH) score,” represents the latest approach in scoring systems. In this system, patients with a score of 2–3 points appear to benefit from surgical management, although this claim requires further verification. The four main surgical options for the treatment of PBSH are craniotomy, stereotactic hematoma puncture and drainage, endoscopic hematoma removal, and external ventricular drainage. Nevertheless, the management of PBSH still primarily involves conservative treatment methods and surgery is generally not recommended, according to current practice. However, the ongoing clinical trial, entitled Safety and Efficacy of Surgical Treatment in Severe Primary Pontine Hemorrhage Evacuation (STIPE), should provide additional evidence to support the surgical treatment of PBSH. Therefore, we advocate the update of epidemiological data and re-evaluation of PBSH treatment in a contemporary context.
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Affiliation(s)
- Danyang Chen
- Department of Neurology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Yingxin Tang
- Department of Neurology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Hao Nie
- Department of Geriatrics, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Ping Zhang
- Department of Neurology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Wenzhi Wang
- Department of Neuroepidemiology, Beijing Neurosurgical Institute, Capital Medical University, Beijing, China
| | - Qiang Dong
- Department of Neurology, Huashan Hospital, Fudan University, Shanghai, China
| | - Guofeng Wu
- Department of Emergency, Affiliated Hospital of Guizhou Medical University, Guiyang, China
| | - Mengzhou Xue
- The Department of Cerebrovascular Diseases, The Second Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Yuping Tang
- Department of Neurology, Huashan Hospital, Fudan University, Shanghai, China
| | - Wenjie Liu
- Beijing WanTeFu Medical Apparatus Co., Ltd., Beijing, China
| | - Chao Pan
- Department of Neurology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Zhouping Tang
- Department of Neurology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
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Li J, Liao X, Yu Z, Li H, Zheng J. Predictive Ability of Ultraearly Hematoma Growth and Spot Sign for Redefined Hematoma Expansion in Patients with Spontaneous Intracerebral Hemorrhage. J Stroke Cerebrovasc Dis 2021; 30:105950. [PMID: 34214962 DOI: 10.1016/j.jstrokecerebrovasdis.2021.105950] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2021] [Revised: 06/03/2021] [Accepted: 06/13/2021] [Indexed: 02/08/2023] Open
Abstract
BACKGROUND Redefined hematoma expansion (rHE) including intraventricular hematoma expansion (IVHE) is a new concept in intracerebral hemorrhage (ICH), with better prognostic ability compared to the conventional hematoma expansion. Ultraearly hematoma growth (uHG) and computed tomography angiography (CTA) spot sign are both useful indictors to predict HE and poor clinical outcome. This study aims to explore the clinical characteristics of rHE in retrospective cohort and evaluate the predictive ability of uHG and spot sign in rHE. MATERIALS AND METHODS This study included nontraumatic spontaneous ICH patients from June 1st 2013 and January 1st 2018 in West China Hospital. Multivariate logistic regression was used to determine risk factors for HE/IVHE/rHE and primary outcomes of ICH patients. Receiver operating characteristic (ROC) analysis was performed to assess the accuracy of uHG and spot sign for predicting HE/IVHE/rHE. RESULTS This retrospective cohort included 469 consecutive patients with ICH. rHE was significantly associated with clinical variables including Glasgow coma scale (GCS), time to initial CT, presence of IVH, hematoma volume, presence of spot sign, and uHG. uHG and spot sign were independent risk factors for rHE. ROC analysis indicated that both uHG (AUC 0.726, 95%CI 0.680-0.773) and spot sign (AUC 0.735, 95%CI 0.686-0.785) possessed high predictive accuracy for rHE. HE and rHE were independent risk factors for 1-month mortality and 3-month functional outcome. CONCLUSIONS Both uHG and the spot sign were considered to be good predictors for rHE, and the spot sign appeared to have a better predictive accuracy.
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Affiliation(s)
- Junhong Li
- Department of Neurosurgery, West China Hospital of Sichuan University, Chengdu, Sichuan 610041, PR China.
| | - Xiang Liao
- Department of Cardiology, PLA Rocket Force Characteristic Medical Center, Beijing 100088, PR China..
| | - Zhiyuan Yu
- Department of Neurosurgery, West China Hospital of Sichuan University, Chengdu, Sichuan 610041, PR China.
| | - Hao Li
- Department of Neurosurgery, West China Hospital of Sichuan University, Chengdu, Sichuan 610041, PR China.
| | - Jun Zheng
- Department of Neurosurgery, West China Hospital of Sichuan University, Chengdu, Sichuan 610041, PR China.
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Gladstone DJ, Aviv RI, Demchuk AM, Hill MD, Thorpe KE, Khoury JC, Sucharew HJ, Al-Ajlan F, Butcher K, Dowlatshahi D, Gubitz G, De Masi S, Hall J, Gregg D, Mamdani M, Shamy M, Swartz RH, Del Campo CM, Cucchiara B, Panagos P, Goldstein JN, Carrozzella J, Jauch EC, Broderick JP, Flaherty ML. Effect of Recombinant Activated Coagulation Factor VII on Hemorrhage Expansion Among Patients With Spot Sign-Positive Acute Intracerebral Hemorrhage: The SPOTLIGHT and STOP-IT Randomized Clinical Trials. JAMA Neurol 2021; 76:1493-1501. [PMID: 31424491 DOI: 10.1001/jamaneurol.2019.2636] [Citation(s) in RCA: 73] [Impact Index Per Article: 24.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
Importance Intracerebral hemorrhage (ICH) is a devastating stroke type that lacks effective treatments. An imaging biomarker of ICH expansion-the computed tomography (CT) angiography spot sign-may identify a subgroup that could benefit from hemostatic therapy. Objective To investigate whether recombinant activated coagulation factor VII (rFVIIa) reduces hemorrhage expansion among patients with spot sign-positive ICH. Design, Setting, and Participants In parallel investigator-initiated, multicenter, double-blind, placebo-controlled randomized clinical trials in Canada ("Spot Sign" Selection of Intracerebral Hemorrhage to Guide Hemostatic Therapy [SPOTLIGHT]) and the United States (The Spot Sign for Predicting and Treating ICH Growth Study [STOP-IT]) with harmonized protocols and a preplanned individual patient-level pooled analysis, patients presenting to the emergency department with an acute primary spontaneous ICH and a spot sign on CT angiography were recruited. Data were collected from November 2010 to May 2016. Data were analyzed from November 2016 to May 2017. Interventions Eligible patients were randomly assigned 80 μg/kg of intravenous rFVIIa or placebo as soon as possible within 6.5 hours of stroke onset. Main Outcomes and Measures Head CT at 24 hours assessed parenchymal ICH volume expansion from baseline (primary outcome) and total (ie, parenchymal plus intraventricular) hemorrhage volume expansion (secondary outcome). The pooled analysis compared hemorrhage expansion between groups by analyzing 24-hour volumes in a linear regression model adjusted for baseline volumes, time from stroke onset to treatment, and trial. Results Of the 69 included patients, 35 (51%) were male, and the median (interquartile range [IQR]) age was 70 (59-80) years. Baseline median (IQR) ICH volumes were 16.3 (9.6-39.2) mL in the rFVIIa group and 20.4 (8.6-32.6) mL in the placebo group. Median (IQR) time from CT to treatment was 71 (57-96) minutes, and the median (IQR) time from stroke onset to treatment was 178 (138-197) minutes. The median (IQR) increase in ICH volume from baseline to 24 hours was small in both the rFVIIa group (2.5 [0-10.2] mL) and placebo group (2.6 [0-6.6] mL). After adjustment, there was no difference between groups on measures of ICH or total hemorrhage expansion. At 90 days, 9 of 30 patients in the rFVIIa group and 13 of 34 in the placebo group had died or were severely disabled (P = .60). Conclusions and Relevance Among patients with spot sign-positive ICH treated a median of about 3 hours from stroke onset, rFVIIa did not significantly improve radiographic or clinical outcomes. Trial Registration ClinicalTrials.gov identifier: NCT01359202 and NCT00810888.
