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Horn M, Teleg E, Tanaka K, Al Sultan A, Kasickova L, Ohara T, Ojha P, Wasyliw S, Marzoughi S, Banerjee A, Kulkarni G, Horn K, Bobyn A, Neweduk A, Singh N, Qiu W, Rodriguez-Luna D, Dowlatshahi D, Goyal M, Menon BK, Demchuk AM. Timing of Spot Sign Appearance, Spot Sign Volume, and Leakage Rate among Phases of Multiphase CTA Predict Intracerebral Hemorrhage Growth. AJNR Am J Neuroradiol 2024; 45:693-700. [PMID: 38782592 DOI: 10.3174/ajnr.a8254] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2023] [Accepted: 01/23/2024] [Indexed: 05/25/2024]
Abstract
BACKGROUND AND PURPOSE The presence of spot sign is associated with a high risk of hematoma growth. Our aim was to investigate the timing of the appearance, volume, and leakage rate of the spot sign for predicting hematoma growth in acute intracerebral hemorrhage using multiphase CTA. MATERIALS AND METHODS In this single-center retrospective study, multiphase CTA in 3 phases was performed in acute intracerebral hemorrhage (defined as intraparenchymal ± intraventricular hemorrhages). Phases of the spot sign first appearance, spot sign volumes (microliter), and leakage rates among phases (microliter/second) were measured. Associations between baseline clinical and imaging variables including spot sign volume parameters (volume and leakage rate divided by median) and hematoma growth (>6 mL) were investigated using regression models. Receiver operating characteristic analysis was used as appropriate. RESULTS Two hundred seventeen patients (131 men; median age, 70 years) were included. The spot sign was detected in 21.7%, 30.0%, and 29.0% in the first, second, and third phases, respectively, with median volumes of 19.7, 31.4, and 34.8 μl in these phases. Hematoma growth was seen in 44 patients (20.3%). By means of modeling, the following variables, namely the spot sign appearing in the first phase, first phase spot sign volume, spot sign appearing in the second or third phase, and spot sign positive and negative leakage rates, were associated with hematoma growth. Among patients with a spot sign, the absolute leakage rate accounting for both positive and negative leakage rates was also associated with hematoma growth (per 1-μl/s increase; OR, 1.26; 95% CI, 1.04-1.52). Other hematoma growth predictors were stroke history, baseline NIHSS score, onset-to-imaging time, and baseline hematoma volume (all P values < .05). CONCLUSIONS The timing of the appearance of the spot sign, volume, and leakage rate were all associated with hematoma growth. Development of automated software to generate these spot sign volumetric parameters would be an important next step to maximize the potential of temporal intracerebral hemorrhage imaging such as multiphase CTA for identifying those most at risk of hematoma growth.
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Affiliation(s)
- MacKenzie Horn
- From the Foothills Medical Centre, Department of Clinical Neurosciences (M.H., E.T., K.T., A.A.S., P.O., K.H., A. Bobyn, A.N., N.S., B.K.M., A.M.D.), University of Calgary, Calgary, Alberta, Canada
| | - Ericka Teleg
- From the Foothills Medical Centre, Department of Clinical Neurosciences (M.H., E.T., K.T., A.A.S., P.O., K.H., A. Bobyn, A.N., N.S., B.K.M., A.M.D.), University of Calgary, Calgary, Alberta, Canada
| | - Koji Tanaka
- From the Foothills Medical Centre, Department of Clinical Neurosciences (M.H., E.T., K.T., A.A.S., P.O., K.H., A. Bobyn, A.N., N.S., B.K.M., A.M.D.), University of Calgary, Calgary, Alberta, Canada
| | - Abdulaziz Al Sultan
- From the Foothills Medical Centre, Department of Clinical Neurosciences (M.H., E.T., K.T., A.A.S., P.O., K.H., A. Bobyn, A.N., N.S., B.K.M., A.M.D.), University of Calgary, Calgary, Alberta, Canada
| | - Linda Kasickova
- Department of Neurology (L.K.), University Ostrava, Ostrava, Czech Republic
| | - Tomoyuki Ohara
- Department of Neurology (T.O.), Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Piyush Ojha
- From the Foothills Medical Centre, Department of Clinical Neurosciences (M.H., E.T., K.T., A.A.S., P.O., K.H., A. Bobyn, A.N., N.S., B.K.M., A.M.D.), University of Calgary, Calgary, Alberta, Canada
| | - Sanchea Wasyliw
- Department of Medicine (S.W.), Division of Neurology, University of Saskatchewan, Saskatoon, Canada
| | - Sina Marzoughi
- Department of Medicine (S.M.), Division of Neurology, University of British Columbia, Vancouver, British Columbia, Canada
| | - Ankur Banerjee
- Department of Medicine (A. Banerjee), Division of Neurology, University of Alberta, Edmonton, Alberta, Canada
| | - Girish Kulkarni
- Department of Neurology (G.K.), National Institute of Mental Health and Neurosciences, Bengaluru, India
| | - Kennedy Horn
- From the Foothills Medical Centre, Department of Clinical Neurosciences (M.H., E.T., K.T., A.A.S., P.O., K.H., A. Bobyn, A.N., N.S., B.K.M., A.M.D.), University of Calgary, Calgary, Alberta, Canada
| | - Amy Bobyn
- From the Foothills Medical Centre, Department of Clinical Neurosciences (M.H., E.T., K.T., A.A.S., P.O., K.H., A. Bobyn, A.N., N.S., B.K.M., A.M.D.), University of Calgary, Calgary, Alberta, Canada
| | - Anneliese Neweduk
- From the Foothills Medical Centre, Department of Clinical Neurosciences (M.H., E.T., K.T., A.A.S., P.O., K.H., A. Bobyn, A.N., N.S., B.K.M., A.M.D.), University of Calgary, Calgary, Alberta, Canada
| | - Nishita Singh
- From the Foothills Medical Centre, Department of Clinical Neurosciences (M.H., E.T., K.T., A.A.S., P.O., K.H., A. Bobyn, A.N., N.S., B.K.M., A.M.D.), University of Calgary, Calgary, Alberta, Canada
| | - Wu Qiu
- Department of Biomedical Engineering (W.Q.), Huazhong University of Science and Technology, Wuhan, China
| | - David Rodriguez-Luna
- Department of Neurology (D.R.-L.), Vall d'Hebron University Hospital, Barcelona, Spain
| | - Dar Dowlatshahi
- Department of Medicine (D.D.), Division of Neurology, University of Ottawa, Ottawa, Ontario, Canada
| | - Mayank Goyal
- Department of Radiology (M.G., B.K.M., A.M.D.), University of Calgary, Calgary, Alberta, Canada
- Hotchikiss Brain Institute (M.G., B.K.M., A.M.D.), Cumming School of Medicine, University of Calgary, Calgary, Canada
| | - Bijoy K Menon
- From the Foothills Medical Centre, Department of Clinical Neurosciences (M.H., E.T., K.T., A.A.S., P.O., K.H., A. Bobyn, A.N., N.S., B.K.M., A.M.D.), University of Calgary, Calgary, Alberta, Canada
- Department of Radiology (M.G., B.K.M., A.M.D.), University of Calgary, Calgary, Alberta, Canada
- Department of Community Health Sciences (B.K.M.), University of Calgary, Calgary, Alberta, Canada
- Hotchikiss Brain Institute (M.G., B.K.M., A.M.D.), Cumming School of Medicine, University of Calgary, Calgary, Canada
| | - Andrew M Demchuk
- From the Foothills Medical Centre, Department of Clinical Neurosciences (M.H., E.T., K.T., A.A.S., P.O., K.H., A. Bobyn, A.N., N.S., B.K.M., A.M.D.), University of Calgary, Calgary, Alberta, Canada
- Department of Radiology (M.G., B.K.M., A.M.D.), University of Calgary, Calgary, Alberta, Canada
- Hotchikiss Brain Institute (M.G., B.K.M., A.M.D.), Cumming School of Medicine, University of Calgary, Calgary, Canada
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Murthy SB. Emergent Management of Intracerebral Hemorrhage. Continuum (Minneap Minn) 2024; 30:641-661. [PMID: 38830066 DOI: 10.1212/con.0000000000001422] [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: 06/05/2024]
Abstract
OBJECTIVE Nontraumatic intracerebral hemorrhage (ICH) is a potentially devastating cerebrovascular disorder. Several randomized trials have assessed interventions to improve ICH outcomes. This article summarizes some of the recent developments in the emergent medical and surgical management of acute ICH. LATEST DEVELOPMENTS Recent data have underscored the protracted course of recovery after ICH, particularly in patients with severe disability, cautioning against early nihilism and withholding of life-sustaining treatments. The treatment of ICH has undergone rapid evolution with the implementation of intensive blood pressure control, novel reversal strategies for coagulopathy, innovations in systems of care such as mobile stroke units for hyperacute ICH care, and the emergence of newer minimally invasive surgical approaches such as the endoport and endoscope-assisted evacuation techniques. ESSENTIAL POINTS This review discusses the current state of evidence in ICH and its implications for practice, using case illustrations to highlight some of the nuances involved in the management of acute ICH.
