1
|
Senff JR, Singh SD, Pasi M, Jolink WM, Rodrigues MA, Schreuder FH, Staals J, Schreuder T, Douwes JP, Talsma J, McKaig BN, Kourkoulis C, Yechoor N, Anderson CD, Puy L, Cordonnier C, Wermer MJ, Rothwell PM, Rosand J, Klijn CJ, Al-Shahi Salman R, Rinkel GJ, Viswanathan A, Goldstein JN, Brouwers HB. Long-Term Outcomes in Patients With Spontaneous Cerebellar Hemorrhage: An International Cohort Study. Stroke 2024; 55:1210-1217. [PMID: 38487876 PMCID: PMC11045548 DOI: 10.1161/strokeaha.123.044622] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2023] [Revised: 11/28/2023] [Accepted: 12/13/2023] [Indexed: 04/19/2024]
Abstract
BACKGROUND Spontaneous intracerebral hemorrhage (ICH) in the cerebellum has a poor short-term prognosis, whereas data on the long-term case fatality and recurrent vascular events are sparse. Herewith, we aimed to assess the long-term case fatality and recurrence rate of vascular events after a first cerebellar ICH. METHODS In this international cohort study, we included patients from 10 hospitals (the United States and Europe from 1997 to 2017) aged ≥18 years with a first spontaneous cerebellar ICH who were discharged alive. Data on long-term case fatality and recurrence of vascular events (recurrent ICH [supratentoria or infratentorial], ischemic stroke, myocardial infarction, or major vascular surgery) were collected for survival analysis and absolute event rate calculation. RESULTS We included 405 patients with cerebellar ICH (mean age [SD], 72 [13] years, 49% female). The median survival time was 67 months (interquartile range, 23-100 months), with a cumulative survival rate of 34% at 10-year follow-up (median follow-up time per center ranged: 15-80 months). In the 347 patients with data on vascular events 92 events occurred in 78 patients, after initial cerebellar ICH: 31 (8.9%) patients had a recurrent ICH (absolute event rate, 1.8 per 100 patient-years [95% CI, 1.2-2.6]), 39 (11%) had an ischemic stroke (absolute event rate, 2.3 [95% CI, 1.6-3.2]), 13 (3.7%) had a myocardial infarction (absolute event rate, 0.8 [95% CI, 0.4-1.3]), and 5 (1.4%) underwent major vascular surgery (absolute event rate, 0.3 [95% CI, 0.1-0.7]). The median time to a first vascular event during follow-up was 27 months (interquartile range, 8.7-50 months), with a cumulative hazard of 47% at 10 years. CONCLUSIONS The long-term prognosis of patients who survive a first spontaneous cerebellar ICH is poor and comparable to that of patients who survive a first supratentorial ICH. Further identification of patients at high risk of vascular events following the initial cerebellar ICH is needed. Including patients with cerebellar ICH in randomized controlled trials on secondary prevention of patients with ICH is warranted.
Collapse
Affiliation(s)
- Jasper R. Senff
- Department of Neurology and Neurosurgery, Brain Center Rudolf Magnus, University Medical Center Utrecht, the Netherlands (J.R.S., S.D.S., J.P.J.D., J.T., G.J.E.R., H.B.B.)
- Henry and Allison McCance Center for Brain Health, Massachusetts General Hospital, Boston (J.R.S., S.D.S., C.K., N.Y., C.D.A., J.R.)
- Department of Neurology (J.R.S., S.D.S., C.K., N.Y., J.R.), Massachusetts General Hospital, Boston
- Center for Genomic Medicine (J.R.S., C.K., N.Y., C.D.A., S.D.S., J.R.), Massachusetts General Hospital, Boston
- Broad Institute, Cambridge (J.R.S., S.D.S., J.R.S., C.K., N.Y., C.D.A., J.R.)
| | - Sanjula D. Singh
- Department of Neurology and Neurosurgery, Brain Center Rudolf Magnus, University Medical Center Utrecht, the Netherlands (J.R.S., S.D.S., J.P.J.D., J.T., G.J.E.R., H.B.B.)
- Henry and Allison McCance Center for Brain Health, Massachusetts General Hospital, Boston (J.R.S., S.D.S., C.K., N.Y., C.D.A., J.R.)
- JPK Stroke Center (S.D.S., M.P., A.V.), Massachusetts General Hospital Stroke Research Center, Harvard Medical School, Boston
- Department of Neurology (J.R.S., S.D.S., C.K., N.Y., J.R.), Massachusetts General Hospital, Boston
- Center for Genomic Medicine (J.R.S., C.K., N.Y., C.D.A., S.D.S., J.R.), Massachusetts General Hospital, Boston
- Broad Institute, Cambridge (J.R.S., S.D.S., J.R.S., C.K., N.Y., C.D.A., J.R.)
| | - Marco Pasi
- JPK Stroke Center (S.D.S., M.P., A.V.), Massachusetts General Hospital Stroke Research Center, Harvard Medical School, Boston
- University Lille, Inserm, CHU Lille, U1172 – LilNCog – Lille Neuroscience & Cognition, France (M.P., L.P., C.C.)
- Neurology Department, University Hospital of Tours, INSERM U1253 iBrain, France (M.P.)
| | - Wilmar M.T. Jolink
- Department of Neurology, Isala Hospital, Zwolle, the Netherlands (W.M.T.J.)
| | - Mark A. Rodrigues
- Centre for Clinical Brain Sciences, The University of Edinburgh, United Kingdom (M.A.R., R.A.-S.S.)
- Department of Neuroradiology, NHS Lothian, United Kingdom (M.A.R.)
| | - Floris H.B.M. Schreuder
- Department of Neurology, Donders Institute for Brain Cognition & Behavior, Radboud University Medical Center, Nijmegen, the Netherlands (F.H.B.M.S., C.J.M.K.)
| | - Julie Staals
- Department of Neurology and School for Cardiovascular Diseases (CARIM), Maastricht University Medical Center, the Netherlands (J.S.)
| | - Tobien Schreuder
- Department of Neurology, Zuyderland Medical Center, Heerlen, the Netherlands (T.S.)
| | - Jules P.J. Douwes
- Department of Neurology and Neurosurgery, Brain Center Rudolf Magnus, University Medical Center Utrecht, the Netherlands (J.R.S., S.D.S., J.P.J.D., J.T., G.J.E.R., H.B.B.)
| | - Jelmer Talsma
- Department of Neurology and Neurosurgery, Brain Center Rudolf Magnus, University Medical Center Utrecht, the Netherlands (J.R.S., S.D.S., J.P.J.D., J.T., G.J.E.R., H.B.B.)
| | - Brenna N. McKaig
- Department of Emergency Medicine (B.N.M., J.N.G.), Massachusetts General Hospital Stroke Research Center, Harvard Medical School, Boston
| | - Christina Kourkoulis
- Henry and Allison McCance Center for Brain Health, Massachusetts General Hospital, Boston (J.R.S., S.D.S., C.K., N.Y., C.D.A., J.R.)
- Department of Neurology (J.R.S., S.D.S., C.K., N.Y., J.R.), Massachusetts General Hospital, Boston
- Center for Genomic Medicine (J.R.S., C.K., N.Y., C.D.A., S.D.S., J.R.), Massachusetts General Hospital, Boston
- Broad Institute, Cambridge (J.R.S., S.D.S., J.R.S., C.K., N.Y., C.D.A., J.R.)
| | - Nirupama Yechoor
- Henry and Allison McCance Center for Brain Health, Massachusetts General Hospital, Boston (J.R.S., S.D.S., C.K., N.Y., C.D.A., J.R.)
- Department of Neurology (J.R.S., S.D.S., C.K., N.Y., J.R.), Massachusetts General Hospital, Boston
- Center for Genomic Medicine (J.R.S., C.K., N.Y., C.D.A., S.D.S., J.R.), Massachusetts General Hospital, Boston
- Broad Institute, Cambridge (J.R.S., S.D.S., J.R.S., C.K., N.Y., C.D.A., J.R.)
| | - Christopher D. Anderson
- Henry and Allison McCance Center for Brain Health, Massachusetts General Hospital, Boston (J.R.S., S.D.S., C.K., N.Y., C.D.A., J.R.)
- Center for Genomic Medicine (J.R.S., C.K., N.Y., C.D.A., S.D.S., J.R.), Massachusetts General Hospital, Boston
- Broad Institute, Cambridge (J.R.S., S.D.S., J.R.S., C.K., N.Y., C.D.A., J.R.)
- Department of Neurology, Brigham and Women’s Hospital, Boston (C.D.A.)
| | - Laurent Puy
- University Lille, Inserm, CHU Lille, U1172 – LilNCog – Lille Neuroscience & Cognition, France (M.P., L.P., C.C.)
| | - Charlotte Cordonnier
- University Lille, Inserm, CHU Lille, U1172 – LilNCog – Lille Neuroscience & Cognition, France (M.P., L.P., C.C.)
| | | | - Peter M. Rothwell
- Wolfson Centre for Prevention of Stroke and Dementia, Nuffield Department of Clinical Neurosciences, University of Oxford, United Kingdom (P.M.R.)
| | - Jonathan Rosand
- Henry and Allison McCance Center for Brain Health, Massachusetts General Hospital, Boston (J.R.S., S.D.S., C.K., N.Y., C.D.A., J.R.)
- Department of Neurology (J.R.S., S.D.S., C.K., N.Y., J.R.), Massachusetts General Hospital, Boston
- Center for Genomic Medicine (J.R.S., C.K., N.Y., C.D.A., S.D.S., J.R.), Massachusetts General Hospital, Boston
- Broad Institute, Cambridge (J.R.S., S.D.S., J.R.S., C.K., N.Y., C.D.A., J.R.)
| | - Catharina J.M. Klijn
- Department of Neurology, Donders Institute for Brain Cognition & Behavior, Radboud University Medical Center, Nijmegen, the Netherlands (F.H.B.M.S., C.J.M.K.)
| | - Rustam Al-Shahi Salman
- Centre for Clinical Brain Sciences, The University of Edinburgh, United Kingdom (M.A.R., R.A.-S.S.)
| | - Gabriël J.E. Rinkel
- Department of Neurology and Neurosurgery, Brain Center Rudolf Magnus, University Medical Center Utrecht, the Netherlands (J.R.S., S.D.S., J.P.J.D., J.T., G.J.E.R., H.B.B.)
| | - Anand Viswanathan
- JPK Stroke Center (S.D.S., M.P., A.V.), Massachusetts General Hospital Stroke Research Center, Harvard Medical School, Boston
| | - Joshua N. Goldstein
- Department of Emergency Medicine (B.N.M., J.N.G.), Massachusetts General Hospital Stroke Research Center, Harvard Medical School, Boston
| | - H. Bart Brouwers
- Department of Neurology and Neurosurgery, Brain Center Rudolf Magnus, University Medical Center Utrecht, the Netherlands (J.R.S., S.D.S., J.P.J.D., J.T., G.J.E.R., H.B.B.)
- Department of Neurosurgery, Elisabeth-TweeSteden Hospital, Tilburg, the Netherlands (H.B.B.)
| |
Collapse
|
2
|
Singh SD, Oreskovic T, Carr S, Papier K, Conroy M, Senff JR, Chemali Z, Gutierrez-Martinez L, Parodi L, Mayerhofer E, Marini S, Nunley C, Newhouse A, Ouyang A, Brouwers HB, Westover B, Rivier C, Falcone G, Howard V, Howard G, Pikula A, Ibrahim S, Sheth KN, Yechoor N, Lazar RM, Anderson CD, Tanzi RE, Fricchione G, Littlejohns T, Rosand J. The predictive validity of a Brain Care Score for dementia and stroke: data from the UK Biobank cohort. Front Neurol 2023; 14:1291020. [PMID: 38107629 PMCID: PMC10725202 DOI: 10.3389/fneur.2023.1291020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2023] [Accepted: 11/03/2023] [Indexed: 12/19/2023] Open
Abstract
Introduction The 21-point Brain Care Score (BCS) was developed through a modified Delphi process in partnership with practitioners and patients to promote behavior changes and lifestyle choices in order to sustainably reduce the risk of dementia and stroke. We aimed to assess the associations of the BCS with risk of incident dementia and stroke. Methods The BCS was derived from the United Kingdom Biobank (UKB) baseline evaluation for participants aged 40-69 years, recruited between 2006-2010. Associations of BCS and risk of subsequent incident dementia and stroke were estimated using Cox proportional hazard regressions, adjusted for sex assigned at birth and stratified by age groups at baseline. Results The BCS (median: 12; IQR:11-14) was derived for 398,990 UKB participants (mean age: 57; females: 54%). There were 5,354 incident cases of dementia and 7,259 incident cases of stroke recorded during a median follow-up of 12.5 years. A five-point higher BCS at baseline was associated with a 59% (95%CI: 40-72%) lower risk of dementia among participants aged <50. Among those aged 50-59, the figure was 32% (95%CI: 20-42%) and 8% (95%CI: 2-14%) for those aged >59 years. A five-point higher BCS was associated with a 48% (95%CI: 39-56%) lower risk of stroke among participants aged <50, 52% (95%CI, 47-56%) among those aged 50-59, and 33% (95%CI, 29-37%) among those aged >59. Discussion The BCS has clinically relevant and statistically significant associations with risk of dementia and stroke in approximately 0.4 million UK people. Future research includes investigating the feasibility, adaptability and implementation of the BCS for patients and providers worldwide.
Collapse
Affiliation(s)
- Sanjula D. Singh
- Henry and Allison McCance Center for Brain Health, Massachusetts General Hospital, Boston, MA, United States
- Nuffield Department of Population Health, University of Oxford, Oxford, United Kingdom
- Department of Neurology, Massachusetts General Hospital, Boston, MA, United States
- Broad Institute of MIT and Harvard, Cambridge, MA, United States
- Center for Genomic Medicine, Massachusetts General Hospital, Boston, MA, United States
| | - Tin Oreskovic
- Nuffield Department of Population Health, University of Oxford, Oxford, United Kingdom
| | - Sinclair Carr
- Institute for Health Metrics and Evaluation, University of Washington, Seattle, WA, United States
- Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston, MA, United States
| | - Keren Papier
- Nuffield Department of Population Health, University of Oxford, Oxford, United Kingdom
| | - Megan Conroy
- Nuffield Department of Population Health, University of Oxford, Oxford, United Kingdom
| | - Jasper R. Senff
- Henry and Allison McCance Center for Brain Health, Massachusetts General Hospital, Boston, MA, United States
- Department of Neurology, Massachusetts General Hospital, Boston, MA, United States
- Broad Institute of MIT and Harvard, Cambridge, MA, United States
- Center for Genomic Medicine, Massachusetts General Hospital, Boston, MA, United States
- Department of Neurology and Neurosurgery, Brain Center Rudolf Magnus, University Medical Center Utrecht, Utrecht, Netherlands
| | - Zeina Chemali
- Henry and Allison McCance Center for Brain Health, Massachusetts General Hospital, Boston, MA, United States
- Department of Neurology, Massachusetts General Hospital, Boston, MA, United States
- Division of Neuropsychiatry, Massachusetts General Hospital, Boston, MA, United States
| | - Leidys Gutierrez-Martinez
- Henry and Allison McCance Center for Brain Health, Massachusetts General Hospital, Boston, MA, United States
- Department of Neurology, Massachusetts General Hospital, Boston, MA, United States
- Broad Institute of MIT and Harvard, Cambridge, MA, United States
- Center for Genomic Medicine, Massachusetts General Hospital, Boston, MA, United States
| | - Livia Parodi
- Henry and Allison McCance Center for Brain Health, Massachusetts General Hospital, Boston, MA, United States
- Department of Neurology, Massachusetts General Hospital, Boston, MA, United States
- Broad Institute of MIT and Harvard, Cambridge, MA, United States
- Center for Genomic Medicine, Massachusetts General Hospital, Boston, MA, United States
| | - Ernst Mayerhofer
- Henry and Allison McCance Center for Brain Health, Massachusetts General Hospital, Boston, MA, United States
- Department of Neurology, Massachusetts General Hospital, Boston, MA, United States
- Broad Institute of MIT and Harvard, Cambridge, MA, United States
- Center for Genomic Medicine, Massachusetts General Hospital, Boston, MA, United States
| | - Sandro Marini
- Henry and Allison McCance Center for Brain Health, Massachusetts General Hospital, Boston, MA, United States
- Department of Neurology, Massachusetts General Hospital, Boston, MA, United States
- Broad Institute of MIT and Harvard, Cambridge, MA, United States
- Center for Genomic Medicine, Massachusetts General Hospital, Boston, MA, United States
| | - Courtney Nunley
- Henry and Allison McCance Center for Brain Health, Massachusetts General Hospital, Boston, MA, United States
| | - Amy Newhouse
- Henry and Allison McCance Center for Brain Health, Massachusetts General Hospital, Boston, MA, United States
- Division of Neuropsychiatry, Massachusetts General Hospital, Boston, MA, United States
- Department of Medicine, Massachusetts General Hospital, Boston, MA, United States
| | - An Ouyang
- Henry and Allison McCance Center for Brain Health, Massachusetts General Hospital, Boston, MA, United States
- Department of Neurology, Massachusetts General Hospital, Boston, MA, United States
| | - H. Bart Brouwers
- Department of Neurology and Neurosurgery, Brain Center Rudolf Magnus, University Medical Center Utrecht, Utrecht, Netherlands
| | - Brandon Westover
- Henry and Allison McCance Center for Brain Health, Massachusetts General Hospital, Boston, MA, United States
- Department of Neurology, Massachusetts General Hospital, Boston, MA, United States
- Broad Institute of MIT and Harvard, Cambridge, MA, United States
| | - Cyprien Rivier
- Department of Neurology, Yale School of Medicine, New Haven, CT, United States
| | - Guido Falcone
- Department of Neurology, Yale School of Medicine, New Haven, CT, United States
| | - Virginia Howard
- Department of Biostatistics, School of Public Health, University of Alabama at Birmingham, Birmingham, AL, United States
| | - George Howard
- Department of Biostatistics, School of Public Health, University of Alabama at Birmingham, Birmingham, AL, United States
| | - Aleksandra Pikula
- Department of Medicine (Neurology), University of Toronto, Toronto, ON, Canada
- Krembil Brain Institute, Toronto, ON, Canada
- Lawrence S Bloomberg Faculty of Nursing, University of Toronto, Toronto, ON, Canada
| | - Sarah Ibrahim
- Department of Medicine (Neurology), University of Toronto, Toronto, ON, Canada
- Krembil Brain Institute, Toronto, ON, Canada
- Lawrence S Bloomberg Faculty of Nursing, University of Toronto, Toronto, ON, Canada
| | - Kevin N. Sheth
- Department of Neurology, Yale School of Medicine, New Haven, CT, United States
| | - Nirupama Yechoor
- Henry and Allison McCance Center for Brain Health, Massachusetts General Hospital, Boston, MA, United States
- Department of Neurology, Massachusetts General Hospital, Boston, MA, United States
- Broad Institute of MIT and Harvard, Cambridge, MA, United States
- Center for Genomic Medicine, Massachusetts General Hospital, Boston, MA, United States
| | - Ronald M. Lazar
- McKnight Brain Institute, Department of Neurology, School of Medicine, University of Alabama School of Medicine, Birmingham, AL, United States
| | - Christopher D. Anderson
- Henry and Allison McCance Center for Brain Health, Massachusetts General Hospital, Boston, MA, United States
- Department of Neurology, Massachusetts General Hospital, Boston, MA, United States
- Broad Institute of MIT and Harvard, Cambridge, MA, United States
- Center for Genomic Medicine, Massachusetts General Hospital, Boston, MA, United States
- Department of Neurology, Brigham and Women’s Hospital, Boston, MA, United States
| | - Rudolph E. Tanzi
- Henry and Allison McCance Center for Brain Health, Massachusetts General Hospital, Boston, MA, United States
| | - Gregory Fricchione
- Henry and Allison McCance Center for Brain Health, Massachusetts General Hospital, Boston, MA, United States
- Benson-Henry Institute for Mind Body Medicine, Massachusetts General Hospital, Boston, MA, United States
| | - Thomas Littlejohns
- Nuffield Department of Population Health, University of Oxford, Oxford, United Kingdom
| | - Jonathan Rosand
- Henry and Allison McCance Center for Brain Health, Massachusetts General Hospital, Boston, MA, United States
- Department of Neurology, Massachusetts General Hospital, Boston, MA, United States
- Broad Institute of MIT and Harvard, Cambridge, MA, United States
- Center for Genomic Medicine, Massachusetts General Hospital, Boston, MA, United States
| |
Collapse
|
3
|
Mahmoodi AL, Landers MJF, Rutten GJM, Brouwers HB. Characterization and Classification of Spatial White Matter Tract Alteration Patterns in Glioma Patients Using Magnetic Resonance Tractography: A Systematic Review and Meta-Analysis. Cancers (Basel) 2023; 15:3631. [PMID: 37509291 PMCID: PMC10377290 DOI: 10.3390/cancers15143631] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2023] [Revised: 07/03/2023] [Accepted: 07/10/2023] [Indexed: 07/30/2023] Open
Abstract
INTRODUCTION Magnetic resonance (MR) tractography can be used to study the spatial relations between gliomas and white matter (WM) tracts. Various spatial patterns of WM tract alterations have been described in the literature. We reviewed classification systems of these patterns, and investigated whether low-grade gliomas (LGGs) and high-grade gliomas (HGGs) demonstrate distinct spatial WM tract alteration patterns. METHODS We conducted a systematic review and meta-analysis to summarize the evidence regarding MR tractography studies that investigated spatial WM tract alteration patterns in glioma patients. RESULTS Eleven studies were included. Overall, four spatial WM tract alteration patterns were reported in the current literature: displacement, infiltration, disruption/destruction and edematous. There was a considerable heterogeneity in the operational definitions of these terms. In a subset of studies, sufficient homogeneity in the classification systems was found to analyze pooled results for the displacement and infiltration patterns. Our meta-analyses suggested that LGGs displaced WM tracts significantly more often than HGGs (n = 259 patients, RR: 1.79, 95% CI [1.14, 2.79], I2 = 51%). No significant differences between LGGs and HGGs were found for WM tract infiltration (n = 196 patients, RR: 1.19, 95% CI [0.95, 1.50], I2 = 4%). CONCLUSIONS The low number of included studies and their considerable methodological heterogeneity emphasize the need for a more uniform classification system to study spatial WM tract alteration patterns using MR tractography. This review provides a first step towards such a classification system, by showing that the current literature is inconclusive and that the ability of fractional anisotropy (FA) to define spatial WM tract alteration patterns should be critically evaluated. We found variations in spatial WM tract alteration patterns between LGGs and HGGs, when specifically examining displacement and infiltration in a subset of the included studies.
Collapse
Affiliation(s)
- Arash L Mahmoodi
- Department of Neurosurgery, Elisabeth-TweeSteden Hospital, Hilvarenbeekseweg 60, 5022 GC Tilburg, The Netherlands
| | - Maud J F Landers
- Department of Neurosurgery, Elisabeth-TweeSteden Hospital, Hilvarenbeekseweg 60, 5022 GC Tilburg, The Netherlands
| | - Geert-Jan M Rutten
- Department of Neurosurgery, Elisabeth-TweeSteden Hospital, Hilvarenbeekseweg 60, 5022 GC Tilburg, The Netherlands
| | - H Bart Brouwers
- Department of Neurosurgery, Elisabeth-TweeSteden Hospital, Hilvarenbeekseweg 60, 5022 GC Tilburg, The Netherlands
| |
Collapse
|
4
|
Landers MJF, Brouwers HB, Kortman GJ, Boukrab I, De Baene W, Rutten GJM. Oligodendrogliomas tend to infiltrate the frontal aslant tract, whereas astrocytomas tend to displace it. Neuroradiology 2023:10.1007/s00234-023-03153-6. [PMID: 37127719 DOI: 10.1007/s00234-023-03153-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2022] [Accepted: 04/13/2023] [Indexed: 05/03/2023]
Abstract
INTRODUCTION MR-tractography is increasingly used in neurosurgical practice to evaluate the anatomical relationships between glioma and nearby subcortical tracts. In some patients, the subcortical tracts seem displaced by the glioma, while in other patients, the subcortical tracts seem infiltrated without displacement. At this point, it is unknown whether these different patterns are related to tumor type. The aim of this exploratory study was to investigate whether tumor type is related to the spatial tractography pattern of the frontal aslant tract (FAT) in low-grade gliomas (LGGs). METHODS In 64 IDH-mutated LGG patients, the FAT was generated using a pipeline for automatic tractography. In 41 patients, the glioma adjoined the FAT, and four blinded reviewers independently assessed the following two dichotomous categories (yes/no): (i) glioma displaces the tract, and (ii) glioma infiltrates the tract. RESULTS Fisher's exact tests demonstrated strong and significant positive associations between displacement and astrocytomas (p = .002, φ = .497) and infiltration and oligodendrogliomas (p = .004, φ = .484). The interobserver agreement was good for both categories: (i) κ = 0.76 and (ii) κ = 0.71. CONCLUSION High sensitivity but low specificity for displacement in astrocytomas demonstrates that in the case of an astrocytoma, the tract is most likely displaced, but that displacement in itself is not necessarily predictive for astrocytomas, as oligodendrogliomas may both infiltrate and displace a tract. Overall, these results demonstrate that oligodendrogliomas tend to infiltrate the nearby subcortical tract, whereas astrocytomas only tend to displace it.