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Affiliation(s)
- David J Gladstone
- Division of Neurology, Department of Medicine, University of Toronto, Toronto, Ontario, Canada.,Hurvitz Brain Sciences Program, Sunnybrook Research Institute, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Richard I Aviv
- Hurvitz Brain Sciences Program, Sunnybrook Research Institute, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada.,Department of Medical Imaging, University of Toronto, Toronto, Ontario, Canada
| | - Andrew M Demchuk
- Department of Clinical Neurosciences and Radiology, Hotchkiss Brain Institute, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Michael D Hill
- Department of Clinical Neurosciences and Radiology, Hotchkiss Brain Institute, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada.,Department of Community Health Sciences and Medicine, Hotchkiss Brain Institute, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Kevin E Thorpe
- Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada.,Applied Health Research Centre, Li Ka Shing Knowledge Institute of St Michael's Hospital, Toronto, Ontario, Canada
| | - Jane C Khoury
- Division of Biostatistics and Epidemiology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio.,Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Heidi J Sucharew
- Division of Biostatistics and Epidemiology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio.,Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Fahad Al-Ajlan
- Department of Neurosciences, King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia
| | - Ken Butcher
- University of New South Wales, Prince of Wales Clinical School, Sydney, New South Wales, Australia
| | - Dar Dowlatshahi
- Ottawa Hospital Research Institute, University of Ottawa, Ottawa, Ontario, Canada
| | - Gord Gubitz
- Division of Neurology, Department of Medicine, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Stephanie De Masi
- Applied Health Research Centre, Li Ka Shing Knowledge Institute of St Michael's Hospital, Toronto, Ontario, Canada
| | - Judith Hall
- Applied Health Research Centre, Li Ka Shing Knowledge Institute of St Michael's Hospital, Toronto, Ontario, Canada
| | - David Gregg
- Division of Cardiology, Department of Medicine, Medical University of South Carolina, Charleston
| | - Muhammad Mamdani
- Applied Health Research Centre, Li Ka Shing Knowledge Institute of St Michael's Hospital, Toronto, Ontario, Canada
| | | | - Richard H Swartz
- Division of Neurology, Department of Medicine, University of Toronto, Toronto, Ontario, Canada.,Hurvitz Brain Sciences Program, Sunnybrook Research Institute, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - C Martin Del Campo
- Division of Neurology, Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Brett Cucchiara
- Department of Neurology, University of Pennsylvania, Philadelphia
| | - Peter Panagos
- Department of Emergency Medicine, Washington University in St Louis, St Louis, Missouri
| | - Joshua N Goldstein
- Department of Emergency Medicine, Massachusetts General Hospital, Boston
| | - Janice Carrozzella
- Department of Radiology, University of Cincinnati Academic Health Center, Cincinnati, Ohio
| | - Edward C Jauch
- Mission Research Institute, Mission Health System, Asheville, North Carolina
| | - Joseph P Broderick
- Department of Neurology, University of Cincinnati Academic Health Center, Cincinnati, Ohio
| | - Matthew L Flaherty
- Department of Neurology, University of Cincinnati Academic Health Center, Cincinnati, Ohio
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Affiliation(s)
- Barbara Casolla
- Department of Neurology, University Lille, Inserm U1171, Degenerative & Vascular Cognitive Disorders, Centre Hospitalier Universitaire de Lille, Lille, France
| | - Charlotte Cordonnier
- Department of Neurology, University Lille, Inserm U1171, Degenerative & Vascular Cognitive Disorders, Centre Hospitalier Universitaire de Lille, Lille, France
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Singh SD, Pasi M, Schreuder FHBM, Morotti A, Senff JR, Warren AD, McKaig BN, Schwab K, Gurol ME, Rosand J, Greenberg SM, Viswanathan A, Klijn CJM, Rinkel GJE, Goldstein JN, Brouwers HB. Computed Tomography Angiography Spot Sign, Hematoma Expansion, and Functional Outcome in Spontaneous Cerebellar Intracerebral Hemorrhage. Stroke 2021; 52:2902-2909. [PMID: 34126759 DOI: 10.1161/strokeaha.120.033297] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
[Figure: see text].
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Affiliation(s)
- Sanjula D Singh
- Hemorrhagic Stroke Research Program, Department of Neurology, Massachusetts General Hospital Stroke Research Center (S.D.S., A.D.W., B.N.M., K.S., M.E.G., J.R., S.M.G., A.V.), Massachusetts General Hospital, Harvard Medical School, Boston.,Department of Neurology and Neurosurgery, Brain Center Rudolf Magnus, University Medical Center Utrecht, the Netherlands (S.D.S., J.R.S., G.J.E.R., H.B.B.)
| | - Marco Pasi
- University of Lille, Inserm, CHU Lille, U1172 - LilNCog - Lille Neuroscience and Cognition, France (M.P.)
| | - Floris H B M Schreuder
- Department of Neurology, Donders Institute for Brain Cognition and Behavior, Center for Neuroscience, Radboud University Medical Center, Nijmegen, the Netherlands (F.H.B.M.S., C.J.M.K.)
| | - Andrea Morotti
- ASST Valcamonica, Neurology Unit, Esine (BS), Italy (A.M.)
| | - Jasper R Senff
- Department of Neurology and Neurosurgery, Brain Center Rudolf Magnus, University Medical Center Utrecht, the Netherlands (S.D.S., J.R.S., G.J.E.R., H.B.B.)
| | - Andrew D Warren
- Hemorrhagic Stroke Research Program, Department of Neurology, Massachusetts General Hospital Stroke Research Center (S.D.S., A.D.W., B.N.M., K.S., M.E.G., J.R., S.M.G., A.V.), Massachusetts General Hospital, Harvard Medical School, Boston
| | - Brenna N McKaig
- Hemorrhagic Stroke Research Program, Department of Neurology, Massachusetts General Hospital Stroke Research Center (S.D.S., A.D.W., B.N.M., K.S., M.E.G., J.R., S.M.G., A.V.), Massachusetts General Hospital, Harvard Medical School, Boston
| | - Kristin Schwab
- Hemorrhagic Stroke Research Program, Department of Neurology, Massachusetts General Hospital Stroke Research Center (S.D.S., A.D.W., B.N.M., K.S., M.E.G., J.R., S.M.G., A.V.), Massachusetts General Hospital, Harvard Medical School, Boston
| | - M Edip Gurol
- Hemorrhagic Stroke Research Program, Department of Neurology, Massachusetts General Hospital Stroke Research Center (S.D.S., A.D.W., B.N.M., K.S., M.E.G., J.R., S.M.G., A.V.), Massachusetts General Hospital, Harvard Medical School, Boston
| | - Jonathan Rosand
- Hemorrhagic Stroke Research Program, Department of Neurology, Massachusetts General Hospital Stroke Research Center (S.D.S., A.D.W., B.N.M., K.S., M.E.G., J.R., S.M.G., A.V.), Massachusetts General Hospital, Harvard Medical School, Boston.,Center for Genomic Medicine (J.R.), Massachusetts General Hospital, Harvard Medical School, Boston.,Division of Neurocritical Care and Emergency Neurology (J.R., J.N.G.), Massachusetts General Hospital, Harvard Medical School, Boston
| | - Steven M Greenberg
- Hemorrhagic Stroke Research Program, Department of Neurology, Massachusetts General Hospital Stroke Research Center (S.D.S., A.D.W., B.N.M., K.S., M.E.G., J.R., S.M.G., A.V.), Massachusetts General Hospital, Harvard Medical School, Boston
| | - Anand Viswanathan
- Hemorrhagic Stroke Research Program, Department of Neurology, Massachusetts General Hospital Stroke Research Center (S.D.S., A.D.W., B.N.M., K.S., M.E.G., J.R., S.M.G., A.V.), Massachusetts General Hospital, Harvard Medical School, Boston
| | - Catharina J M Klijn
- Department of Neurology, Donders Institute for Brain Cognition and Behavior, Center for Neuroscience, Radboud University Medical Center, Nijmegen, the Netherlands (F.H.B.M.S., C.J.M.K.)
| | - Gabriel J E Rinkel
- Department of Neurology and Neurosurgery, Brain Center Rudolf Magnus, University Medical Center Utrecht, the Netherlands (S.D.S., J.R.S., G.J.E.R., H.B.B.)
| | - Joshua N Goldstein
- Division of Neurocritical Care and Emergency Neurology (J.R., J.N.G.), Massachusetts General Hospital, Harvard Medical School, Boston.,Department of Emergency Medicine (J.N.G.), Massachusetts General Hospital, Harvard Medical School, Boston
| | - H Bart Brouwers
- Department of Neurology and Neurosurgery, Brain Center Rudolf Magnus, University Medical Center Utrecht, the Netherlands (S.D.S., J.R.S., G.J.E.R., H.B.B.)