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Kuang L, Fei S, Zhou H, Huang L, Guo C, Cheng J, Guo W, Ye Y, Wang R, Xiong H, Zhang J, Tang D, Zou L, Qiu X, Yu Y, Song L. Added Value of Frequency of Imaging Markers for Prediction of Outcome After Intracerebral Hemorrhage: A Secondary Analysis of Existing Data. Neurocrit Care 2024:10.1007/s12028-024-01963-x. [PMID: 38506972 DOI: 10.1007/s12028-024-01963-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2023] [Accepted: 02/16/2024] [Indexed: 03/22/2024]
Abstract
BACKGROUND Frequency of imaging markers (FIM) has been identified as an independent predictor of hematoma expansion in patients with intracerebral hemorrhage (ICH), but its impact on clinical outcome of ICH is yet to be determined. The aim of the present study was to investigate this association. METHODS This study was a secondary analysis of our prior research. The data for this study were derived from six retrospective cohorts of ICH from January 2018 to August 2022. All consecutive study participants were examined within 6 h of stroke onset on neuroimaging. FIM was defined as the ratio of the number of imaging markers on noncontrast head tomography (i.e., hypodensities, blend sign, and island sign) to onset-to-neuroimaging time. The primary poor outcome was defined as a modified Rankin Scale score of 3-6 at 3 months. RESULTS A total of 1253 patients with ICH were included for final analysis. Among those with available follow-up results, 713 (56.90%) exhibited a poor neurologic outcome at 3 months. In a univariate analysis, FIM was associated with poor prognosis (odds ratio 4.36; 95% confidence interval 3.31-5.74; p < 0.001). After adjustment for age, Glasgow Coma Scale score, systolic blood pressure, hematoma volume, and intraventricular hemorrhage, FIM was still an independent predictor of worse prognosis (odds ratio 3.26; 95% confidence interval 2.37-4.48; p < 0.001). Based on receiver operating characteristic curve analysis, a cutoff value of 0.28 for FIM was associated with 0.69 sensitivity, 0.66 specificity, 0.73 positive predictive value, 0.62 negative predictive value, and 0.71 area under the curve for the diagnosis of poor outcome. CONCLUSIONS The metric of FIM is associated with 3-month poor outcome after ICH. The novel indicator that helps identify patients who are likely within the 6-h time window at risk for worse outcome would be a valuable addition to the clinical management of ICH.
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Affiliation(s)
- Lianghong Kuang
- Department of Neurology, Huangshi Central Hospital, Affiliated Hospital of Hubei Polytechnic University, Huangshi, China
| | - Shinuan Fei
- Department of Pediatrics, Huangshi Maternity and Children's Health Hospital, Affiliated Maternity and Children's Health Hospital of Hubei Polytechnic University, Huangshi, China
| | - Hang Zhou
- Department of Radiology, Xiangyang Central Hospital, Affiliated Hospital of Hubei University of Arts and Science, Xiangyang, China
| | - Le Huang
- Postgraduate Joint Training Base of Huangshi Central Hospital, Wuhan University of Science and Technology, Huangshi, China
| | - Cailian Guo
- Postgraduate Joint Training Base of Huangshi Central Hospital, Wuhan University of Science and Technology, Huangshi, China
| | - Jun Cheng
- Computer School, Hubei Polytechnic University, Huangshi, China
| | - Wenmin Guo
- Department of Radiology, Xiangyang No. 1 People's Hospital, Hubei University of Medicine, Xiangyang, China
| | - Yu Ye
- Department of Radiology, Huangshi Central Hospital, Affiliated Hospital of Hubei Polytechnic University, No. 141, Tianjin Road, Huangshigang District, Huangshi, 435000, China
| | - Rujia Wang
- Department of Radiology, Tangshan Gongren Hospital, Tangshan, China
| | - Hui Xiong
- Department of Radiology, Huangshi Central Hospital, Affiliated Hospital of Hubei Polytechnic University, No. 141, Tianjin Road, Huangshigang District, Huangshi, 435000, China
| | - Ji Zhang
- Department of Clinical Laboratory, Xiangyang Central Haspital, Affiliated Hospital of Hubei University of Arts and Science, Xiangyang, China
| | - Dongfang Tang
- Department of Neurosurgery, Xiangyang Central Hospital, Affiliated Hospital of Hubei University of Arts and Science, Xiangyang, China
| | - Liwei Zou
- Department of Radiology, The Second Affiliated Hospital of Anhui Medical University, Hefei, China
| | - Xiaoming Qiu
- Department of Radiology, Huangshi Central Hospital, Affiliated Hospital of Hubei Polytechnic University, No. 141, Tianjin Road, Huangshigang District, Huangshi, 435000, China
| | - Yongqiang Yu
- Department of Radiology, The First Affiliated Hospital of Anhui Medical University, Hefei, China
| | - Lei Song
- Department of Radiology, Huangshi Central Hospital, Affiliated Hospital of Hubei Polytechnic University, No. 141, Tianjin Road, Huangshigang District, Huangshi, 435000, China.
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Li Q, Li F, Liu H, Li Y, Chen H, Yang W, Duan S, Zhang H. CT-based radiomics models predict spontaneous intracerebral hemorrhage expansion and are comparable with CT angiography spot sign. Front Neurol 2024; 15:1332509. [PMID: 38476195 PMCID: PMC10929015 DOI: 10.3389/fneur.2024.1332509] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2023] [Accepted: 01/30/2024] [Indexed: 03/14/2024] Open
Abstract
Background and purpose This study aimed to investigate the efficacy of radiomics, based on non-contrast computed tomography (NCCT) and computed tomography angiography (CTA) images, in predicting early hematoma expansion (HE) in patients with spontaneous intracerebral hemorrhage (SICH). Additionally, the predictive performance of these models was compared with that of the established CTA spot sign. Materials and methods A retrospective analysis was conducted using CT images from 182 patients with SICH. Data from the patients were divided into a training set (145 cases) and a testing set (37 cases) using random stratified sampling. Two radiomics models were constructed by combining quantitative features extracted from NCCT images (the NCCT model) and CTA images (the CTA model) using a logistic regression (LR) classifier. Additionally, a univariate LR model based on the CTA spot sign (the spot sign model) was established. The predictive performance of the two radiomics models and the spot sign model was compared according to the area under the receiver operating characteristic (ROC) curve (AUC). Results For the training set, the AUCs of the NCCT, CTA, and spot sign models were 0.938, 0.904, and 0.726, respectively. Both the NCCT and CTA models demonstrated superior predictive performance compared to the spot sign model (all P < 0.001), with the performance of the two radiomics models being comparable (P = 0.068). For the testing set, the AUCs of the NCCT, CTA, and spot sign models were 0.925, 0.873, and 0.720, respectively, with only the NCCT model exhibiting significantly greater predictive value than the spot sign model (P = 0.041). Conclusion Radiomics models based on NCCT and CTA images effectively predicted HE in patients with SICH. The predictive performances of the NCCT and CTA models were similar, with the NCCT model outperforming the spot sign model. These findings suggest that this approach has the potential to reduce the need for CTA examinations, thereby reducing radiation exposure and the use of contrast agents in future practice for the purpose of predicting hematoma expansion.
