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Vagal V, Venema SU, Behymer TP, Mistry EA, Sekar P, Sawyer RP, Gilkerson L, Moomaw CJ, Haverbusch M, Coleman ER, Flaherty ML, Van Sanford C, Stanton RJ, Anderson C, Rosand J, Woo D. White Matter Lesion Severity is Associated with Intraventricular Hemorrhage in Spontaneous Intracerebral Hemorrhage. J Stroke Cerebrovasc Dis 2020; 29:104661. [PMID: 32122778 DOI: 10.1016/j.jstrokecerebrovasdis.2020.104661] [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] [Received: 10/01/2019] [Revised: 12/15/2019] [Accepted: 01/10/2020] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND Intraventricular hemorrhage (IVH) and white matter lesion (WML) severity are associated with higher rates of death and disability in intracerebral hemorrhage (ICH). A prior report identified an increased risk of IVH with greater WML burden but did not control for location of ICH. We sought to determine whether a higher degree of WML is associated with a higher risk of IVH after controlling for ICH location. METHODS Utilizing the patient population from 2 large ICH studies; the Genetic and Environmental Risk Factors for Hemorrhagic Stroke (GERFHS III) Study and the Ethnic/Racial Variations of Intracerebral Hemorrhage study, we graded WML using the Van Swieten Scale (0-1 for mild, 2 for moderate, and 3-4 for severe WML) and presence or absence of IVH in baseline CT scans. We used multivariable regression models to adjust for relevant covariates. RESULTS Among 3023 ICH patients, 1260 (41.7%) had presence of IVH. In patients with IVH, the proportion of severe WML (28.6%) was higher compared with patients without IVH (21.8%) (P < .0001). Multivariable analysis demonstrated that moderate-severe WML, deep ICH, and increasing ICH volume were independently associated with presence of IVH. We found an increased risk of IVH with moderate-severe WML (OR = 1.38; 95%Cl 1.03-1.86, P = .0328) in the subset of lobar hemorrhages. CONCLUSIONS Moderate to severe WML is a risk for IVH. Even in lobar ICH hemorrhages, severe WML leads to an independent increased risk for ventricular rupture.
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Affiliation(s)
- Vaibhav Vagal
- University of Cincinnati, Department of Neurology, Cincinnati, Ohio.
| | - Simone U Venema
- Massachusetts General Hospital, Department of Neurology, Boston, Massachusetts
| | - Tyler P Behymer
- University of Cincinnati, Department of Neurology, Cincinnati, Ohio
| | - Eva A Mistry
- Vanderbilt University Medical Center, Department of Neurology, Nashville, Tennessee
| | - Padmini Sekar
- University of Cincinnati, Department of Neurology, Cincinnati, Ohio
| | - Russell P Sawyer
- University of Cincinnati, Department of Neurology, Cincinnati, Ohio
| | - Lee Gilkerson
- University of Cincinnati, Department of Neurology, Cincinnati, Ohio
| | - Charles J Moomaw
- University of Cincinnati, Department of Neurology, Cincinnati, Ohio
| | - Mary Haverbusch
- University of Cincinnati, Department of Neurology, Cincinnati, Ohio
| | | | | | | | - Robert J Stanton
- University of Cincinnati, Department of Neurology, Cincinnati, Ohio
| | | | - Jonathan Rosand
- Massachusetts General Hospital, Department of Neurology, Boston, Massachusetts
| | - Daniel Woo
- University of Cincinnati, Department of Neurology, Cincinnati, Ohio
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Hatcher S, Chen C, Govindarajan P. Prehospital Systolic Hypertension and Outcomes in Patients with Spontaneous Intracerebral Hemorrhage. Cureus 2017; 9:e998. [PMID: 28280651 PMCID: PMC5325744 DOI: 10.7759/cureus.998] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2016] [Accepted: 01/26/2017] [Indexed: 12/02/2022] Open
Abstract