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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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Yi P, Xu M, Chen P, Luo Y, Wang D, Wang H, Wang C. Eliminating vascular interference from the Spot Sign contributes to predicting hematoma expansion in individuals with spontaneous cerebral hemorrhages. Acta Neurol Belg 2021; 121:521-528. [PMID: 31734794 DOI: 10.1007/s13760-019-01244-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2019] [Accepted: 11/07/2019] [Indexed: 10/25/2022]
Abstract
The computed tomography angiography (CTA) Spot Sign is an effective means of predicting hematoma expansion (HE) in the context of spontaneous intracerebral hemorrhage (ICH). We investigated whether continuous CTA source images could differentiate the Spot Sign and blood vessels in the hematoma, and whether it would improve Spot Sign accuracy as an HE predictor. We screened for the presence of CTA Spot Sign in individuals affected by spontaneous ICH within 24 h of symptom development. Based on our findings, we determined the sensitivity, specificity, and positive/negative predictive values of this sign as a predictor of HE both on its own and following the exclusion of blood vessels. In addition, a receiver-operating characteristic approach was used to assess the accuracy of Spot Sign with and without elimination of vascular interference. A total of 265 patients were included in this study. The Spot Sign was observed in 100 patients, including in 29 patients wherein it was confirmed to be blood vessels as determined based upon continuous CTA source images. With respect to predicting HE, Spot Sign sensitivity, specificity, positive predictive values, and negative predictive values were 57%, 71%, 48% and 78%, respectively. Following the exclusion of blood vessels, these values were 57%, 87%, 68% and 81%, respectively. Spot Sign area under the curve after excluding blood vessels was 0.718, which was higher than that of the Spot Sign (0.638). After continuous CTA, source images are used to exclude blood vessels in the hematoma, the Spot Sign is thus more accurate in predicting HE.
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30
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Tseng WC, Wang YF, Wang TG, Hsiao MY. Early spot sign is associated with functional outcomes in primary intracerebral hemorrhage survivors. BMC Neurol 2021; 21:131. [PMID: 33743639 PMCID: PMC7980675 DOI: 10.1186/s12883-021-02146-3] [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: 08/03/2020] [Accepted: 03/08/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The computed tomography angiography (CTA) spot sign is a validated predictor of hematoma expansion and 30-day mortality in intracerebral hemorrhage (ICH). However, whether the spot sign predicts worse functional outcomes among ICH survivors remains unclear. This study investigated the frequency of the spot sign and its association with functional outcomes and length of hospital stay among ICH survivors. METHODS This was a retrospective analysis of consecutive patients with primary ICH who received CTA within 24 h from presentation to admission to the emergency department of a single medical center between January 2007 and December 2017. Patients who died before discharge and those referred from other hospitals were excluded. CTAs with motion artifacts were excluded from the analysis. The presence of a spot sign was examined by an experienced neuroradiologist. Functional outcomes were determined based on the modified Rankin Scale (mRS) score and Barthel Index (BI). Severe dependency in activities of daily living (ADL) was defined as BI of ≤60 and severe disability as an mRS score of ≥4. Odds ratio (OR) and multiple linear regression were used as measures of association. RESULTS In total, 66 patients met the inclusion criteria, of whom 9 (13.64%) were positive for a spot sign. No significant differences were observed in baseline characteristics between patients with and without a spot sign. Patients with a spot sign tended to be severely dependent in ADL at discharge (66.67% vs 41.07%; OR = 2.87; p = 0.15) and were more likely to require ICH-related surgery (66.67% vs 24.56%; OR = 6.14; p = 0.01). In multiple linear regression, patients with a higher spot sign score had a significantly longer hospital stay (coefficient = 9.57; 95% CI = 2.11-17.03; p = 0.013). CONCLUSIONS The presence of a spot sign is a common finding and is associated with longer hospital stay and possibly worse functional outcomes in ICH survivors.
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Affiliation(s)
- Wen-Che Tseng
- Department of Physical Medicine and Rehabilitation, National Taiwan University Hospital, 7, Zhongshan S. Rd., Taipei, Taiwan
| | - Yu-Fen Wang
- Department of Medical Imaging, National Taiwan University Hospital, 7, Zhongshan S. Rd., Taipei, Taiwan
| | - Tyng-Guey Wang
- Department of Physical Medicine and Rehabilitation, National Taiwan University Hospital, 7, Zhongshan S. Rd., Taipei, Taiwan.,Department of Physical Medicine and Rehabilitation, College of Medicine, National Taiwan University, 7, Zhongshan S. Rd., Taipei, Taiwan
| | - Ming-Yen Hsiao
- Department of Physical Medicine and Rehabilitation, National Taiwan University Hospital, 7, Zhongshan S. Rd., Taipei, Taiwan. .,Department of Physical Medicine and Rehabilitation, College of Medicine, National Taiwan University, 7, Zhongshan S. Rd., Taipei, Taiwan.
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Chen Q, Zhu D, Liu J, Zhang M, Xu H, Xiang Y, Zhan C, Zhang Y, Huang S, Yang Y. Clinical-radiomics Nomogram for Risk Estimation of Early Hematoma Expansion after Acute Intracerebral Hemorrhage. Acad Radiol 2021; 28:307-317. [PMID: 32238303 DOI: 10.1016/j.acra.2020.02.021] [Citation(s) in RCA: 33] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2019] [Revised: 02/05/2020] [Accepted: 02/14/2020] [Indexed: 10/24/2022]
Abstract
RATIONALE AND OBJECTIVES Noncontrast CT-based radiomics signature has shown ability for detecting hematoma expansion (HE) in spontaneous intracerebral hemorrhage (ICH). We sought to compare its predictive performance with clinical risk factors and develop a clinical-radiomics nomogram to assess the risk of early HE. MATERIALS AND METHODS In total, 1153 patients with ICH who underwent baseline cranial CT within 6 hours and follow-up scans within 72 hours of stroke onset were enrolled, of whom 864 (75%) were assigned to the derivation cohort and 289 (25%) to the validation cohort. Based on LASSO algorithm or stepwise logistic regression analysis, three models (clinical model, radiomics model, and hybrid model) were constructed to predict HE. The Akaike information criterion (AIC) and likelihood ratio test (LRT) were used for comparing the goodness of fit of the three models, and the AUC was used to evaluate their discrimination ability for HE. RESULTS The hybrid model (AIC = 681.426; χ2= 128.779) was the optimal model with the lowest AIC and highest chi-square values compared to the radiomics model (AIC = 767.979; χ2 = 110.234) or the clinical model (AIC = 753.757; χ2 = 56.448). The radiomics model was superior in the prediction of HE to the clinical model in both derivation (p = 0.009) and validation (p = 0.022) cohorts. In both datasets, the clinical-radiomics nomogram showed satisfactory discrimination and calibration for detecting HE (AUC = 0.771, Sensitivity = 87.0%; AUC = 0.820, Sensitivity = 88.1%; respectively). CONCLUSION Among patients with acute ICH, noncontrast CT-based radiomics model outperformed the clinical-only model in the prediction of HE, and the established clinical-radiomics nomogram with favorable performance can offer a noninvasive tool for the risk stratification of HE.