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Affiliation(s)
- Qingrun Li
- Department of Radiology, Traditional Chinese Medicine Hospital of Dianjiang Chongqing, Chongqing, China
| | - Feng Li
- Department of Radiology, Traditional Chinese Medicine Hospital of Dianjiang Chongqing, Chongqing, China
| | - Hao Liu
- Department of Research and Development, Yizhun Medical AI Co. Ltd., Beijing, China
| | - Yan Li
- Department of Radiology, Northern Jiangsu People's Hospital, Yangzhou, Jiangsu, China
| | - Hongri Chen
- Department of Radiology, Northern Jiangsu People's Hospital, Yangzhou, Jiangsu, China
| | - Wenrui Yang
- Department of Radiology, Northern Jiangsu People's Hospital, Yangzhou, Jiangsu, China
| | - Shaofeng Duan
- Precision Health Institution, GE Healthcare, Shanghai, China
| | - Hongying Zhang
- Department of Radiology, Northern Jiangsu People's Hospital, Yangzhou, Jiangsu, China
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Ortega V, Diaz OM. True Spot Sign within a Cerebellar Hematoma Visualized in Digital Subtraction Angiography and Dyna-CT. Clin Neuroradiol 2023; 33:1151-1153. [PMID: 37280390 DOI: 10.1007/s00062-023-01298-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2023] [Accepted: 04/24/2023] [Indexed: 06/08/2023]
Affiliation(s)
| | - Orlando M Diaz
- Department of Interventional Neuroradiology, Houston Methodist Hospital, Houston, TX, USA
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Zachrison KS, Goldstein JN, Jauch E, Radecki RP, Madsen TE, Adeoye O, Oostema JA, Feeser VR, Ganti L, Lo BM, Meurer W, Corral M, Rothenberg C, Chaturvedi A, Goyal P, Venkatesh AK. Clinical Performance Measures for Emergency Department Care for Adults With Intracranial Hemorrhage. Ann Emerg Med 2023; 82:258-269. [PMID: 37074253 DOI: 10.1016/j.annemergmed.2023.03.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2022] [Revised: 02/28/2023] [Accepted: 03/07/2023] [Indexed: 04/20/2023]
Abstract
Though select inpatient-based performance measures exist for the care of patients with nontraumatic intracranial hemorrhage, emergency departments lack measurement instruments designed to support and improve care processes in the hyperacute phase. To address this, we propose a set of measures applying a syndromic (rather than diagnosis-based) approach informed by performance data from a national sample of community EDs participating in the Emergency Quality Network Stroke Initiative. To develop the measure set, we convened a workgroup of experts in acute neurologic emergencies. The group considered the appropriate use case for each proposed measure: internal quality improvement, benchmarking, or accountability, and examined data from Emergency Quality Network Stroke Initiative-participating EDs to consider the validity and feasibility of proposed measures for quality measurement and improvement applications. The initially conceived set included 14 measure concepts, of which 7 were selected for inclusion in the measure set after a review of data and further deliberation. Proposed measures include 2 for quality improvement, benchmarking, and accountability (Last 2 Recorded Systolic Blood Pressure Measurements Under 150 and Platelet Avoidance), 3 for quality improvement and benchmarking (Proportion of Patients on Oral Anticoagulants Receiving Hemostatic Medications, Median ED Length of Stay for admitted patients, and Median Length of Stay for transferred patients), and 2 for quality improvement only (Severity Assessment in the ED and Computed Tomography Angiography Performance). The proposed measure set warrants further development and validation to support broader implementation and advance national health care quality goals. Ultimately, applying these measures may help identify opportunities for improvement and focus quality improvement resources on evidence-based targets.
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Affiliation(s)
- Kori S Zachrison
- Department of Emergency Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, MA.
| | - Joshua N Goldstein
- Department of Emergency Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, MA
| | | | - Ryan P Radecki
- Department of Emergency Medicine, Christchurch Hospital, Christchurch, New Zealand
| | - Tracy E Madsen
- Department of Emergency Medicine, Warren Alpert Medical School of Brown University, Providence, RI
| | - Opeolu Adeoye
- Department of Emergency Medicine, Washington University School of Medicine in St Louis, St Louis, MO
| | - John A Oostema
- Department of Emergency Medicine, Michigan State University College of Human Medicine, East Lansing, MI
| | - V Ramana Feeser
- Department of Emergency Medicine, Virginia Commonwealth University, Richmond, VA
| | - Latha Ganti
- Department of Emergency Medicine, University of Central Florida College of Medicine, Orlando, FL
| | - Bruce M Lo
- Department of Emergency Medicine, Sentara Norfolk General Hospital/Eastern Virginia Medical School, Norfolk, VA
| | - William Meurer
- Departments of Emergency Medicine and Neurology, University of Michigan Medical School, Ann Arbor, MI
| | | | - Craig Rothenberg
- Department of Emergency Medicine, Yale School of Medicine, New Haven, CT
| | | | - Pawan Goyal
- American College of Emergency Physicians, Irving, TX
| | - Arjun K Venkatesh
- Department of Emergency Medicine, Yale School of Medicine, New Haven, CT
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Lee J, Park ST, Hwang SC, Kim JY, Lee AL, Chang KH. Dual-energy computed tomography material decomposition improves prediction accuracy of hematoma expansion in traumatic intracranial hemorrhage. PLoS One 2023; 18:e0289110. [PMID: 37498879 PMCID: PMC10374090 DOI: 10.1371/journal.pone.0289110] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2022] [Accepted: 05/22/2023] [Indexed: 07/29/2023] Open
Abstract
OBJECTIVE The angiographic spot sign (AS) on CT angiography (CTA) is known to be useful for predicting expansion in intracranial hemorrhage, but its use is limited due to its relatively low sensitivity. Recently, dual-energy computed tomography (DECT) has been shown to be superior in distinguishing between hemorrhage and iodine. This study aimed to evaluate the diagnostic performance of hematoma expansion (HE) using DECT AS in traumatic intracranial hemorrhage. METHODS We recruited participants with intracranial hemorrhage confirmed via CTA for suspected traumatic cerebrovascular injuries. We evaluated AS on both conventional-like and fusion images of DECT. AS is grouped into three categories: intralesional enhancement without change, delayed enhancement (DE), and growing contrast leakage (GL). HE was evaluated by measuring hematoma size on DECT and follow-up CT. Logistic regression analysis was used to evaluate whether AS on fusion images was a significant risk factor for HE. Diagnostic accuracy was calculated, and the results from conventional-like and fusion images were compared. RESULTS Thirty-nine hematomas in 24 patients were included in this study. Of these, 18 hematomas in 13 patients showed expansion on follow-up CT. Among the expanders, AS and GL on fusion images were noted in 13 and 5 hematomas, respectively. In non-expanders, 10 and 1 hematoma showed AS and GL, respectively. In the logistic regression model, GL on the fusion image was a significant independent risk factor for predicting HE. However, when AS was used on conventional-like images, no factors significantly predicted HE. In the receiver operating characteristic curve analysis, the area under the curve of AS on the fusion images was 0.71, with a sensitivity and specificity of 66.7% and 76.2%, respectively. CONCLUSIONS GL on fusion images of DECT in traumatic intracranial hemorrhage is a significant independent radiologic risk factor for predicting HE. The AS of DECT fusion images has improved sensitivity compared to that of conventional-like images.
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Affiliation(s)
- Jungbin Lee
- Department of Radiology, Soonchunhyang University Bucheon Hospital, Bucheon, Korea
| | - Sung-Tae Park
- Department of Radiology, Soonchunhyang University Seoul Hospital, Seoul, Korea
| | - Sun-Chul Hwang
- Department of Neurosurgery, Soonchunhyang University Bucheon Hospital, Bucheon, Korea
| | - Jung Youn Kim
- Department of Radiology, Cha University Bundang Medical Center, Seongnam, Korea
| | - A Leum Lee
- Department of Radiology, Soonchunhyang University Bucheon Hospital, Bucheon, Korea
| | - Kee-Hyun Chang
- Department of Radiology, Human Medical Imaging and Intervention Center, Seoul, Korea
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Haupenthal D, Schwab S, Kuramatsu JB. Hematoma expansion in intracerebral hemorrhage - the right target? Neurol Res Pract 2023; 5:36. [PMID: 37496094 PMCID: PMC10373350 DOI: 10.1186/s42466-023-00256-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2023] [Accepted: 05/30/2023] [Indexed: 07/28/2023] Open
Abstract
BACKGROUND The avoidance of hematoma expansion is the most important therapeutic goal during acute care of patients with intracerebral hemorrhage. Hematoma expansion occurs in up to 20-40% of patients and leads to poorer patient outcome in one of the most severe sub-types of stroke. MAIN TEXT At current, randomized controlled trials have failed to provide evidence for interventions that effectively improve functional outcome in patients with intracerebral hemorrhage. Hence, hematoma expansion may serve as important surrogate target that appears causally linked with a poorer prognosis. Therefore, reduction of hematoma expansion rates will eventually translate to improved patient outcome overall. Recent years have shed light on the importance of early and aggressive treatment in order to reduce the risk for hematoma expansion in these patients. Time measures and imaging markers have been identified that may allow patient selection at very high risk for hematoma expansion. CONCLUSIONS Refinements in patient selection may increase chance for randomized trials to show true benefit. Therefore, this current review article will critically evaluate and discuss available evidence associated with hematoma expansion in patients with intracerebral hemorrhage.