Collapse
Affiliation(s)
- M J F Landers
- Department of Neurosurgery, Elisabeth-Tweesteden Hospital Tilburg, Tilburg, The Netherlands.
- Department of Cognitive Neuropsychology, Tilburg University, Tilburg, The Netherlands.
| | - H B Brouwers
- Department of Neurosurgery, Elisabeth-Tweesteden Hospital Tilburg, Tilburg, The Netherlands
| | - G J Kortman
- Department of Neuroradiology, Elisabeth-Tweesteden Hospital Tilburg, Tilburg, The Netherlands
| | - I Boukrab
- Department of Neuroradiology, Elisabeth-Tweesteden Hospital Tilburg, Tilburg, The Netherlands
| | - W De Baene
- Department of Neurosurgery, Elisabeth-Tweesteden Hospital Tilburg, Tilburg, The Netherlands
- Department of Cognitive Neuropsychology, Tilburg University, Tilburg, The Netherlands
| | - G J M Rutten
- Department of Neurosurgery, Elisabeth-Tweesteden Hospital Tilburg, Tilburg, The Netherlands
| |
Collapse
|
5
|
Singh SD, Pasi M, Schreuder FHBM, Morotti A, Senff JR, Warren AD, McKaig BN, Schwab K, Gurol ME, Rosand J, Greenberg SM, Viswanathan A, Klijn CJM, Rinkel GJE, Goldstein JN, Brouwers HB. Computed Tomography Angiography Spot Sign, Hematoma Expansion, and Functional Outcome in Spontaneous Cerebellar Intracerebral Hemorrhage. Stroke 2021; 52:2902-2909. [PMID: 34126759 DOI: 10.1161/strokeaha.120.033297] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
[Figure: see text].
Collapse
Affiliation(s)
- Sanjula D Singh
- Hemorrhagic Stroke Research Program, Department of Neurology, Massachusetts General Hospital Stroke Research Center (S.D.S., A.D.W., B.N.M., K.S., M.E.G., J.R., S.M.G., A.V.), Massachusetts General Hospital, Harvard Medical School, Boston.,Department of Neurology and Neurosurgery, Brain Center Rudolf Magnus, University Medical Center Utrecht, the Netherlands (S.D.S., J.R.S., G.J.E.R., H.B.B.)
| | - Marco Pasi
- University of Lille, Inserm, CHU Lille, U1172 - LilNCog - Lille Neuroscience and Cognition, France (M.P.)
| | - Floris H B M Schreuder
- Department of Neurology, Donders Institute for Brain Cognition and Behavior, Center for Neuroscience, Radboud University Medical Center, Nijmegen, the Netherlands (F.H.B.M.S., C.J.M.K.)
| | - Andrea Morotti
- ASST Valcamonica, Neurology Unit, Esine (BS), Italy (A.M.)
| | - Jasper R Senff
- Department of Neurology and Neurosurgery, Brain Center Rudolf Magnus, University Medical Center Utrecht, the Netherlands (S.D.S., J.R.S., G.J.E.R., H.B.B.)
| | - Andrew D Warren
- Hemorrhagic Stroke Research Program, Department of Neurology, Massachusetts General Hospital Stroke Research Center (S.D.S., A.D.W., B.N.M., K.S., M.E.G., J.R., S.M.G., A.V.), Massachusetts General Hospital, Harvard Medical School, Boston
| | - Brenna N McKaig
- Hemorrhagic Stroke Research Program, Department of Neurology, Massachusetts General Hospital Stroke Research Center (S.D.S., A.D.W., B.N.M., K.S., M.E.G., J.R., S.M.G., A.V.), Massachusetts General Hospital, Harvard Medical School, Boston
| | - Kristin Schwab
- Hemorrhagic Stroke Research Program, Department of Neurology, Massachusetts General Hospital Stroke Research Center (S.D.S., A.D.W., B.N.M., K.S., M.E.G., J.R., S.M.G., A.V.), Massachusetts General Hospital, Harvard Medical School, Boston
| | - M Edip Gurol
- Hemorrhagic Stroke Research Program, Department of Neurology, Massachusetts General Hospital Stroke Research Center (S.D.S., A.D.W., B.N.M., K.S., M.E.G., J.R., S.M.G., A.V.), Massachusetts General Hospital, Harvard Medical School, Boston
| | - Jonathan Rosand
- Hemorrhagic Stroke Research Program, Department of Neurology, Massachusetts General Hospital Stroke Research Center (S.D.S., A.D.W., B.N.M., K.S., M.E.G., J.R., S.M.G., A.V.), Massachusetts General Hospital, Harvard Medical School, Boston.,Center for Genomic Medicine (J.R.), Massachusetts General Hospital, Harvard Medical School, Boston.,Division of Neurocritical Care and Emergency Neurology (J.R., J.N.G.), Massachusetts General Hospital, Harvard Medical School, Boston
| | - Steven M Greenberg
- Hemorrhagic Stroke Research Program, Department of Neurology, Massachusetts General Hospital Stroke Research Center (S.D.S., A.D.W., B.N.M., K.S., M.E.G., J.R., S.M.G., A.V.), Massachusetts General Hospital, Harvard Medical School, Boston
| | - Anand Viswanathan
- Hemorrhagic Stroke Research Program, Department of Neurology, Massachusetts General Hospital Stroke Research Center (S.D.S., A.D.W., B.N.M., K.S., M.E.G., J.R., S.M.G., A.V.), Massachusetts General Hospital, Harvard Medical School, Boston
| | - Catharina J M Klijn
- Department of Neurology, Donders Institute for Brain Cognition and Behavior, Center for Neuroscience, Radboud University Medical Center, Nijmegen, the Netherlands (F.H.B.M.S., C.J.M.K.)
| | - Gabriel J E Rinkel
- Department of Neurology and Neurosurgery, Brain Center Rudolf Magnus, University Medical Center Utrecht, the Netherlands (S.D.S., J.R.S., G.J.E.R., H.B.B.)
| | - Joshua N Goldstein
- Division of Neurocritical Care and Emergency Neurology (J.R., J.N.G.), Massachusetts General Hospital, Harvard Medical School, Boston.,Department of Emergency Medicine (J.N.G.), Massachusetts General Hospital, Harvard Medical School, Boston
| | - H Bart Brouwers
- Department of Neurology and Neurosurgery, Brain Center Rudolf Magnus, University Medical Center Utrecht, the Netherlands (S.D.S., J.R.S., G.J.E.R., H.B.B.)
| |
Collapse
|
6
|
Singh SD, Schreuder FHBM, van Nieuwenhuizen KM, Jolink WM, Senff JR, Goldstein JN, Boogaarts J, Klijn CJM, Rinkel GJE, Brouwers HB. Secondary Hematoma Evacuation and Outcome After Initial Conservative Approach for Patients with Cerebellar Hematoma Larger than 3 cm. Neurocrit Care 2021; 35:680-686. [PMID: 33650011 PMCID: PMC8692294 DOI: 10.1007/s12028-021-01203-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2020] [Accepted: 01/30/2021] [Indexed: 11/29/2022]
Abstract
Background In patients with spontaneous cerebellar intracerebral hemorrhage (ICH) guidelines advocate evacuation when the hematoma diameter is > 3 cm. We studied outcome in patients with cerebellar ICH > 3 cm who did not undergo immediate hematoma evacuation. Methods We included consecutive patients with cerebellar ICH > 3 cm at two academic hospitals between 2008 and 2017. Patients who died < 24 h (h) were excluded because of probable confounding by indication. We determined patient characteristics, hematoma volumes, EVD placement, secondary hematoma evacuation, in-hospital and 3-month case-fatality, and functional outcome. Results Of 130 patients with cerebellar ICH, 98 (77%) had a hematoma > 3 cm of whom 22 (23%) died < 24 h and 28 (29%) underwent hematoma evacuation < 24 h. Thus, 48 patients were initially treated conservatively (mean age 70 ± 13, 24 (50%) female). Of these 48 patients, 7 (15%) underwent secondary hematoma evacuation > 24 h, of whom 1 (14%) had received an EVD < 24 h. Five others also received an EVD < 24 h without subsequent hematoma evacuation. Of the 41 patients without secondary hematoma evacuation, 11 (28%) died and 20 (51%) had a favorable outcome (mRS of 0–3) at 3 months. The 7 patients who underwent secondary hematoma evacuation had a decrease in GCS score of at least two points prior to surgery; two (29%) had deceased at 3 months; and 5 (71%) had a good functional outcome (mRS 0–3). Conclusions While cerebellar ICH > 3 cm is often considered an indication for immediate hematoma evacuation, there may be a subgroup of patients in whom surgery can be safely deferred. Further data are needed to assess the optimal timing and indications of surgical treatment in these patients. Supplementary Information The online version contains supplementary material available at 10.1007/s12028-021-01203-6.
Collapse
Affiliation(s)
- Sanjula D Singh
- Department of Neurology and Neurosurgery, Brain Center Rudolf Magnus, University Medical Center Utrecht, Utrecht, The Netherlands. .,Division of Neurocritical Care and Emergency Neurology, Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, USA.
| | - Floris H B M Schreuder
- Department of Neurology, Donders Institute for Brain Cognition and Behavior, Center for Neuroscience, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Koen M van Nieuwenhuizen
- Department of Neurology and Neurosurgery, Brain Center Rudolf Magnus, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Wilmar M Jolink
- Department of Neurology and Neurosurgery, Brain Center Rudolf Magnus, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Jasper R Senff
- Department of Neurology and Neurosurgery, Brain Center Rudolf Magnus, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Joshua N Goldstein
- Division of Neurocritical Care and Emergency Neurology, Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, USA
| | - Jeroen Boogaarts
- Department of Neurology, Donders Institute for Brain Cognition and Behavior, Center for Neuroscience, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Catharina J M Klijn
- Department of Neurology, Donders Institute for Brain Cognition and Behavior, Center for Neuroscience, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Gabriel J E Rinkel
- Department of Neurology and Neurosurgery, Brain Center Rudolf Magnus, University Medical Center Utrecht, Utrecht, The Netherlands
| | - H Bart Brouwers
- Department of Neurology and Neurosurgery, Brain Center Rudolf Magnus, University Medical Center Utrecht, Utrecht, The Netherlands
| |
Collapse
|
7
|
Uniken Venema SM, Marini S, Lena UK, Morotti A, Jessel M, Moomaw CJ, Kourkoulis C, Testai FD, Kittner SJ, Brouwers HB, James ML, Woo D, Anderson CD, Rosand J. Impact of Cerebral Small Vessel Disease on Functional Recovery After Intracerebral Hemorrhage. Stroke 2019; 50:2722-2728. [PMID: 31446887 DOI: 10.1161/strokeaha.119.025061] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
Background and Purpose- In this study, we aim to investigate the association of computed tomography-based markers of cerebral small vessel disease with functional outcome and recovery after intracerebral hemorrhage. Methods- Computed tomographic scans of patients in the ERICH study (Ethnic and Racial Variations of Intracerebral Hemorrhage) were evaluated for the extent of leukoaraiosis and cerebral atrophy using visual rating scales. Poor functional outcome was defined as a modified Rankin Scale (mRS) of ≥3. Multivariable logistic and linear regression models were used to explore the associations of cerebral small vessel disease imaging markers with poor functional outcome at discharge and, as a measure of recovery, change in mRS from discharge to 90 days poststroke. Results- After excluding in-hospital deaths, data from 2344 patients, 583 (24.9%) with good functional outcome (mRS of 0-2) at discharge and 1761 (75.1%) with poor functional outcome (mRS of 3-5) at discharge, were included. Increasing extent of leukoaraiosis (P for trend, 0.01) and only severe (grade 4) global atrophy (odds ratio, 2.02; 95% CI, 1.22-3.39, P=0.007) were independently associated with poor functional outcome at discharge. Mean (SD) mRS change from discharge to 90-day follow-up was 0.57 (1.18). Increasing extent of leukoaraiosis (P for trend, 0.002) and severe global atrophy (β [SE], -0.23 [0.115]; P=0.045) were independently associated with less improvement in mRS from discharge to 90 days poststroke. Conclusions- In intracerebral hemorrhage survivors, the extent of cerebral small vessel disease at the time of intracerebral hemorrhage is associated with poor functional outcome at hospital discharge and impaired functional recovery from discharge to 90 days poststroke.
Collapse
Affiliation(s)
- Simone M Uniken Venema
- From the Center for Genomic Medicine (S.M.U.V., S.M., U.K.L., C.K., C.D.A., J.R.), Massachusetts General Hospital, Boston
| | - Sandro Marini
- From the Center for Genomic Medicine (S.M.U.V., S.M., U.K.L., C.K., C.D.A., J.R.), Massachusetts General Hospital, Boston.,Division of Neurocritical Care and Emergency Neurology, Department of Neurology (S.M., C.D.A., J.R.).,J.P. Kistler Stroke Research Center (S.M., M.J., C.D.A., J.R.), Massachusetts General Hospital, Harvard Medical School, Boston
| | - Umme K Lena
- From the Center for Genomic Medicine (S.M.U.V., S.M., U.K.L., C.K., C.D.A., J.R.), Massachusetts General Hospital, Boston
| | - Andrea Morotti
- Stroke Unit, Instituto Neurologico Nazionale a Carattere Scientifico (IRCCS) Mondino Foundation, Pavia, Italy (A.M.)
| | - Michael Jessel
- J.P. Kistler Stroke Research Center (S.M., M.J., C.D.A., J.R.), Massachusetts General Hospital, Harvard Medical School, Boston
| | - Charles J Moomaw
- Department Neurology and Rehabilitation Medicine, University of Cincinnati College of Medicine, OH (C.J.M., D.W.)
| | - Christina Kourkoulis
- From the Center for Genomic Medicine (S.M.U.V., S.M., U.K.L., C.K., C.D.A., J.R.), Massachusetts General Hospital, Boston.,Henry and Allison McCance Center for Brain Health (C.K., C.D.A., J.R.), Massachusetts General Hospital, Boston
| | - Fernando D Testai
- Department of Neurology and Rehabilitation, University of Illinois College of Medicine, Chicago (F.D.T.)
| | - Steven J Kittner
- Department of Neurology, Baltimore Veterans Administration Medical Center, University of Maryland School of Medicine (S.J.K.)
| | - H Bart Brouwers
- Department of Neurosurgery, Brain Center Rudolf Magnus, University Medical Center Utrecht, the Netherlands (H.B.B.)
| | - Michael L James
- Departments of Anesthesiology (M.L.J.), Brain Injury Translational Research Center, Duke University, Durham, NC.,Neurology (M.L.J.), Brain Injury Translational Research Center, Duke University, Durham, NC
| | - Daniel Woo
- Department Neurology and Rehabilitation Medicine, University of Cincinnati College of Medicine, OH (C.J.M., D.W.)
| | - Christopher D Anderson
- Henry and Allison McCance Center for Brain Health (C.K., C.D.A., J.R.), Massachusetts General Hospital, Boston.,Division of Neurocritical Care and Emergency Neurology, Department of Neurology (S.M., C.D.A., J.R.).,J.P. Kistler Stroke Research Center (S.M., M.J., C.D.A., J.R.), Massachusetts General Hospital, Harvard Medical School, Boston
| | - Jonathan Rosand
- From the Center for Genomic Medicine (S.M.U.V., S.M., U.K.L., C.K., C.D.A., J.R.), Massachusetts General Hospital, Boston.,Henry and Allison McCance Center for Brain Health (C.K., C.D.A., J.R.), Massachusetts General Hospital, Boston.,Division of Neurocritical Care and Emergency Neurology, Department of Neurology (S.M., C.D.A., J.R.).,J.P. Kistler Stroke Research Center (S.M., M.J., C.D.A., J.R.), Massachusetts General Hospital, Harvard Medical School, Boston
| |
Collapse
|
8
|
De Boer B, See AP, Bart Brouwers H, Rinkel G, Princiotta C, Broekman MLD. A coil in the hair-a case report of percutaneous coil migration. Acta Neurochir (Wien) 2018; 160:2397-2399. [PMID: 30284020 PMCID: PMC6267699 DOI: 10.1007/s00701-018-3689-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2018] [Accepted: 09/21/2018] [Indexed: 11/26/2022]
Abstract
Coil migration following cerebral aneurysm treatment has been described and may result in stroke, recurrent aneurysm, or local mass effect. Cerebral coil embolization is also applied in arteriovenous malformations and arteriovenous fistulas, but these pathologies are relatively rare and coil migration is not as well described. Furthermore, these cases are more commonly treated with combinations of multiple modalities to achieve cure. Embolization, surgery, and radiation each have risks and benefits and combinations may have synergistic risks and benefits not seen in monotherapy. We report a case of extravascular and extra-corporeal coil migration after embolization and craniectomy to treat a patient with hemorrhage from an arteriovenous fistula.
Collapse
Affiliation(s)
- Bart De Boer
- Department of Neurosurgery, Brain Center Rudolf Magnus, University Medical Center Utrecht, HP G03.124, PO Box 85500, 3508 GA, Utrecht, The Netherlands
| | - Alfred P See
- Department of Neurosurgery, Brigham and Women's Hospital, Boston, MA, 02115, USA
| | - H Bart Brouwers
- Department of Neurosurgery, Brain Center Rudolf Magnus, University Medical Center Utrecht, HP G03.124, PO Box 85500, 3508 GA, Utrecht, The Netherlands
| | - Gabriël Rinkel
- Department of Neurosurgery, Brain Center Rudolf Magnus, University Medical Center Utrecht, HP G03.124, PO Box 85500, 3508 GA, Utrecht, The Netherlands
| | - Ciro Princiotta
- Department of Radiology, Instituto delle Scienze Neurologiche di Bologna, Ospedale Bellaria, Bologna, Italy
| | - Marike L D Broekman
- Department of Neurosurgery, Brain Center Rudolf Magnus, University Medical Center Utrecht, HP G03.124, PO Box 85500, 3508 GA, Utrecht, The Netherlands.
| |
Collapse
|
9
|
Simjian T, Muskens IS, Lamba N, Yunusa I, Wong K, Veronneau R, Kronenburg A, Brouwers HB, Smith TR, Mekary RA, Broekman MLD. Dexamethasone Administration and Mortality in Patients with Brain Abscess: A Systematic Review and Meta-Analysis. World Neurosurg 2018; 115:257-263. [PMID: 29705232 DOI: 10.1016/j.wneu.2018.04.130] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2018] [Revised: 04/17/2018] [Accepted: 04/18/2018] [Indexed: 11/17/2022]
Abstract
BACKGROUND Dexamethasone has been used to treat cerebral edema associated with brain abscess. Whereas some argue that dexamethasone might aid antibiotic treatment, others believe that because of its immunosuppressive characteristics, it might have a negative impact on outcomes. How corticosteroid use affects overall mortality of brain abscess patients remains unclear. METHODS A systematic search of the literature was conducted in accordance with PRISMA guidelines. PubMed, Embase, and Cochrane databases were utilized to identify all studies related to patients diagnosed with a brain abscess treated with dexamethasone. The main outcome of interest was mortality. Pooled effect estimates were calculated using fixed-effects (FE) and random-effects (RE) models. RESULTS After removal of duplicates, 1681 articles were extracted from the literature of which 11 were included. These included 7 cohort studies and 4 case series. Indications to administer dexamethasone were either hospital brain abscess protocol or clinical presentation of cerebral edema. The 7 cohort studies involving 571 patients with brain abscesses comprised of 330 patients treated with standard of care (SOC) plus dexamethasone and 241 patients treated with SOC alone, after aspiration or surgical management of the abscess in either group. Pooling results from all seven cohort studies demonstrated a nonsignificant mortality benefit comparing SOC and dexamethasone patients to SOC patients (FE: risk ratio [RR], 0.94; 95% confidence interval [CI], 0.64-1.37; RE: RR, 0.95; 95% CI, 049-1.82; I2 = 53.9%; P for heterogeneity = 0.04). CONCLUSIONS In patients with a brain abscess treated with antibiotics, the use of dexamethasone was not associated with increased mortality.
Collapse
Affiliation(s)
- Thomas Simjian
- Computational Neuroscience Outcomes Center, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA; MCPHS University, Boston, Massachusetts, USA
| | - Ivo S Muskens
- Computational Neuroscience Outcomes Center, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA; Department of Neurosurgery, Brain Center Rudolf Magnus, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Nayan Lamba
- Computational Neuroscience Outcomes Center, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Ismaeel Yunusa
- Computational Neuroscience Outcomes Center, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA; MCPHS University, Boston, Massachusetts, USA
| | | | | | - Annick Kronenburg
- Department of Neurosurgery, Brain Center Rudolf Magnus, University Medical Center Utrecht, Utrecht, The Netherlands
| | - H Bart Brouwers
- Department of Neurosurgery, Brain Center Rudolf Magnus, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Timothy R Smith
- Computational Neuroscience Outcomes Center, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Rania A Mekary
- Computational Neuroscience Outcomes Center, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA; MCPHS University, Boston, Massachusetts, USA
| | - Marike L D Broekman
- Computational Neuroscience Outcomes Center, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA; Department of Neurosurgery, Brain Center Rudolf Magnus, University Medical Center Utrecht, Utrecht, The Netherlands.
| |
Collapse
|
10
|
Boland T, Henderson GV, Gibbons FK, Brouwers HB, Greenberg SM, Raffeld M, Kourkoulis CE, Rosand J, Christopher KB. Hypernatremia at Hospital Discharge and Out of Hospital Mortality Following Primary Intracerebral Hemorrhage. Neurocrit Care 2017; 25:110-6. [PMID: 26842718 DOI: 10.1007/s12028-015-0234-6] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
BACKGROUND AND PURPOSE In patients with intracerebral hemorrhage (ICH), it is not clear if hypernatremia is merely a marker of disease severity or if elevated sodium levels are harmful. We hypothesized that hypernatremia at hospital discharge in primary ICH patients would be associated with increased mortality following discharge. METHODS We performed a two-center observational study of critically ill ICH patients in Boston. We studied 5100 patients, age ≥18 years, who were diagnosed with ICH (ICD-9 code 431), received medical or surgical critical care between 1997 and 2011 and survived hospitalization. The exposure of interest was serum sodium within 24 h of hospital discharge, categorized as Na ≤ 145 mmol/L and Na > 145 mmol/L. The primary outcome was 30-day post-discharge mortality. Odds ratios were estimated by logistic regression models adjusted for age, race, gender, Deyo-Charlson Index, patient type (medical versus surgical) and sepsis. RESULTS In ICH patients who received critical care and survived hospitalization, the serum sodium at discharge was a predictor of post-discharge mortality. Patients with a discharge Na > 145 mmol/L have an OR for mortality in the 30 days following hospital discharge of 1.82 (95 %CI 1.38-2.38; P < 0.001) and an adjusted OR of 1.87 (95 %CI 1.40-2.48; P < 0.001) both relative to patients with a discharge Na ≤ 145 mmol/L. The adjusted model showed good discrimination AUC 0.77 (95 %CI 0.74-0.79) and calibration (Hosmer-Lemeshow χ (2) P = 0.68). CONCLUSIONS In critically ill ICH patients who survive hospitalization, hypernatremia at the time of discharge is a robust predictor of post-discharge mortality.