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Is the detectability of the spot sign on CT angiography depending on slice thickness and reconstruction type? Clin Neurol Neurosurg 2021; 203:106559. [PMID: 33618171 DOI: 10.1016/j.clineuro.2021.106559] [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: 01/19/2021] [Revised: 02/08/2021] [Accepted: 02/09/2021] [Indexed: 10/22/2022]
Abstract
OBJECTIVE The spot sign is a validated imaging marker widely used in CT angiography (CTA) to detect active bleeding and a higher risk of hematoma expansion in patients with intracerebral hemorrhage (ICH). The aim of this study was to investigate the detectability of spot signs on thin multiplanar projection reconstruction (MPR) images compared to thicker maximum intensity projection (MIP) images. METHODS In this retrospective analysis, we assessed imaging data of 146 patients with primary hypertensive/microangiopathic ICH who received emergency non-contrast computed tomography (NCCT) and CTA. Two experienced radiologists, blinded to each other, evaluated images of thin (1 mm) MPR images and thick (3 mm) MIP images on the presence of spot signs and performed a consensus reading. Kappa tests were used for data comparison. RESULTS In total, spot signs were observed in 27 cases (=18.5 %) in both thin MPR and thick MIP slices. Detectability of the spot sign did not differ in 1 mm MPR images and 3 mm MIP images (Cohen's kappa, 1.0; p = 0.00). Also, when the readings of the two radiologists were analyzed separately, results for MPR and MIP slices were similar (MPR: Cohen's kappa, 0.81, p = 0.00; MIP: Cohen's kappa, 0.74; p = 0.00). CONCLUSION No significant difference in the detectability of the spot sign could be demonstrated when comparing 1 mm MPR images with 3 mm MIP images.
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Sheng J, Yang J, Cai S, Zhuang D, Li T, Chen X, Wang G, Dai J, Ding F, Tian L, Zheng F, Tian F, Huang M, Li K, Chen W. Development and external validation of a novel multihematoma fuzzy sign on computed tomography for predicting traumatic intraparenchymal hematoma expansion. Sci Rep 2021; 11:2042. [PMID: 33479430 PMCID: PMC7819987 DOI: 10.1038/s41598-021-81685-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2020] [Accepted: 01/11/2021] [Indexed: 02/05/2023] Open
Abstract
Acute traumatic intraparenchymal hematoma (tICH) expansion is a devastating neurological complication that is associated with poor outcome after cerebral contusion. This study aimed to develop and validate a novel noncontrast computed tomography (CT) (NCCT) multihematoma fuzzy sign to predict acute tICH expansion. In this multicenter, prospective cohort study, multihematoma fuzzy signs on baseline CT were found in 212 (43.89%) of total 482 patients. Patients with the multihematoma fuzzy sign had a higher frequency of tICH expansion than those without (90.79% (138) vs. 46.71% (71)). The presence of multihematoma fuzzy sign was associated with increased risk for acute tICH expansion in entire cohort (odds ratio [OR]: 16.15; 95% confidence interval (CI) 8.85-29.47; P < 0.001) and in the cohort after propensity-score matching (OR: 9.37; 95% CI 4.52-19.43; P < 0.001). Receiver operating characteristic analysis indicated a better discriminative ability of the presence of multihematoma fuzzy sign for acute tICH expansion (AUC = 0.79; 95% CI 0.76-0.83), as was also observed in an external validation cohort (AUC = 0.76; 95% CI 0.67-0.84). The novel NCCT marker of multihematoma fuzzy sign could be easily identified on baseline CT and is an easy-to-use predictive tool for tICH expansion in the early stage of cerebral contusion.
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Affiliation(s)
- Jiangtao Sheng
- Department of Microbiology and Immunology and Key Immunopathology Laboratory of Guangdong Province, Shantou University Medical College, 22 Xinling Road, Shantou, Guangdong, China
| | - Jinhua Yang
- Department of Neurosurgery, First Affiliated Hospital of Shantou University Medical College, 57 Changping Road, Shantou, Guangdong, China
| | - Shirong Cai
- Department of Neurosurgery, First Affiliated Hospital of Shantou University Medical College, 57 Changping Road, Shantou, Guangdong, China
| | - Dongzhou Zhuang
- Department of Neurosurgery, First Affiliated Hospital of Shantou University Medical College, 57 Changping Road, Shantou, Guangdong, China
| | - Tian Li
- Department of Microbiology and Immunology and Key Immunopathology Laboratory of Guangdong Province, Shantou University Medical College, 22 Xinling Road, Shantou, Guangdong, China
| | - Xiaoxuan Chen
- Department of Microbiology and Immunology and Key Immunopathology Laboratory of Guangdong Province, Shantou University Medical College, 22 Xinling Road, Shantou, Guangdong, China
| | - Gefei Wang
- Department of Microbiology and Immunology and Key Immunopathology Laboratory of Guangdong Province, Shantou University Medical College, 22 Xinling Road, Shantou, Guangdong, China
| | - Jianping Dai
- Department of Microbiology and Immunology and Key Immunopathology Laboratory of Guangdong Province, Shantou University Medical College, 22 Xinling Road, Shantou, Guangdong, China
| | - Faxiu Ding
- Department of Neurosurgery, First Affiliated Hospital of Shantou University Medical College, 57 Changping Road, Shantou, Guangdong, China
| | - Lu Tian
- Department of Microbiology and Immunology and Key Immunopathology Laboratory of Guangdong Province, Shantou University Medical College, 22 Xinling Road, Shantou, Guangdong, China
| | - Fengqing Zheng
- Department of Microbiology and Immunology and Key Immunopathology Laboratory of Guangdong Province, Shantou University Medical College, 22 Xinling Road, Shantou, Guangdong, China
| | - Fei Tian
- Department of Neurosurgery, Second Affiliated Hospital of Shantou University Medical College, Shantou, Guangdong, China
| | - Mindong Huang
- Department of Neurosurgery, Affiliated Jieyang Hospital of Sun Yat-Sen University, Jieyang, Guangdong, China
| | - Kangsheng Li
- Department of Microbiology and Immunology and Key Immunopathology Laboratory of Guangdong Province, Shantou University Medical College, 22 Xinling Road, Shantou, Guangdong, China.
| | - Weiqiang Chen
- Department of Neurosurgery, First Affiliated Hospital of Shantou University Medical College, 57 Changping Road, Shantou, Guangdong, China.
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Sheng J, Li T, Zhuang D, Cai S, Yang J, Ding F, Chen X, Tian F, Huang M, Li L, Li K, Chen W. The Monocyte-to-Lymphocyte Ratio at Hospital Admission Is a Novel Predictor for Acute Traumatic Intraparenchymal Hemorrhage Expansion after Cerebral Contusion. Mediators Inflamm 2020; 2020:5483981. [PMID: 33456370 PMCID: PMC7785383 DOI: 10.1155/2020/5483981] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2020] [Revised: 11/27/2020] [Accepted: 12/12/2020] [Indexed: 02/05/2023] Open
Abstract
PURPOSE To explore the potential of monocyte-to-lymphocyte ratio (MLR) at hospital admission for predicting acute traumatic intraparenchymal hematoma (tICH) expansion in patients with cerebral contusion. Patients and Methods. This multicenter, observational study included patients with available at-hospital admission (baseline) and follow-up computed tomography for volumetric analysis (retrospective development cohort: 1146 patients; prospective validation cohort: 207 patients). Semiautomated software assessed tICH expansion (defined as ≥33% or 5 mL absolute growth). MLR was acquired from routine blood tests upon admission. We constructed two predictive models: basic combined model of clinical and imaging variables and MLR combined model of both MLR and other variables in the basic model. Receiver operating characteristic (ROC) analysis and decision curve analysis (DCA) were used to estimate the performance of MLR for predicting acute tICH expansion. RESULTS MLR was significantly larger in patients with acute tICH expansion compared to those without acute tICH expansion (mean [SD], 1.08 [1.05] vs. 0.59 [0.37], P < 0.001). A nonlinear positive relationship between MLR and the incidence of acute tICH expansion was observed. Multivariate logistic regression indicated MLR as an independent risk factor for acute tICH expansion (odds ratio (OR), 5.88; 95% confidence interval (CI), 4.02-8.61). The power of the multivariate model for predicting acute tICH expansion was substantially improved with the inclusion of MLR (AUC 0.86 vs. AUC 0.74, P < 0.001), as was also observed in an external validation cohort (AUC 0.83 vs. AUC 0.71, P < 0.001). The net benefit of MLR model was higher between threshold probabilities of 20-100% in DCA. For clinical application, a nomogram derived from the multivariate model with MLR was introduced. In addition, MLR was positively associated with 6-month unfavorable outcome. CONCLUSION MLR is a novel predictor for traumatic parenchymatous hematoma expansion. A nomogram derived from the MLR model may provide an easy-to-use tool for predicting acute tICH expansion and promoting the individualized treatment of patients with hemorrhagic cerebral contusion. MLR is associated with long-term outcome after cerebral contusion.