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Affiliation(s)
- David Haupenthal
- Department of Neurology, University Hospital Erlangen, Friedrich-Alexander-University of Erlangen-Nuremberg (FAU), Schwabachanlage 6, 91054, Erlangen, Germany
| | - Stefan Schwab
- Department of Neurology, University Hospital Erlangen, Friedrich-Alexander-University of Erlangen-Nuremberg (FAU), Schwabachanlage 6, 91054, Erlangen, Germany
| | - Joji B Kuramatsu
- Department of Neurology, University Hospital Erlangen, Friedrich-Alexander-University of Erlangen-Nuremberg (FAU), Schwabachanlage 6, 91054, Erlangen, Germany.
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Liu R, Chen C, Zhao Y, Tang Y, Shen W, Xie Z. The Osaka prognostic score and Naples prognostic score: novel biomarkers for predicting short-term outcomes after spontaneous intracerebral hemorrhage. BMC Neurol 2023; 23:272. [PMID: 37464311 DOI: 10.1186/s12883-023-03287-3] [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: 01/27/2023] [Accepted: 06/15/2023] [Indexed: 07/20/2023] Open
Abstract
OBJECTIVES Poor immune-nutritional status has been associated with an unfavorable outcome in critical illness. The Osaka prognostic score (OPS) and the Naples prognostic score (NPS), based on inflammatory and nutritional status, has been shown to predict prognosis following cancer and other diseases. The aim of this study was to investigate the relationship between the OPS and NPS and the short-term outcomes of patients with intracerebral hemorrhage (ICH). METHODS We retrospectively analyzed the clinical data of patients hospitalized with spontaneous ICH (n = 340) at The Second Affiliated Hospital of Chongqing Medical University between August 2016 and August 2021. Inclusion criteria included patients aged between 18 and 70, and if a blood sample was taken for laboratory testing within 24 h of admission (serum C-reactive protein, albumin, total cholesterol, and counts for neutrophils, lymphocytes, and monocytes were collected on admission). Exclusion criteria included a non-spontaneous cause of ICH and patient death during hospitalization. Patients were divided into four groups based on OPS or five groups according to NPS. Outcomes were evaluated by the modified Rankin Scale (mRS) at six months post-ICH hospitalization. An unfavorable outcome was defined as a mRS score ≥ 3. RESULTS A total of 289 patients met our inclusion criteria. The unfavorable outcome group had older age, a lower Glasgow Coma Scale score, a higher rate of complications and cerebral herniation, a longer hospital stay, and higher OPS and NPS when compared with the favorable outcome group. Univariate analysis showed that both OPS and NPS were strongly correlated with mRS (r = 0.196,P < 0.001; r = 0.244, P = 0.001, respectively). Multivariate analysis further showed that OPS and NPS were both independent predictors of unfavorable outcomes for patients with ICH with adjusted odds ratios of 1.802 (95% confidence interval [CI]:1.140-2.847, P = 0.012) and 1.702 (95% CI: 1.225-2.635, P = 0.02), respectively. The area under the curve (AUC) of NPS for predicting a poor outcome was 0.732 (95% CI: 0.665-0.799), which was similar to the AUC of OPS 0.724 (95% CI: 0.657-0.792). CONCLUSIONS In this cohort, a higher OPS and NPS on admission was associated with poor outcome at six months following ICH, supporting their potential role as markers for predicting the outcome of patients with ICH.
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Affiliation(s)
- Rui Liu
- Department of Neurosurgery, The Second Affiliated Hospital, Chongqing Medical University, 76 Linjiang Road, Chongqing, 400010, People's Republic of China
| | - Changcun Chen
- Department of Neurosurgery, The Second Affiliated Hospital, Chongqing Medical University, 76 Linjiang Road, Chongqing, 400010, People's Republic of China
| | - Yutong Zhao
- Department of Neurosurgery, The Second Affiliated Hospital, Chongqing Medical University, 76 Linjiang Road, Chongqing, 400010, People's Republic of China
| | - Yuguang Tang
- Department of Neurosurgery, The Second Affiliated Hospital, Chongqing Medical University, 76 Linjiang Road, Chongqing, 400010, People's Republic of China
| | - Weiwei Shen
- Department of Endocrinology, The First Affiliated Hospital, Chongqing Medical and Pharmaceutical College, 301 Dashi Road,, 400060, Chongqing, People's Republic of China.
| | - Zongyi Xie
- Department of Neurosurgery, The Second Affiliated Hospital, Chongqing Medical University, 76 Linjiang Road, Chongqing, 400010, People's Republic of China.
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10
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Huang YW, Huang HL, Li ZP, Yin XS. Research advances in imaging markers for predicting hematoma expansion in intracerebral hemorrhage: a narrative review. Front Neurol 2023; 14:1176390. [PMID: 37181553 PMCID: PMC10166819 DOI: 10.3389/fneur.2023.1176390] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2023] [Accepted: 04/03/2023] [Indexed: 05/16/2023] Open
Abstract
Introduction Stroke is a major global health concern and is ranked as the second leading cause of death worldwide, with the third highest incidence of disability. Intracerebral hemorrhage (ICH) is a devastating form of stroke that is responsible for a significant proportion of stroke-related morbidity and mortality worldwide. Hematoma expansion (HE), which occurs in up to one-third of ICH patients, is a strong predictor of poor prognosis and can be potentially preventable if high-risk patients are identified early. In this review, we provide a comprehensive summary of previous research in this area and highlight the potential use of imaging markers for future research studies. Recent advances Imaging markers have been developed in recent years to aid in the early detection of HE and guide clinical decision-making. These markers have been found to be effective in predicting HE in ICH patients and include specific manifestations on Computed Tomography (CT) and CT Angiography (CTA), such as the spot sign, leakage sign, spot-tail sign, island sign, satellite sign, iodine sign, blend sign, swirl sign, black hole sign, and hypodensities. The use of imaging markers holds great promise for improving the management and outcomes of ICH patients. Conclusion The management of ICH presents a significant challenge, and identifying high-risk patients for HE is crucial to improving outcomes. The use of imaging markers for HE prediction can aid in the rapid identification of such patients and may serve as potential targets for anti-HE therapies in the acute phase of ICH. Therefore, further research is needed to establish the reliability and validity of these markers in identifying high-risk patients and guiding appropriate treatment decisions.