Collapse
Affiliation(s)
- Torrey Boland
- Department of Neurology, Rush University Medical Center, Chicago, IL, USA
| | - Galen V Henderson
- Department of Neurology, Brigham and Women's Hospital, Boston, MA, USA
| | - Fiona K Gibbons
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Massachusetts General Hospital, Boston, MA, USA
| | - H Bart Brouwers
- Department of Neurosurgery, Brain Center Rudolf Magnus, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Steven M Greenberg
- Department of Neurology, Massachusetts General Hospital, Boston, MA, USA
| | - Miriam Raffeld
- Department of Neurology and Center for Human Genetic Research, Massachusetts General Hospital, Boston, MA, USA
| | - Christina E Kourkoulis
- Department of Neurology and Center for Human Genetic Research, Massachusetts General Hospital, Boston, MA, USA
| | - Jonathan Rosand
- Department of Neurology and Center for Human Genetic Research, Massachusetts General Hospital, Boston, MA, USA
| | - Kenneth B Christopher
- The Nathan E. Hellman Memorial Laboratory, Renal Division, Department of Medicine, Brigham and Women's Hospital, 75 Francis Street, MRB 418, Boston, MA, 02115, USA.
| |
Collapse
|
11
|
Morotti A, Brouwers HB, Romero JM, Jessel MJ, Vashkevich A, Schwab K, Afzal MR, Cassarly C, Greenberg SM, Martin RH, Qureshi AI, Rosand J, Goldstein JN. Intensive Blood Pressure Reduction and Spot Sign in Intracerebral Hemorrhage: A Secondary Analysis of a Randomized Clinical Trial. JAMA Neurol 2017. [PMID: 28628707 DOI: 10.1001/jamaneurol.2017.1014] [Citation(s) in RCA: 71] [Impact Index Per Article: 10.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
Importance The computed tomographic angiography (CTA) spot sign is associated with intracerebral hemorrhage (ICH) expansion and may mark those patients most likely to benefit from intensive blood pressure (BP) reduction. Objective To investigate whether the spot sign is associated with ICH expansion across a wide range of centers and whether intensive BP reduction decreases hematoma expansion and improves outcome in patients with ICH and a spot sign. Design, Setting, and Participants SCORE-IT (Spot Sign Score in Restricting ICH Growth) is a preplanned prospective observational study nested in the Antihypertensive Treatment of Acute Cerebral Hemorrhage II (ATACH-II) randomized clinical trial. Participants included consecutive patients with primary ICH who underwent a CTA within 8 hours from onset at 59 sites from May 15, 2011, through December 19, 2015. Data were analyzed for the present study from July 1 to August 31, 2016. Main Outcomes and Measures Patients in ATACH-II were randomized to intensive (systolic BP target, <140 mm Hg) vs standard (systolic BP target, <180 mm Hg) BP reduction within 4.5 hours from onset. Expansion of ICH was defined as hematoma growth of greater than 33%, and an unfavorable outcome was defined as a 90-day modified Rankin Scale score of 4 or greater (range, 0-6). The association among BP reduction, ICH expansion, and outcome was investigated with multivariable logistic regression. Results A total of 133 patients (83 men [62.4%] and 50 women [37.6%]; mean [SD] age, 61.9 [13.1] years) were included. Of these, 53 (39.8%) had a spot sign, and 24 of 123 without missing data (19.5%) experienced ICH expansion. The spot sign was associated with expansion with sensitivity of 0.54 (95% CI, 0.34-0.74) and specificity of 0.63 (95% CI, 0.53-0.72). After adjustment for potential confounders, intensive BP treatment was not associated with a significant reduction of ICH expansion (relative risk, 0.83; 95% CI, 0.27-2.51; P = .74) or improved outcome (relative risk of 90-day modified Rankin Scale score ≥4, 1.24; 95% CI, 0.53-2.91; P = .62) in spot sign-positive patients. Conclusions and Relevance The predictive performance of the spot sign for ICH expansion was lower than in prior reports from single-center studies. No evidence suggested that patients with ICH and a spot sign specifically benefit from intensive BP reduction. Trial Registration clinicaltrials.gov Identifier: NCT01176565.
Collapse
Affiliation(s)
- Andrea Morotti
- Division of Neurocritical Care and Emergency Neurology, Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston.,J. P. Kistler Stroke Research Center, Massachusetts General Hospital, Harvard Medical School, Boston
| | - H Bart Brouwers
- Department of Neurosurgery, Brain Center Rudolf Magnus University Medical Center, Utrecht, the Netherlands
| | - Javier M Romero
- J. P. Kistler Stroke Research Center, Massachusetts General Hospital, Harvard Medical School, Boston.,Neuroradiology Service, Department of Radiology, Massachusetts General Hospital, Harvard Medical School, Boston
| | - Michael J Jessel
- J. P. Kistler Stroke Research Center, Massachusetts General Hospital, Harvard Medical School, Boston
| | - Anastasia Vashkevich
- J. P. Kistler Stroke Research Center, Massachusetts General Hospital, Harvard Medical School, Boston
| | - Kristin Schwab
- J. P. Kistler Stroke Research Center, Massachusetts General Hospital, Harvard Medical School, Boston
| | | | - Christy Cassarly
- Department of Public Health Sciences, Medical University of South Carolina, Charleston
| | - Steven M Greenberg
- J. P. Kistler Stroke Research Center, Massachusetts General Hospital, Harvard Medical School, Boston
| | - Renee Hebert Martin
- Department of Public Health Sciences, Medical University of South Carolina, Charleston
| | - Adnan I Qureshi
- Zeenat Qureshi Stroke Research Center, University of Minnesota, Minneapolis
| | - Jonathan Rosand
- Division of Neurocritical Care and Emergency Neurology, Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston.,J. P. Kistler Stroke Research Center, Massachusetts General Hospital, Harvard Medical School, Boston
| | - Joshua N Goldstein
- Division of Neurocritical Care and Emergency Neurology, Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston.,J. P. Kistler Stroke Research Center, Massachusetts General Hospital, Harvard Medical School, Boston.,Department of Emergency Medicine, Massachusetts General Hospital, Harvard Medical School, Boston
| | | |
Collapse
|
12
|
Morotti A, Boulouis G, Romero JM, Brouwers HB, Jessel MJ, Vashkevich A, Schwab K, Afzal MR, Cassarly C, Greenberg SM, Martin RH, Qureshi AI, Rosand J, Goldstein JN. Blood pressure reduction and noncontrast CT markers of intracerebral hemorrhage expansion. Neurology 2017; 89:548-554. [PMID: 28701501 DOI: 10.1212/wnl.0000000000004210] [Citation(s) in RCA: 95] [Impact Index Per Article: 13.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2016] [Accepted: 05/15/2017] [Indexed: 12/15/2022] Open
Abstract
OBJECTIVE To validate various noncontrast CT (NCCT) predictors of hematoma expansion in a large international cohort of ICH patients and investigate whether intensive blood pressure (BP) treatment reduces ICH growth and improves outcome in patients with these markers. METHODS We analyzed patients enrolled in the Antihypertensive Treatment of Acute Cerebral Hemorrhage II (ATACH-II) randomized controlled trial. Participants were assigned to intensive (systolic BP <140 mm Hg) vs standard (systolic BP <180 mm Hg) treatment within 4.5 hours from onset. The following NCCT markers were identified: intrahematoma hypodensities, black hole sign, swirl sign, blend sign, heterogeneous hematoma density, and irregular shape. ICH expansion was defined as hematoma growth >33% and unfavorable outcome was defined as modified Rankin Scale score >3 at 90 days. Logistic regression was used to identify predictors of ICH expansion and explore the association between NCCT signs and clinical benefit from intensive BP treatment. RESULTS A total of 989 patients were included (mean age 62 years, 61.9% male), of whom 186/869 experienced hematoma expansion (21.4%) and 361/952 (37.9%) had unfavorable outcome. NCCT markers independently predicted ICH expansion (all p < 0.01) with overall accuracy ranging from 61% to 78% and good interrater reliability (k > 0.6 for all markers). There was no evidence of an interaction between NCCT markers and benefit from intensive BP reduction (all p for interaction >0.10). CONCLUSIONS NCCT signs reliably identify ICH patients at high risk of hematoma growth. However, we found no evidence that patients with these markers specifically benefit from intensive BP reduction. CLINICALTRIALSGOV IDENTIFIER NCT01176565.
Collapse
Affiliation(s)
- Andrea Morotti
- From the Department of Neurology, Division of Neurocritical Care and Emergency Neurology (A.M., J.M.R., J.N.G.), Neuroradiology Service, Department of Radiology (J.M.R.), the J.P. Kistler Stroke Research Center (A.M., G.B., J.M.R., M.J.J., A.V., K.S., S.M.G., J.R., J.N.G.), and Department of Emergency Medicine (J.N.G.), Massachusetts General Hospital, Harvard Medical School, Boston; Department of Neuroradiology (G.B.), Université Paris Descartes, INSERM S894, DHU Neurovasc, Centre Hospitalier Sainte-Anne, Paris, France; Department of Neurosurgery (H.B.B.), Brain Center, Rudolf Magnus University Medical Center, Utrecht, the Netherlands; Zeenat Qureshi Stroke Research Center (M.R.A., A.I.Q.), University of Minnesota, Minneapolis; and Department of Public Health Sciences (C.C., R.H.M.), Medical University of South Carolina, Charleston.
| | - Gregoire Boulouis
- From the Department of Neurology, Division of Neurocritical Care and Emergency Neurology (A.M., J.M.R., J.N.G.), Neuroradiology Service, Department of Radiology (J.M.R.), the J.P. Kistler Stroke Research Center (A.M., G.B., J.M.R., M.J.J., A.V., K.S., S.M.G., J.R., J.N.G.), and Department of Emergency Medicine (J.N.G.), Massachusetts General Hospital, Harvard Medical School, Boston; Department of Neuroradiology (G.B.), Université Paris Descartes, INSERM S894, DHU Neurovasc, Centre Hospitalier Sainte-Anne, Paris, France; Department of Neurosurgery (H.B.B.), Brain Center, Rudolf Magnus University Medical Center, Utrecht, the Netherlands; Zeenat Qureshi Stroke Research Center (M.R.A., A.I.Q.), University of Minnesota, Minneapolis; and Department of Public Health Sciences (C.C., R.H.M.), Medical University of South Carolina, Charleston
| | - Javier M Romero
- From the Department of Neurology, Division of Neurocritical Care and Emergency Neurology (A.M., J.M.R., J.N.G.), Neuroradiology Service, Department of Radiology (J.M.R.), the J.P. Kistler Stroke Research Center (A.M., G.B., J.M.R., M.J.J., A.V., K.S., S.M.G., J.R., J.N.G.), and Department of Emergency Medicine (J.N.G.), Massachusetts General Hospital, Harvard Medical School, Boston; Department of Neuroradiology (G.B.), Université Paris Descartes, INSERM S894, DHU Neurovasc, Centre Hospitalier Sainte-Anne, Paris, France; Department of Neurosurgery (H.B.B.), Brain Center, Rudolf Magnus University Medical Center, Utrecht, the Netherlands; Zeenat Qureshi Stroke Research Center (M.R.A., A.I.Q.), University of Minnesota, Minneapolis; and Department of Public Health Sciences (C.C., R.H.M.), Medical University of South Carolina, Charleston
| | - H Bart Brouwers
- From the Department of Neurology, Division of Neurocritical Care and Emergency Neurology (A.M., J.M.R., J.N.G.), Neuroradiology Service, Department of Radiology (J.M.R.), the J.P. Kistler Stroke Research Center (A.M., G.B., J.M.R., M.J.J., A.V., K.S., S.M.G., J.R., J.N.G.), and Department of Emergency Medicine (J.N.G.), Massachusetts General Hospital, Harvard Medical School, Boston; Department of Neuroradiology (G.B.), Université Paris Descartes, INSERM S894, DHU Neurovasc, Centre Hospitalier Sainte-Anne, Paris, France; Department of Neurosurgery (H.B.B.), Brain Center, Rudolf Magnus University Medical Center, Utrecht, the Netherlands; Zeenat Qureshi Stroke Research Center (M.R.A., A.I.Q.), University of Minnesota, Minneapolis; and Department of Public Health Sciences (C.C., R.H.M.), Medical University of South Carolina, Charleston
| | - Michael J Jessel
- From the Department of Neurology, Division of Neurocritical Care and Emergency Neurology (A.M., J.M.R., J.N.G.), Neuroradiology Service, Department of Radiology (J.M.R.), the J.P. Kistler Stroke Research Center (A.M., G.B., J.M.R., M.J.J., A.V., K.S., S.M.G., J.R., J.N.G.), and Department of Emergency Medicine (J.N.G.), Massachusetts General Hospital, Harvard Medical School, Boston; Department of Neuroradiology (G.B.), Université Paris Descartes, INSERM S894, DHU Neurovasc, Centre Hospitalier Sainte-Anne, Paris, France; Department of Neurosurgery (H.B.B.), Brain Center, Rudolf Magnus University Medical Center, Utrecht, the Netherlands; Zeenat Qureshi Stroke Research Center (M.R.A., A.I.Q.), University of Minnesota, Minneapolis; and Department of Public Health Sciences (C.C., R.H.M.), Medical University of South Carolina, Charleston
| | - Anastasia Vashkevich
- From the Department of Neurology, Division of Neurocritical Care and Emergency Neurology (A.M., J.M.R., J.N.G.), Neuroradiology Service, Department of Radiology (J.M.R.), the J.P. Kistler Stroke Research Center (A.M., G.B., J.M.R., M.J.J., A.V., K.S., S.M.G., J.R., J.N.G.), and Department of Emergency Medicine (J.N.G.), Massachusetts General Hospital, Harvard Medical School, Boston; Department of Neuroradiology (G.B.), Université Paris Descartes, INSERM S894, DHU Neurovasc, Centre Hospitalier Sainte-Anne, Paris, France; Department of Neurosurgery (H.B.B.), Brain Center, Rudolf Magnus University Medical Center, Utrecht, the Netherlands; Zeenat Qureshi Stroke Research Center (M.R.A., A.I.Q.), University of Minnesota, Minneapolis; and Department of Public Health Sciences (C.C., R.H.M.), Medical University of South Carolina, Charleston
| | - Kristin Schwab
- From the Department of Neurology, Division of Neurocritical Care and Emergency Neurology (A.M., J.M.R., J.N.G.), Neuroradiology Service, Department of Radiology (J.M.R.), the J.P. Kistler Stroke Research Center (A.M., G.B., J.M.R., M.J.J., A.V., K.S., S.M.G., J.R., J.N.G.), and Department of Emergency Medicine (J.N.G.), Massachusetts General Hospital, Harvard Medical School, Boston; Department of Neuroradiology (G.B.), Université Paris Descartes, INSERM S894, DHU Neurovasc, Centre Hospitalier Sainte-Anne, Paris, France; Department of Neurosurgery (H.B.B.), Brain Center, Rudolf Magnus University Medical Center, Utrecht, the Netherlands; Zeenat Qureshi Stroke Research Center (M.R.A., A.I.Q.), University of Minnesota, Minneapolis; and Department of Public Health Sciences (C.C., R.H.M.), Medical University of South Carolina, Charleston
| | - Mohammad Rauf Afzal
- From the Department of Neurology, Division of Neurocritical Care and Emergency Neurology (A.M., J.M.R., J.N.G.), Neuroradiology Service, Department of Radiology (J.M.R.), the J.P. Kistler Stroke Research Center (A.M., G.B., J.M.R., M.J.J., A.V., K.S., S.M.G., J.R., J.N.G.), and Department of Emergency Medicine (J.N.G.), Massachusetts General Hospital, Harvard Medical School, Boston; Department of Neuroradiology (G.B.), Université Paris Descartes, INSERM S894, DHU Neurovasc, Centre Hospitalier Sainte-Anne, Paris, France; Department of Neurosurgery (H.B.B.), Brain Center, Rudolf Magnus University Medical Center, Utrecht, the Netherlands; Zeenat Qureshi Stroke Research Center (M.R.A., A.I.Q.), University of Minnesota, Minneapolis; and Department of Public Health Sciences (C.C., R.H.M.), Medical University of South Carolina, Charleston
| | - Christy Cassarly
- From the Department of Neurology, Division of Neurocritical Care and Emergency Neurology (A.M., J.M.R., J.N.G.), Neuroradiology Service, Department of Radiology (J.M.R.), the J.P. Kistler Stroke Research Center (A.M., G.B., J.M.R., M.J.J., A.V., K.S., S.M.G., J.R., J.N.G.), and Department of Emergency Medicine (J.N.G.), Massachusetts General Hospital, Harvard Medical School, Boston; Department of Neuroradiology (G.B.), Université Paris Descartes, INSERM S894, DHU Neurovasc, Centre Hospitalier Sainte-Anne, Paris, France; Department of Neurosurgery (H.B.B.), Brain Center, Rudolf Magnus University Medical Center, Utrecht, the Netherlands; Zeenat Qureshi Stroke Research Center (M.R.A., A.I.Q.), University of Minnesota, Minneapolis; and Department of Public Health Sciences (C.C., R.H.M.), Medical University of South Carolina, Charleston
| | - Steven M Greenberg
- From the Department of Neurology, Division of Neurocritical Care and Emergency Neurology (A.M., J.M.R., J.N.G.), Neuroradiology Service, Department of Radiology (J.M.R.), the J.P. Kistler Stroke Research Center (A.M., G.B., J.M.R., M.J.J., A.V., K.S., S.M.G., J.R., J.N.G.), and Department of Emergency Medicine (J.N.G.), Massachusetts General Hospital, Harvard Medical School, Boston; Department of Neuroradiology (G.B.), Université Paris Descartes, INSERM S894, DHU Neurovasc, Centre Hospitalier Sainte-Anne, Paris, France; Department of Neurosurgery (H.B.B.), Brain Center, Rudolf Magnus University Medical Center, Utrecht, the Netherlands; Zeenat Qureshi Stroke Research Center (M.R.A., A.I.Q.), University of Minnesota, Minneapolis; and Department of Public Health Sciences (C.C., R.H.M.), Medical University of South Carolina, Charleston
| | - Reneé Hebert Martin
- From the Department of Neurology, Division of Neurocritical Care and Emergency Neurology (A.M., J.M.R., J.N.G.), Neuroradiology Service, Department of Radiology (J.M.R.), the J.P. Kistler Stroke Research Center (A.M., G.B., J.M.R., M.J.J., A.V., K.S., S.M.G., J.R., J.N.G.), and Department of Emergency Medicine (J.N.G.), Massachusetts General Hospital, Harvard Medical School, Boston; Department of Neuroradiology (G.B.), Université Paris Descartes, INSERM S894, DHU Neurovasc, Centre Hospitalier Sainte-Anne, Paris, France; Department of Neurosurgery (H.B.B.), Brain Center, Rudolf Magnus University Medical Center, Utrecht, the Netherlands; Zeenat Qureshi Stroke Research Center (M.R.A., A.I.Q.), University of Minnesota, Minneapolis; and Department of Public Health Sciences (C.C., R.H.M.), Medical University of South Carolina, Charleston
| | - Adnan I Qureshi
- From the Department of Neurology, Division of Neurocritical Care and Emergency Neurology (A.M., J.M.R., J.N.G.), Neuroradiology Service, Department of Radiology (J.M.R.), the J.P. Kistler Stroke Research Center (A.M., G.B., J.M.R., M.J.J., A.V., K.S., S.M.G., J.R., J.N.G.), and Department of Emergency Medicine (J.N.G.), Massachusetts General Hospital, Harvard Medical School, Boston; Department of Neuroradiology (G.B.), Université Paris Descartes, INSERM S894, DHU Neurovasc, Centre Hospitalier Sainte-Anne, Paris, France; Department of Neurosurgery (H.B.B.), Brain Center, Rudolf Magnus University Medical Center, Utrecht, the Netherlands; Zeenat Qureshi Stroke Research Center (M.R.A., A.I.Q.), University of Minnesota, Minneapolis; and Department of Public Health Sciences (C.C., R.H.M.), Medical University of South Carolina, Charleston
| | - Jonathan Rosand
- From the Department of Neurology, Division of Neurocritical Care and Emergency Neurology (A.M., J.M.R., J.N.G.), Neuroradiology Service, Department of Radiology (J.M.R.), the J.P. Kistler Stroke Research Center (A.M., G.B., J.M.R., M.J.J., A.V., K.S., S.M.G., J.R., J.N.G.), and Department of Emergency Medicine (J.N.G.), Massachusetts General Hospital, Harvard Medical School, Boston; Department of Neuroradiology (G.B.), Université Paris Descartes, INSERM S894, DHU Neurovasc, Centre Hospitalier Sainte-Anne, Paris, France; Department of Neurosurgery (H.B.B.), Brain Center, Rudolf Magnus University Medical Center, Utrecht, the Netherlands; Zeenat Qureshi Stroke Research Center (M.R.A., A.I.Q.), University of Minnesota, Minneapolis; and Department of Public Health Sciences (C.C., R.H.M.), Medical University of South Carolina, Charleston
| | - Joshua N Goldstein
- From the Department of Neurology, Division of Neurocritical Care and Emergency Neurology (A.M., J.M.R., J.N.G.), Neuroradiology Service, Department of Radiology (J.M.R.), the J.P. Kistler Stroke Research Center (A.M., G.B., J.M.R., M.J.J., A.V., K.S., S.M.G., J.R., J.N.G.), and Department of Emergency Medicine (J.N.G.), Massachusetts General Hospital, Harvard Medical School, Boston; Department of Neuroradiology (G.B.), Université Paris Descartes, INSERM S894, DHU Neurovasc, Centre Hospitalier Sainte-Anne, Paris, France; Department of Neurosurgery (H.B.B.), Brain Center, Rudolf Magnus University Medical Center, Utrecht, the Netherlands; Zeenat Qureshi Stroke Research Center (M.R.A., A.I.Q.), University of Minnesota, Minneapolis; and Department of Public Health Sciences (C.C., R.H.M.), Medical University of South Carolina, Charleston
| | | |
Collapse
|
13
|
Boulouis G, Morotti A, Brouwers HB, Charidimou A, Jessel MJ, Auriel E, Pontes-Neto O, Ayres A, Vashkevich A, Schwab KM, Rosand J, Viswanathan A, Gurol ME, Greenberg SM, Goldstein JN. Association Between Hypodensities Detected by Computed Tomography and Hematoma Expansion in Patients With Intracerebral Hemorrhage. JAMA Neurol 2017; 73:961-8. [PMID: 27323314 DOI: 10.1001/jamaneurol.2016.1218] [Citation(s) in RCA: 161] [Impact Index Per Article: 23.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
IMPORTANCE Hematoma expansion is a potentially modifiable predictor of poor outcome following an acute intracerebral hemorrhage (ICH). The ability to identify patients with ICH who are likeliest to experience hematoma expansion and therefore likeliest to benefit from expansion-targeted treatments remains an unmet need. Hypodensities within an ICH detected by noncontrast computed tomography (NCCT) have been suggested as a predictor of hematoma expansion. OBJECTIVE To determine whether hypodense regions, irrespective of their specific patterns, are associated with hematoma expansion in patients with ICH. DESIGN, SETTING, AND PARTICIPANTS We analyzed a large cohort of 784 patients with ICH (the development cohort; 55.6% female), examined NCCT findings for any hypodensity, and replicated our findings on a different cohort of patients (the replication cohort; 52.7% female). Baseline and follow-up NCCT data from consecutive patients with ICH presenting to a tertiary care hospital between 1994 and 2015 were retrospectively analyzed. Data analyses were performed between December 2015 and January 2016. MAIN OUTCOMES AND MEASURES Hypodensities were analyzed by 2 independent blinded raters. The association between hypodensities and hematoma expansion (>6 cm3 or 33% of baseline volume) was determined by multivariable logistic regression after controlling for other variables associated with hematoma expansion in univariate analyses with P ≤ .10. RESULTS A total of 1029 patients were included in the analysis. In the development and replication cohorts, 222 of 784 patients (28.3%) and 99 of 245 patients (40.4%; 321 of 1029 patients [31.2%]), respectively, had NCCT scans that demonstrated hypodensities at baseline (κ = 0.87 for interrater reliability). In univariate analyses, hypodensities were associated with hematoma expansion (86 of 163 patients with hematoma expansion had hypodensities [52.8%], whereas 136 of 621 patients without hematoma expansion had hypodensities [21.9%]; P < .001). The association between hypodensities and hematoma expansion remained significant (odds ratio, 3.42 [95% CI, 2.21-5.31]; P < .001) in a multivariable model; other independent predictors of hematoma expansion were a CT angiography spot sign, a shorter time to CT, warfarin use, and older age. The independent predictive value of hypodensities was again demonstrated in the replication cohort (odds ratio, 4.37 [95% CI, 2.05-9.62]; P < .001). CONCLUSION AND RELEVANCE Hypodensities within an acute ICH detected on an NCCT scan may predict hematoma expansion, independent of other clinical and imaging predictors. This novel marker may help clarify the mechanism of hematoma expansion and serve as a useful addition to clinical algorithms for determining the risk of and treatment stratification for hematoma expansion.
