A Novel 10-Point Score System to Predict Early Hematoma Growth in Patients With Spontaneous Intracerebral Hemorrhage

The relationship between perihematomal edema and hematoma expansion in acute spontaneous intracerebral hemorrhage: an exploratory radiomics analysis study

Background

The relationship between early perihematomal edema (PHE) and hematoma expansion (HE) is unclear. We investigated this relationship in patients with acute spontaneous intracerebral hemorrhage (ICH), using radiomics.

Methods

In this multicenter retrospective study, we analyzed 490 patients with spontaneous ICH who underwent non-contrast computed tomography within 6 h of symptom onset, with follow-up imaging at 24 h. We performed HE and PHE image segmentation, and feature extraction and selection to identify HE-associated optimal radiomics features. We calculated radiomics scores of hematoma (Radscores_HEA) and PHE (Radscores_PHE) and constructed a combined model (Radscore_HEA_PHE). Relationships of the PHE radiomics features or Radscores_PHE with clinical variables, hematoma imaging signs, Radscores_HEA, and HE were assessed by univariate, correlation, and multivariate analyses. We compared predictive performances in the training (n = 296) and validation (n = 194) cohorts.

Results

Shape_VoxelVolume and Shape_MinorAxisLength of PHE were identified as optimal radiomics features associated with HE. Radscore_PHE (odds ratio = 1.039, p = 0.032) was an independent HE risk factor after adjusting for the ICH onset time, Glasgow Coma Scale score, baseline hematoma volume, hematoma shape, hematoma density, midline shift, and Radscore_HEA. The areas under the receiver operating characteristic curve of Radscore_PHE in the training and validation cohorts were 0.808 and 0.739, respectively. After incorporating Radscore_PHE, the integrated discrimination improvements of Radscore_HEA_PHE in the training and validation cohorts were 0.009 (p = 0.086) and -0.011 (p < 0.001), respectively.

Conclusion

Radscore_PHE, based on Shape_VoxelVolume and Shape_MinorAxisLength of PHE, independently predicts HE, while Radscore_PHE did not add significant incremental value to Radscore_HEA.

Research advances in imaging markers for predicting hematoma expansion in intracerebral hemorrhage: a narrative review

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.

Links Between Swallowing and Consciousness: A Narrative Review

This literature review explores a wide range of themes addressing the links between swallowing and consciousness. Signs of consciousness are historically based on the principle of differentiating reflexive from volitional behaviors. We show that the sequencing of the components of swallowing falls on a continuum of voluntary to reflex behaviors and we describe several types of volitional and non-volitional swallowing tasks. The frequency, speed of initiation of the swallowing reflex, efficacy of the pharyngeal phase of swallowing and coordination between respiration and swallowing are influenced by the level of consciousness during non-pathological modifications of consciousness such as sleep and general anesthesia. In patients with severe brain injury, the level of consciousness is associated with several components related to swallowing, such as the possibility of extubation, risk of pneumonia, type of feeding or components directly related to swallowing such as oral or pharyngeal abnormalities. Based on our theoretical and empirical analysis, the efficacy of the oral phase and the ability to receive exclusive oral feeding seem to be the most robust signs of consciousness related to swallowing in patients with disorders of consciousness. Components of the pharyngeal phase (in terms of abilities of saliva management) and evoked cough may be influenced by consciousness, but further studies are necessary to determine if they constitute signs of consciousness as such or only cortically mediated behaviors. This review also highlights the critical lack of tools and techniques to assess and treat dysphagia in patients with disorders of consciousness.

Functional Investigation of Meningeal Lymphatic System in Experimental Intracerebral Hemorrhage

Background:

Promotion of hematoma resolution in a timely manner reduces intracerebral hemorrhage (ICH) brain injury induced by toxic blood components and subsequent neuroinflammation. The meningeal lymphatic system is responsible for clearance of macromolecules and pathogenic substances from the central nervous system; however, its role in intraparenchymal hematoma clearance and ICH outcomes is unknown. In the present study, we aimed to understand the contribution of the meningeal lymphatic system to ICH pathologies and to test whether pharmacological enhancement of meningeal lymphatic function promotes hematoma resolution and brain recovery after ICH.

Methods:

Immunofluorescence of whole-mount meninges was used to measure complexity and coverage level of meningeal lymphatic vasculature following ICH induction. Fluorescent microbeads and PKH-26-labeled erythrocytes were used to evaluate drainage function of the meningeal lymphatic system. Visudyne treatment, deep cervical lymph node ligation, and VEGF (vascular endothelial growth factor)-C injection were performed to manipulate meningeal lymphatic function. Neurobehavioral performance and hematoma volume were assayed by the cylinder test and histological measurements. Iron deposition, residual erythrocytes, neuronal loss, and astrogliosis were assessed by immunohistochemistry and antibody-based fluorescence staining.

