1
|
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.
Collapse
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
| |
Collapse
|
2
|
MRI spot sign in acute intracerebral hemorrhage: an independent biomarker of hematoma expansion and poor functional outcome. J Neurol 2023; 270:1531-1542. [PMID: 36434128 DOI: 10.1007/s00415-022-11498-w] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2022] [Revised: 11/17/2022] [Accepted: 11/18/2022] [Indexed: 11/27/2022]
Abstract
BACKGROUND In acute intracerebral hemorrhage (ICH), the prognostic value of the MRI spot sign on hematoma expansion (HE) and poor functional outcome is poorly known. METHODS We retrospectively included patients admitted over a 4-year period for an acute ICH in a single institution using MRI as the first-line imaging tool. The presence and number of MRI spot signs on contrast-enhanced T1-weighted imaging was evaluated by one neuroradiologist, blinded from outcomes. The primary outcome was HE, defined as > 6 mL or > 33% ICH volume growth from initial MRI to 24-48 h follow-up imaging; the secondary outcome was poor 3-month modified Rankin score (4-6). RESULTS Overall, 147 patients were included, and 62% had a spot sign. Among the 130 patients with follow-up imaging, 24% experienced HE. HE occurred in 6%, 21% and 43% patients with 0, 1 and ≥ 2 spots, respectively (P < 0.001). The MRI spot sign was independently associated with HE (adjusted OR 6.15 [95% CI 1.60-23.65]; P = 0.008), with a dose-dependent effect. The negative and positive predictive values of the spot sign for HE were 0.94 and 0.35, respectively. Poor functional outcome occurred in 27%, 32% and 71% patients with 0, 1 and ≥ 2 spots, respectively (P < 0.001). In multivariable analysis, the presence of ≥ 2 spots was independently associated with poor functional outcome (adjusted OR 3.67 [95% CI 1.21-11.10]; P = 0.024). CONCLUSION The MRI spot sign is an independent biomarker of HE, and the presence of ≥ 2 spots is independently associated with poor 3-month outcome. The lack of spot sign is highly predictive of a favorable evolution.
Collapse
|
3
|
Zhang R, Yong VW, Xue M. Revisiting Minocycline in Intracerebral Hemorrhage: Mechanisms and Clinical Translation. Front Immunol 2022; 13:844163. [PMID: 35401553 PMCID: PMC8993500 DOI: 10.3389/fimmu.2022.844163] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2021] [Accepted: 02/24/2022] [Indexed: 01/31/2023] Open
Abstract
Intracerebral hemorrhage (ICH) is an important subtype of stroke with an unsatisfactory prognosis of high mortality and disability. Although many pre-clinical studies and clinical trials have been performed in the past decades, effective therapy that meaningfully improve prognosis and outcomes of ICH patients is still lacking. An active area of research is towards alleviating secondary brain injury after ICH through neuroprotective pharmaceuticals and in which minocycline is a promising candidate. Here, we will first discuss new insights into the protective mechanisms of minocycline for ICH including reducing iron-related toxicity, maintenance of blood-brain barrier, and alleviating different types of cell death from preclinical data, then consider its shortcomings. Finally, we will review clinical trial perspectives for minocycline in ICH. We hope that this summary and discussion about updated information on minocycline as a viable treatment for ICH can facilitate further investigations.
Collapse
Affiliation(s)
- Ruiyi Zhang
- The Departments of Cerebrovascular Diseases, The Second Affiliated Hospital of Zhengzhou University, Zhengzhou, China
- Henan Medical Key Laboratory of Translational Cerebrovascular Diseases, The Second Affiliated Hospital of Zhengzhou University, Zhengzhou, China
- Hotchkiss Brain Institute, University of Calgary, Calgary, AB, Canada
- Department of Clinical Neurosciences, University of Calgary, Calgary, AB, Canada
| | - V. Wee Yong
- Hotchkiss Brain Institute, University of Calgary, Calgary, AB, Canada
- Department of Clinical Neurosciences, University of Calgary, Calgary, AB, Canada
| | - Mengzhou Xue
- The Departments of Cerebrovascular Diseases, The Second Affiliated Hospital of Zhengzhou University, Zhengzhou, China
- Henan Medical Key Laboratory of Translational Cerebrovascular Diseases, The Second Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| |
Collapse
|
4
|
Berthaud JV, Morgenstern LB, Zahuranec DB. Medical Therapy of Intracerebral and Intraventricular Hemorrhage. Stroke 2022. [DOI: 10.1016/b978-0-323-69424-7.00059-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
|
5
|
From Spot Sign to Bleeding on the Spot: Classic and Original Signs of Expanding Primary Spontaneous Intracerebral Hematoma. Case Rep Radiol 2021; 2021:9716952. [PMID: 34820144 PMCID: PMC8608540 DOI: 10.1155/2021/9716952] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2021] [Accepted: 10/28/2021] [Indexed: 12/02/2022] Open
Abstract
Expansion of a primary spontaneous intracranial hemorrhage (PSICH) has become lately of increasing interest, especially after the emergence of its early predictors. However, these signs lacked sensitivity and specificity. The flood phenomenon, defined as a drastic increase in the size of a PSICH during the same magnetic resonance study, was first described in this paper based on the data of a university medical center in Lebanon. Moreover, further review of this data resulted in 205 studies with presumed diagnosis of primary spontaneous intracranial hemorrhage within the last 10 years, of which 29 exams showed typical predictors of hematoma expansion on computed tomography. The intended benefit of this observation is to draw the radiologists' attention towards minimal variations in the volume of the hematoma between the two extreme sequences of the same MRI study, in order to detect inconspicuous flood phenomena—a direct sign of hematoma expansion.
Collapse
|
6
|
Li Z, You M, Long C, Bi R, Xu H, He Q, Hu B. Hematoma Expansion in Intracerebral Hemorrhage: An Update on Prediction and Treatment. Front Neurol 2020; 11:702. [PMID: 32765408 PMCID: PMC7380105 DOI: 10.3389/fneur.2020.00702] [Citation(s) in RCA: 45] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2020] [Accepted: 06/09/2020] [Indexed: 12/15/2022] Open
Abstract
Intracerebral hemorrhage (ICH) is the most lethal type of stroke, but there is no specific treatment. After years of effort, neurologists have found that hematoma expansion (HE) is a vital predictor of poor prognosis in ICH patients, with a not uncommon incidence ranging widely from 13 to 38%. Herein, the progress of studies on HE after ICH in recent years is updated, and the topics of definition, prevalence, risk factors, prediction score models, mechanisms, treatment, and prospects of HE are covered in this review. The risk factors and prediction score models, including clinical, imaging, and laboratory characteristics, are elaborated in detail, but limited by sensitivity, specificity, and inconvenience to clinical practice. The management of HE is also discussed from bench work to bed practice. However, the upmost problem at present is that there is no treatment for HE proven to definitely improve clinical outcomes. Further studies are needed to identify more accurate predictors and effective treatment to reduce HE.
Collapse
Affiliation(s)
- Zhifang Li
- Department of Neurology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Mingfeng You
- Department of Neurology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Chunnan Long
- Department of Neurology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Rentang Bi
- Department of Neurology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Haoqiang Xu
- Department of Neurology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Quanwei He
- Department of Neurology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Bo Hu
- Department of Neurology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| |
Collapse
|
7
|
|
8
|
Ritchie DJ, Li CQ, Hoshide R, Vinocur D. Intraparenchymal extravasation of gadolinium mimicking an enhancing brain tumor. Neuroradiol J 2019; 32:273-276. [PMID: 31124756 DOI: 10.1177/1971400919853789] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Gadolinium (Gd)-enhanced magnetic resonance imaging plays an essential role in the detection, characterization, and staging of intracranial neoplasms and vascular abnormalities. Although Gd is helpful in a majority of situations, it can lead to diagnostic misinterpretation in the setting of active vascular extravasation. Scarce reports of intracranial extravasation of Gd are present in the literature. Here, we report the first case of surgically proven spontaneous intraparenchymal extravasation of Gd mimicking an enhancing intra-axial neoplasm in a pediatric patient. Early and accurate recognition of Gd extravasation is critical in obtaining the accurate diagnosis and triaging patients expeditiously into proper avenues of care.