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Affiliation(s)
- Jiangtao Sheng
- Department of Microbiology and Immunology & Key Immunopathology Laboratory of Guangdong Province, Shantou University Medical College, Shantou, Guangdong, China
| | - Tian Li
- Department of Microbiology and Immunology & Key Immunopathology Laboratory of Guangdong Province, Shantou University Medical College, Shantou, Guangdong, China
| | - Dongzhou Zhuang
- Department of Neurosurgery, First Affiliated Hospital of Shantou University Medical College, Shantou, Guangdong, China
| | - Shirong Cai
- Department of Neurosurgery, First Affiliated Hospital of Shantou University Medical College, Shantou, Guangdong, China
| | - Jinhua Yang
- Department of Neurosurgery, First Affiliated Hospital of Shantou University Medical College, Shantou, Guangdong, China
| | - Faxiu Ding
- Department of Neurosurgery, First Affiliated Hospital of Shantou University Medical College, Shantou, Guangdong, China
| | - Xiaoxuan Chen
- Department of Microbiology and Immunology & Key Immunopathology Laboratory of Guangdong Province, Shantou University Medical College, Shantou, Guangdong, China
| | - Fei Tian
- Department of Neurosurgery, Second Affiliated Hospital of Shantou University Medical College, Shantou, Guangdong, China
| | - Mindong Huang
- Department of Neurosurgery, Affiliated Jieyang Hospital of Sun Yat-sen University, Jieyang, Guangdong, China
| | - Lianjie Li
- Department of Neurosurgery, Fuzhou General Hospital of Xiamen University Medical College, Fuzhou, Fujian, China
| | - Kangsheng Li
- Department of Microbiology and Immunology & Key Immunopathology Laboratory of Guangdong Province, Shantou University Medical College, Shantou, Guangdong, China
| | - Weiqiang Chen
- Department of Neurosurgery, First Affiliated Hospital of Shantou University Medical College, Shantou, Guangdong, China
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Zhang C, Ge H, Zhong J, Yin Y, Fang X, Zou Y, Feng H, Hu R. Development and validation of a nomogram for predicting hematoma expansion in intracerebral hemorrhage. J Clin Neurosci 2020; 82:99-104. [PMID: 33317748 DOI: 10.1016/j.jocn.2020.10.027] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2020] [Revised: 09/15/2020] [Accepted: 10/18/2020] [Indexed: 11/19/2022]
Abstract
BACKGROUND AND OBJECTIVE To develop and validate a clinical nomogram for individualized predicting hematoma expansion (HE) in patients with Intracerebral Hemorrhage (ICH). METHODS A total of 1025 patients with ICH were retrospectively enrolled in the development cohort between 2010 and 2016. We identified and integrated significant factors for HE to build a nomogram. The model was subjected to validation with a separate cohort of 397 patients from the 2017-2019. The predictive accuracy and discriminative ability were measured by concordance index (C-index). The primary outcome was HE, defined as hematoma growth more than 6 mL or 33% increase in the volume. RESULTS A total of 1025 patients were included for univariable analysis. HE occurred in 180 patients (17.6%). The time to initial CT (≤6h vs. >6 h; p = 0.001), NIHSS score (0-4 vs. 5-14 vs. ≥15; p = 0.031), CTA spot sign (yes vs. no vs. absent; p = 0.018), hypodensities (p = 0.000), blend sign (p = 0.005), and INR (<1.2 vs. ≥1.2; p = 0.009) were identified and entered into the nomogram. The calibration curves for probability of HE showed optimal agreement between nomogram prediction and actual observation. The C-index was 0.751. The validation cohort consisted of 397 patients and HE occurred in 78 patients (19.6%). The C-index was 0.743. CONCLUSIONS We developed and validated a nomogram that can individually predict HE for ICH in Chinese populations. This practical prognostic nomogram may help clinicians make decision of clinical practice and design of clinical studies.
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Affiliation(s)
- Chao Zhang
- Department of Neurosurgery and Key Laboratory of Neurotrauma, Southwest Hospital, Third Military Medical University (Army Medical University), Chongqing 400038, China
| | - Hongfei Ge
- Department of Neurosurgery and Key Laboratory of Neurotrauma, Southwest Hospital, Third Military Medical University (Army Medical University), Chongqing 400038, China
| | - Jun Zhong
- Department of Neurosurgery and Key Laboratory of Neurotrauma, Southwest Hospital, Third Military Medical University (Army Medical University), Chongqing 400038, China
| | - Yi Yin
- Department of Neurosurgery and Key Laboratory of Neurotrauma, Southwest Hospital, Third Military Medical University (Army Medical University), Chongqing 400038, China
| | - Xuanyu Fang
- Department of Neurosurgery and Key Laboratory of Neurotrauma, Southwest Hospital, Third Military Medical University (Army Medical University), Chongqing 400038, China
| | - Yongjie Zou
- Department of Neurosurgery and Key Laboratory of Neurotrauma, Southwest Hospital, Third Military Medical University (Army Medical University), Chongqing 400038, China
| | - Hua Feng
- Department of Neurosurgery and Key Laboratory of Neurotrauma, Southwest Hospital, Third Military Medical University (Army Medical University), Chongqing 400038, China
| | - Rong Hu
- Department of Neurosurgery and Key Laboratory of Neurotrauma, Southwest Hospital, Third Military Medical University (Army Medical University), Chongqing 400038, China.
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Wang J, Wang W, Liu Y, Zhao X. Associations Between Levels of High-Sensitivity C-Reactive Protein and Outcome After Intracerebral Hemorrhage. Front Neurol 2020; 11:535068. [PMID: 33123072 PMCID: PMC7573166 DOI: 10.3389/fneur.2020.535068] [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: 02/14/2020] [Accepted: 08/27/2020] [Indexed: 11/13/2022] Open
Abstract
Background: Patients with spontaneous intracerebral hemorrhage (ICH) have high mortality and morbidity rates; approximately one-third of patients with ICH experience hematoma expansion (HE). The spot sign is an established and validated imaging marker for HE. High-sensitivity C-reactive protein (hs-CRP) is an established laboratory marker for inflammation and secondary brain injury following ICH. Objective: To determine the association between the spot sign and hs-CRP, hematoma expansion, and clinical outcomes. Methods: Between December 2014 and September 2016, we prospectively recruited 1,964 patients with acute symptomatic ICH at 13 hospitals in Beijing, China. Next, we selected 92 patients within 24 h of the onset of symptoms from this cohort for the present study. ICH was diagnosed in the emergency room by non-contrast computed tomography (NCCT) scans. Follow-up scans were carried out within 48 h to evaluate patients for HE. Multidetector computed tomography angiography (MDCTA) was also used to identify spot signs. Blood samples were collected from each patient at admission in EDTA tubes (for plasma) or vacutainer tubes (for serum). hs-CRP values were determined by a particle-enhanced immunoturbidimetric assay in the laboratory at Beijing Tiantan Hospital, Capital Medical University. Patients were categorized into two groups according to their hs-CRP levels (hs-CRP <3 mg/L, hs-CRP ≥3 mg/L). Results: The incidences of spot sign and HE in our study cohort were 31.5 and 29.3%, respectively. Following the removal of potential confounding variables, stepwise-forward logistic regression analysis identified that an hs-CRP level ≥3 mg/L was not a significant indicator for either spot sign (p = 0.68) or HE (p = 0.07). However, an hs-CRP level ≥3 mg/L (odds ratio: 16.64, 95% confidence interval: 2.11-131.45, p = 0.008) was identified as an independent predictor of an unfavorable outcome 1 year after acute ICH. Conclusions: Our analyses identified that an hs-CRP level ≥3 mg/L was a significant indicator for an unfavorable outcome 1 year after acute ICH.