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Affiliation(s)
- Yong-Wei Huang
- Department of Neurosurgery, Mianyang Central Hospital, School of Medicine, University of Electronic Science and Technology of China, Mianyang, Sichuan, China
| | - Hai-Lin Huang
- Department of Neurosurgery, Mianyang Central Hospital, School of Medicine, University of Electronic Science and Technology of China, Mianyang, Sichuan, China
| | - Zong-Ping Li
- Department of Neurosurgery, Mianyang Central Hospital, School of Medicine, University of Electronic Science and Technology of China, Mianyang, Sichuan, China
| | - Xiao-Shuang Yin
- Department of Immunology, Mianyang Central Hospital, School of Medicine, University of Electronic Science and Technology of China, Mianyang, Sichuan, China
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11
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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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12
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Morotti A, Boulouis G, Dowlatshahi D, Li Q, Shamy M, Al-Shahi Salman R, Rosand J, Cordonnier C, Goldstein JN, Charidimou A. Intracerebral haemorrhage expansion: definitions, predictors, and prevention. Lancet Neurol 2023; 22:159-171. [PMID: 36309041 DOI: 10.1016/s1474-4422(22)00338-6] [Citation(s) in RCA: 25] [Impact Index Per Article: 25.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2022] [Revised: 08/04/2022] [Accepted: 08/09/2022] [Indexed: 12/05/2022]
Abstract
Haematoma expansion affects a fifth of patients within 24 h of the onset of acute intracerebral haemorrhage and is associated with death and disability, which makes it an appealing therapeutic target. The time in which active intervention can be done is short as expansion occurs mostly within the first 3 h after onset. Baseline haemorrhage volume, antithrombotic treatment, and CT angiography spot signs are each associated with increased risk of haematoma expansion. Non-contrast CT features are promising predictors of haematoma expansion, but their potential contribution to current models is under investigation. Blood pressure lowering and haemostatic treatment minimise haematoma expansion but have not led to improved functional outcomes in randomised clinical trials. Ultra-early enrolment and selection of participants on the basis of non-contrast CT imaging markers could focus future clinical trials to show clinical benefit in people at high risk of expansion or investigate heterogeneity of treatment effects in clinical trials with broad inclusion criteria.
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Affiliation(s)
- Andrea Morotti
- Neurology Unit, Department of Neurological Sciences and Vision, Azienda Socio Sanitaria Territoriale Spedali Civili, Brescia, Italy.
| | - Gregoire Boulouis
- Diagnostic and Interventional Neuroradiology Department, University Hospital of Tours, Tours, France
| | - Dar Dowlatshahi
- Department of Medicine, Division of Neurology, University of Ottawa and Ottawa Hospital Research Institute, Ottawa ON, Canada
| | - Qi Li
- Department of Neurology, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Michel Shamy
- Department of Medicine, Division of Neurology, University of Ottawa and Ottawa Hospital Research Institute, Ottawa ON, Canada
| | | | - Jonathan Rosand
- Division of Neurocritical Care, Massachusetts General Hospital, Boston, MA, USA; Henry and Allison McCance Center for Brain Health, Massachusetts General Hospital, Boston, MA, USA
| | - Charlotte Cordonnier
- Universite Lille, Inserm, CHU Lille, U1172, LilNCog, Lille Neuroscience and Cognition, F-59000 Lille, France
| | - Joshua N Goldstein
- Division of Neurocritical Care, Massachusetts General Hospital, Boston, MA, USA; Department of Emergency Medicine, Massachusetts General Hospital, Boston, MA, USA
| | - Andreas Charidimou
- Department of Neurology, Boston University Medical Center, Boston University School of Medicine, Boston, MA, USA
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13
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Hakimi R. Imaging of Central Nervous System Hemorrhage. Continuum (Minneap Minn) 2023; 29:73-103. [PMID: 36795874 DOI: 10.1212/con.0000000000001219] [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: 02/18/2023]
Abstract
OBJECTIVE This article aims to familiarize the reader with the various types of nontraumatic central nervous system (CNS) hemorrhage and the various neuroimaging modalities used to help diagnose and manage them. LATEST DEVELOPMENTS According to the 2019 Global Burden of Diseases, Injuries, and Risk Factors Study, intraparenchymal hemorrhage accounts for 28% of the global stroke burden. In the United States, hemorrhagic stroke makes up 13% of all strokes. The incidence of intraparenchymal hemorrhage increases substantially with age; thus, despite improvements in blood pressure control through various public health measures, the incidence is not decreasing as the population ages. In fact, in the most recent longitudinal study of aging, autopsy findings showed intraparenchymal hemorrhage and cerebral amyloid angiopathy in 30% to 35% of patients. ESSENTIAL POINTS Rapid identification of CNS hemorrhage, which includes intraparenchymal hemorrhage, intraventricular hemorrhage, and subarachnoid hemorrhage, requires either head CT or brain MRI. Once hemorrhage is identified on the screening neuroimaging study, the pattern of blood in conjunction with the history and physical examination can guide subsequent neuroimaging, laboratory, and ancillary tests as part of the etiologic assessment. After determination of the cause, the chief aims of the treatment regimen are reducing hemorrhage expansion and preventing subsequent complications such as cytotoxic cerebral edema, brain compression, and obstructive hydrocephalus. In addition, nontraumatic spinal cord hemorrhage will also be briefly discussed.
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14
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Jiang YW, Xu XJ, Wang R, Chen CM. Efficacy of non-enhanced computer tomography-based radiomics for predicting hematoma expansion: A meta-analysis. Front Oncol 2023; 12:973104. [PMID: 36703784 PMCID: PMC9872032 DOI: 10.3389/fonc.2022.973104] [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: 06/20/2022] [Accepted: 12/20/2022] [Indexed: 01/11/2023] Open
Abstract
Background This meta-analysis aimed to assess the efficacy of radiomics using non-enhanced computed tomography (NCCT) for predicting hematoma expansion in patients with spontaneous intracerebral hemorrhage. Methods Throughout the inception of the project to April 11, 2022, a comprehensive search was conducted on PubMed, Embase, and Cochrane Central Register of Controlled Trials. The methodological quality of studies in this analysis was assessed by the radiomics quality scoring system (RQS). A meta-analysis of radiomic studies based on NCCT for predicting hematoma expansion in patients with intracerebral hemorrhage was performed. The efficacy of the radiomics approach and non-contrast CT markers was compared using network meta-analysis (NMA). Results Ten articles comprising a total of 1525 patients were quantitatively analyzed for hematoma expansion after cerebral hemorrhage using radiomics. Based on the included studies, the mean RQS was 14.4. The AUC value (95% confidence interval) of the radiomics model was 0.80 (0.76-0.83). Five articles comprising 846 patients were included in the NMA. The results synthesized according to Bayesian NMA revealed that the predictive ability of the radiomics model outperformed most of the NCCT biomarkers. Conclusions The NCCT-based radiomics approach has the potential to predict hematoma expansion. Compared to NCCT biomarkers, we recommend a radiomics approach. Standardization of the radiomics approach is required for further clinical implementation. Systematic review registration https://www.crd.york.ac.uk/PROSPERO/display_record.php?RecordID=324034, identifier [CRD42022324034].
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15
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Nontraumatic Neurosurgical Emergencies. Crit Care Nurs Q 2023; 46:2-16. [DOI: 10.1097/cnq.0000000000000434] [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]
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16
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Gil-Garcia CA, Alvarez EF, Garcia RC, Mendoza-Lopez AC, Gonzalez-Hermosillo LM, Garcia-Blanco MDC, Valadez ER. Essential topics about the imaging diagnosis and treatment of Hemorrhagic Stroke: a comprehensive review of the 2022 AHA guidelines. Curr Probl Cardiol 2022; 47:101328. [PMID: 35870549 DOI: 10.1016/j.cpcardiol.2022.101328] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2022] [Accepted: 07/17/2022] [Indexed: 11/03/2022]
Abstract
Intracerebral hemorrhage (ICH) is a severe stroke with a high death rate (40 % mortality). The prevalence of hemorrhagic stroke has increased globally, with changes in the underlying cause over time as anticoagulant use and hypertension treatment have improved. The fundamental etiology of ICH and the mechanisms of harm from ICH, particularly the complex interaction between edema, inflammation, and blood product toxicity, have been thoroughly revised by the American Heart Association (AHA) in 2022. Although numerous trials have investigated the best medicinal and surgical management of ICH, there is still no discernible improvement in survival and functional tests. Small vessel diseases, such as cerebral amyloid angiopathy (CAA) or deep perforator arteriopathy (hypertensive arteriopathy), are the most common causes of spontaneous non-traumatic intracerebral hemorrhage (ICH). Even though ICH only causes 10-15% of all strokes, it contributes significantly to morbidity and mortality, with few acute or preventive treatments proven effective. Current AHA guidelines acknowledge up to 89% sensitivity for unenhanced brain CT and 81% for brain MRI. The imaging findings of both methods are helpful for initial diagnosis and follow-up, sometimes necessary a few hours after admission, especially for detecting hemorrhagic transformation or hematoma expansion. This review summarized the essential topics on hemorrhagic stroke epidemiology, risk factors, physiopathology, mechanisms of injury, current management approaches, findings in neuroimaging, goals and outcomes, recommendations for lifestyle modifications, and future research directions ICH. A list of updated references is included for each topic.