Collapse
Affiliation(s)
- Gregoire Boulouis
- Hemorrhagic Stroke Research Program, Department of Neurology, Massachusetts General Hospital Stroke Research Center, Harvard Medical School, Boston
| | - Andrea Morotti
- Hemorrhagic Stroke Research Program, Department of Neurology, Massachusetts General Hospital Stroke Research Center, Harvard Medical School, Boston
| | - H Bart Brouwers
- Hemorrhagic Stroke Research Program, Department of Neurology, Massachusetts General Hospital Stroke Research Center, Harvard Medical School, Boston2Department of Neurosurgery, Brain Center Rudolf Magnus, University Medical Center Utrecht, Utrecht Universi
| | - Andreas Charidimou
- Hemorrhagic Stroke Research Program, Department of Neurology, Massachusetts General Hospital Stroke Research Center, Harvard Medical School, Boston
| | - Michael J Jessel
- Hemorrhagic Stroke Research Program, Department of Neurology, Massachusetts General Hospital Stroke Research Center, Harvard Medical School, Boston
| | - Eitan Auriel
- Hemorrhagic Stroke Research Program, Department of Neurology, Massachusetts General Hospital Stroke Research Center, Harvard Medical School, Boston
| | - Octávio Pontes-Neto
- Hemorrhagic Stroke Research Program, Department of Neurology, Massachusetts General Hospital Stroke Research Center, Harvard Medical School, Boston
| | - Alison Ayres
- Hemorrhagic Stroke Research Program, Department of Neurology, Massachusetts General Hospital Stroke Research Center, Harvard Medical School, Boston
| | - Anastasia Vashkevich
- Hemorrhagic Stroke Research Program, Department of Neurology, Massachusetts General Hospital Stroke Research Center, Harvard Medical School, Boston
| | - Kristin M Schwab
- Hemorrhagic Stroke Research Program, Department of Neurology, Massachusetts General Hospital Stroke Research Center, Harvard Medical School, Boston
| | - Jonathan Rosand
- Hemorrhagic Stroke Research Program, Department of Neurology, Massachusetts General Hospital Stroke Research Center, Harvard Medical School, Boston3Division of Neurocritical Care and Emergency Neurology, Massachusetts General Hospital, Harvard Medical Sch
| | - Anand Viswanathan
- Hemorrhagic Stroke Research Program, Department of Neurology, Massachusetts General Hospital Stroke Research Center, Harvard Medical School, Boston
| | - Mahmut E Gurol
- Hemorrhagic Stroke Research Program, Department of Neurology, Massachusetts General Hospital Stroke Research Center, Harvard Medical School, Boston
| | - Steven M Greenberg
- Hemorrhagic Stroke Research Program, Department of Neurology, Massachusetts General Hospital Stroke Research Center, Harvard Medical School, Boston
| | - Joshua N Goldstein
- Hemorrhagic Stroke Research Program, Department of Neurology, Massachusetts General Hospital Stroke Research Center, Harvard Medical School, Boston3Division of Neurocritical Care and Emergency Neurology, Massachusetts General Hospital, Harvard Medical Sch
| |
Collapse
|
14
|
Boulouis G, van Etten ES, Charidimou A, Auriel E, Morotti A, Pasi M, Haley KE, Brouwers HB, Ayres AM, Vashkevich A, Jessel MJ, Schwab KM, Viswanathan A, Greenberg SM, Rosand J, Goldstein JN, Gurol ME. Association of Key Magnetic Resonance Imaging Markers of Cerebral Small Vessel Disease With Hematoma Volume and Expansion in Patients With Lobar and Deep Intracerebral Hemorrhage. JAMA Neurol 2017; 73:1440-1447. [PMID: 27723863 DOI: 10.1001/jamaneurol.2016.2619] [Citation(s) in RCA: 52] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Importance Hematoma expansion is an important determinant of outcome in spontaneous intracerebral hemorrhage (ICH) due to small vessel disease (SVD), but the association between the severity of the underlying SVD and the extent of bleeding at the acute phase is unknown to date. Objective To investigate the association between key magnetic resonance imaging (MRI) markers of SVD (as per the Standards for Reporting Vascular Changes on Neuroimaging [STRIVE] guidelines) and hematoma volume and expansion in patients with lobar or deep ICH. Design, Setting, and Participants Analysis of data collected from 418 consecutive patients admitted with primary lobar or deep ICH to a single tertiary care medical center between January 1, 2000, and October 1, 2012. Data were analyzed on March 4, 2016. Participants were consecutive patients with computed tomographic images allowing ICH volume calculation and MRI allowing imaging markers of SVD assessment. Main Outcomes and Measures The ICH volumes at baseline and within 48 hours after symptom onset were measured in 418 patients with spontaneous ICH without anticoagulant therapy, and hematoma expansion was calculated. Cerebral microbleeds, cortical superficial siderosis, and white matter hyperintensity volume were assessed on MRI. The associations between these SVD markers and ICH volume, as well as hematoma expansion, were investigated using multivariable models. Results This study analyzed 254 patients with lobar ICH (mean [SD] age, 75 [11] years and 140 [55.1%] female) and 164 patients with deep ICH (mean [SD] age 67 [14] years and 71 [43.3%] female). The presence of cortical superficial siderosis was an independent variable associated with larger ICH volume in the lobar ICH group (odds ratio per quintile increase in final ICH volume, 1.49; 95% CI, 1.14-1.94; P = .004). In multivariable models, the absence of cerebral microbleeds was associated with larger ICH volume for both the lobar and deep ICH groups (odds ratios per quintile increase in final ICH volume, 1.41; 95% CI, 1.11-1.81; P = .006 and 1.43; 95% CI, 1.04-1.99; P = .03; respectively) and with hematoma expansion in the lobar ICH group (odds ratio, 1.70; 95% CI, 1.07-2.92; P = .04). The white matter hyperintensity volumes were not associated with either hematoma volume or expansion. Conclusions and Relevance In patients admitted with primary lobar or deep ICH to a single tertiary care medical center, the presence of cortical superficial siderosis was an independent variable associated with larger lobar ICH volume, and the absence of cerebral microbleeds was associated with larger lobar and deep ICHs. The absence of cerebral microbleeds was independently associated with more frequent hematoma expansion in patients with lobar ICH. We provide an analytical framework for future studies aimed at limiting hematoma expansion.
Collapse
Affiliation(s)
- Gregoire Boulouis
- Hemorrhagic Stroke Research Program, Department of Neurology, Massachusetts General Hospital Stroke Research Center, Harvard Medical School, Boston
| | - Ellis S van Etten
- Hemorrhagic Stroke Research Program, Department of Neurology, Massachusetts General Hospital Stroke Research Center, Harvard Medical School, Boston2Department of Neurology, Leiden University Medical Center, Leiden, the Netherlands
| | - Andreas Charidimou
- Hemorrhagic Stroke Research Program, Department of Neurology, Massachusetts General Hospital Stroke Research Center, Harvard Medical School, Boston
| | - Eitan Auriel
- Hemorrhagic Stroke Research Program, Department of Neurology, Massachusetts General Hospital Stroke Research Center, Harvard Medical School, Boston
| | - Andrea Morotti
- Hemorrhagic Stroke Research Program, Department of Neurology, Massachusetts General Hospital Stroke Research Center, Harvard Medical School, Boston
| | - Marco Pasi
- Hemorrhagic Stroke Research Program, Department of Neurology, Massachusetts General Hospital Stroke Research Center, Harvard Medical School, Boston
| | - Kellen E Haley
- Hemorrhagic Stroke Research Program, Department of Neurology, Massachusetts General Hospital Stroke Research Center, Harvard Medical School, Boston
| | - H Bart Brouwers
- Hemorrhagic Stroke Research Program, Department of Neurology, Massachusetts General Hospital Stroke Research Center, Harvard Medical School, Boston3Brain Center Rudolf Magnus, Department of Neurosurgery, University Medical Center Utrecht, Heidelberglaan, Utrecht, the Netherlands
| | - Alison M Ayres
- Hemorrhagic Stroke Research Program, Department of Neurology, Massachusetts General Hospital Stroke Research Center, Harvard Medical School, Boston
| | - Anastasia Vashkevich
- Hemorrhagic Stroke Research Program, Department of Neurology, Massachusetts General Hospital Stroke Research Center, Harvard Medical School, Boston
| | - Michael J Jessel
- Hemorrhagic Stroke Research Program, Department of Neurology, Massachusetts General Hospital Stroke Research Center, Harvard Medical School, Boston
| | - Kristin M Schwab
- Hemorrhagic Stroke Research Program, Department of Neurology, Massachusetts General Hospital Stroke Research Center, Harvard Medical School, Boston
| | - Anand Viswanathan
- Hemorrhagic Stroke Research Program, Department of Neurology, Massachusetts General Hospital Stroke Research Center, Harvard Medical School, Boston
| | - Steven M Greenberg
- Hemorrhagic Stroke Research Program, Department of Neurology, Massachusetts General Hospital Stroke Research Center, Harvard Medical School, Boston
| | - Jonathan Rosand
- Hemorrhagic Stroke Research Program, Department of Neurology, Massachusetts General Hospital Stroke Research Center, Harvard Medical School, Boston
| | - Joshua N Goldstein
- Hemorrhagic Stroke Research Program, Department of Neurology, Massachusetts General Hospital Stroke Research Center, Harvard Medical School, Boston4Division of Neurocritical Care and Emergency Neurology, Massachusetts General Hospital, Harvard Medical School, Boston
| | - M Edip Gurol
- Hemorrhagic Stroke Research Program, Department of Neurology, Massachusetts General Hospital Stroke Research Center, Harvard Medical School, Boston
| |
Collapse
|
15
|
Anderson CD, Falcone GJ, Phuah CL, Radmanesh F, Brouwers HB, Battey TWK, Biffi A, Peloso GM, Liu DJ, Ayres AM, Goldstein JN, Viswanathan A, Greenberg SM, Selim M, Meschia JF, Brown DL, Worrall BB, Silliman SL, Tirschwell DL, Flaherty ML, Kraft P, Jagiella JM, Schmidt H, Hansen BM, Jimenez-Conde J, Giralt-Steinhauer E, Elosua R, Cuadrado-Godia E, Soriano C, van Nieuwenhuizen KM, Klijn CJM, Rannikmae K, Samarasekera N, Al-Shahi Salman R, Sudlow CL, Deary IJ, Morotti A, Pezzini A, Pera J, Urbanik A, Pichler A, Enzinger C, Norrving B, Montaner J, Fernandez-Cadenas I, Delgado P, Roquer J, Lindgren A, Slowik A, Schmidt R, Kidwell CS, Kittner SJ, Waddy SP, Langefeld CD, Abecasis G, Willer CJ, Kathiresan S, Woo D, Rosand J. Genetic variants in CETP increase risk of intracerebral hemorrhage. Ann Neurol 2016; 80:730-740. [PMID: 27717122 PMCID: PMC5115931 DOI: 10.1002/ana.24780] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2016] [Revised: 09/13/2016] [Accepted: 09/13/2016] [Indexed: 12/26/2022]
Abstract
Objective In observational epidemiologic studies, higher plasma high‐density lipoprotein cholesterol (HDL‐C) has been associated with increased risk of intracerebral hemorrhage (ICH). DNA sequence variants that decrease cholesteryl ester transfer protein (CETP) gene activity increase plasma HDL‐C; as such, medicines that inhibit CETP and raise HDL‐C are in clinical development. Here, we test the hypothesis that CETP DNA sequence variants associated with higher HDL‐C also increase risk for ICH. Methods We performed 2 candidate‐gene analyses of CETP. First, we tested individual CETP variants in a discovery cohort of 1,149 ICH cases and 1,238 controls from 3 studies, followed by replication in 1,625 cases and 1,845 controls from 5 studies. Second, we constructed a genetic risk score comprised of 7 independent variants at the CETP locus and tested this score for association with HDL‐C as well as ICH risk. Results Twelve variants within CETP demonstrated nominal association with ICH, with the strongest association at the rs173539 locus (odds ratio [OR] = 1.25, standard error [SE] = 0.06, p = 6.0 × 10−4) with no heterogeneity across studies (I2 = 0%). This association was replicated in patients of European ancestry (p = 0.03). A genetic score of CETP variants found to increase HDL‐C by ∼2.85mg/dl in the Global Lipids Genetics Consortium was strongly associated with ICH risk (OR = 1.86, SE = 0.13, p = 1.39 × 10−6). Interpretation Genetic variants in CETP associated with increased HDL‐C raise the risk of ICH. Given ongoing therapeutic development in CETP inhibition and other HDL‐raising strategies, further exploration of potential adverse cerebrovascular outcomes may be warranted. Ann Neurol 2016;80:730–740
Collapse
Affiliation(s)
- Christopher D Anderson
- Center for Human Genetic Research, Massachusetts General Hospital (MGH), Boston, MA.,J. Philip Kistler Stroke Research Center, Department of Neurology, MGH, Boston, MA.,Division of Neurocritical Care and Emergency Neurology, Department of Neurology, MGH, Boston, MA.,Program in Medical and Population Genetics, Broad Institute, Cambridge, MA
| | - Guido J Falcone
- Center for Human Genetic Research, Massachusetts General Hospital (MGH), Boston, MA.,J. Philip Kistler Stroke Research Center, Department of Neurology, MGH, Boston, MA.,Division of Neurocritical Care and Emergency Neurology, Department of Neurology, MGH, Boston, MA.,Program in Medical and Population Genetics, Broad Institute, Cambridge, MA.,Departments of Epidemiology and Biostatistics, Harvard T. H. Chan School of Public Health, Boston, MA
| | - Chia-Ling Phuah
- Center for Human Genetic Research, Massachusetts General Hospital (MGH), Boston, MA.,J. Philip Kistler Stroke Research Center, Department of Neurology, MGH, Boston, MA.,Division of Neurocritical Care and Emergency Neurology, Department of Neurology, MGH, Boston, MA.,Program in Medical and Population Genetics, Broad Institute, Cambridge, MA
| | - Farid Radmanesh
- Center for Human Genetic Research, Massachusetts General Hospital (MGH), Boston, MA.,J. Philip Kistler Stroke Research Center, Department of Neurology, MGH, Boston, MA.,Division of Neurocritical Care and Emergency Neurology, Department of Neurology, MGH, Boston, MA.,Program in Medical and Population Genetics, Broad Institute, Cambridge, MA
| | - H Bart Brouwers
- Center for Human Genetic Research, Massachusetts General Hospital (MGH), Boston, MA.,J. Philip Kistler Stroke Research Center, Department of Neurology, MGH, Boston, MA.,Division of Neurocritical Care and Emergency Neurology, Department of Neurology, MGH, Boston, MA.,Program in Medical and Population Genetics, Broad Institute, Cambridge, MA
| | - Thomas W K Battey
- Center for Human Genetic Research, Massachusetts General Hospital (MGH), Boston, MA.,J. Philip Kistler Stroke Research Center, Department of Neurology, MGH, Boston, MA.,Division of Neurocritical Care and Emergency Neurology, Department of Neurology, MGH, Boston, MA.,Program in Medical and Population Genetics, Broad Institute, Cambridge, MA
| | - Alessandro Biffi
- Center for Human Genetic Research, Massachusetts General Hospital (MGH), Boston, MA.,J. Philip Kistler Stroke Research Center, Department of Neurology, MGH, Boston, MA.,Program in Medical and Population Genetics, Broad Institute, Cambridge, MA.,Division of Behavioral Neurology, Department of Neurology, MGH, Boston, MA.,Division of Psychiatry, Department of Psychiatry, MGH, Boston, MA
| | - Gina M Peloso
- Center for Human Genetic Research, Massachusetts General Hospital (MGH), Boston, MA.,Program in Medical and Population Genetics, Broad Institute, Cambridge, MA
| | - Dajiang J Liu
- Department of Public Health Sciences, Institute of Personalized Medicine, Penn State College of Medicine, Hershey, PA
| | - Alison M Ayres
- Center for Human Genetic Research, Massachusetts General Hospital (MGH), Boston, MA.,J. Philip Kistler Stroke Research Center, Department of Neurology, MGH, Boston, MA
| | | | - Anand Viswanathan
- J. Philip Kistler Stroke Research Center, Department of Neurology, MGH, Boston, MA
| | - Steven M Greenberg
- J. Philip Kistler Stroke Research Center, Department of Neurology, MGH, Boston, MA
| | - Magdy Selim
- Department of Neurology, Beth Israel Deaconess Medical Center, Boston, MA
| | | | - Devin L Brown
- Stroke Program, Department of Neurology, University of Michigan Health System, Ann Arbor, MI
| | - Bradford B Worrall
- Departments of Neurology and Public Health Sciences, University of Virginia Health System, Charlottesville, VA
| | - Scott L Silliman
- Department of Neurology, University of Florida College of Medicine, Jacksonville, FL
| | - David L Tirschwell
- Stroke Center, Harborview Medical Center, University of Washington, Seattle, WA
| | - Matthew L Flaherty
- Department of Neurology, University of Cincinnati College of Medicine, Cincinnati, OH
| | - Peter Kraft
- Departments of Epidemiology and Biostatistics, Harvard T. H. Chan School of Public Health, Boston, MA
| | - Jeremiasz M Jagiella
- Department of Neurology, Jagiellonian University Medical College, Krakow, Poland
| | - Helena Schmidt
- Institute of Molecular Biology and Biochemistry, Medical University Graz, Graz, Austria
| | - Björn M Hansen
- Division of Neurology, Department of Clinical Sciences Lund, Lund University, Lund, Sweden.,Division of Neurology, Department of Neurology and Rehabilitation Medicine, Skåne University Hospital, Lund, Sweden
| | - Jordi Jimenez-Conde
- Neurovascular Research Unit, Department of Neurology, Municipal Institute of Medical Investigation-Hospital of the Sea, Autonomous University of Barcelona, Barcelona, Spain.,Program in Inflammation and Cardiovascular Disorders, Municipal Institute of Medical Investigation-Hospital of the Sea, Autonomous University of Barcelona, Barcelona, Spain
| | - Eva Giralt-Steinhauer
- Neurovascular Research Unit, Department of Neurology, Municipal Institute of Medical Investigation-Hospital of the Sea, Autonomous University of Barcelona, Barcelona, Spain.,Program in Inflammation and Cardiovascular Disorders, Municipal Institute of Medical Investigation-Hospital of the Sea, Autonomous University of Barcelona, Barcelona, Spain
| | - Roberto Elosua
- Neurovascular Research Unit, Department of Neurology, Municipal Institute of Medical Investigation-Hospital of the Sea, Autonomous University of Barcelona, Barcelona, Spain.,Program in Inflammation and Cardiovascular Disorders, Municipal Institute of Medical Investigation-Hospital of the Sea, Autonomous University of Barcelona, Barcelona, Spain
| | - Elisa Cuadrado-Godia
- Neurovascular Research Unit, Department of Neurology, Municipal Institute of Medical Investigation-Hospital of the Sea, Autonomous University of Barcelona, Barcelona, Spain.,Program in Inflammation and Cardiovascular Disorders, Municipal Institute of Medical Investigation-Hospital of the Sea, Autonomous University of Barcelona, Barcelona, Spain
| | - Carolina Soriano
- Neurovascular Research Unit, Department of Neurology, Municipal Institute of Medical Investigation-Hospital of the Sea, Autonomous University of Barcelona, Barcelona, Spain.,Program in Inflammation and Cardiovascular Disorders, Municipal Institute of Medical Investigation-Hospital of the Sea, Autonomous University of Barcelona, Barcelona, Spain
| | - Koen M van Nieuwenhuizen
- Department of Neurology and Neurosurgery, Brain Center Rudolf Magnus, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Catharina J M Klijn
- Department of Neurology and Neurosurgery, Brain Center Rudolf Magnus, University Medical Center Utrecht, Utrecht, the Netherlands.,Department of Neurology, Donders Institute for Brain, Cognition, and Behavior, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Kristiina Rannikmae
- Division of Clinical Brain Sciences, University of Edinburgh, Edinburgh, United Kingdom
| | - Neshika Samarasekera
- Division of Clinical Brain Sciences, University of Edinburgh, Edinburgh, United Kingdom
| | | | - Catherine L Sudlow
- Division of Clinical Brain Sciences, University of Edinburgh, Edinburgh, United Kingdom.,Institute for Genetics and Molecular Medicine, University of Edinburgh, Edinburgh, United Kingdom
| | - Ian J Deary
- Centre for Cognitive Ageing and Cognitive Epidemiology, University of Edinburgh, Edinburgh, United Kingdom
| | - Andrea Morotti
- Department of Clinical and Experimental Sciences, Neurology Clinic, University of Brescia, Brescia, Italy
| | - Alessandro Pezzini
- Department of Clinical and Experimental Sciences, Neurology Clinic, University of Brescia, Brescia, Italy
| | - Joanna Pera
- Department of Neurology, Jagiellonian University Medical College, Krakow, Poland
| | - Andrzej Urbanik
- Department of Neurology, Jagiellonian University Medical College, Krakow, Poland
| | | | - Christian Enzinger
- Department of Neurology, Medical University of Graz, Graz, Austria.,Division of Neuroradiology, Department of Radiology, Medical University of Graz, Graz, Austria
| | - Bo Norrving
- Division of Neurology, Department of Clinical Sciences Lund, Lund University, Lund, Sweden.,Division of Neurology, Department of Neurology and Rehabilitation Medicine, Skåne University Hospital, Lund, Sweden
| | - Joan Montaner
- Neurovascular Research Laboratory and Neurovascular Unit, Research Institute, Vall d'Hebron Hospital, Autonomous University of Barcelona, Barcelona, Spain
| | - Israel Fernandez-Cadenas
- Neurovascular Research Laboratory and Neurovascular Unit, Research Institute, Vall d'Hebron Hospital, Autonomous University of Barcelona, Barcelona, Spain.,Stroke Pharmacogenomics and Genetics, Terrassa Mutual Teaching and Research Foundation, Terrassa Mutual Hospital, Terrassa, Spain
| | - Pilar Delgado
- Neurovascular Research Laboratory and Neurovascular Unit, Research Institute, Vall d'Hebron Hospital, Autonomous University of Barcelona, Barcelona, Spain
| | - Jaume Roquer
- Neurovascular Research Unit, Department of Neurology, Municipal Institute of Medical Investigation-Hospital of the Sea, Autonomous University of Barcelona, Barcelona, Spain.,Program in Inflammation and Cardiovascular Disorders, Municipal Institute of Medical Investigation-Hospital of the Sea, Autonomous University of Barcelona, Barcelona, Spain
| | - Arne Lindgren
- Division of Neurology, Department of Clinical Sciences Lund, Lund University, Lund, Sweden.,Division of Neurology, Department of Neurology and Rehabilitation Medicine, Skåne University Hospital, Lund, Sweden
| | - Agnieszka Slowik
- Department of Neurology, Jagiellonian University Medical College, Krakow, Poland
| | - Reinhold Schmidt
- Department of Neurology, Medical University of Graz, Graz, Austria
| | | | - Steven J Kittner
- Department of Neurology, Baltimore Veterans Administration Medical Center and University of Maryland School of Medicine, Baltimore, MD
| | - Salina P Waddy
- National Institute of Neurological Disorders and Stroke, National Institutes of Health, Bethesda, MD
| | - Carl D Langefeld
- Center for Public Health Genomics and Department of Biostatistical Sciences, Wake Forest University, Winston-Salem, NC
| | - Goncalo Abecasis
- Center for Statistical Genetics, Department of Biostatistics, University of Michigan School of Public Health, Ann Arbor, MI
| | - Cristen J Willer
- Division of Cardiology, Department of Internal Medicine, University of Michigan Medical School, Ann Arbor, MI.,Department of Human Genetics, University of Michigan Medical School, Ann Arbor, MI
| | - Sekar Kathiresan
- Center for Human Genetic Research, Massachusetts General Hospital (MGH), Boston, MA.,Program in Medical and Population Genetics, Broad Institute, Cambridge, MA.,Cardiovascular Disease Prevention Center, MGH, Boston, MA
| | - Daniel Woo
- Department of Neurology, University of Cincinnati College of Medicine, Cincinnati, OH
| | - Jonathan Rosand
- Center for Human Genetic Research, Massachusetts General Hospital (MGH), Boston, MA.,J. Philip Kistler Stroke Research Center, Department of Neurology, MGH, Boston, MA.,Division of Neurocritical Care and Emergency Neurology, Department of Neurology, MGH, Boston, MA.,Program in Medical and Population Genetics, Broad Institute, Cambridge, MA
| | | |
Collapse
|
16
|
Morotti A, Romero JM, Jessel MJ, Brouwers HB, Gupta R, Schwab K, Vashkevich A, Ayres A, Anderson CD, Gurol ME, Viswanathan A, Greenberg SM, Rosand J, Goldstein JN. Effect of CTA Tube Current on Spot Sign Detection and Accuracy for Prediction of Intracerebral Hemorrhage Expansion. AJNR Am J Neuroradiol 2016; 37:1781-1786. [PMID: 27197985 DOI: 10.3174/ajnr.a4810] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2016] [Accepted: 03/17/2016] [Indexed: 11/07/2022]
Abstract
BACKGROUND AND PURPOSE Reduction of CT tube current is an effective strategy to minimize radiation load. However, tube current is also a major determinant of image quality. We investigated the impact of CTA tube current on spot sign detection and diagnostic performance for intracerebral hemorrhage expansion. MATERIALS AND METHODS We retrospectively analyzed a prospectively collected cohort of consecutive patients with primary intracerebral hemorrhage from January 2001 to April 2015 who underwent CTA. The study population was divided into 2 groups according to the median CTA tube current level: low current (<350 mA) and high current (≥350 mA). CTA first-pass readings for spot sign presence were independently analyzed by 2 readers. Baseline and follow-up hematoma volumes were assessed by semiautomated computer-assisted volumetric analysis. Sensitivity, specificity, positive and negative predictive values, and accuracy of spot sign in predicting hematoma expansion were calculated. RESULTS This study included 709 patients (288 and 421 in the low- and high-current groups, respectively). A higher proportion of low-current scans identified at least 1 spot sign (20.8% versus 14.7%, P = .034), but hematoma expansion frequency was similar in the 2 groups (18.4% versus 16.2%, P = .434). Sensitivity and positive and negative predictive values were not significantly different between the 2 groups. Conversely, high-current scans showed superior specificity (91% versus 84%, P = .015) and overall accuracy (84% versus 77%, P = .038). CONCLUSIONS CTA obtained at high levels of tube current showed better diagnostic accuracy for prediction of hematoma expansion by using spot sign. These findings may have implications for future studies using the CTA spot sign to predict hematoma expansion for clinical trials.