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Affiliation(s)
- Jing Wang
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,China National Clinical Research Center for Neurological Diseases, Beijing, China.,Center of Stroke, Beijing Institute for Brain Disorders, Beijing, China.,Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease, Beijing, China.,Beijing Key Laboratory of Central Nervous System Injury, Beijing, China
| | - Wenjuan Wang
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,China National Clinical Research Center for Neurological Diseases, Beijing, China.,Center of Stroke, Beijing Institute for Brain Disorders, Beijing, China.,Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease, Beijing, China.,Beijing Key Laboratory of Central Nervous System Injury, Beijing, China
| | - Yanfang Liu
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,China National Clinical Research Center for Neurological Diseases, Beijing, China.,Center of Stroke, Beijing Institute for Brain Disorders, Beijing, China.,Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease, Beijing, China.,Beijing Key Laboratory of Central Nervous System Injury, Beijing, China
| | - Xingquan Zhao
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,China National Clinical Research Center for Neurological Diseases, Beijing, China.,Center of Stroke, Beijing Institute for Brain Disorders, Beijing, China.,Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease, Beijing, China.,Beijing Key Laboratory of Central Nervous System Injury, Beijing, China
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Gupta R, Krishnam SP, Schaefer PW, Lev MH, Gilberto Gonzalez R. An East Coast Perspective on Artificial Intelligence and Machine Learning: Part 1: Hemorrhagic Stroke Imaging and Triage. Neuroimaging Clin N Am 2020; 30:459-466. [PMID: 33038996 DOI: 10.1016/j.nic.2020.07.005] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Hemorrhagic stroke is a medical emergency. Artificial intelligence techniques and algorithms may be used to automatically detect and quantitate intracranial hemorrhage in a semiautomated fashion. This article reviews the use of deep learning convolutional neural networks for managing hemorrhagic stroke. Such a capability may be used to alert appropriate care teams, make decisions about patient transport from a primary care center to a comprehensive stroke center, and assist in treatment selection. This article reviews artificial intelligence algorithms for intracranial hemorrhage detection, quantification, and prognostication. Multiple algorithms currently being explored are described and illustrated with the help of examples.
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Affiliation(s)
- Rajiv Gupta
- Department of Radiology, Division of Neuroradiology, Massachusetts General Hospital, Harvard Medical School, Room: GRB-273A, 55 Fruit Street, Boston, MA 02114, USA.
| | - Sanjith Prahas Krishnam
- Department of Neurology, University of Alabama at Birmingham, SC 350, 1720 2nd Avenue South, Birmingham, AL 35294, USA
| | - Pamela W Schaefer
- Department of Radiology, Division of Neuroradiology, Massachusetts General Hospital, Harvard Medical School, Room: GRB-273A, 55 Fruit Street, Boston, MA 02114, USA
| | - Michael H Lev
- Department of Radiology, Division of Emergency Radiology, Massachusetts General Hospital, Harvard Medical School, Room: GRB-273A, 55 Fruit Street, Boston, MA 02114, USA; Department of Radiology, Division of Neuroradiology, Massachusetts General Hospital, Room: GRB-273A, 55 Fruit Street, Boston, MA 02114, USA
| | - R Gilberto Gonzalez
- Department of Radiology, Division of Neuroradiology, Massachusetts General Hospital, Harvard Medical School, Room: GRB-273A, 55 Fruit Street, Boston, MA 02114, USA
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38
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Chu H, Huang C, Dong J, Dong Q, Tang Y. Absolute hypodensity sign by noncontrast computed tomography as a reliable predictor for early hematoma expansion. BRAIN HEMORRHAGES 2020. [DOI: 10.1016/j.hest.2020.07.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
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39
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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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40
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Barra ME, Das AS, Hayes BD, Rosenthal ES, Rosovsky RP, Fuh L, Patel AB, Goldstein JN, Roberts RJ. Evaluation of andexanet alfa and four-factor prothrombin complex concentrate (4F-PCC) for reversal of rivaroxaban- and apixaban-associated intracranial hemorrhages. J Thromb Haemost 2020; 18:1637-1647. [PMID: 32291874 DOI: 10.1111/jth.14838] [Citation(s) in RCA: 75] [Impact Index Per Article: 18.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2020] [Revised: 04/07/2020] [Accepted: 04/08/2020] [Indexed: 12/01/2022]
Abstract
BACKGROUND/OBJECTIVE Before approval of andexanet alfa, off-label treatment with 4-factor prothrombin complex concentrate (4F-PCC) was often utilized for the management of life-threatening hemorrhages associated with oral factor Xa inhibitors. We evaluated the operational processes and outcomes of patients with oral factor Xa inhibitor-associated intracranial hemorrhages (ICH) treated with andexanet alfa or 4F-PCC. METHODS We performed a retrospective, single-center case series of rivaroxaban or apixaban-associated ICH between 2016-2019 treated with andexanet alfa or 4F-PCC. Good or excellent hemostatic effectiveness, good functional outcome (Glasgow Outcome Score [GOS]> 3) at hospital discharge, and incidence of thrombosis within 30 days were reported. RESULTS Eighteen patients were included in the andexanet alfa cohort and 11 in the 4F-PCC cohort. Excellent or good hemostasis occurred in 88.9% of andexanet alfa-treated patients and 60% of 4F-PCC-treated patients. Good functional outcome on discharge occurred in 55.6% of andexanet alfa-treated patients and 9.1% of 4F-PCC-treated patients. Thrombotic complications occurred in 16.7% of andexanet alfa-treated patients and 9.1% of 4F-PCC-treated patients. Median order-to-administration time was 1.1 hours [0.8-1.4] versus 0.5 hours [0.1-0.8] in the andexanet alfa and 4F-PCC group, respectively. The median cost of therapy was $29970/patient versus $6925/patient in the andexanet alfa and 4F-PCC group, respectively. CONCLUSIONS We observed higher rates of occurrence of good or excellent hemostasis and GOS > 3 on hospital discharge and increased incidence of thrombosis in patients who received andexanet alfa compared to 4F-PCC for oral factor Xa inhibitor reversal. However, patients receiving 4F-PCC had lower pre-reversal Glasgow Coma Scale (GCS)score and larger pre-reversal ICH volume.