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Affiliation(s)
| | | | | | | | | | | | - Ernesto-Roldan Valadez
- Directorado de investigación, Hospital General de Mexico "Dr. Eduardo Liceaga," 06720, CDMX, Mexico; I.M. Sechenov First Moscow State Medical University (Sechenov University), Department of Radiology, 119992, Moscow, Russia.
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17
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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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18
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Greenberg SM, Ziai WC, Cordonnier C, Dowlatshahi D, Francis B, Goldstein JN, Hemphill JC, Johnson R, Keigher KM, Mack WJ, Mocco J, Newton EJ, Ruff IM, Sansing LH, Schulman S, Selim MH, Sheth KN, Sprigg N, Sunnerhagen KS. 2022 Guideline for the Management of Patients With Spontaneous Intracerebral Hemorrhage: A Guideline From the American Heart Association/American Stroke Association. Stroke 2022; 53:e282-e361. [PMID: 35579034 DOI: 10.1161/str.0000000000000407] [Citation(s) in RCA: 333] [Impact Index Per Article: 166.5] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
| | | | | | | | | | | | | | | | | | - William J Mack
- AHA Stroke Council Scientific Statement Oversight Committee on Clinical Practice Guideline liaison
| | | | | | - Ilana M Ruff
- AHA Stroke Council Stroke Performance Measures Oversight Committee liaison
| | | | | | | | - Kevin N Sheth
- AHA Stroke Council Scientific Statement Oversight Committee on Clinical Practice Guideline liaison.,AAN representative
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19
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The Predictive Accuracy of the Delayed Spot Sign for Haematoma Expansion in Spontaneous Supratentorial Intracerebral Haemorrhage: A Systematic Review and Meta-Analysis. J Stroke Cerebrovasc Dis 2022; 31:106379. [DOI: 10.1016/j.jstrokecerebrovasdis.2022.106379] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2021] [Revised: 01/24/2022] [Accepted: 01/29/2022] [Indexed: 11/17/2022] Open
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20
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Mahendran SA, Flower O, Hemphill JC. Head CT for the intensivist: 10 tips and pearls. Minerva Anestesiol 2022; 88:508-515. [PMID: 35199970 DOI: 10.23736/s0375-9393.22.16200-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Head imaging is an essential diagnostic tool for the management of patients with most acute neurological emergencies involving the brain. While numerous modalities including magnetic resonance imaging and catheter angiography play a role, computed tomography (CT) of the brain is far and away the most widely utilized technique because of its widespread availability and the fact that it is usually easier to implement in critically ill and potentially unstable patients. CT is particularly useful in identifying acute intracranial hemorrhage and this makes it often indispensable in the management of patients with traumatic brain injury and hemorrhagic stroke. However, shortcomings in identifying early ischemia on non-contrast CT mean that care must be taken in considering findings early after symptom onset, with newer CT sequences such as CT angiography and CT perfusion adding value. The critical role played by intensivist in managing neurocritical care patients necessitates familiarity and ability with viewing and understanding the advantages and shortcomings of head CT imaging and under which circumstances other modalities may be appropriate to obtain. This manuscript provides ten different circumstances commonly encountered in neurocritical care and how intensivists can use CT for the benefit of their patients.
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Affiliation(s)
- Sajeev A Mahendran
- Malcolm Fisher Intensive Care Unit, Royal North Shore Hospital, Sydney NSW, Australia
| | - Oliver Flower
- Malcolm Fisher Intensive Care Unit, Royal North Shore Hospital, Sydney NSW, Australia
| | - J Claude Hemphill
- Department of Neurology, University of California, San Francisco, CA, USA -
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21
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Yassi N, Zhao H, Churilov L, Campbell BCV, Wu T, Ma H, Cheung A, Kleinig T, Brown H, Choi P, Jeng JS, Ranta A, Wang HK, Cloud GC, Grimley R, Shah D, Spratt N, Cho DY, Mahawish K, Sanders L, Worthington J, Clissold B, Meretoja A, Yogendrakumar V, Ton MD, Dang DP, Phuong NTM, Nguyen HT, Hsu CY, Sharma G, Mitchell PJ, Yan B, Parsons MW, Levi C, Donnan GA, Davis SM. Tranexamic acid for intracerebral haemorrhage within 2 hours of onset: protocol of a phase II randomised placebo-controlled double-blind multicentre trial. Stroke Vasc Neurol 2021; 7:158-165. [PMID: 34848566 PMCID: PMC9067256 DOI: 10.1136/svn-2021-001070] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2021] [Accepted: 10/12/2021] [Indexed: 11/17/2022] Open
Abstract
Rationale Haematoma growth is common early after intracerebral haemorrhage (ICH), and is a key determinant of outcome. Tranexamic acid, a widely available antifibrinolytic agent with an excellent safety profile, may reduce haematoma growth. Methods and design Stopping intracerebral haemorrhage with tranexamic acid for hyperacute onset presentation including mobile stroke units (STOP-MSU) is a phase II double-blind, randomised, placebo-controlled, multicentre, international investigator-led clinical trial, conducted within the estimand statistical framework. Hypothesis In patients with spontaneous ICH, treatment with tranexamic acid within 2 hours of onset will reduce haematoma expansion compared with placebo. Sample size estimates A sample size of 180 patients (90 in each arm) would be required to detect an absolute difference in the primary outcome of 20% (placebo 39% vs treatment 19%) under a two-tailed significance level of 0.05. An adaptive sample size re-estimation based on the outcomes of 144 patients will allow a possible increase to a prespecified maximum of 326 patients. Intervention Participants will receive 1 g intravenous tranexamic acid over 10 min, followed by 1 g intravenous tranexamic acid over 8 hours; or matching placebo. Primary efficacy measure The primary efficacy measure is the proportion of patients with haematoma growth by 24±6 hours, defined as either ≥33% relative increase or ≥6 mL absolute increase in haematoma volume between baseline and follow-up CT scan. Discussion We describe the rationale and protocol of STOP-MSU, a phase II trial of tranexamic acid in patients with ICH within 2 hours from onset, based in participating mobile stroke units and emergency departments.