Collapse
|
9
|
Spot Sign in Acute Intracerebral Hemorrhage in Magnetic Resonance Imaging: A Case Report and Review of the Literature. Neurologist 2018; 23:104-107. [PMID: 29722746 DOI: 10.1097/nrl.0000000000000178] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
INTRODUCTION Intracranial hemorrhage (ICH) is associated with significant mortality and morbidity. Current treatment paradigms focus on correcting hypertension and coagulopathy to prevent hematoma expansion. Magnetic resonance imaging (MRI) is becoming more common in the hyperactive phase of ICH management. The finding of contrast extravasation (ie, spot sign) on MRI may be a marker of active bleeding. We present a case of MRI spot sign and review of the literature. CASE REPORT We present a patient on oral coumadin for history of deep venous thrombosis and pulmonary embolus who presented with a right basal ganglia hemorrhage. She had a computed tomography angiography showing contrast extravasation and also had a hyperacute MRI showing similar contrast extravasation. Follow-up imaging showed hematoma enlargement. DISCUSSION We present here a case of corroboration of the computed tomography angiography spot sign with the MRI spot sign. The prognostic value of the MRI spot sign is unclear. Future studies should evaluate the prognostic value of the hyperacute MRI in ICH management.
Collapse
|
10
|
Nadeau CA, Dietrich K, Wilkinson CM, Crawford AM, George GN, Nichol HK, Colbourne F. Prolonged Blood-Brain Barrier Injury Occurs After Experimental Intracerebral Hemorrhage and Is Not Acutely Associated with Additional Bleeding. Transl Stroke Res 2018; 10:287-297. [PMID: 29949086 PMCID: PMC6526148 DOI: 10.1007/s12975-018-0636-9] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2018] [Revised: 05/07/2018] [Accepted: 06/04/2018] [Indexed: 01/27/2023]
Abstract
Intracerebral hemorrhage (ICH) causes blood-brain barrier (BBB) damage along with altered element levels in the brain. BBB permeability was quantified at 3, 7, and 14 days with Evans Blue dye after collagenase-induced ICH in rat. At peak permeability (day 3), a gadolinium (Gd)-based contrast agent was injected to further characterize BBB disruption, and X-ray fluorescence imaging (XFI) was used to map Gd, Fe, Cl, and other elements. XFI revealed that Ca, Cl, Gd, and Fe concentrations were significantly elevated, whereas K was significantly decreased. Therefore, using Gd-XFI, we co-determined BBB dysfunction with alterations in the metallome, including those that contribute to cell death and functional outcome. Warfarin was administered 3 days post-ICH to investigate whether additional or new bleeding occurs during peak BBB dysfunction, and hematoma volume was assessed on day 4. Warfarin administration prolonged bleeding time after a peripheral cut-induced bleed, but warfarin did not worsen hematoma volume. Accordingly, extensive BBB leakage occurred after ICH, but did not appear to affect total hematoma size.
Collapse
Affiliation(s)
- Colby A Nadeau
- Department of Psychology, University of Alberta, P217 Biological Sciences Building, Edmonton, Alberta, T6G 2E9, Canada
| | - Kristen Dietrich
- Neuroscience and Mental Health Institute, University of Alberta, Edmonton, Canada
| | - Cassandra M Wilkinson
- Department of Psychology, University of Alberta, P217 Biological Sciences Building, Edmonton, Alberta, T6G 2E9, Canada
| | - Andrew M Crawford
- Molecular and Environmental Sciences Group, Department of Geological Sciences, University of Saskatchewan, Saskatoon, Canada
| | - Graham N George
- Molecular and Environmental Sciences Group, Department of Geological Sciences, University of Saskatchewan, Saskatoon, Canada.,Department of Chemistry, University of Saskatchewan, Saskatoon, Canada
| | - Helen K Nichol
- Department of Anatomy and Cell Biology, University of Saskatchewan, Saskatoon, Canada
| | - Frederick Colbourne
- Department of Psychology, University of Alberta, P217 Biological Sciences Building, Edmonton, Alberta, T6G 2E9, Canada. .,Neuroscience and Mental Health Institute, University of Alberta, Edmonton, Canada.
| |
Collapse
|
11
|
Gadolinium-Based Contrast Agent Extravasation Mimicking Subarachnoid Hemorrhage After Electroconvulsive Therapy. World Neurosurg 2018; 114:130-133. [PMID: 29551720 DOI: 10.1016/j.wneu.2018.03.063] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2018] [Revised: 03/07/2018] [Accepted: 03/09/2018] [Indexed: 11/24/2022]
Abstract
BACKGROUND Electroconvulsive therapy (ECT) is a safe method that has been applied for many years in medical treatment-resistant depression treatment. In this case report, contrast extravasation due to deterioration of the blood-brain barrier after ECT mimicking subarachnoid hemorrhage (SAH) on magnetic resonance imaging (MRI) is discussed. CASE DESCRIPTION A 70-year-old male patient who underwent ECT presented with sulcal hyperintensities suggesting subarachnoid hemorrhage on fluid-attenuated inversion recovery sequence of MRI obtained after ECT. However, there was no evidence to suggest SAH on nonenhanced brain computed tomography. CONCLUSION It should be kept in mind that patients may have contrast extravasation due to deterioration of the blood-brain barrier after ECT, and other alternative methods should be used for the diagnosis of SAH in these patients, not MRI.
Collapse
|
12
|
Terceño M, Serena J, Bragado I, Silva Y. Contrast extravasation through MRI precedes cerebral hemorrhage in a patient with eclampsia. Neurol Sci 2016; 38:693-694. [PMID: 27885447 DOI: 10.1007/s10072-016-2781-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2015] [Accepted: 11/21/2016] [Indexed: 10/20/2022]
Affiliation(s)
- Mikel Terceño
- Department of Neurology, Doctor Josep Trueta Hospital, IDIBGI, Av de França s/n, 17007, Girona, Spain.
| | - Joaquín Serena
- Department of Neurology, Doctor Josep Trueta Hospital, IDIBGI, Av de França s/n, 17007, Girona, Spain
| | - Irene Bragado
- Department of Neurology, Doctor Josep Trueta Hospital, IDIBGI, Av de França s/n, 17007, Girona, Spain
| | - Yolanda Silva
- Department of Neurology, Doctor Josep Trueta Hospital, IDIBGI, Av de França s/n, 17007, Girona, Spain
| |
Collapse
|
13
|
Orito K, Morioka M. Response by Orito and Morioka to Letter Regarding Article, "Leakage Sign for Primary Intracerebral Hemorrhage: A Novel Predictor of Hematoma Growth". Stroke 2016; 47:e212. [PMID: 27382007 DOI: 10.1161/strokeaha.116.013619] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Kimihiko Orito
- Department of Neurosurgery, Kurume University School of Medicine, Fukuoka, Japan
| | - Motohiro Morioka
- Department of Neurosurgery, Kurume University School of Medicine, Fukuoka, Japan
| |
Collapse
|
14
|
Murai Y. Letter by Murai Regarding Article, "Leakage Sign for Primary Intracerebral Hemorrhage: A Novel Predictor of Hematoma Growth". Stroke 2016; 47:e211. [PMID: 27382008 DOI: 10.1161/strokeaha.116.013575] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Yasuo Murai
- Department of Neurological Surgery, Nippon Medical School, Tokyo, Japan
| |
Collapse
|
15
|
Active extravasation of gadolinium-based contrast agent into the subdural space following lumbar puncture. Clin Imaging 2016; 40:591-3. [PMID: 27317202 DOI: 10.1016/j.clinimag.2016.03.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2015] [Revised: 02/18/2016] [Accepted: 03/04/2016] [Indexed: 11/20/2022]
Abstract
A 38year-old male presented with cauda equina syndrome following multiple lumbar puncture attempts. Lumbar spine magnetic resonance imaging (MRI) showed a subdural hematoma and an area of apparent contrast enhancement in the spinal canal on sagittal post-contrast images. Axial post-contrast images obtained seven minutes later demonstrated an increase in size and change in shape of the region of apparent contrast enhancement, indicating active extravasation of the contrast agent. This is the first reported case of active extravasation of gadolinium-based contrast agent in the spine.