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Affiliation(s)
- Megan E Barra
- Department of Pharmacy, Massachusetts General Hospital, Boston, MA, USA
| | - Alvin S Das
- Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Bryan D Hayes
- Department of Pharmacy, Massachusetts General Hospital, Boston, MA, USA
- Department of Emergency Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Eric S Rosenthal
- Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Rachel P Rosovsky
- Department of Medicine, Division of Hematology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Lanting Fuh
- Department of Pharmacy, Massachusetts General Hospital, Boston, MA, USA
| | - Aman B Patel
- Department of Neurosurgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Joshua N Goldstein
- Department of Emergency Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Russel J Roberts
- Department of Pharmacy, Massachusetts General Hospital, Boston, MA, USA
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Caton MT, Wiggins WF, Nunez D. The “connecting vessel” sign: an imaging biomarker to differentiate ruptured infected (mycotic) intracranial aneurysm mimicking the CTA spot sign. Emerg Radiol 2020; 27:259-268. [DOI: 10.1007/s10140-020-01749-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2019] [Accepted: 01/03/2020] [Indexed: 10/25/2022]
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42
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Lv XN, Li Q. Imaging predictors for hematoma expansion in patients with intracerebral hemorrhage: A current review. BRAIN HEMORRHAGES 2020. [DOI: 10.1016/j.hest.2020.05.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
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43
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Zhang M, Chen J, Zhan C, Liu J, Chen Q, Xia T, Zhang T, Zhu D, Chen C, Yang Y. Blend Sign Is a Strong Predictor of the Extent of Early Hematoma Expansion in Spontaneous Intracerebral Hemorrhage. Front Neurol 2020; 11:334. [PMID: 32508731 PMCID: PMC7248383 DOI: 10.3389/fneur.2020.00334] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2020] [Accepted: 04/07/2020] [Indexed: 01/18/2023] Open
Abstract
Background and Purpose: It is unclear which imaging marker is optimal for predicting the extent of hematoma expansion (EHE). We aimed to compare the usefulness of the blend sign (BS) with that of other non-contrast computed tomography (NCCT) markers for predicting the EHE in patients with spontaneous intracerebral hemorrhage (sICH). Methods: Patients with sICH admitted to our Neurology Emergency Department between September 2013 and January 2019 were enrolled. The EHE was calculated as the absolute increase in hematoma volume between baseline and follow-up CT (within 72 h). The EHE was categorized into four groups: "no growth," "minimal change" (≤5.1 ml), "moderate change" (5.1-12.5 ml), and "massive change" (>12.5 ml). Univariate and multivariate analyses were performed to investigate the relationship between the NCCT markers [BS, black hole sign (BHS), satellite sign, and island sign] and the EHE. Results: A total of 1,111 sICH patients were included (median age: 60 years; 66.5% males). Multiple linear regression analysis showed that the presence of the BS and BHS was independently associated with the EHE, after adjusting for confounders (P < 0.001 and P = 0.003, respectively). The presence of the BS and BHS was positively correlated with growth category (r = 0.285 and r = 0.199, both Ps < 0.001). The BS demonstrated a better predictive performance for the EHE than did the BHS [area under the curve (AUC): 0.67 vs. 0.57; both Ps < 0.001]. Conclusions: In patients with acute sICH, the BS showed a better performance in predicting the EHE compared with other NCCT markers. This imaging marker may help identify patients at a high risk of significant hematoma expansion and may facilitate its early management.
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Affiliation(s)
| | | | | | | | | | | | | | | | | | - Yunjun Yang
- Department of Radiology, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, China
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Minimal Computed Tomography Attenuation Value Within the Hematoma is Associated with Hematoma Expansion and Poor Outcome in Intracerebral Hemorrhage Patients. Neurocrit Care 2020; 31:455-465. [PMID: 31363998 DOI: 10.1007/s12028-019-00754-z] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
BACKGROUND Early hematoma expansion in intracerebral hemorrhage (ICH) patients is associated with poor outcome. We aimed to investigate whether the minimal computed tomography (CT) attenuation value predicted hematoma expansion and poor outcome. METHODS This study involved spontaneous ICH patients of two cohorts who underwent baseline CT scan within 6 h after ICH onset and follow-up CT scan within 24 h after initial CT scan. We determined the critical value of the minimal CT attenuation value via retrospective analysis of the data from a derivation cohort. Then, a prospective study on the validation cohort of three clinical centers was performed for determining the association between the minimal CT attenuation value and hematoma expansion as well as poor outcome (modified Rankin Scale scores > 3) at 90 days by using univariate and multivariate logistic regression analyses. RESULTS One hundred and forty eight ICH patients were included in the derivation cohort. Minimal CT attenuation value ≤ 31 Hounsfield units (HU) was demonstrated as the critical value to predict hematoma expansion by using receiver operating characteristic analysis. A total of 311 ICH patients were enrolled in the validation cohort, 86 (27.7%) and 133 (42.8%) of which were found hematoma expansion and poor outcome. Minimal CT attenuation value ≤ 31 HU was positive in 73 patients (23.5%). The multivariate logistic regression analysis demonstrated minimal CT attenuation value and minimal CT attenuation value ≤ 31 HU independently predicted hematoma expansion (p < 0.001) and poor outcome (p < 0.001). The sensitivity, specificity, positive predictive value, negative predictive value, and accuracy of minimal CT attenuation value ≤ 31 HU for hematoma expansion and poor outcome prediction were 64.0, 92.0, 75.3, 87.0, 84.2 and 45.1%, 92.7%, 82.2%, 69.3%, 72.3%, respectively. CONCLUSIONS The minimal CT attenuation value independently predicts early hematoma expansion and poor outcome in patients with ICH.
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Yogendrakumar V, Moores M, Sikora L, Shamy M, Ramsay T, Fergusson D, Dowlatshahi D. Evaluating Hematoma Expansion Scores in Acute Spontaneous Intracerebral Hemorrhage. Stroke 2020; 51:1305-1308. [DOI: 10.1161/strokeaha.119.028574] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background and Purpose—
In acute spontaneous intracerebral hemorrhage, multiple hematoma expansion scores have been proposed for use in clinical trial environments. We performed a systematic scoping review to identify all existing hematoma expansion scores and describe their development, validation, and relative performance.
Methods—
Two reviewers searched MEDLINE, PUBMED, EMBASE, and CENTRAL (Cochrane Central Register of Controlled Trials) for studies that derived or validated a hematoma expansion prediction score in adults presenting with spontaneous intracerebral hemorrhage. A descriptive analysis of the extracted data was performed, focusing on score development techniques and predictive capabilities.
Results—
Of the 14 434 records retrieved, 15 studies met inclusion criteria and 10 prediction scores were identified. Validation analysis using independent samples was performed in 9 studies on 5 scores. All derivation studies reported high performance with C statistics ranging from 0.72 to 0.93. In validation, the C-statistic range was broader with studies reporting 0.62 to 0.77. For every score, the risk of expansion increased with each point increase, although patients with high scores were rare.
Conclusions—
At present, 10 hematoma expansion scores have been developed, of which 5 have been externally validated. Real-world performance in validation studies was lower than performance in derivation studies. Data from the current literature are insufficient to support a meaningful meta-analysis.