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Affiliation(s)
- Nawaf Yassi
- Department of Medicine and Neurology, Melbourne Brain Centre at The Royal Melbourne Hospital, The University of Melbourne, Parkville, Victoria, Australia .,Population Health and Immunity Division, Walter and Eliza Hall Institute of Medical Research, Parkville, Victoria, Australia
| | - Henry Zhao
- Department of Medicine and Neurology, Melbourne Brain Centre at The Royal Melbourne Hospital, The University of Melbourne, Parkville, Victoria, Australia.,Ambulance Victoria, Melbourne, Victoria, Australia
| | - Leonid Churilov
- Department of Medicine and Neurology, Melbourne Brain Centre at The Royal Melbourne Hospital, The University of Melbourne, Parkville, Victoria, Australia.,Melbourne Medical School, The University of Melbourne, Melbourne, Victoria, Australia
| | - Bruce C V Campbell
- Department of Medicine and Neurology, Melbourne Brain Centre at The Royal Melbourne Hospital, The University of Melbourne, Parkville, Victoria, Australia.,Stroke Division, The Florey Institute of Neuroscience and Mental Health, Parkville, Victoria, Australia
| | - Teddy Wu
- Department of Neurology, Christchurch Hospital, Christchurch, New Zealand
| | - Henry Ma
- Department of Neurology, Monash Medical Centre, Monash University, Clayton, Victoria, Australia
| | - Andrew Cheung
- Department of Interventional Neuroradiology, Liverpool Hospital, Liverpool, New South Wales, Australia
| | - Timothy Kleinig
- Department of Neurology, Royal Adelaide Hospital, Adelaide, South Australia, Australia
| | - Helen Brown
- Department of Neurology, Princess Alexandra Hospital, Woolloongabba, Queensland, Australia
| | - Philip Choi
- Department of Neurology, Box Hill Hospital, Eastern Health, Box Hill, Victoria, Australia
| | - Jiann-Shing Jeng
- Stroke Centre and Department of Neurology, National Taiwan University Hospital, Taipei, Taiwan
| | - Annemarei Ranta
- Department of Medicine, Dunedin School of Medicine, University of Otago, Wellington, New Zealand
| | - Hao-Kuang Wang
- Department of Neurosurgery, E-Da Hospital, Yanchao, Kaohsiung, Taiwan
| | - Geoffrey C Cloud
- Department of Neurology, Alfred Hospital, Melbourne, Victoria, Australia.,Department of Clinical Neuroscience, Monash University Central Clinical School, Melbourne, Victoria, Australia
| | - Rohan Grimley
- Department of Medicine, Sunshine Coast University Hospital, Nambour, Queensland, Australia
| | - Darshan Shah
- Department of Neurology, Gold Coast University Hospital, Southport, Queensland, Australia
| | - Neil Spratt
- Department of Neurology, John Hunter Hospital, The University of Newcastle, Newcastle, New South Wales, Australia
| | - Der-Yang Cho
- Department of Neurosurgery, China Medical University Hospital, Taichung, Taiwan
| | - Karim Mahawish
- Department of Internal Medicine, Palmerston North Hospital, Palmerston North, New Zealand
| | - Lauren Sanders
- Department of Neurology, St Vincent's Hospital, Fitzroy, Victoria, Australia
| | - John Worthington
- Department of Neurology, Royal Prince Alfred Hospital, Camperdown, New South Wales, Australia
| | - Ben Clissold
- Department of Neurology, Geelong Hospital, Geelong, Victoria, Australia
| | - Atte Meretoja
- Department of Neurology, Helsinki University Hospital, Helsinki, Finland
| | - Vignan Yogendrakumar
- Department of Medicine and Neurology, Melbourne Brain Centre at The Royal Melbourne Hospital, The University of Melbourne, Parkville, Victoria, Australia
| | - Mai Duy Ton
- Stroke Center, Bach Mai Hospital, Hanoi, Viet Nam
| | - Duc Phuc Dang
- Stroke Department, 103 Military Hospital, Hanoi, Hanoi, Viet Nam
| | | | - Huy-Thang Nguyen
- Department of Cerebrovascular Disease, 115 Hospital, Ho Chi Minh City, Viet Nam
| | - Chung Y Hsu
- Department of Neurology, China Medical University, Taichung, Taiwan
| | - Gagan Sharma
- Department of Medicine and Neurology, Melbourne Brain Centre at The Royal Melbourne Hospital, The University of Melbourne, Parkville, Victoria, Australia
| | - Peter J Mitchell
- Department of Radiology, Royal Melbourne Hospital, University of Melbourne, Melbourne, Victoria, Australia
| | - Bernard Yan
- Department of Medicine and Neurology, Melbourne Brain Centre at The Royal Melbourne Hospital, The University of Melbourne, Parkville, Victoria, Australia
| | - Mark W Parsons
- Department of Medicine and Neurology, Melbourne Brain Centre at The Royal Melbourne Hospital, The University of Melbourne, Parkville, Victoria, Australia.,Department of Neurology, Liverpool Hospital, Ingham Institute for Applied Medical Research, University of New South Wales South Western Sydney Clinical School, Sydney, New South Wales, Australia
| | - Christopher Levi
- Department of Neurology, John Hunter Hospital, The University of Newcastle, Newcastle, New South Wales, Australia
| | - Geoffrey A Donnan
- Department of Medicine and Neurology, Melbourne Brain Centre at The Royal Melbourne Hospital, The University of Melbourne, Parkville, Victoria, Australia
| | - Stephen M Davis
- Department of Medicine and Neurology, Melbourne Brain Centre at The Royal Melbourne Hospital, The University of Melbourne, Parkville, Victoria, Australia
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22
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Arba F, Rinaldi C, Boulouis G, Fainardi E, Charidimou A, Morotti A. Noncontrast Computed Tomography Markers of Cerebral Hemorrhage Expansion: Diagnostic Accuracy Meta-Analysis. Int J Stroke 2021; 17:17474930211061639. [PMID: 34842473 DOI: 10.1177/17474930211061639] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
BACKGROUND AND PURPOSE Assess the diagnostic accuracy of noncontrast computed tomography (NCCT) markers of hematoma expansion in patients with primary intracerebral hemorrhage. METHODS We performed a meta-analysis of observational studies and randomized controlled trials with available data for calculation of sensitivity and specificity of NCCT markers for hematoma expansion (absolute growth >6 or 12.5 mL and/or relative growth >33%). The following NCCT markers were analyzed: irregular shape, island sign (shape-related features); hypodensity, heterogeneous density, blend sign, black hole sign, and swirl sign (density-related features). Pooled accuracy values for each marker were derived from hierarchical logistic regression models. RESULTS A total of 10,363 subjects from 23 eligible studies were included. Significant risk of bias of included studies was noted. Hematoma expansion frequency ranged from 7% to 40%, mean intracerebral hemorrhage volume from 9 to 27.8 ml, presence of NCCT markers from 9% (island sign) to 82% (irregular shape). Among shape features, sensitivity ranged from 0.32 (95%CI = 0.20-0.47) for island sign to 0.68 (95%CI = 0.57-0.77) for irregular shape, specificity ranged from 0.47 (95%CI = 0.36-0.59) for irregular shape to 0.92 (95%CI = 0.85-0.96) for island sign; among density features sensitivity ranged from 0.28 (95%CI = 0.21-0.35) for black hole sign to 0.63 (95%CI = 0.44-0.78) for hypodensity, specificity ranged from 0.65 (95%CI = 0.56-0.73) for heterogeneous density to 0.89 (95%CI = 0.85-0.92) for blend sign. CONCLUSION Diagnostic accuracy of NCCT markers remains suboptimal for implementation in clinical trials although density features performed better than shape-related features. This analysis may help in better tailoring patients' selection for hematoma expansion targeted trials.
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Affiliation(s)
- Francesco Arba
- Stroke Unit, Careggi University Hospital, Florence, Italy
| | - Chiara Rinaldi
- Stroke Unit, Careggi University Hospital, Florence, Italy
| | - Gregoire Boulouis
- Neuroradiology Department, Centre Hospitalier Sainte-Anne, Paris, France
| | - Enrico Fainardi
- Department of Experimental and Clinical Medicine, 9300University of Florence, Florence, Italy
| | - Andreas Charidimou
- Hemorrhagic Stroke Research Program, Department of Neurology, Massachusetts General Hospital Stroke Research Center, Harvard Medical School, Boston, USA
| | - Andrea Morotti
- Neurology Unit, Department of Clinical and Experimental Sciences, 9297University of Brescia, Brescia, Italy
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23
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Li Y, Wen D, Cui W, Chen Y, Zhang F, Yuan M, Xiao H, Li H, Ma L, Hu X, You C. The Prognostic Value of the Acute Phase Systemic Immune-Inflammation Index in Patients With Intracerebral Hemorrhage. Front Neurol 2021; 12:628557. [PMID: 34113303 PMCID: PMC8185273 DOI: 10.3389/fneur.2021.628557] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2020] [Accepted: 03/30/2021] [Indexed: 02/05/2023] Open
Abstract
Background and Purpose: The systemic immune–inflammation index (SII) is a novel prognostic index in various diseases. We evaluated the predictive value of SII in patients with intracerebral hemorrhage (ICH). Methods: Patients with primary spontaneous ICH were enrolled. SII was constructed based on peripheral platelet (P), neutrophil (N), and lymphocyte (L) and defined as P*N/L. In addition to admission testing, acute phase SII was collected to analyze the potential dynamic change. Poor outcome was defined as modified Rankin Scale of more than 3 at 90 days. Results: We included 291 patients; 98 (34%) achieved favorable functional outcomes. Day-1 SII was higher and was more related to poor outcome than was admission SII. Median time of day-1 SII was 29 h from onset. Day-1 SII had an OR in outcome (mRS >3) 1.74 (95% CI = 1.03–3.00, p = 0.04). The binary cutoff point of SII calculated using the area under the curve (AUC) method was 1,700 × 109/L, AUC 0.699 (95% CI = 0.627–0.774) (sensitivity 53.3%, specificity 77.3%) (OR = 2.36, 95% CI = 1.09–5.26, p = 0.03). Conclusions: SII, especially day-1 SII, was highly associated with 90-day functional outcome in patients with ICH and could be used to predict outcomes.