Collapse
|
16
|
Murai Y, Ikeda Y, Morita A. Letter by Murai et al Regarding Article, “Spot Sign in Acute Intracerebral Hemorrhage in Dynamic T1-Weighted Magnetic Resonance Imaging”. Stroke 2016; 47:e84. [DOI: 10.1161/strokeaha.116.012812] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Yasuo Murai
- Department of Neurological Surgery, Nippon Medical School, Tokyo, Japan
| | - Yukio Ikeda
- Department of Neurosurgery, Tokyo Medical University, Hachioji Medical Center, Tokyo, Japan
| | - Akio Morita
- Department of Neurological Surgery, Nippon Medical School, Tokyo, Japan
| |
Collapse
|
17
|
Zahuranec DB, Morgenstern LB. Medical Therapy of Intracerebral and Intraventricular Hemorrhage. Stroke 2016. [DOI: 10.1016/b978-0-323-29544-4.00057-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
|
18
|
Schindlbeck KA, Santaella A, Galinovic I, Krause T, Rocco A, Nolte CH, Villringer K, Fiebach JB. Spot Sign in Acute Intracerebral Hemorrhage in Dynamic T1-Weighted Magnetic Resonance Imaging. Stroke 2015; 47:417-23. [PMID: 26715459 DOI: 10.1161/strokeaha.115.011570] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2015] [Accepted: 11/18/2015] [Indexed: 11/16/2022]
Abstract
BACKGROUND AND PURPOSE In computed tomographic imaging of acute intracerebral hemorrhage spot sign on computed tomographic angiography has been established as a marker for hematoma expansion and poor clinical outcome. Although, magnetic resonance imaging (MRI) can accurately visualize acute intracerebral hemorrhage, a corresponding MRI marker is lacking to date. METHODS We prospectively examined 50 consecutive patients with acute intracerebral hemorrhage within 24 hours of symptom onset. The MRI protocol consisted of a standard stroke protocol and dynamic contrast-enhanced T1-weighted imaging with a time resolution of 7.07 s/batch. Stroke scores were assessed at admission and at time of discharge. Volume measurements of hematoma size and spot sign were performed with MRIcron. RESULTS Contrast extravasation within sites of the hemorrhage (MRI spot sign) was seen in 46% of the patients. Patients with an MRI spot sign had a significantly shorter time to imaging than those without (P<0.001). The clinical outcome measured by the modified Rankin Scale was significantly worse in patients with spot sign compared with those without (P≤0.001). Hematoma expansion was observed in the spot sign group compared with the nonspot sign group, although the differences were not significant. CONCLUSIONS Spot sign can be detected using MRI on postcontrast T1-weighted and dynamic T1-weighted images. It is associated with worse clinical outcome. The time course of contrast extravasation in dynamic T1 images indicates that these spots represent ongoing bleeding.
Collapse
Affiliation(s)
- Katharina A Schindlbeck
- From the Department of Neurology, Charité - Universitätsmedizin Berlin, Berlin, Germany (K.A.S., A.R., C.H.N.); International Graduate Program Medical Neurosciences, Berlin, Germany (A.S.); and Center for Stroke Research Berlin (CSB), Berlin, Germany (I.G., T.K., K.V., J.B.F.).
| | - Anna Santaella
- From the Department of Neurology, Charité - Universitätsmedizin Berlin, Berlin, Germany (K.A.S., A.R., C.H.N.); International Graduate Program Medical Neurosciences, Berlin, Germany (A.S.); and Center for Stroke Research Berlin (CSB), Berlin, Germany (I.G., T.K., K.V., J.B.F.)
| | - Ivana Galinovic
- From the Department of Neurology, Charité - Universitätsmedizin Berlin, Berlin, Germany (K.A.S., A.R., C.H.N.); International Graduate Program Medical Neurosciences, Berlin, Germany (A.S.); and Center for Stroke Research Berlin (CSB), Berlin, Germany (I.G., T.K., K.V., J.B.F.)
| | - Thomas Krause
- From the Department of Neurology, Charité - Universitätsmedizin Berlin, Berlin, Germany (K.A.S., A.R., C.H.N.); International Graduate Program Medical Neurosciences, Berlin, Germany (A.S.); and Center for Stroke Research Berlin (CSB), Berlin, Germany (I.G., T.K., K.V., J.B.F.)
| | - Andrea Rocco
- From the Department of Neurology, Charité - Universitätsmedizin Berlin, Berlin, Germany (K.A.S., A.R., C.H.N.); International Graduate Program Medical Neurosciences, Berlin, Germany (A.S.); and Center for Stroke Research Berlin (CSB), Berlin, Germany (I.G., T.K., K.V., J.B.F.)
| | - Christian H Nolte
- From the Department of Neurology, Charité - Universitätsmedizin Berlin, Berlin, Germany (K.A.S., A.R., C.H.N.); International Graduate Program Medical Neurosciences, Berlin, Germany (A.S.); and Center for Stroke Research Berlin (CSB), Berlin, Germany (I.G., T.K., K.V., J.B.F.)
| | - Kersten Villringer
- From the Department of Neurology, Charité - Universitätsmedizin Berlin, Berlin, Germany (K.A.S., A.R., C.H.N.); International Graduate Program Medical Neurosciences, Berlin, Germany (A.S.); and Center for Stroke Research Berlin (CSB), Berlin, Germany (I.G., T.K., K.V., J.B.F.)
| | - Jochen B Fiebach
- From the Department of Neurology, Charité - Universitätsmedizin Berlin, Berlin, Germany (K.A.S., A.R., C.H.N.); International Graduate Program Medical Neurosciences, Berlin, Germany (A.S.); and Center for Stroke Research Berlin (CSB), Berlin, Germany (I.G., T.K., K.V., J.B.F.)
| |
Collapse
|
19
|
Rosa M, da Rocha AJ, Maia ACM, Saade N, Veiga JCE, Romero JM. Contusion Contrast Extravasation Depicted on Multidetector Computed Tomography Angiography Predicts Growth and Mortality in Traumatic Brain Contusion. J Neurotrauma 2015. [PMID: 26214242 DOI: 10.1089/neu.2015.4062] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Traumatic brain injury (TBI) is the main cause of death in trauma victims and causes high rates of disability and neurological sequelae. Approximately 38-65% of traumatic brain contusions (TBC) demonstrate hemorrhagic expansion on serial computed tomography (CT) scans. Thus far, however, no single variable can accurately predict the hemorrhage expansion of a TBC. Our purpose was to evaluate contrast extravasation (CE) as a predictor of expansion, mortality, and poor outcome in TBC in a Brazilian cohort. After Institutional Review Board approval, we used multidetector CT angiography (MDCTA) to study 121 consecutive patients (106 men, 87.6%) with ages varying from 10 to 85 years. Informed consent was obtained from all subjects. The clinical and imaging findings were correlated with the findings on the initial MDCTA using either the Fisher exact test or Student t test and a multivariate logistic regression model. Of the persons who presented CE in TBC, 21.8% died (in-hospital mortality), whereas in the absence of this sign, the mortality rate was 7.6% (p = 0.014). In addition, expansion of the hemorrhagic component of the TBC was detected in 61.1% of the CE-positive patients, whereas expansion was only observed in 10% of the CE-negative patients (p < 0.001). Poor outcome was observed in 24.2% of the patients in the CE-negative group, but in the presence of CE, 72.7% evolved with poor outcome (p < 0.001). The CE was a strong independent predictor of expansion, poor outcome, and increased risk of in-hospital mortality in our series of patients with TBC.