BACKGROUND It is well known that hematoma volume and expansion is associated with poor outcomes in patients with spontaneous intracerebral hemorrhage (sICH). The factors associated with hematoma volume and possible expansion include the use of anticoagulant medications, autoimmune or bacterial diseases that reduce platelet production, and genetic defects of Von Willebrand factor causing inhibition or reduction of platelet aggregation. However, little is known about the role of elevated systolic blood pressure (SBP) on hematoma volume and its ultimate role on sICH when identified in the prehospital setting. Our objectives were to determine the prevalence of elevated SBP among diagnosed sICH patients transported by emergency medical services (EMS), and to explore possible associations between prehospital elevated SBP and hematoma volume. METHODS This is a hypothesis-generating study for which we used a retrospective observational design. The subjects included 243 adult patients who were seen and treated for sICH in an emergency department serving a county hospital in a large metropolitan city. Elevated SBP in the setting of sICH was defined as ≥140 mm Hg. A univariate analysis was performed to investigate associations between patient demographics, elevated SBP, and sICH characteristics with the pre-determined outcome of hematoma volume. We then performed a multivariable logistic regression model to determine if elevated prehospital SBP remained associated with hematoma volume. RESULTS The number of subjects with a hospital-based diagnosis of sICH was 243. Of those, 193 (79%) were transported by an ambulance. Among those transported by ambulance, 180 (93%) had a documented prehospital SBP; out of those patients with a documented SBP, 173 (96%) showed an elevated SBP of ≥140 mm Hg, and 82 (46%) had a hematoma volume of ≥30 mL. Our univariate analysis showed that sICH patients with an elevated prehospital SBP of ≥140 mm Hg were associated with hematoma volume. The multivariable regression model showed that elevated prehospital SBP (≥140 mm Hg) was associated with larger hematoma volumes (odds ratio (OR) 3.86 95% confidence interval (CI) 1.02-4.60). CONCLUSIONS Prehospital elevated SBP is associated with larger hematoma volume in patients with sICH. Future studies should confirm these findings in a larger cohort of patients.
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Affiliation(s)
- Stacy Hatcher
- Department of Surgery, University of California San Francisco
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Calvert JS, Price DA, Barton CW, Chettipally UK, Das R. Discharge recommendation based on a novel technique of homeostatic analysis. J Am Med Inform Assoc 2017; 24:24-29. [PMID: 27026611 PMCID: PMC7654071 DOI: 10.1093/jamia/ocw014] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2015] [Revised: 12/30/2015] [Accepted: 01/21/2016] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVE We propose a computational framework for integrating diverse patient measurements into an aggregate health score and applying it to patient stability prediction. MATERIALS AND METHODS We mapped retrospective patient data from the Multiparameter Intelligent Monitoring in Intensive Care (MIMIC) II clinical database into a discrete multidimensional space, which was searched for measurement combinations and trends relevant to patient outcomes of interest. Patient trajectories through this space were then used to make outcome predictions. As a case study, we built AutoTriage, a patient stability prediction tool to be used for discharge recommendation. RESULTS AutoTriage correctly identified 3 times as many stabilizing patients as existing tools and achieved an accuracy of 92.9% (95% CI: 91.6-93.9%), while maintaining 94.5% specificity. Analysis of AutoTriage parameters revealed that interdependencies between risk factors comprised the majority of each patient stability score. DISCUSSION AutoTriage demonstrated an improvement in the sensitivity of existing stability prediction tools, while considering patient safety upon discharge. The relative contributions of risk factors indicated that time-series trends and measurement interdependencies are most important to stability prediction. CONCLUSION Our results motivate the application of multidimensional analysis to other clinical problems and highlight the importance of risk factor trends and interdependencies in outcome prediction.