Collapse
Affiliation(s)
- A Morotti
- From the Department of Clinical and Experimental Sciences (A.M.), Neurology Clinic, University of Brescia, Brescia, Italy
- J.P. Kistler Stroke Research Center (A.M., M.J.J., K.S., A. Vashkevich, A.A., C.D.A., M.E.G., A. Viswanathan, S.M.G., J.R., J.N.G.)
| | - J M Romero
- Neuroradiology Service, Department of Radiology (J.M.R., R.G.)
| | - M J Jessel
- J.P. Kistler Stroke Research Center (A.M., M.J.J., K.S., A. Vashkevich, A.A., C.D.A., M.E.G., A. Viswanathan, S.M.G., J.R., J.N.G.)
| | - H B Brouwers
- Department of Neurosurgery (H.B.B.), Brain Center Rudolf Magnus, University Medical Center, Utrecht, the Netherlands
| | - R Gupta
- Neuroradiology Service, Department of Radiology (J.M.R., R.G.)
| | - K Schwab
- J.P. Kistler Stroke Research Center (A.M., M.J.J., K.S., A. Vashkevich, A.A., C.D.A., M.E.G., A. Viswanathan, S.M.G., J.R., J.N.G.)
| | - A Vashkevich
- J.P. Kistler Stroke Research Center (A.M., M.J.J., K.S., A. Vashkevich, A.A., C.D.A., M.E.G., A. Viswanathan, S.M.G., J.R., J.N.G.)
| | - A Ayres
- J.P. Kistler Stroke Research Center (A.M., M.J.J., K.S., A. Vashkevich, A.A., C.D.A., M.E.G., A. Viswanathan, S.M.G., J.R., J.N.G.)
| | - C D Anderson
- J.P. Kistler Stroke Research Center (A.M., M.J.J., K.S., A. Vashkevich, A.A., C.D.A., M.E.G., A. Viswanathan, S.M.G., J.R., J.N.G.)
| | - M E Gurol
- J.P. Kistler Stroke Research Center (A.M., M.J.J., K.S., A. Vashkevich, A.A., C.D.A., M.E.G., A. Viswanathan, S.M.G., J.R., J.N.G.)
| | - A Viswanathan
- J.P. Kistler Stroke Research Center (A.M., M.J.J., K.S., A. Vashkevich, A.A., C.D.A., M.E.G., A. Viswanathan, S.M.G., J.R., J.N.G.)
| | - S M Greenberg
- J.P. Kistler Stroke Research Center (A.M., M.J.J., K.S., A. Vashkevich, A.A., C.D.A., M.E.G., A. Viswanathan, S.M.G., J.R., J.N.G.)
| | - J Rosand
- J.P. Kistler Stroke Research Center (A.M., M.J.J., K.S., A. Vashkevich, A.A., C.D.A., M.E.G., A. Viswanathan, S.M.G., J.R., J.N.G.)
- Division of Neurocritical Care and Emergency Neurology (J.R., J.N.G.)
| | - J N Goldstein
- J.P. Kistler Stroke Research Center (A.M., M.J.J., K.S., A. Vashkevich, A.A., C.D.A., M.E.G., A. Viswanathan, S.M.G., J.R., J.N.G.)
- Division of Neurocritical Care and Emergency Neurology (J.R., J.N.G.)
- Department of Emergency Medicine (J.N.G.), Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| |
Collapse
|
17
|
Boulouis G, Morotti A, Brouwers HB, Charidimou A, Jessel MJ, Auriel E, Pontes-Neto O, Ayres A, Vashkevich A, Schwab KM, Rosand J, Viswanathan A, Gurol ME, Greenberg SM, Goldstein JN. Noncontrast Computed Tomography Hypodensities Predict Poor Outcome in Intracerebral Hemorrhage Patients. Stroke 2016; 47:2511-6. [PMID: 27601380 DOI: 10.1161/strokeaha.116.014425] [Citation(s) in RCA: 61] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2016] [Accepted: 08/02/2016] [Indexed: 11/16/2022]
Abstract
BACKGROUND AND PURPOSE Noncontrast computed tomographic (CT) hypodensities have been shown to be associated with hematoma expansion in intracerebral hemorrhage (ICH), but their impact on functional outcome is yet to be determined. We evaluated whether baseline noncontrast CT hypodensities are associated with poor clinical outcome. METHODS We performed a retrospective review of a prospectively collected cohort of consecutive patients with primary ICH presenting to a single academic medical center between 1994 and 2016. The presence of CT hypodensities was assessed by 2 independent raters on the baseline CT. Unfavorable outcome was defined as a modified Rankin score >3 at 90 days. The associations between CT hypodensities and unfavorable outcome were investigated using uni- and multivariable logistic regression models. RESULTS During the study period, 1342 patients presented with ICH and 800 met restrictive inclusion criteria (baseline CT available for review, and 90-day outcome available). Three hundred and four (38%) patients showed hypodensities on CT, and 520 (65%) patients experienced unfavorable outcome. In univariate analysis, patients with unfavorable outcome were more likely to demonstrate hypodensities (48% versus 20%; P<0.0001). After adjustment for age, admission Glasgow coma scale, warfarin use, intraventricular hemorrhage, baseline ICH volume, and location, CT hypodensities were found to be independently associated with an increase in the odds of unfavorable outcome (odds ratio 1.70, 95% confidence interval [1.10-2.65]; P=0.018). CONCLUSIONS The presence of noncontract CT hypodensities at baseline independently predicts poor outcome and comes as a useful and widely available addition to our ability to predict ICH patients' clinical evolution.
Collapse
Affiliation(s)
- Gregoire Boulouis
- From the Hemorrhagic Stroke Research Program, Department of Neurology, Massachusetts General Hospital Stroke Research Center, Harvard Medical School, Boston (G.B., A.M., H.B.B., A.C., M.J.J., E.A., O.P.-N., A.A., A. Vashkevich, K.M.S., J.R., A. Viswanathan, M.E.G., S.M.G., J.N.G.); Department of Neurosurgery, Brain Center Rudolf Magnus, University Medical Center Utrecht, Utrecht University, The Netherlands (H.B.B.); Stroke Service, Department of Neuroscience and Behavioral Sciences, Ribeirao Pre- to School of Medicine, University of Sao Paulo (O.P.-N.); Division of Neurocritical Care and Emergency Neurology, Massachusetts General Hospital, Harvard Medical School, Boston (J.R., J.N.G.); Department of Emergency Medicine, Massachusetts General Hospital, Boston (J.N.G.).
| | - Andrea Morotti
- From the Hemorrhagic Stroke Research Program, Department of Neurology, Massachusetts General Hospital Stroke Research Center, Harvard Medical School, Boston (G.B., A.M., H.B.B., A.C., M.J.J., E.A., O.P.-N., A.A., A. Vashkevich, K.M.S., J.R., A. Viswanathan, M.E.G., S.M.G., J.N.G.); Department of Neurosurgery, Brain Center Rudolf Magnus, University Medical Center Utrecht, Utrecht University, The Netherlands (H.B.B.); Stroke Service, Department of Neuroscience and Behavioral Sciences, Ribeirao Pre- to School of Medicine, University of Sao Paulo (O.P.-N.); Division of Neurocritical Care and Emergency Neurology, Massachusetts General Hospital, Harvard Medical School, Boston (J.R., J.N.G.); Department of Emergency Medicine, Massachusetts General Hospital, Boston (J.N.G.)
| | - H Bart Brouwers
- From the Hemorrhagic Stroke Research Program, Department of Neurology, Massachusetts General Hospital Stroke Research Center, Harvard Medical School, Boston (G.B., A.M., H.B.B., A.C., M.J.J., E.A., O.P.-N., A.A., A. Vashkevich, K.M.S., J.R., A. Viswanathan, M.E.G., S.M.G., J.N.G.); Department of Neurosurgery, Brain Center Rudolf Magnus, University Medical Center Utrecht, Utrecht University, The Netherlands (H.B.B.); Stroke Service, Department of Neuroscience and Behavioral Sciences, Ribeirao Pre- to School of Medicine, University of Sao Paulo (O.P.-N.); Division of Neurocritical Care and Emergency Neurology, Massachusetts General Hospital, Harvard Medical School, Boston (J.R., J.N.G.); Department of Emergency Medicine, Massachusetts General Hospital, Boston (J.N.G.)
| | - Andreas Charidimou
- From the Hemorrhagic Stroke Research Program, Department of Neurology, Massachusetts General Hospital Stroke Research Center, Harvard Medical School, Boston (G.B., A.M., H.B.B., A.C., M.J.J., E.A., O.P.-N., A.A., A. Vashkevich, K.M.S., J.R., A. Viswanathan, M.E.G., S.M.G., J.N.G.); Department of Neurosurgery, Brain Center Rudolf Magnus, University Medical Center Utrecht, Utrecht University, The Netherlands (H.B.B.); Stroke Service, Department of Neuroscience and Behavioral Sciences, Ribeirao Pre- to School of Medicine, University of Sao Paulo (O.P.-N.); Division of Neurocritical Care and Emergency Neurology, Massachusetts General Hospital, Harvard Medical School, Boston (J.R., J.N.G.); Department of Emergency Medicine, Massachusetts General Hospital, Boston (J.N.G.)
| | - Michael J Jessel
- From the Hemorrhagic Stroke Research Program, Department of Neurology, Massachusetts General Hospital Stroke Research Center, Harvard Medical School, Boston (G.B., A.M., H.B.B., A.C., M.J.J., E.A., O.P.-N., A.A., A. Vashkevich, K.M.S., J.R., A. Viswanathan, M.E.G., S.M.G., J.N.G.); Department of Neurosurgery, Brain Center Rudolf Magnus, University Medical Center Utrecht, Utrecht University, The Netherlands (H.B.B.); Stroke Service, Department of Neuroscience and Behavioral Sciences, Ribeirao Pre- to School of Medicine, University of Sao Paulo (O.P.-N.); Division of Neurocritical Care and Emergency Neurology, Massachusetts General Hospital, Harvard Medical School, Boston (J.R., J.N.G.); Department of Emergency Medicine, Massachusetts General Hospital, Boston (J.N.G.)
| | - Eitan Auriel
- From the Hemorrhagic Stroke Research Program, Department of Neurology, Massachusetts General Hospital Stroke Research Center, Harvard Medical School, Boston (G.B., A.M., H.B.B., A.C., M.J.J., E.A., O.P.-N., A.A., A. Vashkevich, K.M.S., J.R., A. Viswanathan, M.E.G., S.M.G., J.N.G.); Department of Neurosurgery, Brain Center Rudolf Magnus, University Medical Center Utrecht, Utrecht University, The Netherlands (H.B.B.); Stroke Service, Department of Neuroscience and Behavioral Sciences, Ribeirao Pre- to School of Medicine, University of Sao Paulo (O.P.-N.); Division of Neurocritical Care and Emergency Neurology, Massachusetts General Hospital, Harvard Medical School, Boston (J.R., J.N.G.); Department of Emergency Medicine, Massachusetts General Hospital, Boston (J.N.G.)
| | - Octavio Pontes-Neto
- From the Hemorrhagic Stroke Research Program, Department of Neurology, Massachusetts General Hospital Stroke Research Center, Harvard Medical School, Boston (G.B., A.M., H.B.B., A.C., M.J.J., E.A., O.P.-N., A.A., A. Vashkevich, K.M.S., J.R., A. Viswanathan, M.E.G., S.M.G., J.N.G.); Department of Neurosurgery, Brain Center Rudolf Magnus, University Medical Center Utrecht, Utrecht University, The Netherlands (H.B.B.); Stroke Service, Department of Neuroscience and Behavioral Sciences, Ribeirao Pre- to School of Medicine, University of Sao Paulo (O.P.-N.); Division of Neurocritical Care and Emergency Neurology, Massachusetts General Hospital, Harvard Medical School, Boston (J.R., J.N.G.); Department of Emergency Medicine, Massachusetts General Hospital, Boston (J.N.G.)
| | - Alison Ayres
- From the Hemorrhagic Stroke Research Program, Department of Neurology, Massachusetts General Hospital Stroke Research Center, Harvard Medical School, Boston (G.B., A.M., H.B.B., A.C., M.J.J., E.A., O.P.-N., A.A., A. Vashkevich, K.M.S., J.R., A. Viswanathan, M.E.G., S.M.G., J.N.G.); Department of Neurosurgery, Brain Center Rudolf Magnus, University Medical Center Utrecht, Utrecht University, The Netherlands (H.B.B.); Stroke Service, Department of Neuroscience and Behavioral Sciences, Ribeirao Pre- to School of Medicine, University of Sao Paulo (O.P.-N.); Division of Neurocritical Care and Emergency Neurology, Massachusetts General Hospital, Harvard Medical School, Boston (J.R., J.N.G.); Department of Emergency Medicine, Massachusetts General Hospital, Boston (J.N.G.)
| | - Anastasia Vashkevich
- From the Hemorrhagic Stroke Research Program, Department of Neurology, Massachusetts General Hospital Stroke Research Center, Harvard Medical School, Boston (G.B., A.M., H.B.B., A.C., M.J.J., E.A., O.P.-N., A.A., A. Vashkevich, K.M.S., J.R., A. Viswanathan, M.E.G., S.M.G., J.N.G.); Department of Neurosurgery, Brain Center Rudolf Magnus, University Medical Center Utrecht, Utrecht University, The Netherlands (H.B.B.); Stroke Service, Department of Neuroscience and Behavioral Sciences, Ribeirao Pre- to School of Medicine, University of Sao Paulo (O.P.-N.); Division of Neurocritical Care and Emergency Neurology, Massachusetts General Hospital, Harvard Medical School, Boston (J.R., J.N.G.); Department of Emergency Medicine, Massachusetts General Hospital, Boston (J.N.G.)
| | - Kristin M Schwab
- From the Hemorrhagic Stroke Research Program, Department of Neurology, Massachusetts General Hospital Stroke Research Center, Harvard Medical School, Boston (G.B., A.M., H.B.B., A.C., M.J.J., E.A., O.P.-N., A.A., A. Vashkevich, K.M.S., J.R., A. Viswanathan, M.E.G., S.M.G., J.N.G.); Department of Neurosurgery, Brain Center Rudolf Magnus, University Medical Center Utrecht, Utrecht University, The Netherlands (H.B.B.); Stroke Service, Department of Neuroscience and Behavioral Sciences, Ribeirao Pre- to School of Medicine, University of Sao Paulo (O.P.-N.); Division of Neurocritical Care and Emergency Neurology, Massachusetts General Hospital, Harvard Medical School, Boston (J.R., J.N.G.); Department of Emergency Medicine, Massachusetts General Hospital, Boston (J.N.G.)
| | - Jonathan Rosand
- From the Hemorrhagic Stroke Research Program, Department of Neurology, Massachusetts General Hospital Stroke Research Center, Harvard Medical School, Boston (G.B., A.M., H.B.B., A.C., M.J.J., E.A., O.P.-N., A.A., A. Vashkevich, K.M.S., J.R., A. Viswanathan, M.E.G., S.M.G., J.N.G.); Department of Neurosurgery, Brain Center Rudolf Magnus, University Medical Center Utrecht, Utrecht University, The Netherlands (H.B.B.); Stroke Service, Department of Neuroscience and Behavioral Sciences, Ribeirao Pre- to School of Medicine, University of Sao Paulo (O.P.-N.); Division of Neurocritical Care and Emergency Neurology, Massachusetts General Hospital, Harvard Medical School, Boston (J.R., J.N.G.); Department of Emergency Medicine, Massachusetts General Hospital, Boston (J.N.G.)
| | - Anand Viswanathan
- From the Hemorrhagic Stroke Research Program, Department of Neurology, Massachusetts General Hospital Stroke Research Center, Harvard Medical School, Boston (G.B., A.M., H.B.B., A.C., M.J.J., E.A., O.P.-N., A.A., A. Vashkevich, K.M.S., J.R., A. Viswanathan, M.E.G., S.M.G., J.N.G.); Department of Neurosurgery, Brain Center Rudolf Magnus, University Medical Center Utrecht, Utrecht University, The Netherlands (H.B.B.); Stroke Service, Department of Neuroscience and Behavioral Sciences, Ribeirao Pre- to School of Medicine, University of Sao Paulo (O.P.-N.); Division of Neurocritical Care and Emergency Neurology, Massachusetts General Hospital, Harvard Medical School, Boston (J.R., J.N.G.); Department of Emergency Medicine, Massachusetts General Hospital, Boston (J.N.G.)
| | - Mahmut E Gurol
- From the Hemorrhagic Stroke Research Program, Department of Neurology, Massachusetts General Hospital Stroke Research Center, Harvard Medical School, Boston (G.B., A.M., H.B.B., A.C., M.J.J., E.A., O.P.-N., A.A., A. Vashkevich, K.M.S., J.R., A. Viswanathan, M.E.G., S.M.G., J.N.G.); Department of Neurosurgery, Brain Center Rudolf Magnus, University Medical Center Utrecht, Utrecht University, The Netherlands (H.B.B.); Stroke Service, Department of Neuroscience and Behavioral Sciences, Ribeirao Pre- to School of Medicine, University of Sao Paulo (O.P.-N.); Division of Neurocritical Care and Emergency Neurology, Massachusetts General Hospital, Harvard Medical School, Boston (J.R., J.N.G.); Department of Emergency Medicine, Massachusetts General Hospital, Boston (J.N.G.)
| | - Steven M Greenberg
- From the Hemorrhagic Stroke Research Program, Department of Neurology, Massachusetts General Hospital Stroke Research Center, Harvard Medical School, Boston (G.B., A.M., H.B.B., A.C., M.J.J., E.A., O.P.-N., A.A., A. Vashkevich, K.M.S., J.R., A. Viswanathan, M.E.G., S.M.G., J.N.G.); Department of Neurosurgery, Brain Center Rudolf Magnus, University Medical Center Utrecht, Utrecht University, The Netherlands (H.B.B.); Stroke Service, Department of Neuroscience and Behavioral Sciences, Ribeirao Pre- to School of Medicine, University of Sao Paulo (O.P.-N.); Division of Neurocritical Care and Emergency Neurology, Massachusetts General Hospital, Harvard Medical School, Boston (J.R., J.N.G.); Department of Emergency Medicine, Massachusetts General Hospital, Boston (J.N.G.)
| | - Joshua N Goldstein
- From the Hemorrhagic Stroke Research Program, Department of Neurology, Massachusetts General Hospital Stroke Research Center, Harvard Medical School, Boston (G.B., A.M., H.B.B., A.C., M.J.J., E.A., O.P.-N., A.A., A. Vashkevich, K.M.S., J.R., A. Viswanathan, M.E.G., S.M.G., J.N.G.); Department of Neurosurgery, Brain Center Rudolf Magnus, University Medical Center Utrecht, Utrecht University, The Netherlands (H.B.B.); Stroke Service, Department of Neuroscience and Behavioral Sciences, Ribeirao Pre- to School of Medicine, University of Sao Paulo (O.P.-N.); Division of Neurocritical Care and Emergency Neurology, Massachusetts General Hospital, Harvard Medical School, Boston (J.R., J.N.G.); Department of Emergency Medicine, Massachusetts General Hospital, Boston (J.N.G.)
| |
Collapse
|
18
|
Dowlatshahi D, Brouwers HB, Demchuk AM, Hill MD, Aviv RI, Ufholz LA, Reaume M, Wintermark M, Hemphill JC, Murai Y, Wang Y, Zhao X, Wang Y, Li N, Sorimachi T, Matsumae M, Steiner T, Rizos T, Greenberg SM, Romero JM, Rosand J, Goldstein JN, Sharma M. Predicting Intracerebral Hemorrhage Growth With the Spot Sign: The Effect of Onset-to-Scan Time. Stroke 2016; 47:695-700. [PMID: 26846857 DOI: 10.1161/strokeaha.115.012012] [Citation(s) in RCA: 74] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2015] [Accepted: 01/06/2016] [Indexed: 01/01/2023]
Abstract
BACKGROUND AND PURPOSE Hematoma expansion after acute intracerebral hemorrhage is common and is associated with early deterioration and poor clinical outcome. The computed tomographic angiography (CTA) spot sign is a promising predictor of expansion; however, frequency and predictive values are variable across studies, possibly because of differences in onset-to-CTA time. We performed a patient-level meta-analysis to define the relationship between onset-to-CTA time and frequency and predictive ability of the spot sign. METHODS We completed a systematic review for studies of CTA spot sign and hematoma expansion. We subsequently pooled patient-level data on the frequency and predictive values for significant hematoma expansion according to 5 predefined categorized onset-to-CTA times. We calculated spot-sign frequency both as raw and frequency-adjusted rates. RESULTS Among 2051 studies identified, 12 met our inclusion criteria. Baseline hematoma volume, spot-sign status, and time-to-CTA were available for 1176 patients, and 1039 patients had follow-up computed tomographies for hematoma expansion analysis. The overall spot sign frequency was 26%, decreasing from 39% within 2 hours of onset to 13% beyond 8 hours (P<0.001). There was a significant decrease in hematoma expansion in spot-positive patients as onset-to-CTA time increased (P=0.004), with positive predictive values decreasing from 53% to 33%. CONCLUSIONS The frequency of the CTA spot sign is inversely related to intracerebral hemorrhage onset-to-CTA time. Furthermore, the positive predictive value of the spot sign for significant hematoma expansion decreases as time-to-CTA increases. Our results offer more precise risk stratification for patients with acute intracerebral hemorrhage and will help refine clinical prediction rules for intracerebral hemorrhage expansion.