Collapse
Affiliation(s)
- Marcos Rosa
- 1 Section of Neuroradiology , Santa Casa de Misericórdia de São Paulo, São Paulo SP, Brazil .,2 Section of Radiology, Federal University of Espírito Santo , Vitória ES, Brazil
| | - Antônio José da Rocha
- 1 Section of Neuroradiology , Santa Casa de Misericórdia de São Paulo, São Paulo SP, Brazil
| | | | - Nelson Saade
- 3 Division of Neurosurgery , Santa Casa de Misericórdia de São Paulo, São Paulo SP, Brazil
| | | | - Javier M Romero
- 4 Division of Neuroradiology, Massachusetts General Hospital , Harvard Medical School, Boston, Massachusetts
| |
Collapse
|
20
|
Keep RF, Zhou N, Xiang J, Andjelkovic AV, Hua Y, Xi G. Vascular disruption and blood-brain barrier dysfunction in intracerebral hemorrhage. Fluids Barriers CNS 2014; 11:18. [PMID: 25120903 PMCID: PMC4130123 DOI: 10.1186/2045-8118-11-18] [Citation(s) in RCA: 152] [Impact Index Per Article: 15.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2014] [Accepted: 08/07/2014] [Indexed: 12/11/2022] Open
Abstract
This article reviews current knowledge of the mechanisms underlying the initial hemorrhage and secondary blood-brain barrier (BBB) dysfunction in primary spontaneous intracerebral hemorrhage (ICH) in adults. Multiple etiologies are associated with ICH, for example, hypertension, Alzheimer's disease, vascular malformations and coagulopathies (genetic or drug-induced). After the initial bleed, there can be continued bleeding over the first 24 hours, so-called hematoma expansion, which is associated with adverse outcomes. A number of clinical trials are focused on trying to limit such expansion. Significant progress has been made on the causes of BBB dysfunction after ICH at the molecular and cell signaling level. Blood components (e.g. thrombin, hemoglobin, iron) and the inflammatory response to those components play a large role in ICH-induced BBB dysfunction. There are current clinical trials of minimally invasive hematoma removal and iron chelation which may limit such dysfunction. Understanding the mechanisms underlying the initial hemorrhage and secondary BBB dysfunction in ICH is vital for developing methods to prevent and treat this devastating form of stroke.
Collapse
Affiliation(s)
- Richard F Keep
- Department of Neurosurgery, University of Michigan, Ann Arbor, Michigan 48109-2200, USA ; Department of Molecular & Integrative Physiology, University of Michigan, Ann Arbor, USA
| | - Ningna Zhou
- Department of Neurosurgery, University of Michigan, Ann Arbor, Michigan 48109-2200, USA ; Department of Pharmacology, Yunnan University of Traditional Chinese Medicine, Kunming, China
| | - Jianming Xiang
- Department of Neurosurgery, University of Michigan, Ann Arbor, Michigan 48109-2200, USA
| | | | - Ya Hua
- Department of Neurosurgery, University of Michigan, Ann Arbor, Michigan 48109-2200, USA
| | - Guohua Xi
- Department of Neurosurgery, University of Michigan, Ann Arbor, Michigan 48109-2200, USA
| |
Collapse
|
21
|
Rosa Júnior M, Rocha AJD, Saade N, Maia Júnior ACM, Gagliardi RJ. Active extravasation of contrast within the hemorrhage (spot sign): a multidetector computed tomography finding that predicts growth and a worse prognosis in non-traumatic intracerebral hemorrhage. ARQUIVOS DE NEURO-PSIQUIATRIA 2014; 71:791-7. [PMID: 24212517 DOI: 10.1590/0004-282x20130124] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/01/2013] [Accepted: 06/03/2013] [Indexed: 11/22/2022]
Abstract
Intracerebral hemorrhage (ICH) causes high rates of disability and neurological sequelae Objective To evaluate spot signs as predictors of expansion and worse prognosis in non-traumatic ICH in a Brazilian cohort. Method We used multidetector computed tomography angiography to study 65 consecutive patients (40 men, 61.5%), with ages varying from 33 to 89 years (median age 55 years). Clinical and imaging findings were correlated with the findings based on the initial imaging. Results Of the individuals who presented a spot sign, 73.7% died (in-hospital mortality), whereas in the absence of a spot sign the mortality rate was 43.0%. Although expansion of ICH was detected in 75% of the patients with a spot sign, expansion was observed in only 9.0% of the patients who did not present a spot sign. Conclusions The spot sign strongly predicted expansion in non-traumatic ICH and an increased risk of in-hospital mortality.
Collapse
Affiliation(s)
- Marcos Rosa Júnior
- Santa Casa de Misericórdia de São Paulo, Section of Neuroradiology, São PauloSP, Brazil
| | | | | | | | | |
Collapse
|
22
|
Aviv RI, Huynh T, Huang Y, Ramsay D, Van Slyke P, Dumont D, Asmah P, Alkins R, Liu R, Hynynen K. An in vivo, MRI-integrated real-time model of active contrast extravasation in acute intracerebral hemorrhage. AJNR Am J Neuroradiol 2014; 35:1693-9. [PMID: 24763419 DOI: 10.3174/ajnr.a3939] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
BACKGROUND AND PURPOSE The "spot sign" or contrast extravasation is strongly associated with hematoma formation and growth. An animal model of contrast extravasation is important to test existing and novel therapeutic interventions to inform present and future clinical studies. The purpose of this study was to create an animal model of contrast extravasation in acute intracerebral hemorrhage. MATERIALS AND METHODS Twenty-eight hemispheres of Yorkshire male swine were insonated with an MR imaging-guided focused sonography system following lipid microsphere infusion and mean arterial pressure elevation. The rate of contrast leakage was quantified by using dynamic contrast-enhanced MR imaging and was classified as contrast extravasation or postcontrast leakage by using postcontrast T1. Hematoma volume was measured on gradient recalled-echo MR imaging performed 2 hours postprocedure. Following this procedure, sacrificed brain was subjected to histopathologic examination. Power level, burst length, and blood pressure elevation were correlated with leakage rate, hematoma size, and vessel abnormality extent. RESULTS Median (intracerebral hemorrhage) contrast extravasation leakage was higher than postcontrast leakage (11.3; 6.3-23.2 versus 2.4; 1.1-3.1 mL/min/100 g; P<.001). Increasing burst length, gradient recalled-echo hematoma (ρ=0.54; 95% CI, 0.2-0.8; P=.007), and permeability were correlated (ρ=0.55; 95% CI, 0.1-0.8; P=.02). Median permeability (P=.02), gradient recalled-echo hematoma (P=.02), and dynamic contrast-enhanced volumes (P=.02) were greater at 1000 ms than at 10 ms. Within each burst-length subgroup, incremental contrast leakage was seen with mean arterial pressure elevation (ρ=0.2-0.8). CONCLUSIONS We describe a novel MR imaging-integrated real-time swine intracerebral hemorrhage model of acute hematoma growth and contrast extravasation.