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Affiliation(s)
| | | | - Christopher W Barton
- Department of Emergency Medicine, University of California San Francisco, San Francisco, CA, USA
| | - Uli K Chettipally
- Department of Emergency Medicine, University of California San Francisco, San Francisco, CA, USA
- Kaiser Permanente South San Francisco Medical Center, South San Francisco, CA, USA
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Rannikmäe K, Woodfield R, Anderson CS, Charidimou A, Chiewvit P, Greenberg SM, Jeng JS, Meretoja A, Palm F, Putaala J, Rinkel GJ, Rosand J, Rost NS, Strbian D, Tatlisumak T, Tsai CF, Wermer MJ, Werring D, Yeh SJ, Al-Shahi Salman R, Sudlow CL. Reliability of intracerebral hemorrhage classification systems: A systematic review. Int J Stroke 2016; 11:626-36. [PMID: 27091144 DOI: 10.1177/1747493016641962] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2015] [Accepted: 02/04/2016] [Indexed: 11/17/2022]
Abstract
BACKGROUND Accurately distinguishing non-traumatic intracerebral hemorrhage (ICH) subtypes is important since they may have different risk factors, causal pathways, management, and prognosis. We systematically assessed the inter- and intra-rater reliability of ICH classification systems. METHODS We sought all available reliability assessments of anatomical and mechanistic ICH classification systems from electronic databases and personal contacts until October 2014. We assessed included studies' characteristics, reporting quality and potential for bias; summarized reliability with kappa value forest plots; and performed meta-analyses of the proportion of cases classified into each subtype. SUMMARY OF REVIEW We included 8 of 2152 studies identified. Inter- and intra-rater reliabilities were substantial to perfect for anatomical and mechanistic systems (inter-rater kappa values: anatomical 0.78-0.97 [six studies, 518 cases], mechanistic 0.89-0.93 [three studies, 510 cases]; intra-rater kappas: anatomical 0.80-1 [three studies, 137 cases], mechanistic 0.92-0.93 [two studies, 368 cases]). Reporting quality varied but no study fulfilled all criteria and none was free from potential bias. All reliability studies were performed with experienced raters in specialist centers. Proportions of ICH subtypes were largely consistent with previous reports suggesting that included studies are appropriately representative. CONCLUSIONS Reliability of existing classification systems appears excellent but is unknown outside specialist centers with experienced raters. Future reliability comparisons should be facilitated by studies following recently published reporting guidelines.
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Affiliation(s)
| | | | - Craig S Anderson
- The George Institute for Global Health, Royal Prince Alfred Hospital and the University of Sydney, Australia
| | - Andreas Charidimou
- Stroke Research Group, Department of Brain Repair and Rehabilitation, UCL Institute of Neurology and National Hospital for Neurology and Neurosurgery, UK
| | - Pipat Chiewvit
- Department of Radiology, Faculty of Medicine, Siriraj Hospital, Mahidol University, Thailand
| | | | - Jiann-Shing Jeng
- Stroke Center and Department of Neurology, National Taiwan University Hospital, Taiwan
| | - Atte Meretoja
- Department of Neurology, Helsinki University Central Hospital, Finland Departments of Medicine and the Florey, Royal Melbourne Hospital, University of Melbourne, Australia
| | - Frederic Palm
- Department of Neurology, Städtisches Klinikum Ludwigshafen, Germany
| | - Jukka Putaala
- Department of Neurology, Helsinki University Central Hospital, Finland
| | - Gabriel Je Rinkel
- Department of Neurology and Neurosurgery, Brain Center Rudolf Magnus, University Medical Center Utrecht, The Netherlands
| | - Jonathan Rosand
- Department of Neurology, Massachusetts General Hospital, USA Center for Human Genetic Research, Massachusetts General Hospital, USA Program in Medical and Population Genetics, Broad Institute, USA
| | - Natalia S Rost
- Center for Human Genetic Research, Massachusetts General Hospital, USA
| | - Daniel Strbian
- Department of Neurology, Helsinki University Central Hospital, Finland
| | - Turgut Tatlisumak
- Department of Neurology, Helsinki University Central Hospital, Finland Institute of Neuroscience and Physiology, Sahlgrenska Academy, University of Gothenburg, Sweden Department of Neurology, Sahlgrenska University Hospital, Sweden
| | - Chung-Fen Tsai
- Department of Neurology, Cardinal Tien Hospital, School of Medicine, Fu-Jen Catholic University, Taiwan
| | - Marieke Jh Wermer
- Department of Neurology, Leiden University Medical Center, The Netherlands
| | - David Werring
- Stroke Research Group, Department of Brain Repair and Rehabilitation, UCL Institute of Neurology and National Hospital for Neurology and Neurosurgery, UK
| | - Shin-Joe Yeh
- Stroke Center and Department of Neurology, National Taiwan University Hospital, Taiwan