Collapse
Affiliation(s)
- Dar Dowlatshahi
- From the Department of Medicine, University of Ottawa and Ottawa Hospital Research Institute, Ottawa, Ontario, Canada (D.D., M.R.); Departments of Neurology (H.B.B., S.M.G., J.R.), Radiology (J.M.R.) and Emergency Medicine (J.N.G.), Massachusetts General Hospital and Harvard Medical School, Boston; Department of Neurosurgery, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands (H.B.B.); Department of Clinical Neurosciences, Hotchkiss Brain Institute and Calgary Stroke Program, University of Calgary, Calgary, Alberta, Canada (A.M.D., M.D.H.); Department of Medical Imaging, Sunnybrook Health Sciences Center, University of Toronto, Toronto, ON, Canada (R.I.A.); Health Sciences Library, University of Ottawa, Ottawa, Ontario, Canada (L.-A.U.); Department of Radiology, Neuroradiology Division, Stanford University, Stanford, CA (M.W.); Department of Neurology, University of California, San Francisco (J.C.H.); Department of Neurological Surgery, Nippon Medical School, Tokyo, Japan (Y.M.); Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China (Yongjun Wang, X.Z., Yilong Wang, N.L.); Department of Neurosurgery, Tokai University, Japan (T. Sorimachi, M.M.); Department of Neurology, University of Heidelberg, Germany (T. Steiner, T.R.); Klinikum Frankfurt Höchst, Germany (T. Steiner); and Department of Medicine, McMaster University, Population Health Research Institute, Hamilton, Ontario, Canada (M.S.).
| | - H Bart Brouwers
- From the Department of Medicine, University of Ottawa and Ottawa Hospital Research Institute, Ottawa, Ontario, Canada (D.D., M.R.); Departments of Neurology (H.B.B., S.M.G., J.R.), Radiology (J.M.R.) and Emergency Medicine (J.N.G.), Massachusetts General Hospital and Harvard Medical School, Boston; Department of Neurosurgery, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands (H.B.B.); Department of Clinical Neurosciences, Hotchkiss Brain Institute and Calgary Stroke Program, University of Calgary, Calgary, Alberta, Canada (A.M.D., M.D.H.); Department of Medical Imaging, Sunnybrook Health Sciences Center, University of Toronto, Toronto, ON, Canada (R.I.A.); Health Sciences Library, University of Ottawa, Ottawa, Ontario, Canada (L.-A.U.); Department of Radiology, Neuroradiology Division, Stanford University, Stanford, CA (M.W.); Department of Neurology, University of California, San Francisco (J.C.H.); Department of Neurological Surgery, Nippon Medical School, Tokyo, Japan (Y.M.); Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China (Yongjun Wang, X.Z., Yilong Wang, N.L.); Department of Neurosurgery, Tokai University, Japan (T. Sorimachi, M.M.); Department of Neurology, University of Heidelberg, Germany (T. Steiner, T.R.); Klinikum Frankfurt Höchst, Germany (T. Steiner); and Department of Medicine, McMaster University, Population Health Research Institute, Hamilton, Ontario, Canada (M.S.)
| | - Andrew M Demchuk
- From the Department of Medicine, University of Ottawa and Ottawa Hospital Research Institute, Ottawa, Ontario, Canada (D.D., M.R.); Departments of Neurology (H.B.B., S.M.G., J.R.), Radiology (J.M.R.) and Emergency Medicine (J.N.G.), Massachusetts General Hospital and Harvard Medical School, Boston; Department of Neurosurgery, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands (H.B.B.); Department of Clinical Neurosciences, Hotchkiss Brain Institute and Calgary Stroke Program, University of Calgary, Calgary, Alberta, Canada (A.M.D., M.D.H.); Department of Medical Imaging, Sunnybrook Health Sciences Center, University of Toronto, Toronto, ON, Canada (R.I.A.); Health Sciences Library, University of Ottawa, Ottawa, Ontario, Canada (L.-A.U.); Department of Radiology, Neuroradiology Division, Stanford University, Stanford, CA (M.W.); Department of Neurology, University of California, San Francisco (J.C.H.); Department of Neurological Surgery, Nippon Medical School, Tokyo, Japan (Y.M.); Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China (Yongjun Wang, X.Z., Yilong Wang, N.L.); Department of Neurosurgery, Tokai University, Japan (T. Sorimachi, M.M.); Department of Neurology, University of Heidelberg, Germany (T. Steiner, T.R.); Klinikum Frankfurt Höchst, Germany (T. Steiner); and Department of Medicine, McMaster University, Population Health Research Institute, Hamilton, Ontario, Canada (M.S.)
| | - Michael D Hill
- From the Department of Medicine, University of Ottawa and Ottawa Hospital Research Institute, Ottawa, Ontario, Canada (D.D., M.R.); Departments of Neurology (H.B.B., S.M.G., J.R.), Radiology (J.M.R.) and Emergency Medicine (J.N.G.), Massachusetts General Hospital and Harvard Medical School, Boston; Department of Neurosurgery, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands (H.B.B.); Department of Clinical Neurosciences, Hotchkiss Brain Institute and Calgary Stroke Program, University of Calgary, Calgary, Alberta, Canada (A.M.D., M.D.H.); Department of Medical Imaging, Sunnybrook Health Sciences Center, University of Toronto, Toronto, ON, Canada (R.I.A.); Health Sciences Library, University of Ottawa, Ottawa, Ontario, Canada (L.-A.U.); Department of Radiology, Neuroradiology Division, Stanford University, Stanford, CA (M.W.); Department of Neurology, University of California, San Francisco (J.C.H.); Department of Neurological Surgery, Nippon Medical School, Tokyo, Japan (Y.M.); Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China (Yongjun Wang, X.Z., Yilong Wang, N.L.); Department of Neurosurgery, Tokai University, Japan (T. Sorimachi, M.M.); Department of Neurology, University of Heidelberg, Germany (T. Steiner, T.R.); Klinikum Frankfurt Höchst, Germany (T. Steiner); and Department of Medicine, McMaster University, Population Health Research Institute, Hamilton, Ontario, Canada (M.S.)
| | - Richard I Aviv
- From the Department of Medicine, University of Ottawa and Ottawa Hospital Research Institute, Ottawa, Ontario, Canada (D.D., M.R.); Departments of Neurology (H.B.B., S.M.G., J.R.), Radiology (J.M.R.) and Emergency Medicine (J.N.G.), Massachusetts General Hospital and Harvard Medical School, Boston; Department of Neurosurgery, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands (H.B.B.); Department of Clinical Neurosciences, Hotchkiss Brain Institute and Calgary Stroke Program, University of Calgary, Calgary, Alberta, Canada (A.M.D., M.D.H.); Department of Medical Imaging, Sunnybrook Health Sciences Center, University of Toronto, Toronto, ON, Canada (R.I.A.); Health Sciences Library, University of Ottawa, Ottawa, Ontario, Canada (L.-A.U.); Department of Radiology, Neuroradiology Division, Stanford University, Stanford, CA (M.W.); Department of Neurology, University of California, San Francisco (J.C.H.); Department of Neurological Surgery, Nippon Medical School, Tokyo, Japan (Y.M.); Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China (Yongjun Wang, X.Z., Yilong Wang, N.L.); Department of Neurosurgery, Tokai University, Japan (T. Sorimachi, M.M.); Department of Neurology, University of Heidelberg, Germany (T. Steiner, T.R.); Klinikum Frankfurt Höchst, Germany (T. Steiner); and Department of Medicine, McMaster University, Population Health Research Institute, Hamilton, Ontario, Canada (M.S.)
| | - Lee-Anne Ufholz
- From the Department of Medicine, University of Ottawa and Ottawa Hospital Research Institute, Ottawa, Ontario, Canada (D.D., M.R.); Departments of Neurology (H.B.B., S.M.G., J.R.), Radiology (J.M.R.) and Emergency Medicine (J.N.G.), Massachusetts General Hospital and Harvard Medical School, Boston; Department of Neurosurgery, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands (H.B.B.); Department of Clinical Neurosciences, Hotchkiss Brain Institute and Calgary Stroke Program, University of Calgary, Calgary, Alberta, Canada (A.M.D., M.D.H.); Department of Medical Imaging, Sunnybrook Health Sciences Center, University of Toronto, Toronto, ON, Canada (R.I.A.); Health Sciences Library, University of Ottawa, Ottawa, Ontario, Canada (L.-A.U.); Department of Radiology, Neuroradiology Division, Stanford University, Stanford, CA (M.W.); Department of Neurology, University of California, San Francisco (J.C.H.); Department of Neurological Surgery, Nippon Medical School, Tokyo, Japan (Y.M.); Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China (Yongjun Wang, X.Z., Yilong Wang, N.L.); Department of Neurosurgery, Tokai University, Japan (T. Sorimachi, M.M.); Department of Neurology, University of Heidelberg, Germany (T. Steiner, T.R.); Klinikum Frankfurt Höchst, Germany (T. Steiner); and Department of Medicine, McMaster University, Population Health Research Institute, Hamilton, Ontario, Canada (M.S.)
| | - Michael Reaume
- From the Department of Medicine, University of Ottawa and Ottawa Hospital Research Institute, Ottawa, Ontario, Canada (D.D., M.R.); Departments of Neurology (H.B.B., S.M.G., J.R.), Radiology (J.M.R.) and Emergency Medicine (J.N.G.), Massachusetts General Hospital and Harvard Medical School, Boston; Department of Neurosurgery, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands (H.B.B.); Department of Clinical Neurosciences, Hotchkiss Brain Institute and Calgary Stroke Program, University of Calgary, Calgary, Alberta, Canada (A.M.D., M.D.H.); Department of Medical Imaging, Sunnybrook Health Sciences Center, University of Toronto, Toronto, ON, Canada (R.I.A.); Health Sciences Library, University of Ottawa, Ottawa, Ontario, Canada (L.-A.U.); Department of Radiology, Neuroradiology Division, Stanford University, Stanford, CA (M.W.); Department of Neurology, University of California, San Francisco (J.C.H.); Department of Neurological Surgery, Nippon Medical School, Tokyo, Japan (Y.M.); Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China (Yongjun Wang, X.Z., Yilong Wang, N.L.); Department of Neurosurgery, Tokai University, Japan (T. Sorimachi, M.M.); Department of Neurology, University of Heidelberg, Germany (T. Steiner, T.R.); Klinikum Frankfurt Höchst, Germany (T. Steiner); and Department of Medicine, McMaster University, Population Health Research Institute, Hamilton, Ontario, Canada (M.S.)
| | - Max Wintermark
- From the Department of Medicine, University of Ottawa and Ottawa Hospital Research Institute, Ottawa, Ontario, Canada (D.D., M.R.); Departments of Neurology (H.B.B., S.M.G., J.R.), Radiology (J.M.R.) and Emergency Medicine (J.N.G.), Massachusetts General Hospital and Harvard Medical School, Boston; Department of Neurosurgery, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands (H.B.B.); Department of Clinical Neurosciences, Hotchkiss Brain Institute and Calgary Stroke Program, University of Calgary, Calgary, Alberta, Canada (A.M.D., M.D.H.); Department of Medical Imaging, Sunnybrook Health Sciences Center, University of Toronto, Toronto, ON, Canada (R.I.A.); Health Sciences Library, University of Ottawa, Ottawa, Ontario, Canada (L.-A.U.); Department of Radiology, Neuroradiology Division, Stanford University, Stanford, CA (M.W.); Department of Neurology, University of California, San Francisco (J.C.H.); Department of Neurological Surgery, Nippon Medical School, Tokyo, Japan (Y.M.); Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China (Yongjun Wang, X.Z., Yilong Wang, N.L.); Department of Neurosurgery, Tokai University, Japan (T. Sorimachi, M.M.); Department of Neurology, University of Heidelberg, Germany (T. Steiner, T.R.); Klinikum Frankfurt Höchst, Germany (T. Steiner); and Department of Medicine, McMaster University, Population Health Research Institute, Hamilton, Ontario, Canada (M.S.)
| | - J Claude Hemphill
- From the Department of Medicine, University of Ottawa and Ottawa Hospital Research Institute, Ottawa, Ontario, Canada (D.D., M.R.); Departments of Neurology (H.B.B., S.M.G., J.R.), Radiology (J.M.R.) and Emergency Medicine (J.N.G.), Massachusetts General Hospital and Harvard Medical School, Boston; Department of Neurosurgery, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands (H.B.B.); Department of Clinical Neurosciences, Hotchkiss Brain Institute and Calgary Stroke Program, University of Calgary, Calgary, Alberta, Canada (A.M.D., M.D.H.); Department of Medical Imaging, Sunnybrook Health Sciences Center, University of Toronto, Toronto, ON, Canada (R.I.A.); Health Sciences Library, University of Ottawa, Ottawa, Ontario, Canada (L.-A.U.); Department of Radiology, Neuroradiology Division, Stanford University, Stanford, CA (M.W.); Department of Neurology, University of California, San Francisco (J.C.H.); Department of Neurological Surgery, Nippon Medical School, Tokyo, Japan (Y.M.); Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China (Yongjun Wang, X.Z., Yilong Wang, N.L.); Department of Neurosurgery, Tokai University, Japan (T. Sorimachi, M.M.); Department of Neurology, University of Heidelberg, Germany (T. Steiner, T.R.); Klinikum Frankfurt Höchst, Germany (T. Steiner); and Department of Medicine, McMaster University, Population Health Research Institute, Hamilton, Ontario, Canada (M.S.)
| | - Yasuo Murai
- From the Department of Medicine, University of Ottawa and Ottawa Hospital Research Institute, Ottawa, Ontario, Canada (D.D., M.R.); Departments of Neurology (H.B.B., S.M.G., J.R.), Radiology (J.M.R.) and Emergency Medicine (J.N.G.), Massachusetts General Hospital and Harvard Medical School, Boston; Department of Neurosurgery, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands (H.B.B.); Department of Clinical Neurosciences, Hotchkiss Brain Institute and Calgary Stroke Program, University of Calgary, Calgary, Alberta, Canada (A.M.D., M.D.H.); Department of Medical Imaging, Sunnybrook Health Sciences Center, University of Toronto, Toronto, ON, Canada (R.I.A.); Health Sciences Library, University of Ottawa, Ottawa, Ontario, Canada (L.-A.U.); Department of Radiology, Neuroradiology Division, Stanford University, Stanford, CA (M.W.); Department of Neurology, University of California, San Francisco (J.C.H.); Department of Neurological Surgery, Nippon Medical School, Tokyo, Japan (Y.M.); Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China (Yongjun Wang, X.Z., Yilong Wang, N.L.); Department of Neurosurgery, Tokai University, Japan (T. Sorimachi, M.M.); Department of Neurology, University of Heidelberg, Germany (T. Steiner, T.R.); Klinikum Frankfurt Höchst, Germany (T. Steiner); and Department of Medicine, McMaster University, Population Health Research Institute, Hamilton, Ontario, Canada (M.S.)
| | - Yongjun Wang
- From the Department of Medicine, University of Ottawa and Ottawa Hospital Research Institute, Ottawa, Ontario, Canada (D.D., M.R.); Departments of Neurology (H.B.B., S.M.G., J.R.), Radiology (J.M.R.) and Emergency Medicine (J.N.G.), Massachusetts General Hospital and Harvard Medical School, Boston; Department of Neurosurgery, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands (H.B.B.); Department of Clinical Neurosciences, Hotchkiss Brain Institute and Calgary Stroke Program, University of Calgary, Calgary, Alberta, Canada (A.M.D., M.D.H.); Department of Medical Imaging, Sunnybrook Health Sciences Center, University of Toronto, Toronto, ON, Canada (R.I.A.); Health Sciences Library, University of Ottawa, Ottawa, Ontario, Canada (L.-A.U.); Department of Radiology, Neuroradiology Division, Stanford University, Stanford, CA (M.W.); Department of Neurology, University of California, San Francisco (J.C.H.); Department of Neurological Surgery, Nippon Medical School, Tokyo, Japan (Y.M.); Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China (Yongjun Wang, X.Z., Yilong Wang, N.L.); Department of Neurosurgery, Tokai University, Japan (T. Sorimachi, M.M.); Department of Neurology, University of Heidelberg, Germany (T. Steiner, T.R.); Klinikum Frankfurt Höchst, Germany (T. Steiner); and Department of Medicine, McMaster University, Population Health Research Institute, Hamilton, Ontario, Canada (M.S.)
| | - Xingquan Zhao
- From the Department of Medicine, University of Ottawa and Ottawa Hospital Research Institute, Ottawa, Ontario, Canada (D.D., M.R.); Departments of Neurology (H.B.B., S.M.G., J.R.), Radiology (J.M.R.) and Emergency Medicine (J.N.G.), Massachusetts General Hospital and Harvard Medical School, Boston; Department of Neurosurgery, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands (H.B.B.); Department of Clinical Neurosciences, Hotchkiss Brain Institute and Calgary Stroke Program, University of Calgary, Calgary, Alberta, Canada (A.M.D., M.D.H.); Department of Medical Imaging, Sunnybrook Health Sciences Center, University of Toronto, Toronto, ON, Canada (R.I.A.); Health Sciences Library, University of Ottawa, Ottawa, Ontario, Canada (L.-A.U.); Department of Radiology, Neuroradiology Division, Stanford University, Stanford, CA (M.W.); Department of Neurology, University of California, San Francisco (J.C.H.); Department of Neurological Surgery, Nippon Medical School, Tokyo, Japan (Y.M.); Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China (Yongjun Wang, X.Z., Yilong Wang, N.L.); Department of Neurosurgery, Tokai University, Japan (T. Sorimachi, M.M.); Department of Neurology, University of Heidelberg, Germany (T. Steiner, T.R.); Klinikum Frankfurt Höchst, Germany (T. Steiner); and Department of Medicine, McMaster University, Population Health Research Institute, Hamilton, Ontario, Canada (M.S.)
| | - Yilong Wang
- From the Department of Medicine, University of Ottawa and Ottawa Hospital Research Institute, Ottawa, Ontario, Canada (D.D., M.R.); Departments of Neurology (H.B.B., S.M.G., J.R.), Radiology (J.M.R.) and Emergency Medicine (J.N.G.), Massachusetts General Hospital and Harvard Medical School, Boston; Department of Neurosurgery, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands (H.B.B.); Department of Clinical Neurosciences, Hotchkiss Brain Institute and Calgary Stroke Program, University of Calgary, Calgary, Alberta, Canada (A.M.D., M.D.H.); Department of Medical Imaging, Sunnybrook Health Sciences Center, University of Toronto, Toronto, ON, Canada (R.I.A.); Health Sciences Library, University of Ottawa, Ottawa, Ontario, Canada (L.-A.U.); Department of Radiology, Neuroradiology Division, Stanford University, Stanford, CA (M.W.); Department of Neurology, University of California, San Francisco (J.C.H.); Department of Neurological Surgery, Nippon Medical School, Tokyo, Japan (Y.M.); Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China (Yongjun Wang, X.Z., Yilong Wang, N.L.); Department of Neurosurgery, Tokai University, Japan (T. Sorimachi, M.M.); Department of Neurology, University of Heidelberg, Germany (T. Steiner, T.R.); Klinikum Frankfurt Höchst, Germany (T. Steiner); and Department of Medicine, McMaster University, Population Health Research Institute, Hamilton, Ontario, Canada (M.S.)
| | - Na Li
- From the Department of Medicine, University of Ottawa and Ottawa Hospital Research Institute, Ottawa, Ontario, Canada (D.D., M.R.); Departments of Neurology (H.B.B., S.M.G., J.R.), Radiology (J.M.R.) and Emergency Medicine (J.N.G.), Massachusetts General Hospital and Harvard Medical School, Boston; Department of Neurosurgery, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands (H.B.B.); Department of Clinical Neurosciences, Hotchkiss Brain Institute and Calgary Stroke Program, University of Calgary, Calgary, Alberta, Canada (A.M.D., M.D.H.); Department of Medical Imaging, Sunnybrook Health Sciences Center, University of Toronto, Toronto, ON, Canada (R.I.A.); Health Sciences Library, University of Ottawa, Ottawa, Ontario, Canada (L.-A.U.); Department of Radiology, Neuroradiology Division, Stanford University, Stanford, CA (M.W.); Department of Neurology, University of California, San Francisco (J.C.H.); Department of Neurological Surgery, Nippon Medical School, Tokyo, Japan (Y.M.); Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China (Yongjun Wang, X.Z., Yilong Wang, N.L.); Department of Neurosurgery, Tokai University, Japan (T. Sorimachi, M.M.); Department of Neurology, University of Heidelberg, Germany (T. Steiner, T.R.); Klinikum Frankfurt Höchst, Germany (T. Steiner); and Department of Medicine, McMaster University, Population Health Research Institute, Hamilton, Ontario, Canada (M.S.)
| | - Takatoshi Sorimachi
- From the Department of Medicine, University of Ottawa and Ottawa Hospital Research Institute, Ottawa, Ontario, Canada (D.D., M.R.); Departments of Neurology (H.B.B., S.M.G., J.R.), Radiology (J.M.R.) and Emergency Medicine (J.N.G.), Massachusetts General Hospital and Harvard Medical School, Boston; Department of Neurosurgery, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands (H.B.B.); Department of Clinical Neurosciences, Hotchkiss Brain Institute and Calgary Stroke Program, University of Calgary, Calgary, Alberta, Canada (A.M.D., M.D.H.); Department of Medical Imaging, Sunnybrook Health Sciences Center, University of Toronto, Toronto, ON, Canada (R.I.A.); Health Sciences Library, University of Ottawa, Ottawa, Ontario, Canada (L.-A.U.); Department of Radiology, Neuroradiology Division, Stanford University, Stanford, CA (M.W.); Department of Neurology, University of California, San Francisco (J.C.H.); Department of Neurological Surgery, Nippon Medical School, Tokyo, Japan (Y.M.); Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China (Yongjun Wang, X.Z., Yilong Wang, N.L.); Department of Neurosurgery, Tokai University, Japan (T. Sorimachi, M.M.); Department of Neurology, University of Heidelberg, Germany (T. Steiner, T.R.); Klinikum Frankfurt Höchst, Germany (T. Steiner); and Department of Medicine, McMaster University, Population Health Research Institute, Hamilton, Ontario, Canada (M.S.)
| | - Mitsunori Matsumae
- From the Department of Medicine, University of Ottawa and Ottawa Hospital Research Institute, Ottawa, Ontario, Canada (D.D., M.R.); Departments of Neurology (H.B.B., S.M.G., J.R.), Radiology (J.M.R.) and Emergency Medicine (J.N.G.), Massachusetts General Hospital and Harvard Medical School, Boston; Department of Neurosurgery, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands (H.B.B.); Department of Clinical Neurosciences, Hotchkiss Brain Institute and Calgary Stroke Program, University of Calgary, Calgary, Alberta, Canada (A.M.D., M.D.H.); Department of Medical Imaging, Sunnybrook Health Sciences Center, University of Toronto, Toronto, ON, Canada (R.I.A.); Health Sciences Library, University of Ottawa, Ottawa, Ontario, Canada (L.-A.U.); Department of Radiology, Neuroradiology Division, Stanford University, Stanford, CA (M.W.); Department of Neurology, University of California, San Francisco (J.C.H.); Department of Neurological Surgery, Nippon Medical School, Tokyo, Japan (Y.M.); Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China (Yongjun Wang, X.Z., Yilong Wang, N.L.); Department of Neurosurgery, Tokai University, Japan (T. Sorimachi, M.M.); Department of Neurology, University of Heidelberg, Germany (T. Steiner, T.R.); Klinikum Frankfurt Höchst, Germany (T. Steiner); and Department of Medicine, McMaster University, Population Health Research Institute, Hamilton, Ontario, Canada (M.S.)
| | - Thorsten Steiner
- From the Department of Medicine, University of Ottawa and Ottawa Hospital Research Institute, Ottawa, Ontario, Canada (D.D., M.R.); Departments of Neurology (H.B.B., S.M.G., J.R.), Radiology (J.M.R.) and Emergency Medicine (J.N.G.), Massachusetts General Hospital and Harvard Medical School, Boston; Department of Neurosurgery, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands (H.B.B.); Department of Clinical Neurosciences, Hotchkiss Brain Institute and Calgary Stroke Program, University of Calgary, Calgary, Alberta, Canada (A.M.D., M.D.H.); Department of Medical Imaging, Sunnybrook Health Sciences Center, University of Toronto, Toronto, ON, Canada (R.I.A.); Health Sciences Library, University of Ottawa, Ottawa, Ontario, Canada (L.-A.U.); Department of Radiology, Neuroradiology Division, Stanford University, Stanford, CA (M.W.); Department of Neurology, University of California, San Francisco (J.C.H.); Department of Neurological Surgery, Nippon Medical School, Tokyo, Japan (Y.M.); Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China (Yongjun Wang, X.Z., Yilong Wang, N.L.); Department of Neurosurgery, Tokai University, Japan (T. Sorimachi, M.M.); Department of Neurology, University of Heidelberg, Germany (T. Steiner, T.R.); Klinikum Frankfurt Höchst, Germany (T. Steiner); and Department of Medicine, McMaster University, Population Health Research Institute, Hamilton, Ontario, Canada (M.S.)
| | - Timolaos Rizos
- From the Department of Medicine, University of Ottawa and Ottawa Hospital Research Institute, Ottawa, Ontario, Canada (D.D., M.R.); Departments of Neurology (H.B.B., S.M.G., J.R.), Radiology (J.M.R.) and Emergency Medicine (J.N.G.), Massachusetts General Hospital and Harvard Medical School, Boston; Department of Neurosurgery, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands (H.B.B.); Department of Clinical Neurosciences, Hotchkiss Brain Institute and Calgary Stroke Program, University of Calgary, Calgary, Alberta, Canada (A.M.D., M.D.H.); Department of Medical Imaging, Sunnybrook Health Sciences Center, University of Toronto, Toronto, ON, Canada (R.I.A.); Health Sciences Library, University of Ottawa, Ottawa, Ontario, Canada (L.-A.U.); Department of Radiology, Neuroradiology Division, Stanford University, Stanford, CA (M.W.); Department of Neurology, University of California, San Francisco (J.C.H.); Department of Neurological Surgery, Nippon Medical School, Tokyo, Japan (Y.M.); Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China (Yongjun Wang, X.Z., Yilong Wang, N.L.); Department of Neurosurgery, Tokai University, Japan (T. Sorimachi, M.M.); Department of Neurology, University of Heidelberg, Germany (T. Steiner, T.R.); Klinikum Frankfurt Höchst, Germany (T. Steiner); and Department of Medicine, McMaster University, Population Health Research Institute, Hamilton, Ontario, Canada (M.S.)
| | - Steven M Greenberg
- From the Department of Medicine, University of Ottawa and Ottawa Hospital Research Institute, Ottawa, Ontario, Canada (D.D., M.R.); Departments of Neurology (H.B.B., S.M.G., J.R.), Radiology (J.M.R.) and Emergency Medicine (J.N.G.), Massachusetts General Hospital and Harvard Medical School, Boston; Department of Neurosurgery, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands (H.B.B.); Department of Clinical Neurosciences, Hotchkiss Brain Institute and Calgary Stroke Program, University of Calgary, Calgary, Alberta, Canada (A.M.D., M.D.H.); Department of Medical Imaging, Sunnybrook Health Sciences Center, University of Toronto, Toronto, ON, Canada (R.I.A.); Health Sciences Library, University of Ottawa, Ottawa, Ontario, Canada (L.-A.U.); Department of Radiology, Neuroradiology Division, Stanford University, Stanford, CA (M.W.); Department of Neurology, University of California, San Francisco (J.C.H.); Department of Neurological Surgery, Nippon Medical School, Tokyo, Japan (Y.M.); Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China (Yongjun Wang, X.Z., Yilong Wang, N.L.); Department of Neurosurgery, Tokai University, Japan (T. Sorimachi, M.M.); Department of Neurology, University of Heidelberg, Germany (T. Steiner, T.R.); Klinikum Frankfurt Höchst, Germany (T. Steiner); and Department of Medicine, McMaster University, Population Health Research Institute, Hamilton, Ontario, Canada (M.S.)