Collapse
Affiliation(s)
- R I Aviv
- From the Department of Medical Imaging (T.H., R.I.A., R.L.), Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada Medical Imaging (T.H., K.H., R.I.A.), University of Toronto, Toronto, Ontario, Canada
| | - T Huynh
- From the Department of Medical Imaging (T.H., R.I.A., R.L.), Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada Medical Imaging (T.H., K.H., R.I.A.), University of Toronto, Toronto, Ontario, Canada
| | - Y Huang
- Imaging Research (Y.H., K.H.), Sunnybrook Research Institute, Toronto, Ontario, Canada
| | - D Ramsay
- Department of Pathology (D.R.), London Health Sciences Centre, London, Ontario, Canada
| | - P Van Slyke
- The Centre for Proteomic Studies (D.D., P.V.S.)
| | - D Dumont
- Departments of Medical Biophysics (K.H., D.D., R.A., P.A.) The Centre for Proteomic Studies (D.D., P.V.S.)
| | - P Asmah
- Departments of Medical Biophysics (K.H., D.D., R.A., P.A.)
| | - R Alkins
- Departments of Medical Biophysics (K.H., D.D., R.A., P.A.)
| | - R Liu
- From the Department of Medical Imaging (T.H., R.I.A., R.L.), Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - K Hynynen
- Departments of Medical Biophysics (K.H., D.D., R.A., P.A.) Medical Imaging (T.H., K.H., R.I.A.), University of Toronto, Toronto, Ontario, Canada Imaging Research (Y.H., K.H.), Sunnybrook Research Institute, Toronto, Ontario, Canada
| |
Collapse
|
23
|
Sun SJ, Gao PY, Sui BB, Hou XY, Lin Y, Xue J, Zhai RY. “Dynamic spot sign” on CT perfusion source images predicts haematoma expansion in acute intracerebral haemorrhage. Eur Radiol 2013; 23:1846-54. [DOI: 10.1007/s00330-013-2803-4] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2012] [Revised: 01/08/2013] [Accepted: 01/25/2013] [Indexed: 10/27/2022]
|
24
|
What does the CT angiography “spot sign” of intracerebral hemorrhage mean in modern neurosurgical settings with minimally invasive endoscopic techniques? Neurosurg Rev 2012; 36:341-8. [DOI: 10.1007/s10143-012-0437-7] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2011] [Revised: 04/28/2012] [Accepted: 10/03/2012] [Indexed: 01/19/2023]
|
25
|
Prediction of haematoma growth and outcome in patients with intracerebral haemorrhage using the CT-angiography spot sign (PREDICT): a prospective observational study. Lancet Neurol 2012; 11:307-14. [PMID: 22405630 DOI: 10.1016/s1474-4422(12)70038-8] [Citation(s) in RCA: 431] [Impact Index Per Article: 35.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
BACKGROUND In patients with intracerebral haemorrhage (ICH), early haemorrhage expansion affects clinical outcome. Haemostatic treatment reduces haematoma expansion, but fails to improve clinical outcomes in many patients. Proper selection of patients at high risk for haematoma expansion seems crucial to improve outcomes. In this study, we aimed to prospectively validate the CT-angiography (CTA) spot sign for prediction of haematoma expansion. METHODS PREDICT (predicting haematoma growth and outcome in intracerebral haemorrhage using contrast bolus CT) was a multicentre prospective observational cohort study. We recruited patients aged 18 years or older, with ICH smaller than 100 mL, and presenting at less than 6 h from symptom onset. Using two independent core laboratories, one neuroradiologist determined CTA spot-sign status, whereas another neurologist masked for clinical outcomes and imaging measured haematoma volumes by computerised planimetry. The primary outcome was haematoma expansion defined as absolute growth greater than 6 mL or a relative growth of more than 33% from initial CT to follow-up CT. We reported data using standard descriptive statistics stratified by the CTA spot sign. Mortality was assessed with Kaplan-Meier survival analysis. FINDINGS We enrolled 268 patients. Median time from symptom onset to baseline CT was 135 min (range 22-470), and time from onset to CTA was 159 min (32-475). 81 (30%) patients were spot-sign positive. The primary analysis included 228 patients, who had a follow-up CT before surgery or death. Median baseline ICH volume was 19·9 mL (1·5-80·9) in spot-sign-positive patients versus 10·0 mL (0·1-102·7) in spot-sign negative patients (p<0·001). Median ICH expansion was 8·6 mL (-9·3 to 121·7) for spot-sign positive patients and 0·4 mL (-11·7 to 98·3) for spot-negative patients (p<0·001). In those with haematoma expansion, the positive predictive value for the spot sign was61% (95% CI 47–73) for the positive predictive value and 78% (71–84) for the negative predictive value, with 51% (39–63) sensitivity and 85% (78–90) specificity[corrected]. Median 3-month modified Rankin Scale (mRS) was 5 in CTA spot-sign-positive patients, and 3 in spot-sign-negative patients (p<0·001). Mortality at 3 months was 43·4% (23 of 53) in CTA spot-sign positive versus 19·6% (31 of 158) in CTA spot-sign-negative patients (HR 2·4, 95% CI 1·4-4·0, p=0·002). INTERPRETATION These findings confirm previous single-centre studies showing that the CTA spot sign is a predictor of haematoma expansion. The spot sign is recommended as an entry criterion for future trials of haemostatic therapy in patients with acute ICH. FUNDING Canadian Stroke Consortium and NovoNordisk Canada.
Collapse
|
26
|
Kidwell CS, Burgess R, Menon R, Warach S, Latour LL. Hyperacute injury marker (HARM) in primary hemorrhage: a distinct form of CNS barrier disruption. Neurology 2011; 77:1725-8. [PMID: 22031531 DOI: 10.1212/wnl.0b013e318236ef46] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVE The objective of the study was to characterize a previously unreported form of CNS barrier disruption in intracerebral hemorrhage (ICH): hyperacute injury marker (HARM). METHODS In this retrospective cohort analysis of patients presenting with primary ICH, precontrast and postcontrast MRI scans obtained within 5 days of symptom onset were analyzed. The presence of CNS barrier disruption was defined by (1) perihematomal or intrahematomal enhancement visualized on postcontrast T1-weighted MRI or (2) HARM: sulcal or ventricular hyperintensity visualized on postcontrast fluid-attenuated inversion recovery sequences (graded on a 5-point scale). RESULTS Forty-six patients were included in the analysis. Mean age was 65 years, median NIH Stroke Scale score was 7, and mean ICH volume was 12.2 mL (range 0.3-46.9 mL). HARM was visualized in 85% of patients, and this was moderate to severe in 50%. In all cases, the sulcal enhancement was noncontiguous with the hematoma. Of those patients with postcontrast T1-weighted imaging, perihematomal or intrahematomal contrast enhancement was visualized in 75% of patients. CONCLUSIONS This study demonstrates that HARM occurs in intracerebral hemorrhage and that it likely represents a second type of CNS barrier disruption distinct from parenchymal postcontrast T1-weighted enhancement. Similar to T1 enhancement, this phenomenon may serve as a clinically useful biomarker to test therapies aimed at stabilizing acute ICH and CNS barrier disruption. Future studies are needed to further define the time course and prognostic implications of this finding.
Collapse
Affiliation(s)
- C S Kidwell
- Department of Neurology and Georgetown Stroke Center, 4000 Reservoir Road, NW, Building D, Suite 150, Georgetown University Medical Center, Washington, DC 20007, USA.
| | | | | | | | | |
Collapse
|
27
|
Steiner T, Petersson J, Al-Shahi Salman R, Christensen H, Cordonnier C, Csiba L, Harnof S, Krieger D, Mendelow D, Molina C, Montaner J, Overgaard K, Roine RO, Schmutzhard E, Tatlisumak T, Toni D, Stapf C. European research priorities for intracerebral haemorrhage. Cerebrovasc Dis 2011; 32:409-19. [PMID: 21986448 DOI: 10.1159/000330653] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2011] [Accepted: 07/01/2011] [Indexed: 12/31/2022] Open
Abstract
Over 2 million people are affected by intracerebral haemorrhage (ICH) worldwide every year, one third of them dying within 1 month, and many survivors being left with permanent disability. Unlike most other stroke types, the incidence, morbidity and mortality of ICH have not declined over time. No standardised diagnostic workup for the detection of the various underlying causes of ICH currently exists, and the evidence for medical or surgical therapeutic interventions remains limited. A dedicated European research programme for ICH is needed to identify ways to reduce the burden of ICH-related death and disability. The European Research Network on Intracerebral Haemorrhage EURONICH is a multidisciplinary academic research collaboration that has been established to define current research priorities and to conduct large clinical studies on all aspects of ICH.