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Affiliation(s)
- Yunke Li
- Neurosurgery Department of West China Hospital, Sichuan University, Chengdu, China
| | - Dingke Wen
- Neurosurgery Department of West China Hospital, Sichuan University, Chengdu, China
| | - Wenyao Cui
- Neurosurgery Department of West China Hospital, Sichuan University, Chengdu, China
| | - Yuqi Chen
- Neurosurgery Department of West China Hospital, Sichuan University, Chengdu, China
| | - Fazhen Zhang
- Medical School of Sichuan University, Chengdu, China
| | - Maolin Yuan
- Medical School of Sichuan University, Chengdu, China
| | - Han Xiao
- Medical School of Sichuan University, Chengdu, China
| | - Hao Li
- Neurosurgery Department of West China Hospital, Sichuan University, Chengdu, China
| | - Lu Ma
- Neurosurgery Department of West China Hospital, Sichuan University, Chengdu, China
| | - Xin Hu
- Neurosurgery Department of West China Hospital, Sichuan University, Chengdu, China
| | - Chao You
- Neurosurgery Department of West China Hospital, Sichuan University, Chengdu, China
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24
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Liu J, Nie X, Gu H, Zhou Q, Sun H, Tan Y, Liu D, Zheng L, Zhao J, Wang Y, Cao Y, Zhu H, Zhang Y, Yi L, Pu Y, Wen M, Yang Z, Sun S, Wang W, Zhao X, Liu L, Wang Y. Tranexamic acid for acute intracerebral haemorrhage growth based on imaging assessment (TRAIGE): a multicentre, randomised, placebo-controlled trial. Stroke Vasc Neurol 2021; 6:160-169. [PMID: 33795488 PMCID: PMC8258050 DOI: 10.1136/svn-2021-000942] [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: 02/15/2021] [Revised: 03/23/2021] [Accepted: 03/26/2021] [Indexed: 12/17/2022] Open
Abstract
Background Studies show tranexamic acid can reduce the risk of death and early neurological deterioration after intracranial haemorrhage. We aimed to assess whether tranexamic acid reduces haematoma expansion and improves outcome in intracerebral haemorrhage patients susceptible to haemorrhage expansion. Methods We did a prospective, double-blind, randomised, placebo-controlled trial at 10 stroke centres in China. Acute supratentorial intracerebral haemorrhage patients were eligible if they had indication of haemorrhage expansion on admission imaging (eg, spot sign, black hole sign or blend sign), and were treatable within 8 hours of symptom onset. Patients were randomly assigned (1:1) to receive either tranexamic acid or a matching placebo. The primary outcome was intracerebral haematoma growth (>33% relative or >6 mL absolute) at 24 hours. Clinical outcomes were assessed at 90 days. Results Of the 171 included patients, 124 (72.5%) were male, and the mean age was 55.9±11.6 years. 89 patients received tranexamic acid and 82 received placebo. The primary outcome did not differ significantly between the groups: 36 (40.4%) patients in the tranexamic acid group and 34 (41.5%) patients in the placebo group had intracranial haemorrhage growth (OR 0.96, 95% CI 0.52 to 1.77, p=0.89). The proportion of death was lower in the tranexamic acid treatment group than placebo group (8.1% vs 10.0%), but there were no significant differences in secondary outcomes including absolute intracranial haemorrhage growth, death and dependency. Conclusions Among patients susceptible to haemorrhage expansion treated within 8 hours of stroke onset, tranexamic acid did not significantly prevent intracerebral haemorrhage growth. Larger studies are needed to assess safety and efficacy of tranexamic acid in intracerebral haemorrhage patients.
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Affiliation(s)
- Jingyi Liu
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Ximing Nie
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Hongqiu Gu
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Qi Zhou
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Haixin Sun
- Beijing Neurosurgical Institute, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Ying Tan
- Department of Neurology, The First Affiliated Hospital of Xi'an Jiaotong University, Beijing, China
| | - Dacheng Liu
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Lina Zheng
- Department of Medicine and Therapeutics, Prince of Wales Hospital, Shatin, Hong Kong
| | - Jiahui Zhao
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Yan Wang
- Department of Neurology, Tangshan People's Hospital, Tangshan, China
| | - Yibin Cao
- Department of Neurology, Tangshan Gongren Hospital, Tangshan, China
| | - Haomeng Zhu
- Department of Neurology, Beijing Luhe Hospital, Capital Medical University, Beijing, China
| | - Yunpeng Zhang
- Department of Neurology, Beijing Pinggu Hospital, Beijing, China
| | - Lijin Yi
- Department of Neurology, Liangxiang Hospital of Beijing Fangshan District, Beijing, China
| | - Yuehua Pu
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Miao Wen
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Zhonghua Yang
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Shengjun Sun
- Beijing Neurosurgical Institute, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,Department of Neuroradiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Wenzhi Wang
- Beijing Neurosurgical Institute, Beijing Tiantan Hospital, Capital Medical University, 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
| | - Liping Liu
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Yongjun Wang
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China .,China National Clinical Research Center for Neurological Diseases, Beijing, China
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25
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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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26
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Peeters MTJ, Kort KJDD, Houben R, Henneman WJP, Oostenbrugge RJV, Staals J, Postma AA. Dual-Energy CT Angiography Improves Accuracy of Spot Sign for Predicting Hematoma Expansion in Intracerebral Hemorrhage. J Stroke 2021; 23:82-90. [PMID: 33600705 PMCID: PMC7900388 DOI: 10.5853/jos.2020.03531] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2020] [Accepted: 10/22/2020] [Indexed: 12/30/2022] Open
Abstract
Background and Purpose Spot sign (SS) on computed tomography angiography (CTA) is associated with hematoma expansion (HE) and poor outcome after intracerebral hemorrhage (ICH). However, its predictive performance varies across studies, possibly because differentiating hyperdense hemorrhage from contrast media is difficult. We investigated whether dual-energy-CTA (DE-CTA), which can separate hemorrhage from iodinated contrast, improves the diagnostic accuracy of SS for predicting HE.
Methods Primary ICH patients undergoing DE-CTA (both arterial as well as delayed venous phase) and follow-up computed tomography were prospectively included between 2014 and 2019. SS was assessed on both arterial and delayed phase images of the different DE-CTA datasets, i.e., conventional-like mixed images, iodine images, and fusion images. Diagnostic accuracy of SS for prediction of HE was determined on all datasets. The association between SS and HE, and between SS and poor outcome (modified Rankin Scale at 3 months ≥3) was assessed with multivariable logistic regression, using the dataset with highest diagnostic accuracy.
Results Of 139 included patients, 47 showed HE (33.8%). Sensitivity of SS for HE was 32% (accuracy 0.72) on conventional-like mixed arterial images which increased to 76% (accuracy 0.80) on delayed fusion images. Presence of SS on delayed fusion images was independently associated with HE (odds ratio [OR], 17.5; 95% confidence interval [CI], 6.14 to 49.82) and poor outcome (OR, 3.84; 95% CI, 1.16 to 12.73).
Conclusions Presence of SS on DE-CTA, in particular on delayed phase fusion images, demonstrates higher diagnostic performance in predicting HE compared to conventional-like mixed imaging, and it is associated with poor outcome.
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Affiliation(s)
- Michaël T J Peeters
- Department of Neurology and Cardiovascular Research Institute Maastricht, Maastricht University Medical Center, Maastricht, Netherlands
| | - Kim J D de Kort
- Department of Neurology and Cardiovascular Research Institute Maastricht, Maastricht University Medical Center, Maastricht, Netherlands
| | - Rik Houben
- Department of Neurology and Cardiovascular Research Institute Maastricht, Maastricht University Medical Center, Maastricht, Netherlands
| | - Wouter J P Henneman
- Department of Radiology and Nuclear Medicine, MHeNS School for Mental Health and Neuroscience, Maastricht University Medical Center, Maastricht, Netherlands
| | - Robert J van Oostenbrugge
- Department of Neurology and Cardiovascular Research Institute Maastricht, Maastricht University Medical Center, Maastricht, Netherlands
| | - Julie Staals
- Department of Neurology and Cardiovascular Research Institute Maastricht, Maastricht University Medical Center, Maastricht, Netherlands
| | - Alida A Postma
- Department of Radiology and Nuclear Medicine, MHeNS School for Mental Health and Neuroscience, Maastricht University Medical Center, Maastricht, Netherlands
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27
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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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