| | | | - Cathie Lm Sudlow
- Centre for Clinical Brain Sciences, University of Edinburgh, UK Institute for Genetics and Molecular Medicine, University of Edinburgh, UK UK Biobank, UK
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Thompson BB, Béjot Y, Caso V, Castillo J, Christensen H, Flaherty ML, Foerch C, Ghandehari K, Giroud M, Greenberg SM, Hallevi H, Hemphill JC, Heuschmann P, Juvela S, Kimura K, Myint PK, Nagakane Y, Naritomi H, Passero S, Rodríguez-Yáñez MR, Roquer J, Rosand J, Rost NS, Saloheimo P, Salomaa V, Sivenius J, Sorimachi T, Togha M, Toyoda K, Turaj W, Vemmos KN, Wolfe CDA, Woo D, Smith EE. Prior antiplatelet therapy and outcome following intracerebral hemorrhage: a systematic review. Neurology 2010; 75:1333-42. [PMID: 20826714 DOI: 10.1212/wnl.0b013e3181f735e5] [Citation(s) in RCA: 142] [Impact Index Per Article: 10.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Abstract
OBJECTIVES Antiplatelet therapy (APT) promotes bleeding; therefore, APT might worsen outcome in patients with intracerebral hemorrhage (ICH). We performed a systematic review and meta-analysis to address the hypothesis that pre-ICH APT use is associated with mortality and poor functional outcome following ICH. METHODS The Medline and Embase databases were searched in February 2008 using relevant key words, limited to human studies in the English language. Cohort studies of consecutive patients with ICH reporting mortality or functional outcome according to pre-ICH APT use were identified. Of 2,873 studies screened, 10 were judged to meet inclusion criteria by consensus of 2 authors. Additionally, we solicited unpublished data from all authors of cohort studies with >100 patients published within the last 10 years, and received data from 15 more studies. Univariate and multivariable-adjusted odds ratios (ORs) for mortality and poor functional outcome were abstracted as available and pooled using a random effects model. RESULTS We obtained mortality data from 25 cohorts (15 unpublished) and functional outcome data from 21 cohorts (14 unpublished). Pre-ICH APT users had increased mortality in both univariate (OR 1.41, 95% confidence interval [CI] 1.21 to 1.64) and multivariable-adjusted (OR 1.27, 95% CI 1.10 to 1.47) pooled analyses. By contrast, the pooled OR for poor functional outcome was no longer significant when using multivariable-adjusted estimates (univariate OR 1.29, 95% CI 1.09 to 1.53; multivariable-adjusted OR 1.10, 95% CI 0.93 to 1.29). CONCLUSIONS In cohort studies, APT use at the time of ICH compared to no APT use was independently associated with increased mortality but not with poor functional outcome.
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Affiliation(s)
- B B Thompson
- Department of Neurology, Brown University, Providence, RI, USA
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Rønning P, Sorteberg W, Nakstad P, Russell D, Helseth E. Aspects of intracerebral hematomas--an update. Acta Neurol Scand 2008; 118:347-61. [PMID: 18462476 DOI: 10.1111/j.1600-0404.2008.01023.x] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
BACKGROUND In Norway, there are approximately 16000 strokes each year and 15% of these are caused by intracerebral hematomas. Intracerebral hemorrhage (ICH) results from the rupture of blood vessels within the brain parenchyma. ICH occurs as a complication of several diseases, the most prevalent of which is chronic hypertension. When hemorrhage develops in the absence of a pre-existing vascular malformation or brain parenchymal lesion, it is denoted primary ICH. Secondary ICH refers to hemorrhage complicating a pre-existing lesion. Primary ICH is the most common type of hemorrhagic stroke, accounting for approximately 10% of all strokes. Despite aggressive management strategies, the 30-day mortality remains high, at almost 50%, with the majority of deaths occurring within the first 2 days. At 6 months, only 20-30% achieve independent status. MATERIAL AND METHODS This article is based on clinical experience, modern therapeutic guidelines for the treatment of intracerebral hematomas and up-to-date medical literature found in Medline. The article discusses the pathophysiology, clinical aspects, treatment, and the prognosis of intracerebral hematomas. RESULTS AND DISCUSSION Advances in diagnosis, prognosis, pathophysiology, and treatment over the past few decades have significantly advanced our knowledge of ICH; however, much work still needs to be carried out. Future genetic and epidemiologic studies will help identify at-risk populations and hopefully allow for primary prevention. Randomized controlled studies focusing on novel therapeutics should help to minimize secondary injury and hopefully improve morbidity and mortality.
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Affiliation(s)
- P Rønning
- Department of Neurosurgery, Ulleval Universitetssykehus, Oslo, Norway.
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