Collapse
Affiliation(s)
- Thorsten Steiner
- Division of Clinical Neurosciences, Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, UK.
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
28
|
Morgenstern LB, Zahuranec DB. Medical Therapy of Intracerebral and Intraventricular Hemorrhage. Stroke 2011. [DOI: 10.1016/b978-1-4160-5478-8.10055-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
|
29
|
Barras CD, Tress BM, Christensen S, MacGregor L, Collins M, Desmond PM, Skolnick BE, Mayer SA, Broderick JP, Diringer MN, Steiner T, Davis SM. Density and Shape as CT Predictors of Intracerebral Hemorrhage Growth. Stroke 2009; 40:1325-31. [PMID: 19286590 DOI: 10.1161/strokeaha.108.536888] [Citation(s) in RCA: 195] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background and Purpose—
Intracerebral hemorrhage (ICH) growth predicts mortality and functional outcome. We hypothesized that irregular hematoma shape and density heterogeneity, reflecting active, multifocal bleeding or a variable bleeding time course, would predict ICH growth.
Methods—
Three raters examined baseline sub-3-hour CT brain scans of 90 patients in the placebo arm of a Phase IIb trial of recombinant activated Factor VII in ICH. Each rater, blinded to growth data, independently applied novel 5-point categorical scales of density and shape to randomly presented baseline CT images of ICH. Density and shape were defined as either homogeneous/regular (Category 1 to 2) or heterogeneous/irregular (Category 3 to 5). Within- and between-rater reliability was determined for these scales. Growth was assessed as a continuous variable and using 3 binary definitions: (1) any ICH growth; (2) ≥33% or ≥12.5 mL ICH growth; and (3) radial growth >1 mm between baseline and 24-hour CT scan. Patients were divided into tertiles of baseline ICH volume: “small” (0 to 10 mL), “medium” (10 to 25 mL), and “large” (25 to 106 mL).
Results—
Inter- and intrarater agreements for the novel scales exceeded 85% (±1 category). Median growth was significantly higher in the large-volume group compared with the small group (
P
<0.001) and in heterogeneous compared with homogeneous ICH (
P
=0.008). Median growth trended higher in irregular ICHs compared with regular ICHs (
P
=0.084). Small ICHs were more regularly shaped (43%) than medium (17%) and large (3%) ICHs (
P
<0.001). Small ICHs were more homogeneous (73%) compared with medium (37%) and large (17%) ICHs (
P
<0.001). Adjusting for baseline ICH volume and time to scan, density heterogeneity, but not shape irregularity, independently predicted ICH growth (
P
=0.046) on a continuous growth scale.
Conclusions—
Large ICHs were significantly more irregular in shape, heterogeneous in density, and had greater growth. Density heterogeneity independently predicted ICH growth using some definitions.
Collapse
Affiliation(s)
- Christen D. Barras
- From the Departments of Neurology (C.B., S.D.), Radiology (C.B., B.T., S.C., P.D.), and Clinical Epidemiology (L.M.), Royal Melbourne Hospital, The University of Melbourne, Melbourne, Australia; the Department of Mathematics and Statistics (M.C.), The University of Melbourne, Melbourne, Australia; Novo Nordisk, Inc (B.S.), Princeton, NJ; Columbia University (S.A.M.), New York, NY; the University of Cincinnati (J.B.), Cincinnati, Ohio; Washington University School of Medicine (M.D.), St Louis, Mo
| | - Brian M. Tress
- From the Departments of Neurology (C.B., S.D.), Radiology (C.B., B.T., S.C., P.D.), and Clinical Epidemiology (L.M.), Royal Melbourne Hospital, The University of Melbourne, Melbourne, Australia; the Department of Mathematics and Statistics (M.C.), The University of Melbourne, Melbourne, Australia; Novo Nordisk, Inc (B.S.), Princeton, NJ; Columbia University (S.A.M.), New York, NY; the University of Cincinnati (J.B.), Cincinnati, Ohio; Washington University School of Medicine (M.D.), St Louis, Mo
| | - Soren Christensen
- From the Departments of Neurology (C.B., S.D.), Radiology (C.B., B.T., S.C., P.D.), and Clinical Epidemiology (L.M.), Royal Melbourne Hospital, The University of Melbourne, Melbourne, Australia; the Department of Mathematics and Statistics (M.C.), The University of Melbourne, Melbourne, Australia; Novo Nordisk, Inc (B.S.), Princeton, NJ; Columbia University (S.A.M.), New York, NY; the University of Cincinnati (J.B.), Cincinnati, Ohio; Washington University School of Medicine (M.D.), St Louis, Mo
| | - Lachlan MacGregor
- From the Departments of Neurology (C.B., S.D.), Radiology (C.B., B.T., S.C., P.D.), and Clinical Epidemiology (L.M.), Royal Melbourne Hospital, The University of Melbourne, Melbourne, Australia; the Department of Mathematics and Statistics (M.C.), The University of Melbourne, Melbourne, Australia; Novo Nordisk, Inc (B.S.), Princeton, NJ; Columbia University (S.A.M.), New York, NY; the University of Cincinnati (J.B.), Cincinnati, Ohio; Washington University School of Medicine (M.D.), St Louis, Mo
| | - Marnie Collins
- From the Departments of Neurology (C.B., S.D.), Radiology (C.B., B.T., S.C., P.D.), and Clinical Epidemiology (L.M.), Royal Melbourne Hospital, The University of Melbourne, Melbourne, Australia; the Department of Mathematics and Statistics (M.C.), The University of Melbourne, Melbourne, Australia; Novo Nordisk, Inc (B.S.), Princeton, NJ; Columbia University (S.A.M.), New York, NY; the University of Cincinnati (J.B.), Cincinnati, Ohio; Washington University School of Medicine (M.D.), St Louis, Mo
| | - Patricia M. Desmond
- From the Departments of Neurology (C.B., S.D.), Radiology (C.B., B.T., S.C., P.D.), and Clinical Epidemiology (L.M.), Royal Melbourne Hospital, The University of Melbourne, Melbourne, Australia; the Department of Mathematics and Statistics (M.C.), The University of Melbourne, Melbourne, Australia; Novo Nordisk, Inc (B.S.), Princeton, NJ; Columbia University (S.A.M.), New York, NY; the University of Cincinnati (J.B.), Cincinnati, Ohio; Washington University School of Medicine (M.D.), St Louis, Mo
| | - Brett E. Skolnick
- From the Departments of Neurology (C.B., S.D.), Radiology (C.B., B.T., S.C., P.D.), and Clinical Epidemiology (L.M.), Royal Melbourne Hospital, The University of Melbourne, Melbourne, Australia; the Department of Mathematics and Statistics (M.C.), The University of Melbourne, Melbourne, Australia; Novo Nordisk, Inc (B.S.), Princeton, NJ; Columbia University (S.A.M.), New York, NY; the University of Cincinnati (J.B.), Cincinnati, Ohio; Washington University School of Medicine (M.D.), St Louis, Mo
| | - Stephan A. Mayer
- From the Departments of Neurology (C.B., S.D.), Radiology (C.B., B.T., S.C., P.D.), and Clinical Epidemiology (L.M.), Royal Melbourne Hospital, The University of Melbourne, Melbourne, Australia; the Department of Mathematics and Statistics (M.C.), The University of Melbourne, Melbourne, Australia; Novo Nordisk, Inc (B.S.), Princeton, NJ; Columbia University (S.A.M.), New York, NY; the University of Cincinnati (J.B.), Cincinnati, Ohio; Washington University School of Medicine (M.D.), St Louis, Mo
| | - Joseph P. Broderick
- From the Departments of Neurology (C.B., S.D.), Radiology (C.B., B.T., S.C., P.D.), and Clinical Epidemiology (L.M.), Royal Melbourne Hospital, The University of Melbourne, Melbourne, Australia; the Department of Mathematics and Statistics (M.C.), The University of Melbourne, Melbourne, Australia; Novo Nordisk, Inc (B.S.), Princeton, NJ; Columbia University (S.A.M.), New York, NY; the University of Cincinnati (J.B.), Cincinnati, Ohio; Washington University School of Medicine (M.D.), St Louis, Mo
| | - Michael N. Diringer