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Affiliation(s)
- Vignan Yogendrakumar
- From the Division of Neurology (V.Y., M.M., M.S., D.D.), University of Ottawa, Ontario, Canada
| | - Margaret Moores
- From the Division of Neurology (V.Y., M.M., M.S., D.D.), University of Ottawa, Ontario, Canada
| | - Lindsey Sikora
- Health Sciences Library (L.S.), University of Ottawa, Ontario, Canada
| | - Michel Shamy
- From the Division of Neurology (V.Y., M.M., M.S., D.D.), University of Ottawa, Ontario, Canada
| | - Tim Ramsay
- Ottawa Hospital Research Institute (T.R., D.F.), University of Ottawa, Ontario, Canada
| | - Dean Fergusson
- Ottawa Hospital Research Institute (T.R., D.F.), University of Ottawa, Ontario, Canada
| | - Dar Dowlatshahi
- From the Division of Neurology (V.Y., M.M., M.S., D.D.), University of Ottawa, Ontario, Canada
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Soun JE, Montes D, Yu F, Morotti A, Qureshi AI, Barnaure I, Rosand J, Goldstein JN, Romero JM. Spot Sign in Secondary Intraventricular Hemorrhage Predicts Early Neurological Decline. Clin Neuroradiol 2019; 30:761-768. [DOI: 10.1007/s00062-019-00857-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2019] [Accepted: 11/04/2019] [Indexed: 10/25/2022]
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Fu F, Sun S, Liu L, Gu H, Su Y, Li Y. Iodine Sign as a Novel Predictor of Hematoma Expansion and Poor Outcomes in Primary Intracerebral Hemorrhage Patients. Stroke 2019; 49:2074-2080. [PMID: 30354984 DOI: 10.1161/strokeaha.118.022017] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background and Purpose- The aim of the study was to investigate the utility of iodine contrast agent leakage (the iodine sign) analyzed by Gemstone spectral imaging in early hematoma formation compared with that of the spot sign for predicting early hematoma expansion (HE) and poor functional outcomes. Methods- From 2014 to 2017, 91 patients with spontaneous intracerebral hemorrhage who underwent spectral computed tomography angiography within 6 hours of spontaneous intracerebral hemorrhage onset were prospectively included in our study. We defined a positive iodine sign as tiny enhancing foci within the hematoma on Gemstone spectral imaging and an iodine concentration inside the foci of >7.82 (100 µg/mL). Univariate and multivariate logistical regression analyses were performed to assess risk factors for HE, and the predictive value of HE was analyzed. Results- Positive spot and iodine signs were present in 38.5% (35/91) and 57.1% (52/91) of the patients, respectively. Using multivariate analysis, the iodine sign independently predicted HE (odds ratio, 53.67; 95% CI, 11.88-242.42; P<0.001) and had a higher sensitivity (91.5% versus 63.8%), negative predictive value (89.7% versus 69.9%), and accuracy (85.7% versus 75.8%) for detecting HE than the spot sign. The iodine sign, but not the spot sign, was significantly related to poor functional outcomes (severely disabled and vegetative state) in all patients (χ2=29.97; P<0.001). Conclusions- The iodine sign is a reliable and sensitive marker for predicting HE and poor functional outcomes. Clinical Trial Registration- URL: https://www.clinicaltrials.gov . Unique identifier: NCT02625948.
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Affiliation(s)
- Fan Fu
- From the Department of Neuroradiology (F.F., Y.S., Y.L.)
| | - Shengjun Sun
- Beijing Tiantan Hospital, Capital Medical University, China; Department of Neuroradiology, Beijing Neurosurgical Institute, China (S.S.)
| | | | - Hongqiu Gu
- Department of Neurology, Tiantan Clinical Trial and Research Center for Stroke, Beijing Tiantan Hospital, Capital Medical University, China (H.G.)
| | - Yaping Su
- From the Department of Neuroradiology (F.F., Y.S., Y.L.)
| | - Yingying Li
- From the Department of Neuroradiology (F.F., Y.S., Y.L.)
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48
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Phan TG, Krishnadas N, Lai VWY, Batt M, Slater LA, Chandra RV, Srikanth V, Ma H. Meta-Analysis of Accuracy of the Spot Sign for Predicting Hematoma Growth and Clinical Outcomes. Stroke 2019; 50:2030-2036. [PMID: 31272327 DOI: 10.1161/strokeaha.118.024347] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Abstract
Background and Purpose- The computed tomography angiographic spot sign refers to contrast leakage within intracerebral hemorrhage (ICH). It has been proposed as a surrogate radiological marker for ICH growth. We conducted a meta-analysis to study the accuracy of the spot sign for predicting ICH growth and mortality. Methods- PubMed, Medline, conference proceedings, and article references in English up to June 2017 were searched for studies reporting "computed tomography angiography" and "spot sign" or "intracerebral hemorrhage" and "spot sign." Each study was ranked on 27 criteria resulting in a quality rating score. Bivariate random effect meta-analysis was used to calculate positive and negative likelihood ratios and area under summary receiver operating characteristics curve for ICH growth and mortality. Hematoma growth was defined using the change in ≥6 mL or ≥33% increase in volume. Results- There were 26 studies describing 5085 patients, including 15 studies not used in previous meta-analyses. Positive likelihood ratio and negative likelihood ratio for ICH growth were 4.85 (95% CI, 3.85-6.02; I2=76.1%) and 0.49 (95% CI, 0.40-0.58) and mortality were 4.65 (95% CI, 3.67-5.90) and 0.55 (95% CI, 0.40-0.69), respectively. For ICH growth, the pooled sensitivity was 0.57 (95% CI, 0.49-0.64) and pooled false positive rate was 0.12 (95% CI, 0.09-0.14). The post-test probability of ICH growth was 0.57. The area under the curve for ICH growth and mortality was 0.86 and 0.87 (CIs are not provided in bivariate method). Meta-regression showed sensitivity of the test to decline significantly with subsequent year of publication (β=-0.148; 95% CI, -0.295 to -0.001; P=0.05). Higher quality assessment is associated with lower false positive rate (β=-0.074; 95% CI, -0.126 to -0.022; P=0.006). Conclusions- The high area under the curve potentially suggests that the spot sign can predict hematoma growth and mortality. Caution is recommended in its application given the heterogeneity across studies, which is appropriate given the data.
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Affiliation(s)
- Thanh G Phan
- From the Clinical Trials, Imaging and Informatics Division, Stroke and Aging Research Group, School of Clinical Sciences at Monash Health, Monash University, Melbourne, Australia (T.G.P., N.K., V.W.Y.L., M.B., H.M.).,Stroke Unit (T.G.P., N.K., V.W.Y.L., M.B., H.M.), Monash Health, Melbourne, Australia
| | - Natasha Krishnadas
- From the Clinical Trials, Imaging and Informatics Division, Stroke and Aging Research Group, School of Clinical Sciences at Monash Health, Monash University, Melbourne, Australia (T.G.P., N.K., V.W.Y.L., M.B., H.M.).,Stroke Unit (T.G.P., N.K., V.W.Y.L., M.B., H.M.), Monash Health, Melbourne, Australia
| | - Vivian Wai Yun Lai
- From the Clinical Trials, Imaging and Informatics Division, Stroke and Aging Research Group, School of Clinical Sciences at Monash Health, Monash University, Melbourne, Australia (T.G.P., N.K., V.W.Y.L., M.B., H.M.)
| | - Michael Batt
- From the Clinical Trials, Imaging and Informatics Division, Stroke and Aging Research Group, School of Clinical Sciences at Monash Health, Monash University, Melbourne, Australia (T.G.P., N.K., V.W.Y.L., M.B., H.M.).,Stroke Unit (T.G.P., N.K., V.W.Y.L., M.B., H.M.), Monash Health, Melbourne, Australia
| | - Lee-Anne Slater
- Diagnostic imaging (L.-A.S., R.V.C.), Monash Health, Melbourne, Australia
| | - Ronil V Chandra
- Diagnostic imaging (L.-A.S., R.V.C.), Monash Health, Melbourne, Australia
| | - Velandai Srikanth
- Department of Medicine, Peninsula Clinical School, Central Clinical School, Monash University, Frankston Hospital, Melbourne, Australia (V.S.)
| | - Henry Ma
- From the Clinical Trials, Imaging and Informatics Division, Stroke and Aging Research Group, School of Clinical Sciences at Monash Health, Monash University, Melbourne, Australia (T.G.P., N.K., V.W.Y.L., M.B., H.M.).,Stroke Unit (T.G.P., N.K., V.W.Y.L., M.B., H.M.), Monash Health, Melbourne, Australia
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Radiomics for predicting hematoma expansion in patients with hypertensive intraparenchymal hematomas. Eur J Radiol 2019; 115:10-15. [DOI: 10.1016/j.ejrad.2019.04.001] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2018] [Revised: 01/26/2019] [Accepted: 04/01/2019] [Indexed: 11/20/2022]
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50
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Hussein O, Sawalha K, Fritz J, Abd Elazim A, Hamed M, Wei L, Mainali S. The Significance of Contrast Density of the Computed Tomography-Angiographic Spot Sign and its Correlation with Hematoma Expansion. J Stroke Cerebrovasc Dis 2019; 28:1474-1482. [DOI: 10.1016/j.jstrokecerebrovasdis.2019.03.020] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2018] [Revised: 02/24/2019] [Accepted: 03/06/2019] [Indexed: 11/29/2022] Open
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