| | - Javier M Romero
- From the Department of Medicine, University of Ottawa and Ottawa Hospital Research Institute, Ottawa, Ontario, Canada (D.D., M.R.); Departments of Neurology (H.B.B., S.M.G., J.R.), Radiology (J.M.R.) and Emergency Medicine (J.N.G.), Massachusetts General Hospital and Harvard Medical School, Boston; Department of Neurosurgery, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands (H.B.B.); Department of Clinical Neurosciences, Hotchkiss Brain Institute and Calgary Stroke Program, University of Calgary, Calgary, Alberta, Canada (A.M.D., M.D.H.); Department of Medical Imaging, Sunnybrook Health Sciences Center, University of Toronto, Toronto, ON, Canada (R.I.A.); Health Sciences Library, University of Ottawa, Ottawa, Ontario, Canada (L.-A.U.); Department of Radiology, Neuroradiology Division, Stanford University, Stanford, CA (M.W.); Department of Neurology, University of California, San Francisco (J.C.H.); Department of Neurological Surgery, Nippon Medical School, Tokyo, Japan (Y.M.); Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China (Yongjun Wang, X.Z., Yilong Wang, N.L.); Department of Neurosurgery, Tokai University, Japan (T. Sorimachi, M.M.); Department of Neurology, University of Heidelberg, Germany (T. Steiner, T.R.); Klinikum Frankfurt Höchst, Germany (T. Steiner); and Department of Medicine, McMaster University, Population Health Research Institute, Hamilton, Ontario, Canada (M.S.)
| | - Jonathan Rosand
- From the Department of Medicine, University of Ottawa and Ottawa Hospital Research Institute, Ottawa, Ontario, Canada (D.D., M.R.); Departments of Neurology (H.B.B., S.M.G., J.R.), Radiology (J.M.R.) and Emergency Medicine (J.N.G.), Massachusetts General Hospital and Harvard Medical School, Boston; Department of Neurosurgery, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands (H.B.B.); Department of Clinical Neurosciences, Hotchkiss Brain Institute and Calgary Stroke Program, University of Calgary, Calgary, Alberta, Canada (A.M.D., M.D.H.); Department of Medical Imaging, Sunnybrook Health Sciences Center, University of Toronto, Toronto, ON, Canada (R.I.A.); Health Sciences Library, University of Ottawa, Ottawa, Ontario, Canada (L.-A.U.); Department of Radiology, Neuroradiology Division, Stanford University, Stanford, CA (M.W.); Department of Neurology, University of California, San Francisco (J.C.H.); Department of Neurological Surgery, Nippon Medical School, Tokyo, Japan (Y.M.); Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China (Yongjun Wang, X.Z., Yilong Wang, N.L.); Department of Neurosurgery, Tokai University, Japan (T. Sorimachi, M.M.); Department of Neurology, University of Heidelberg, Germany (T. Steiner, T.R.); Klinikum Frankfurt Höchst, Germany (T. Steiner); and Department of Medicine, McMaster University, Population Health Research Institute, Hamilton, Ontario, Canada (M.S.)
| | - Joshua N Goldstein
- From the Department of Medicine, University of Ottawa and Ottawa Hospital Research Institute, Ottawa, Ontario, Canada (D.D., M.R.); Departments of Neurology (H.B.B., S.M.G., J.R.), Radiology (J.M.R.) and Emergency Medicine (J.N.G.), Massachusetts General Hospital and Harvard Medical School, Boston; Department of Neurosurgery, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands (H.B.B.); Department of Clinical Neurosciences, Hotchkiss Brain Institute and Calgary Stroke Program, University of Calgary, Calgary, Alberta, Canada (A.M.D., M.D.H.); Department of Medical Imaging, Sunnybrook Health Sciences Center, University of Toronto, Toronto, ON, Canada (R.I.A.); Health Sciences Library, University of Ottawa, Ottawa, Ontario, Canada (L.-A.U.); Department of Radiology, Neuroradiology Division, Stanford University, Stanford, CA (M.W.); Department of Neurology, University of California, San Francisco (J.C.H.); Department of Neurological Surgery, Nippon Medical School, Tokyo, Japan (Y.M.); Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China (Yongjun Wang, X.Z., Yilong Wang, N.L.); Department of Neurosurgery, Tokai University, Japan (T. Sorimachi, M.M.); Department of Neurology, University of Heidelberg, Germany (T. Steiner, T.R.); Klinikum Frankfurt Höchst, Germany (T. Steiner); and Department of Medicine, McMaster University, Population Health Research Institute, Hamilton, Ontario, Canada (M.S.)
| | - Mukul Sharma
- From the Department of Medicine, University of Ottawa and Ottawa Hospital Research Institute, Ottawa, Ontario, Canada (D.D., M.R.); Departments of Neurology (H.B.B., S.M.G., J.R.), Radiology (J.M.R.) and Emergency Medicine (J.N.G.), Massachusetts General Hospital and Harvard Medical School, Boston; Department of Neurosurgery, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands (H.B.B.); Department of Clinical Neurosciences, Hotchkiss Brain Institute and Calgary Stroke Program, University of Calgary, Calgary, Alberta, Canada (A.M.D., M.D.H.); Department of Medical Imaging, Sunnybrook Health Sciences Center, University of Toronto, Toronto, ON, Canada (R.I.A.); Health Sciences Library, University of Ottawa, Ottawa, Ontario, Canada (L.-A.U.); Department of Radiology, Neuroradiology Division, Stanford University, Stanford, CA (M.W.); Department of Neurology, University of California, San Francisco (J.C.H.); Department of Neurological Surgery, Nippon Medical School, Tokyo, Japan (Y.M.); Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China (Yongjun Wang, X.Z., Yilong Wang, N.L.); Department of Neurosurgery, Tokai University, Japan (T. Sorimachi, M.M.); Department of Neurology, University of Heidelberg, Germany (T. Steiner, T.R.); Klinikum Frankfurt Höchst, Germany (T. Steiner); and Department of Medicine, McMaster University, Population Health Research Institute, Hamilton, Ontario, Canada (M.S.)
| |
Collapse
|
19
|
Heit JJ, Gonzalez RG, Sabbag D, Brouwers HB, Ordonez Rubiano EG, Schaefer PW, Hirsch JA, Romero JM. Detection and characterization of intracranial aneurysms: a 10-year multidetector CT angiography experience in a large center. J Neurointerv Surg 2015; 8:1168-1172. [PMID: 26553878 DOI: 10.1136/neurintsurg-2015-012082] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2015] [Accepted: 10/26/2015] [Indexed: 11/03/2022]
Abstract
BACKGROUND CT angiography (CTA) is increasingly used for the detection, characterization, and follow-up of intracranial aneurysms. A lower threshold to request a CT angiogram may render a patient population that differs from previous studies primarily evaluated with conventional angiography. Our objective was to broaden our knowledge of the factors associated with aneurysm rupture and patient mortality in this population. METHODS All CTA studies performed over a 10-year period at a large neurovascular referral center were reviewed for the presence of an intracranial aneurysm. Patient demographics, mortality, CTA indication, aneurysm location, size, and rupture status were recorded. RESULTS 2927 patients with aneurysms were identified among 29 003 CTAs. 17% of the aneurysms were ruptured at the time of imaging, 24% of aneurysms were incidentally identified, and multiple aneurysms were identified in 34% of patients. Aneurysms most commonly arose from the supraclinoid internal carotid artery (22%), the middle cerebral artery (18%), and the anterior communicating artery (13%). Male sex, age <50 years, aneurysms >6 mm, and aneurysms arising from the anterior communicating artery, posterior communicating artery, or the posterior circulation were independent predictors of aneurysm rupture. Independent mortality predictors included male sex, posterior circulation aneurysms, intraventricular hemorrhage, and intraparenchymal hemorrhage. CONCLUSIONS These results indicate that aneurysms detected on CTA that arise from the anterior communicating artery, posterior communicating artery, or the posterior circulation, measure >6 mm in size, occur in men, and in patients aged <50 years are associated with rupture.
Collapse
Affiliation(s)
- Jeremy J Heit
- Interventional Neuroradiology Division, Department of Radiology, Stanford University Hospital, Stanford, California, USA
| | - R Gilberto Gonzalez
- Neuroradiology Division, Department of Radiology, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - David Sabbag
- Department of Radiology, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - H Bart Brouwers
- Departments of Neurosurgery and Radiology, Brain Center Rudolf Magnus, University Medical Center Utrecht, Utrecht, The Netherlands
| | | | - Pamela W Schaefer
- Neuroradiology Division, Department of Radiology, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Joshua A Hirsch
- Neurointerventional Radiology Division, Department of Radiology, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Javier M Romero
- Neuroradiology Division, Department of Radiology, Massachusetts General Hospital, Boston, Massachusetts, USA
| |
Collapse
|
20
|
Brouwers HB, Battey TWK, Musial HH, Ciura VA, Falcone GJ, Ayres AM, Vashkevich A, Schwab K, Viswanathan A, Anderson CD, Greenberg SM, Pomerantz SR, Ortiz CJ, Goldstein JN, Gonzalez RG, Rosand J, Romero JM. Rate of Contrast Extravasation on Computed Tomographic Angiography Predicts Hematoma Expansion and Mortality in Primary Intracerebral Hemorrhage. Stroke 2015; 46:2498-503. [PMID: 26243220 DOI: 10.1161/strokeaha.115.009659] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2015] [Accepted: 07/01/2015] [Indexed: 11/16/2022]
Abstract
BACKGROUND AND PURPOSE In primary intracerebral hemorrhage, the presence of contrast extravasation after computed tomographic angiography (CTA), termed the spot sign, predicts hematoma expansion and mortality. Because the biological underpinnings of the spot sign are not fully understood, we investigated whether the rate of contrast extravasation, which may reflect the rate of bleeding, predicts expansion and mortality beyond the simple presence of the spot sign. METHODS Consecutive intracerebral hemorrhage patients with first-pass CTA followed by a 90-second delayed postcontrast CT (delayed CTA) were included. CTAs were reviewed for spot sign presence by 2 blinded readers. Spot sign volumes on first-pass and delayed CTA and intracerebral hemorrhage volumes were measured using semiautomated software. Extravasation rates were calculated and tested for association with hematoma expansion and mortality using uni- and multivariable logistic regressions. RESULTS One hundred and sixty-two patients were included, 48 (30%) of whom had ≥1 spot sign. Median spot sign volume was 0.04 mL on first-pass CTA and 0.4 mL on delayed CTA. Median extravasation rate was 0.23 mL/min overall and 0.30 mL/min among expanders versus 0.07 mL/min in nonexpanders. Extravasation rates were also significantly higher in patients who died in hospital: 0.27 mL/min versus 0.04 mL/min. In multivariable analysis, the extravasation rate was independently associated with in-hospital mortality (odds ratio, 1.09 [95% confidence interval, 1.04-1.18], P=0.004), 90-day mortality (odds ratio, 1.15 [95% confidence interval, 1.08-1.27]; P=0.0004), and hematoma expansion (odds ratio, 1.03 [95% confidence interval, 1.01-1.08]; P=0.047). CONCLUSIONS Contrast extravasation rate, or spot sign growth, further refines the ability to predict hematoma expansion and mortality. Our results support the hypothesis that the spot sign directly measures active bleeding in acute intracerebral hemorrhage.
Collapse
Affiliation(s)
- H Bart Brouwers
- From the Department of Neurosurgery, Brain Center Rudolf Magnus, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands (H.B.B.); Center for Human Genetic Research (H.B.B., T.W.K.B., H.H.M., G.J.F., C.D.A., J.R.), Division of Neurocritical Care and Emergency Neurology, Department of Neurology (H.B.B., G.J.F., A. Viswanathan, C.D.A., J.N.G., J.R.), Hemorrhagic Stroke Research Group (H.B.B., T.W.K.B., H.H.M., G.J.F., A.M.A., A. Vashkevich, K.S., A. Viswanathan, C.D.A., S.M.G., J.N.G., J.R.), J. Philip Kistler Stroke Research Center (H.B.B., T.W.K.B., H.H.M., G.J.F., A.M.A., A. Vashkevich, K.S., A. Viswanathan, C.D.A., S.M.G., J.N.G., J.R.), Neuroradiology Service, Department of Radiology (V.A.C., S.R.P., C.J.O., R.G.G., J.M.R.), and Department of Emergency Medicine (J.N.G.), Massachusetts General Hospital, Harvard Medical School, Boston.
| | - Thomas W K Battey
- From the Department of Neurosurgery, Brain Center Rudolf Magnus, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands (H.B.B.); Center for Human Genetic Research (H.B.B., T.W.K.B., H.H.M., G.J.F., C.D.A., J.R.), Division of Neurocritical Care and Emergency Neurology, Department of Neurology (H.B.B., G.J.F., A. Viswanathan, C.D.A., J.N.G., J.R.), Hemorrhagic Stroke Research Group (H.B.B., T.W.K.B., H.H.M., G.J.F., A.M.A., A. Vashkevich, K.S., A. Viswanathan, C.D.A., S.M.G., J.N.G., J.R.), J. Philip Kistler Stroke Research Center (H.B.B., T.W.K.B., H.H.M., G.J.F., A.M.A., A. Vashkevich, K.S., A. Viswanathan, C.D.A., S.M.G., J.N.G., J.R.), Neuroradiology Service, Department of Radiology (V.A.C., S.R.P., C.J.O., R.G.G., J.M.R.), and Department of Emergency Medicine (J.N.G.), Massachusetts General Hospital, Harvard Medical School, Boston
| | - Hayley H Musial
- From the Department of Neurosurgery, Brain Center Rudolf Magnus, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands (H.B.B.); Center for Human Genetic Research (H.B.B., T.W.K.B., H.H.M., G.J.F., C.D.A., J.R.), Division of Neurocritical Care and Emergency Neurology, Department of Neurology (H.B.B., G.J.F., A. Viswanathan, C.D.A., J.N.G., J.R.), Hemorrhagic Stroke Research Group (H.B.B., T.W.K.B., H.H.M., G.J.F., A.M.A., A. Vashkevich, K.S., A. Viswanathan, C.D.A., S.M.G., J.N.G., J.R.), J. Philip Kistler Stroke Research Center (H.B.B., T.W.K.B., H.H.M., G.J.F., A.M.A., A. Vashkevich, K.S., A. Viswanathan, C.D.A., S.M.G., J.N.G., J.R.), Neuroradiology Service, Department of Radiology (V.A.C., S.R.P., C.J.O., R.G.G., J.M.R.), and Department of Emergency Medicine (J.N.G.), Massachusetts General Hospital, Harvard Medical School, Boston
| | - Viesha A Ciura
- From the Department of Neurosurgery, Brain Center Rudolf Magnus, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands (H.B.B.); Center for Human Genetic Research (H.B.B., T.W.K.B., H.H.M., G.J.F., C.D.A., J.R.), Division of Neurocritical Care and Emergency Neurology, Department of Neurology (H.B.B., G.J.F., A. Viswanathan, C.D.A., J.N.G., J.R.), Hemorrhagic Stroke Research Group (H.B.B., T.W.K.B., H.H.M., G.J.F., A.M.A., A. Vashkevich, K.S., A. Viswanathan, C.D.A., S.M.G., J.N.G., J.R.), J. Philip Kistler Stroke Research Center (H.B.B., T.W.K.B., H.H.M., G.J.F., A.M.A., A. Vashkevich, K.S., A. Viswanathan, C.D.A., S.M.G., J.N.G., J.R.), Neuroradiology Service, Department of Radiology (V.A.C., S.R.P., C.J.O., R.G.G., J.M.R.), and Department of Emergency Medicine (J.N.G.), Massachusetts General Hospital, Harvard Medical School, Boston
| | - Guido J Falcone
- From the Department of Neurosurgery, Brain Center Rudolf Magnus, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands (H.B.B.); Center for Human Genetic Research (H.B.B., T.W.K.B., H.H.M., G.J.F., C.D.A., J.R.), Division of Neurocritical Care and Emergency Neurology, Department of Neurology (H.B.B., G.J.F., A. Viswanathan, C.D.A., J.N.G., J.R.), Hemorrhagic Stroke Research Group (H.B.B., T.W.K.B., H.H.M., G.J.F., A.M.A., A. Vashkevich, K.S., A. Viswanathan, C.D.A., S.M.G., J.N.G., J.R.), J. Philip Kistler Stroke Research Center (H.B.B., T.W.K.B., H.H.M., G.J.F., A.M.A., A. Vashkevich, K.S., A. Viswanathan, C.D.A., S.M.G., J.N.G., J.R.), Neuroradiology Service, Department of Radiology (V.A.C., S.R.P., C.J.O., R.G.G., J.M.R.), and Department of Emergency Medicine (J.N.G.), Massachusetts General Hospital, Harvard Medical School, Boston
| | - Alison M Ayres
- From the Department of Neurosurgery, Brain Center Rudolf Magnus, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands (H.B.B.); Center for Human Genetic Research (H.B.B., T.W.K.B., H.H.M., G.J.F., C.D.A., J.R.), Division of Neurocritical Care and Emergency Neurology, Department of Neurology (H.B.B., G.J.F., A. Viswanathan, C.D.A., J.N.G., J.R.), Hemorrhagic Stroke Research Group (H.B.B., T.W.K.B., H.H.M., G.J.F., A.M.A., A. Vashkevich, K.S., A. Viswanathan, C.D.A., S.M.G., J.N.G., J.R.), J. Philip Kistler Stroke Research Center (H.B.B., T.W.K.B., H.H.M., G.J.F., A.M.A., A. Vashkevich, K.S., A. Viswanathan, C.D.A., S.M.G., J.N.G., J.R.), Neuroradiology Service, Department of Radiology (V.A.C., S.R.P., C.J.O., R.G.G., J.M.R.), and Department of Emergency Medicine (J.N.G.), Massachusetts General Hospital, Harvard Medical School, Boston
| | - Anastasia Vashkevich
- From the Department of Neurosurgery, Brain Center Rudolf Magnus, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands (H.B.B.); Center for Human Genetic Research (H.B.B., T.W.K.B., H.H.M., G.J.F., C.D.A., J.R.), Division of Neurocritical Care and Emergency Neurology, Department of Neurology (H.B.B., G.J.F., A. Viswanathan, C.D.A., J.N.G., J.R.), Hemorrhagic Stroke Research Group (H.B.B., T.W.K.B., H.H.M., G.J.F., A.M.A., A. Vashkevich, K.S., A. Viswanathan, C.D.A., S.M.G., J.N.G., J.R.), J. Philip Kistler Stroke Research Center (H.B.B., T.W.K.B., H.H.M., G.J.F., A.M.A., A. Vashkevich, K.S., A. Viswanathan, C.D.A., S.M.G., J.N.G., J.R.), Neuroradiology Service, Department of Radiology (V.A.C., S.R.P., C.J.O., R.G.G., J.M.R.), and Department of Emergency Medicine (J.N.G.), Massachusetts General Hospital, Harvard Medical School, Boston
| | - Kristin Schwab
- From the Department of Neurosurgery, Brain Center Rudolf Magnus, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands (H.B.B.); Center for Human Genetic Research (H.B.B., T.W.K.B., H.H.M., G.J.F., C.D.A., J.R.), Division of Neurocritical Care and Emergency Neurology, Department of Neurology (H.B.B., G.J.F., A. Viswanathan, C.D.A., J.N.G., J.R.), Hemorrhagic Stroke Research Group (H.B.B., T.W.K.B., H.H.M., G.J.F., A.M.A., A. Vashkevich, K.S., A. Viswanathan, C.D.A., S.M.G., J.N.G., J.R.), J. Philip Kistler Stroke Research Center (H.B.B., T.W.K.B., H.H.M., G.J.F., A.M.A., A. Vashkevich, K.S., A. Viswanathan, C.D.A., S.M.G., J.N.G., J.R.), Neuroradiology Service, Department of Radiology (V.A.C., S.R.P., C.J.O., R.G.G., J.M.R.), and Department of Emergency Medicine (J.N.G.), Massachusetts General Hospital, Harvard Medical School, Boston
| | - Anand Viswanathan
- From the Department of Neurosurgery, Brain Center Rudolf Magnus, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands (H.B.B.); Center for Human Genetic Research (H.B.B., T.W.K.B., H.H.M., G.J.F., C.D.A., J.R.), Division of Neurocritical Care and Emergency Neurology, Department of Neurology (H.B.B., G.J.F., A. Viswanathan, C.D.A., J.N.G., J.R.), Hemorrhagic Stroke Research Group (H.B.B., T.W.K.B., H.H.M., G.J.F., A.M.A., A. Vashkevich, K.S., A. Viswanathan, C.D.A., S.M.G., J.N.G., J.R.), J. Philip Kistler Stroke Research Center (H.B.B., T.W.K.B., H.H.M., G.J.F., A.M.A., A. Vashkevich, K.S., A. Viswanathan, C.D.A., S.M.G., J.N.G., J.R.), Neuroradiology Service, Department of Radiology (V.A.C., S.R.P., C.J.O., R.G.G., J.M.R.), and Department of Emergency Medicine (J.N.G.), Massachusetts General Hospital, Harvard Medical School, Boston
| | - Christopher D Anderson
- From the Department of Neurosurgery, Brain Center Rudolf Magnus, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands (H.B.B.); Center for Human Genetic Research (H.B.B., T.W.K.B., H.H.M., G.J.F., C.D.A., J.R.), Division of Neurocritical Care and Emergency Neurology, Department of Neurology (H.B.B., G.J.F., A. Viswanathan, C.D.A., J.N.G., J.R.), Hemorrhagic Stroke Research Group (H.B.B., T.W.K.B., H.H.M., G.J.F., A.M.A., A. Vashkevich, K.S., A. Viswanathan, C.D.A., S.M.G., J.N.G., J.R.), J. Philip Kistler Stroke Research Center (H.B.B., T.W.K.B., H.H.M., G.J.F., A.M.A., A. Vashkevich, K.S., A. Viswanathan, C.D.A., S.M.G., J.N.G., J.R.), Neuroradiology Service, Department of Radiology (V.A.C., S.R.P., C.J.O., R.G.G., J.M.R.), and Department of Emergency Medicine (J.N.G.), Massachusetts General Hospital, Harvard Medical School, Boston
| | - Steven M Greenberg
- From the Department of Neurosurgery, Brain Center Rudolf Magnus, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands (H.B.B.); Center for Human Genetic Research (H.B.B., T.W.K.B., H.H.M., G.J.F., C.D.A., J.R.), Division of Neurocritical Care and Emergency Neurology, Department of Neurology (H.B.B., G.J.F., A. Viswanathan, C.D.A., J.N.G., J.R.), Hemorrhagic Stroke Research Group (H.B.B., T.W.K.B., H.H.M., G.J.F., A.M.A., A. Vashkevich, K.S., A. Viswanathan, C.D.A., S.M.G., J.N.G., J.R.), J. Philip Kistler Stroke Research Center (H.B.B., T.W.K.B., H.H.M., G.J.F., A.M.A., A. Vashkevich, K.S., A. Viswanathan, C.D.A., S.M.G., J.N.G., J.R.), Neuroradiology Service, Department of Radiology (V.A.C., S.R.P., C.J.O., R.G.G., J.M.R.), and Department of Emergency Medicine (J.N.G.), Massachusetts General Hospital, Harvard Medical School, Boston
| | - Stuart R Pomerantz
- From the Department of Neurosurgery, Brain Center Rudolf Magnus, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands (H.B.B.); Center for Human Genetic Research (H.B.B., T.W.K.B., H.H.M., G.J.F., C.D.A., J.R.), Division of Neurocritical Care and Emergency Neurology, Department of Neurology (H.B.B., G.J.F., A. Viswanathan, C.D.A., J.N.G., J.R.), Hemorrhagic Stroke Research Group (H.B.B., T.W.K.B., H.H.M., G.J.F., A.M.A., A. Vashkevich, K.S., A. Viswanathan, C.D.A., S.M.G., J.N.G., J.R.), J. Philip Kistler Stroke Research Center (H.B.B., T.W.K.B., H.H.M., G.J.F., A.M.A., A. Vashkevich, K.S., A. Viswanathan, C.D.A., S.M.G., J.N.G., J.R.), Neuroradiology Service, Department of Radiology (V.A.C., S.R.P., C.J.O., R.G.G., J.M.R.), and Department of Emergency Medicine (J.N.G.), Massachusetts General Hospital, Harvard Medical School, Boston
| | - Claudia J Ortiz
- From the Department of Neurosurgery, Brain Center Rudolf Magnus, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands (H.B.B.); Center for Human Genetic Research (H.B.B., T.W.K.B., H.H.M., G.J.F., C.D.A., J.R.), Division of Neurocritical Care and Emergency Neurology, Department of Neurology (H.B.B., G.J.F., A. Viswanathan, C.D.A., J.N.G., J.R.), Hemorrhagic Stroke Research Group (H.B.B., T.W.K.B., H.H.M., G.J.F., A.M.A., A. Vashkevich, K.S., A. Viswanathan, C.D.A., S.M.G., J.N.G., J.R.), J. Philip Kistler Stroke Research Center (H.B.B., T.W.K.B., H.H.M., G.J.F., A.M.A., A. Vashkevich, K.S., A. Viswanathan, C.D.A., S.M.G., J.N.G., J.R.), Neuroradiology Service, Department of Radiology (V.A.C., S.R.P., C.J.O., R.G.G., J.M.R.), and Department of Emergency Medicine (J.N.G.), Massachusetts General Hospital, Harvard Medical School, Boston
| | - Joshua N Goldstein
- From the Department of Neurosurgery, Brain Center Rudolf Magnus, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands (H.B.B.); Center for Human Genetic Research (H.B.B., T.W.K.B., H.H.M., G.J.F., C.D.A., J.R.), Division of Neurocritical Care and Emergency Neurology, Department of Neurology (H.B.B., G.J.F., A. Viswanathan, C.D.A., J.N.G., J.R.), Hemorrhagic Stroke Research Group (H.B.B., T.W.K.B., H.H.M., G.J.F., A.M.A., A. Vashkevich, K.S., A. Viswanathan, C.D.A., S.M.G., J.N.G., J.R.), J. Philip Kistler Stroke Research Center (H.B.B., T.W.K.B., H.H.M., G.J.F., A.M.A., A. Vashkevich, K.S., A. Viswanathan, C.D.A., S.M.G., J.N.G., J.R.), Neuroradiology Service, Department of Radiology (V.A.C., S.R.P., C.J.O., R.G.G., J.M.R.), and Department of Emergency Medicine (J.N.G.), Massachusetts General Hospital, Harvard Medical School, Boston
| | - R Gilberto Gonzalez
- From the Department of Neurosurgery, Brain Center Rudolf Magnus, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands (H.B.B.); Center for Human Genetic Research (H.B.B., T.W.K.B., H.H.M., G.J.F., C.D.A., J.R.), Division of Neurocritical Care and Emergency Neurology, Department of Neurology (H.B.B., G.J.F., A. Viswanathan, C.D.A., J.N.G., J.R.), Hemorrhagic Stroke Research Group (H.B.B., T.W.K.B., H.H.M., G.J.F., A.M.A., A. Vashkevich, K.S., A. Viswanathan, C.D.A., S.M.G., J.N.G., J.R.), J. Philip Kistler Stroke Research Center (H.B.B., T.W.K.B., H.H.M., G.J.F., A.M.A., A. Vashkevich, K.S., A. Viswanathan, C.D.A., S.M.G., J.N.G., J.R.), Neuroradiology Service, Department of Radiology (V.A.C., S.R.P., C.J.O., R.G.G., J.M.R.), and Department of Emergency Medicine (J.N.G.), Massachusetts General Hospital, Harvard Medical School, Boston
| | - Jonathan Rosand
- From the Department of Neurosurgery, Brain Center Rudolf Magnus, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands (H.B.B.); Center for Human Genetic Research (H.B.B., T.W.K.B., H.H.M., G.J.F., C.D.A., J.R.), Division of Neurocritical Care and Emergency Neurology, Department of Neurology (H.B.B., G.J.F., A. Viswanathan, C.D.A., J.N.G., J.R.), Hemorrhagic Stroke Research Group (H.B.B., T.W.K.B., H.H.M., G.J.F., A.M.A., A. Vashkevich, K.S., A. Viswanathan, C.D.A., S.M.G., J.N.G., J.R.), J. Philip Kistler Stroke Research Center (H.B.B., T.W.K.B., H.H.M., G.J.F., A.M.A., A. Vashkevich, K.S., A. Viswanathan, C.D.A., S.M.G., J.N.G., J.R.), Neuroradiology Service, Department of Radiology (V.A.C., S.R.P., C.J.O., R.G.G., J.M.R.), and Department of Emergency Medicine (J.N.G.), Massachusetts General Hospital, Harvard Medical School, Boston
| | - Javier M Romero
- From the Department of Neurosurgery, Brain Center Rudolf Magnus, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands (H.B.B.); Center for Human Genetic Research (H.B.B., T.W.K.B., H.H.M., G.J.F., C.D.A., J.R.), Division of Neurocritical Care and Emergency Neurology, Department of Neurology (H.B.B., G.J.F., A. Viswanathan, C.D.A., J.N.G., J.R.), Hemorrhagic Stroke Research Group (H.B.B., T.W.K.B., H.H.M., G.J.F., A.M.A., A. Vashkevich, K.S., A. Viswanathan, C.D.A., S.M.G., J.N.G., J.R.), J. Philip Kistler Stroke Research Center (H.B.B., T.W.K.B., H.H.M., G.J.F., A.M.A., A. Vashkevich, K.S., A. Viswanathan, C.D.A., S.M.G., J.N.G., J.R.), Neuroradiology Service, Department of Radiology (V.A.C., S.R.P., C.J.O., R.G.G., J.M.R.), and Department of Emergency Medicine (J.N.G.), Massachusetts General Hospital, Harvard Medical School, Boston
| |
Collapse
|
21
|
Ciura VA, Brouwers HB, Pizzolato R, Ortiz CJ, Rosand J, Goldstein JN, Greenberg SM, Pomerantz SR, Gonzalez RG, Romero JM. Spot sign on 90-second delayed computed tomography angiography improves sensitivity for hematoma expansion and mortality: prospective study. Stroke 2014; 45:3293-7. [PMID: 25300974 DOI: 10.1161/strokeaha.114.005570] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND AND PURPOSE The computed tomography angiography (CTA) spot sign is a validated biomarker for poor outcome and hematoma expansion in intracerebral hemorrhage. The spot sign has proven to be a dynamic entity, with multimodal imaging proving to be of additional value. We investigated whether the addition of a 90-second delayed CTA acquisition would capture additional intracerebral hemorrhage patients with the spot sign and increase the sensitivity of the spot sign. METHODS We prospectively enrolled consecutive intracerebral hemorrhage patients undergoing first pass and 90-second delayed CTA for 18 months at a single academic center. Univariate and multivariate logistic regression were performed to assess clinical and neuroimaging covariates for relationship with hematoma expansion and mortality. RESULTS Sensitivity of the spot sign for hematoma expansion on first pass CTA was 55%, which increased to 64% if the spot sign was present on either CTA acquisition. In multivariate analysis the spot sign presence was associated with significant hematoma expansion: odds ratio, 17.7 (95% confidence interval, 3.7-84.2; P=0.0004), 8.3 (95% confidence interval, 2.0-33.4; P=0.004), and 12.0 (95% confidence interval, 2.9-50.5; P=0.0008) if present on first pass, delayed, or either CTA acquisition, respectively. Spot sign presence on either acquisitions was also significant for mortality. CONCLUSIONS We demonstrate improved sensitivity for predicting hematoma expansion and poor outcome by adding a 90-second delayed CTA, which may enhance selection of patients who may benefit from hemostatic therapy.