- From the Departments of Neurology (C.B., S.D.), Radiology (C.B., B.T., S.C., P.D.), and Clinical Epidemiology (L.M.), Royal Melbourne Hospital, The University of Melbourne, Melbourne, Australia; the Department of Mathematics and Statistics (M.C.), The University of Melbourne, Melbourne, Australia; Novo Nordisk, Inc (B.S.), Princeton, NJ; Columbia University (S.A.M.), New York, NY; the University of Cincinnati (J.B.), Cincinnati, Ohio; Washington University School of Medicine (M.D.), St Louis, Mo
| | - Thorsten Steiner
- From the Departments of Neurology (C.B., S.D.), Radiology (C.B., B.T., S.C., P.D.), and Clinical Epidemiology (L.M.), Royal Melbourne Hospital, The University of Melbourne, Melbourne, Australia; the Department of Mathematics and Statistics (M.C.), The University of Melbourne, Melbourne, Australia; Novo Nordisk, Inc (B.S.), Princeton, NJ; Columbia University (S.A.M.), New York, NY; the University of Cincinnati (J.B.), Cincinnati, Ohio; Washington University School of Medicine (M.D.), St Louis, Mo
| | - Stephen M. Davis
- From the Departments of Neurology (C.B., S.D.), Radiology (C.B., B.T., S.C., P.D.), and Clinical Epidemiology (L.M.), Royal Melbourne Hospital, The University of Melbourne, Melbourne, Australia; the Department of Mathematics and Statistics (M.C.), The University of Melbourne, Melbourne, Australia; Novo Nordisk, Inc (B.S.), Princeton, NJ; Columbia University (S.A.M.), New York, NY; the University of Cincinnati (J.B.), Cincinnati, Ohio; Washington University School of Medicine (M.D.), St Louis, Mo
| |
Collapse
|
30
|
Ederies A, Demchuk A, Chia T, Gladstone DJ, Dowlatshahi D, Bendavit G, Wong K, Symons SP, Aviv RI. Postcontrast CT extravasation is associated with hematoma expansion in CTA spot negative patients. Stroke 2009; 40:1672-6. [PMID: 19286577 DOI: 10.1161/strokeaha.108.541201] [Citation(s) in RCA: 79] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND AND PURPOSE The purpose of this study was to assess the effect of postcontrast CT (PCCT) leakage (PCL) on hematoma growth in CTA spot negative patients. METHODS A retrospective study of 61 patients presenting within 6 hours of primary ICH onset imaged with CT angiography (CTA) and PCCT. Presence of CTA spot sign and PCL were documented. PCL was defined as the presence of contrast extravasation on the PCCT study at a location remote from the CTA spot sign if present. Hematoma expansion was defined as >6 mL or 30% hematoma enlargement. Patients were dichotomized by CTA spot sign presence and PCL and compared for baseline demographic data, hematoma size, and growth using the unpaired t test and Mann-Whitney test for continuous and categorical data, respectively. A probability value <0.05 was considered significant. RESULTS PCL was present in 11/61 patients (18%), occurring in 5 without a spot sign (45%). Spot negative PCL patients demonstrated larger absolute (P=0.02) and percentage hematoma growth (P=0.02) compared to those without PCL. The mean volume and percent increase was 6.7 mL and 26%, respectively. Inclusion of PCL together with CTA spot sign as risk factor for hematoma expansion increased sensitivity from 0.78 (95% CI; 0.52 to 0.94) to 0.94 (95% CI; 0.72 to 1.00) and NPV from 0.90 (95% CI; 0.76 to 0.97) to 0.97 (95% CI; 0.85 to 1.00). CONCLUSIONS Inclusion of PCCT in the investigation of ICH patients allows detection of PCL which, together with the CTA spot sign, increases sensitivity and negative predictive value for predicting hematoma expansion. This finding should be validated in larger studies.
Collapse
Affiliation(s)
- Ashraf Ederies
- Department of Medical Imaging, Division of Neuroradiology, Sunnybrook Health Sciences Centre, University of Toronto, Ontario, Canada
| | | | | | | | | | | | | | | | | |
Collapse
|
31
|
Keep RF, Xiang J, Ennis SR, Andjelkovic A, Hua Y, Xi G, Hoff JT. Blood-brain barrier function in intracerebral hemorrhage. ACTA NEUROCHIRURGICA. SUPPLEMENT 2009; 105:73-7. [PMID: 19066086 DOI: 10.1007/978-3-211-09469-3_15] [Citation(s) in RCA: 138] [Impact Index Per Article: 9.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/03/2022]
Abstract
In this paper, we review current knowledge on blood-brain barrier (BBB) dysfunction following intracerebral hemorrhage (ICH). BBB disruption is a hallmark of ICH-induced brain injury. Such disruption contributes to edema formation, the influx of leukocytes, and the entry of potentially neuroactive agents into the perihematomal brain, all of which may contribute to brain injury. A range of factors have been implicated in inducing BBB disruption, including inflammatory mediators (e.g., cytokines and chemokines), thrombin, hemoglobin breakdown products, oxidative stress, complement, and matrix metalloproteinases. While there is interaction between some of these mediators, it is probable that prevention of ICH-induced BBB disruption will involve blocking multiple pathways or blocking a common end pathway (e.g., by stabilizing tight junction structure). While the effects of ICH on BBB passive permeability have been extensively examined, effects on other 'barrier' properties (metabolic and transport functions) have been less well-studied. However, recent data suggests that ICH can affect transport and that this may help protect the BBB and the brain. Indeed, it is possible in small bleeds that BBB disruption may be beneficial, and it is only in the presence of larger bleeds that disruption has detrimental effects.
Collapse
Affiliation(s)
- R F Keep
- Department of Neurosurgery, University of Michigan Medical School, Ann Arbor, MI 48109-2200, USA.
| | | | | | | | | | | | | |
Collapse
|
32
|
Wada R, Aviv RI, Fox AJ, Sahlas DJ, Gladstone DJ, Tomlinson G, Symons SP. CT angiography "spot sign" predicts hematoma expansion in acute intracerebral hemorrhage. Stroke 2007; 38:1257-62. [PMID: 17322083 DOI: 10.1161/01.str.0000259633.59404.f3] [Citation(s) in RCA: 467] [Impact Index Per Article: 27.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
BACKGROUND AND PURPOSE Morbidity and mortality in spontaneous intracerebral hemorrhage (ICH) are correlated with hematoma progression. We hypothesized that the presence of tiny, enhancing foci ("spot sign") within acute hematomas is associated with hematoma expansion. METHODS We prospectively studied 39 consecutive patients with spontaneous ICH by computed tomography angiography within 3 hours of symptom onset. Scans were reviewed by 3 readers. Patients were dichotomized according to the presence or absence of the spot sign. Clinical and radiological outcomes were compared between groups. The predictive value of this sign was assessed in a multivariate analysis. RESULTS Thirteen patients (33%) demonstrated 31 enhancing foci. Baseline clinical variables were similar in both groups. Hematoma expansion occurred in 11 patients (28%) on follow-up. Seventy-seven percent of patients with and 4% without hematoma expansion demonstrated the spot sign (P<0.0001). Sensitivity, specificity, positive predictive value, negative predictive value, and likelihood ratio for expansion were 91%, 89%, 77%, 96%, and 8.5, respectively. Interobserver agreement was high (kappa=0.92 to 0.94). In patients with the spot sign, mean volume change was greater (P=0.008), extravasation more common (P=0.0005), and median hospital stay longer (P=0.04), and fewer patients achieved a good outcome (modified Rankin Scale score <2), although the latter was not significant (P=0.16). No differences in hydrocephalus (P=1.00), surgical intervention (P=1.00), or death (P=0.60) were noted between groups. In multiple regression, the spot sign independently predicted hematoma expansion (P=0.0003). CONCLUSIONS The computed tomography angiography spot sign is associated with the presence and extent of hematoma progression. Fewer patients achieve a good clinical outcome and hospital stay was longer. Further studies are warranted to validate the ability of this sign to predict clinical outcomes.