Results:

Meningeal lymphangiogenesis and enhanced lymphatic drainage occurred during the late phase of ICH. Ablation and blockage of meningeal lymphatic vessels impeded hematoma clearance, whereas pharmacological enhancement of their function reduced hematoma volume, improved behavioral performance, and reduced brain residual erythrocytes, iron deposition, neuronal loss, and astroglial activation.

Conclusions:

Early enhancement of meningeal lymphatic function is beneficial for ICH recovery. Targeting the meningeal lymphatic system is therefore a potential therapeutic approach for treating ICH.

Comparing the inter-observer reliability of the Tada formula among neurosurgeons while estimating the intracerebral haematoma volume

OBJECTIVE

To compare the inter-observer reliability among neurosurgeons while estimating the intracerebral haematoma (ICH) volume by the Tada formula and assess its influence on predicting the severity and prognosis of various ICHs.

METHODS

We obtained clinical data from 262 consecutive patients with spontaneous ICH. The haematoma volume was independently calculated and compared by 3D Slicer and eight neurosurgeons. The inter-observer reliability was obtained by calculating the intraclass correlation coefficients (ICC) and Cohen's kappa score (kappa), within different shape and volume ICH subgroups. We conducted the receiver operating characteristic analysis to assess the predictive value of the ICH volume evaluated for clinical features, including the Glasgow Coma Scale at the onset of the disease, ICH-related surgical treatments, the length of stay in the intensive care unit, the length of hospitalisation, the modified Rankin Scale score at discharge, and in-hospital deaths.

RESULTS

The median haematoma volume was 17.4 ml (range, 7.3-34.7 ml). The estimated volumes were significantly different among neurosurgeons (p < 0.001). Six out of eight neurosurgeons demonstrated obvious deviations from the 3D Slicer software (p < 0.001). Round (ICC: 0.947) and tapered (ICC: 0.954) haematomas were more consistently evaluated between the neurosurgeons. We observed a substantial strength of agreement between neurosurgeons with kappa> 0.693 and ICC: 0.938 in the entire volume range, and slight to fair strength of agreement with kappa> 0.175 and ICC: 0.689 between 20 ml and 40 ml volume interval. All estimated volumes had a positive predictive value for clinical features, with the area under the curve > 0.5 (p < 0.05). However, the 3D Slicer software performed relatively better than most neurosurgeons.

CONCLUSIONS

There exists a significant inter-observer variability among neurosurgeons when utilizing the Tada formula, thus demonstrating significant implications for ICH-related clinical practices and researches.

In spontaneous intracerebral hematoma patients, prediction of the hematoma expansion risk and mortality risk using radiological and clinical markers and a newly developed scale

Objective: In patients with spontaneous intracerebral hematoma (ICH), early-stage hematoma expansion has been associated with poor prognosis in literature. This study aimed to develop predictive parameter(s) as well as a new scale to define hematoma expansion and short-term prognosis in patients with ICH.Methods: In 46 patients with ICH, Glasgow Coma Scale (GCS) scores, non-contrast CT (NCCT) markers (hematoma volume on admission and follow-up, hypodensity, intraventricular hemorrhage, blend and island sign, BAT score), and modified Rankin Scale scores were evaluated for predicting the hematoma expansion risk and mortality risk. Furthermore, a newly developed scale called the 'HEMRICH scale' was constituted using the GCS score, hematoma volumes, and some NCCT markers.Results: Roc-Curve and Logistic Regression test results revealed that GCS score, initial hematoma volume value, hypodensity, intraventricular haemorrhage, BAT score, and HEMRICH scale score could be the best markers in predicting hematoma expansion risk whereas GCS score, intraventricular haemorrhage, BAT score, hematoma expansion, and HEMRICH scale score could be the best markers in predicting mortality risk (p = 0.01). Moreover, Factor analysis and Reliability test results showed that HEMRICH scale score could predict both hematoma expansion and mortality risks validly (Kaiser-Meyer-Olkin test value = 0.729) and reliably (Cronbach's alpha = 0.564).Conclusion: It was concluded that the GCS score, intraventricular haemorrhage, and BAT score could predict both hematoma expansion risk and mortality risk in the early stage in patients with ICH. Furthermore, it was suggested that the newly produced HEMRICH scale could be a valid and reliable scale for predicting both hematoma expansion and mortality risk.