Collapse
Affiliation(s)
- Ryan Wada
- Division of Neuroradiology, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
| | | | | | | | | | | | | |
Collapse
|
33
|
Priorities for clinical research in intracerebral hemorrhage: report from a National Institute of Neurological Disorders and Stroke workshop. Stroke 2005; 36:e23-41. [PMID: 15692109 DOI: 10.1161/01.str.0000155685.77775.4c] [Citation(s) in RCA: 104] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
BACKGROUND AND PURPOSE Spontaneous intracerebral hemorrhage (ICH) is one of the most lethal stroke types. In December 2003, a National Institute of Neurological Disorders and Stroke (NINDS) workshop was convened to develop a consensus for ICH research priorities. The focus was clinical research aimed at acute ICH in patients. METHODS Workshop participants were divided into 6 groups: (1) current state of ICH research; (2) basic science; and (3) imaging, (4) medical, (5) surgical, and (6) clinical methodology. Each group formulated research priorities before the workshop. At the workshop, these were discussed and refined. RESULTS Recent progress in management of hemorrhage growth, intraventricular hemorrhage, and limitations in the benefit of open craniotomy were noted. The workshop identified the importance of developing animal models to reflect human ICH, as well as the phenomena of rebleeding. More human ICH pathology is needed. Real-time, high-field magnets and 3-dimensional imaging, as well as high-resolution tissue probes, are ICH imaging priorities. Trials of acute blood pressure-lowering in ICH and coagulopathy reversal are medical priorities. The exact role of edema in human ICH pathology and its treatment requires intensive study. Trials of minimally invasive surgical techniques including mechanical and chemical surgical adjuncts are critically important. The methodologic challenges include establishing research networks and a multi-specialty approach. Waiver of consent issues and standardizing care in trials are important issues. Encouragement of young investigators from varied backgrounds to enter the ICH research field is critical. CONCLUSIONS Increasing ICH research is crucial. A collaborative approach is likely to yield therapies for this devastating form of brain injury.
Collapse
|
34
|
Abstract
Technical innovations in neuroimaging have improved diagnosis and prognosis, whereas developments in interventional neuroradiology have extended the range of therapy to different patient populations. These changes in service demand the identification of those clinical and technical factors distinguishing feasibility from futility, in order to increase population efficiency and reduce the harm associated with inappropriate therapy.
Collapse
Affiliation(s)
- M J Souter
- Institute of Neurological Sciences, Southern General Hospital, Glasgow, UK.
| |
Collapse
|
35
|
Becker KJ, Baxter AB, Bybee HM, Tirschwell DL, Abouelsaad T, Cohen WA. Extravasation of radiographic contrast is an independent predictor of death in primary intracerebral hemorrhage. Stroke 1999; 30:2025-32. [PMID: 10512902 DOI: 10.1161/01.str.30.10.2025] [Citation(s) in RCA: 147] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
BACKGROUND AND PURPOSE Hematomas that enlarge following presentation with primary intracerebral hemorrhage (ICH) are associated with increased mortality, but the mechanisms of hematoma enlargement are poorly understood. We interpreted the presence of contrast extravasation into the hematoma after CT angiography (CTA) as evidence of ongoing hemorrhage and sought to identify the clinical significance of contrast extravasation as well as factors associated with the risk of extravasation. METHODS We reviewed the clinical records and radiographic studies of all patients with intracranial hemorrhage undergoing CTA from 1994 to 1997. Only patients with primary ICH were included in this study. Univariate and multivariate logistic regression analyses were performed to determine the associations between clinical and radiological variables and the risk of hospital death or contrast extravasation. RESULTS Data were available for 113 patients. Contrast extravasation was seen in 46% of patients at the time of CTA, and the presence of contrast extravasation was associated with increased fatality: 63.5% versus 16.4% in patients without extravasation (P=0.011). There was a trend toward a shorter time (median+/-SD) from symptom onset to CTA in patients with extravasation (4.6+/-19 hours) than in patients with no evidence of extravasation (6.6+/-28 hours; P=0.065). Multivariate analysis revealed that hematoma size (P=0.022), Glasgow Coma Scale (GCS) score (P=0.016), extravasation of contrast (P=0.006), infratentorial ICH (P=0.014), and lack of surgery (P<0.001) were independently associated with hospital death. Variables independently associated with contrast extravasation were hematoma size (P=0.024), MABP >120 mm Hg (P=0.012), and GCS score of </=8 (P<0.005). CONCLUSIONS Contrast extravasation into the hematoma after ICH is associated with increased fatality. The risk of contrast extravasation is increased with extreme hypertension, depressed consciousness, and large hemorrhages. If contrast extravasation represents ongoing hemorrhage, the findings in this study may have implications for therapy of ICH, particularly with regard to blood pressure management.
Collapse
Affiliation(s)
- K J Becker
- Department of Neurology University of Washington School of Medicine, Harborview Medical Center, Seattle, Washington, USA.
| | | | | | | | | | | |
Collapse
|
36
|
Murai Y, Takagi R, Ikeda Y, Yamamoto Y, Teramoto A. Three-dimensional computerized tomography angiography in patients with hyperacute intracerebral hemorrhage. J Neurosurg 1999; 91:424-31. [PMID: 10470817 DOI: 10.3171/jns.1999.91.3.0424] [Citation(s) in RCA: 58] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECT The authors confirm the usefulness of extravasation detected on three-dimensional computerized tomography (3D-CT) angiography in the diagnosis of continued hemorrhage and establishment of its cause in patients with acute intracerebral hemorrhage (ICH). METHODS Thirty-one patients with acute ICH in whom noncontrast and 3D-CT angiography had been performed within 12 hours of the onset of hemorrhage and in whom conventional cerebral angiographic studies were obtained during the chronic stage were prospectively studied. Noncontrast CT scanning was repeated within 24 hours of the onset of ICH to evaluate hematoma enlargement. Findings indicating extravasation on 3D-CT angiography, including any abnormal area of high density on helical CT scanning, were observed in five patients; three of these demonstrated hematoma enlargement on follow-up CT studies. Thus, specificity was 60% (three correct predictions among five positives) and sensitivity was 100% (19 correct predictions among 19 negatives). Evidence of extravasation on 3D-CT angiography indicates that there is persistent hemorrhage and correlates with enlargement of the hematoma. Regarding the cause of hemorrhage, five cerebral aneurysms were visualized in four patients, and two diagnoses of moyamoya disease and one of unilateral moyamoya phenomenon were made with the aid of 3D-CT angiography. Emergency surgery was performed without conventional angiography in one patient who had an aneurysm, and it was clipped successfully. CONCLUSIONS Overall, 3D-CT angiography was found to be valuable in the diagnosis of the cause of hemorrhage and in the detection of persistent hemorrhage in patients with acute ICH.
Collapse
Affiliation(s)
- Y Murai
- Department of Neurosurgery, Nippon Medical School, Tokyo, Japan
| | | | | | | | | |
Collapse
|