Collapse
Affiliation(s)
- Viesha A Ciura
- From the Division of Neuroradiology, Department of Radiology (V.A.C., R.P., C.J.O., S.R.P., R.G.G., J.M.R.), Center for Human Genetic Research (H.B.B., J.R.), Division of Neurocritical Care and Emergency Neurology, Department of Neurology (H.B.B., J.R., J.N.G.), Department of Neurology, Hemorrhagic Stroke Research Group (H.B.B., J.R., J.N.G., S.M.G.), Department of Neurology, J. Philip Kistler Stroke Research Center (H.B.B., J.R., J.N.G.), and Department of Emergency Medicine (J.N.G.), Massachusetts General Hospital, Harvard Medical School, Boston; and Department of Neurosurgery, Brain Center Rudolf Magnus, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands (H.B.B.)
| | - H Bart Brouwers
- From the Division of Neuroradiology, Department of Radiology (V.A.C., R.P., C.J.O., S.R.P., R.G.G., J.M.R.), Center for Human Genetic Research (H.B.B., J.R.), Division of Neurocritical Care and Emergency Neurology, Department of Neurology (H.B.B., J.R., J.N.G.), Department of Neurology, Hemorrhagic Stroke Research Group (H.B.B., J.R., J.N.G., S.M.G.), Department of Neurology, J. Philip Kistler Stroke Research Center (H.B.B., J.R., J.N.G.), and Department of Emergency Medicine (J.N.G.), Massachusetts General Hospital, Harvard Medical School, Boston; and Department of Neurosurgery, Brain Center Rudolf Magnus, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands (H.B.B.)
| | - Raffaella Pizzolato
- From the Division of Neuroradiology, Department of Radiology (V.A.C., R.P., C.J.O., S.R.P., R.G.G., J.M.R.), Center for Human Genetic Research (H.B.B., J.R.), Division of Neurocritical Care and Emergency Neurology, Department of Neurology (H.B.B., J.R., J.N.G.), Department of Neurology, Hemorrhagic Stroke Research Group (H.B.B., J.R., J.N.G., S.M.G.), Department of Neurology, J. Philip Kistler Stroke Research Center (H.B.B., J.R., J.N.G.), and Department of Emergency Medicine (J.N.G.), Massachusetts General Hospital, Harvard Medical School, Boston; and Department of Neurosurgery, Brain Center Rudolf Magnus, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands (H.B.B.)
| | - Claudia J Ortiz
- From the Division of Neuroradiology, Department of Radiology (V.A.C., R.P., C.J.O., S.R.P., R.G.G., J.M.R.), Center for Human Genetic Research (H.B.B., J.R.), Division of Neurocritical Care and Emergency Neurology, Department of Neurology (H.B.B., J.R., J.N.G.), Department of Neurology, Hemorrhagic Stroke Research Group (H.B.B., J.R., J.N.G., S.M.G.), Department of Neurology, J. Philip Kistler Stroke Research Center (H.B.B., J.R., J.N.G.), and Department of Emergency Medicine (J.N.G.), Massachusetts General Hospital, Harvard Medical School, Boston; and Department of Neurosurgery, Brain Center Rudolf Magnus, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands (H.B.B.)
| | - Jonathan Rosand
- From the Division of Neuroradiology, Department of Radiology (V.A.C., R.P., C.J.O., S.R.P., R.G.G., J.M.R.), Center for Human Genetic Research (H.B.B., J.R.), Division of Neurocritical Care and Emergency Neurology, Department of Neurology (H.B.B., J.R., J.N.G.), Department of Neurology, Hemorrhagic Stroke Research Group (H.B.B., J.R., J.N.G., S.M.G.), Department of Neurology, J. Philip Kistler Stroke Research Center (H.B.B., J.R., J.N.G.), and Department of Emergency Medicine (J.N.G.), Massachusetts General Hospital, Harvard Medical School, Boston; and Department of Neurosurgery, Brain Center Rudolf Magnus, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands (H.B.B.)
| | - Joshua N Goldstein
- From the Division of Neuroradiology, Department of Radiology (V.A.C., R.P., C.J.O., S.R.P., R.G.G., J.M.R.), Center for Human Genetic Research (H.B.B., J.R.), Division of Neurocritical Care and Emergency Neurology, Department of Neurology (H.B.B., J.R., J.N.G.), Department of Neurology, Hemorrhagic Stroke Research Group (H.B.B., J.R., J.N.G., S.M.G.), Department of Neurology, J. Philip Kistler Stroke Research Center (H.B.B., J.R., J.N.G.), and Department of Emergency Medicine (J.N.G.), Massachusetts General Hospital, Harvard Medical School, Boston; and Department of Neurosurgery, Brain Center Rudolf Magnus, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands (H.B.B.)
| | - Steven M Greenberg
- From the Division of Neuroradiology, Department of Radiology (V.A.C., R.P., C.J.O., S.R.P., R.G.G., J.M.R.), Center for Human Genetic Research (H.B.B., J.R.), Division of Neurocritical Care and Emergency Neurology, Department of Neurology (H.B.B., J.R., J.N.G.), Department of Neurology, Hemorrhagic Stroke Research Group (H.B.B., J.R., J.N.G., S.M.G.), Department of Neurology, J. Philip Kistler Stroke Research Center (H.B.B., J.R., J.N.G.), and Department of Emergency Medicine (J.N.G.), Massachusetts General Hospital, Harvard Medical School, Boston; and Department of Neurosurgery, Brain Center Rudolf Magnus, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands (H.B.B.)
| | - Stuart R Pomerantz
- From the Division of Neuroradiology, Department of Radiology (V.A.C., R.P., C.J.O., S.R.P., R.G.G., J.M.R.), Center for Human Genetic Research (H.B.B., J.R.), Division of Neurocritical Care and Emergency Neurology, Department of Neurology (H.B.B., J.R., J.N.G.), Department of Neurology, Hemorrhagic Stroke Research Group (H.B.B., J.R., J.N.G., S.M.G.), Department of Neurology, J. Philip Kistler Stroke Research Center (H.B.B., J.R., J.N.G.), and Department of Emergency Medicine (J.N.G.), Massachusetts General Hospital, Harvard Medical School, Boston; and Department of Neurosurgery, Brain Center Rudolf Magnus, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands (H.B.B.)
| | - R Gilberto Gonzalez
- From the Division of Neuroradiology, Department of Radiology (V.A.C., R.P., C.J.O., S.R.P., R.G.G., J.M.R.), Center for Human Genetic Research (H.B.B., J.R.), Division of Neurocritical Care and Emergency Neurology, Department of Neurology (H.B.B., J.R., J.N.G.), Department of Neurology, Hemorrhagic Stroke Research Group (H.B.B., J.R., J.N.G., S.M.G.), Department of Neurology, J. Philip Kistler Stroke Research Center (H.B.B., J.R., J.N.G.), and Department of Emergency Medicine (J.N.G.), Massachusetts General Hospital, Harvard Medical School, Boston; and Department of Neurosurgery, Brain Center Rudolf Magnus, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands (H.B.B.)
| | - Javier M Romero
- From the Division of Neuroradiology, Department of Radiology (V.A.C., R.P., C.J.O., S.R.P., R.G.G., J.M.R.), Center for Human Genetic Research (H.B.B., J.R.), Division of Neurocritical Care and Emergency Neurology, Department of Neurology (H.B.B., J.R., J.N.G.), Department of Neurology, Hemorrhagic Stroke Research Group (H.B.B., J.R., J.N.G., S.M.G.), Department of Neurology, J. Philip Kistler Stroke Research Center (H.B.B., J.R., J.N.G.), and Department of Emergency Medicine (J.N.G.), Massachusetts General Hospital, Harvard Medical School, Boston; and Department of Neurosurgery, Brain Center Rudolf Magnus, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands (H.B.B.).
| |
Collapse
|
22
|
Falcone GJ, Radmanesh F, Brouwers HB, Battey TWK, Devan WJ, Valant V, Raffeld MR, Chitsike LP, Ayres AM, Schwab K, Goldstein JN, Viswanathan A, Greenberg SM, Selim M, Meschia JF, Brown DL, Worrall BB, Silliman SL, Tirschwell DL, Flaherty ML, Martini SR, Deka R, Biffi A, Kraft P, Woo D, Rosand J, Anderson CD. APOE ε variants increase risk of warfarin-related intracerebral hemorrhage. Neurology 2014; 83:1139-46. [PMID: 25150286 DOI: 10.1212/wnl.0000000000000816] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023] Open
Abstract
OBJECTIVE We aimed to assess the effect of APOE ε variants on warfarin-related intracerebral hemorrhage (wICH), evaluated their predictive power, and tested for interaction with warfarin in causing wICH. METHODS This was a prospective, 2-stage (discovery and replication), case-control study. wICH was classified as lobar or nonlobar based on the location of the hematoma. Controls were sampled from ambulatory clinics (discovery) and random digit dialing (replication). APOE ε variants were directly genotyped. A case-control design and logistic regression analysis were utilized to test for association between APOE ε and wICH. A case-only design and logistic regression analysis were utilized to test for interaction between APOE ε and warfarin. Receiver operating characteristic curves were implemented to evaluate predictive power. RESULTS The discovery stage included 319 wICHs (44% lobar) and 355 controls. APOE ε2 was associated with lobar (odds ratio [OR] 2.46; p < 0.001) and nonlobar wICH (OR 1.67; p = 0.04), whereas ε4 was associated with lobar (OR 2.09; p < 0.001) but not nonlobar wICH (p = 0.35). The replication stage (63 wICHs and 1,030 controls) confirmed the association with ε2 (p = 0.03) and ε4 (p = 0.003) for lobar but not for nonlobar wICH (p > 0.20). Genotyping information on APOE ε variants significantly improved case/control discrimination of lobar wICH (C statistic 0.80). No statistical interaction between warfarin and APOE was found (p > 0.20). CONCLUSIONS APOE ε variants constitute strong risk factors for lobar wICH. APOE exerts its effect independently of warfarin, although power limitations render this absence of interaction preliminary. Evaluation of the predictive ability of APOE in cohort studies is warranted.
Collapse
Affiliation(s)
- Guido J Falcone
- From the Center for Human Genetic Research (G.J.F., F.R., H.B.B., T.W.K.B., W.J.D., V.V., M.R.R., L.P.C., A.M.A., K.S., A.V., S.M.G., A.B., J.R., C.D.A.), J. Philip Kistler Stroke Research Center (G.J.F., F.R., H.B.B., T.W.K.B., W.J.D., V.V., M.R.R., A.B., J.R., C.D.A.), Division of Neurocritical Care and Emergency Neurology, Department of Neurology (G.J.F., F.R., H.B.B., T.W.K.B., W.J.D., M.R.R., A.B., J.R., C.D.A.), and Department of Emergency Medicine (J.N.G.), Massachusetts General Hospital, Boston; Program in Medical and Population Genetics (G.J.F., F.R., H.B.B., T.W.K.B., W.J.D., M.R.R., A.B., J.R., C.D.A.), Broad Institute, Cambridge, MA; Department of Epidemiology (G.J.F., P.K.), Harvard School of Public Health, Boston; Department of Neurology (M.S.), Beth Israel Deaconess Medical Center, Boston, MA; Department of Neurology (J.F.M.), Mayo Clinic, Jacksonville, FL; Stroke Program (D.L.B.), Department of Neurology, University of Michigan Health System, Ann Arbor; Departments of Neurology and Public Health Sciences (B.B.W.), University of Virginia Health System, Charlottesville; Department of Neurology (S.L.S.), University of Florida College of Medicine, Jacksonville; Stroke Center (D.L.T.), Harborview Medical Center, University of Washington, Seattle; and University of Cincinnati College of Medicine (M.L.F., S.R.M., R.D., D.W.), OH
| | - Farid Radmanesh
- From the Center for Human Genetic Research (G.J.F., F.R., H.B.B., T.W.K.B., W.J.D., V.V., M.R.R., L.P.C., A.M.A., K.S., A.V., S.M.G., A.B., J.R., C.D.A.), J. Philip Kistler Stroke Research Center (G.J.F., F.R., H.B.B., T.W.K.B., W.J.D., V.V., M.R.R., A.B., J.R., C.D.A.), Division of Neurocritical Care and Emergency Neurology, Department of Neurology (G.J.F., F.R., H.B.B., T.W.K.B., W.J.D., M.R.R., A.B., J.R., C.D.A.), and Department of Emergency Medicine (J.N.G.), Massachusetts General Hospital, Boston; Program in Medical and Population Genetics (G.J.F., F.R., H.B.B., T.W.K.B., W.J.D., M.R.R., A.B., J.R., C.D.A.), Broad Institute, Cambridge, MA; Department of Epidemiology (G.J.F., P.K.), Harvard School of Public Health, Boston; Department of Neurology (M.S.), Beth Israel Deaconess Medical Center, Boston, MA; Department of Neurology (J.F.M.), Mayo Clinic, Jacksonville, FL; Stroke Program (D.L.B.), Department of Neurology, University of Michigan Health System, Ann Arbor; Departments of Neurology and Public Health Sciences (B.B.W.), University of Virginia Health System, Charlottesville; Department of Neurology (S.L.S.), University of Florida College of Medicine, Jacksonville; Stroke Center (D.L.T.), Harborview Medical Center, University of Washington, Seattle; and University of Cincinnati College of Medicine (M.L.F., S.R.M., R.D., D.W.), OH
| | - H Bart Brouwers
- From the Center for Human Genetic Research (G.J.F., F.R., H.B.B., T.W.K.B., W.J.D., V.V., M.R.R., L.P.C., A.M.A., K.S., A.V., S.M.G., A.B., J.R., C.D.A.), J. Philip Kistler Stroke Research Center (G.J.F., F.R., H.B.B., T.W.K.B., W.J.D., V.V., M.R.R., A.B., J.R., C.D.A.), Division of Neurocritical Care and Emergency Neurology, Department of Neurology (G.J.F., F.R., H.B.B., T.W.K.B., W.J.D., M.R.R., A.B., J.R., C.D.A.), and Department of Emergency Medicine (J.N.G.), Massachusetts General Hospital, Boston; Program in Medical and Population Genetics (G.J.F., F.R., H.B.B., T.W.K.B., W.J.D., M.R.R., A.B., J.R., C.D.A.), Broad Institute, Cambridge, MA; Department of Epidemiology (G.J.F., P.K.), Harvard School of Public Health, Boston; Department of Neurology (M.S.), Beth Israel Deaconess Medical Center, Boston, MA; Department of Neurology (J.F.M.), Mayo Clinic, Jacksonville, FL; Stroke Program (D.L.B.), Department of Neurology, University of Michigan Health System, Ann Arbor; Departments of Neurology and Public Health Sciences (B.B.W.), University of Virginia Health System, Charlottesville; Department of Neurology (S.L.S.), University of Florida College of Medicine, Jacksonville; Stroke Center (D.L.T.), Harborview Medical Center, University of Washington, Seattle; and University of Cincinnati College of Medicine (M.L.F., S.R.M., R.D., D.W.), OH
| | - Thomas W K Battey
- From the Center for Human Genetic Research (G.J.F., F.R., H.B.B., T.W.K.B., W.J.D., V.V., M.R.R., L.P.C., A.M.A., K.S., A.V., S.M.G., A.B., J.R., C.D.A.), J. Philip Kistler Stroke Research Center (G.J.F., F.R., H.B.B., T.W.K.B., W.J.D., V.V., M.R.R., A.B., J.R., C.D.A.), Division of Neurocritical Care and Emergency Neurology, Department of Neurology (G.J.F., F.R., H.B.B., T.W.K.B., W.J.D., M.R.R., A.B., J.R., C.D.A.), and Department of Emergency Medicine (J.N.G.), Massachusetts General Hospital, Boston; Program in Medical and Population Genetics (G.J.F., F.R., H.B.B., T.W.K.B., W.J.D., M.R.R., A.B., J.R., C.D.A.), Broad Institute, Cambridge, MA; Department of Epidemiology (G.J.F., P.K.), Harvard School of Public Health, Boston; Department of Neurology (M.S.), Beth Israel Deaconess Medical Center, Boston, MA; Department of Neurology (J.F.M.), Mayo Clinic, Jacksonville, FL; Stroke Program (D.L.B.), Department of Neurology, University of Michigan Health System, Ann Arbor; Departments of Neurology and Public Health Sciences (B.B.W.), University of Virginia Health System, Charlottesville; Department of Neurology (S.L.S.), University of Florida College of Medicine, Jacksonville; Stroke Center (D.L.T.), Harborview Medical Center, University of Washington, Seattle; and University of Cincinnati College of Medicine (M.L.F., S.R.M., R.D., D.W.), OH
| | - William J Devan
- From the Center for Human Genetic Research (G.J.F., F.R., H.B.B., T.W.K.B., W.J.D., V.V., M.R.R., L.P.C., A.M.A., K.S., A.V., S.M.G., A.B., J.R., C.D.A.), J. Philip Kistler Stroke Research Center (G.J.F., F.R., H.B.B., T.W.K.B., W.J.D., V.V., M.R.R., A.B., J.R., C.D.A.), Division of Neurocritical Care and Emergency Neurology, Department of Neurology (G.J.F., F.R., H.B.B., T.W.K.B., W.J.D., M.R.R., A.B., J.R., C.D.A.), and Department of Emergency Medicine (J.N.G.), Massachusetts General Hospital, Boston; Program in Medical and Population Genetics (G.J.F., F.R., H.B.B., T.W.K.B., W.J.D., M.R.R., A.B., J.R., C.D.A.), Broad Institute, Cambridge, MA; Department of Epidemiology (G.J.F., P.K.), Harvard School of Public Health, Boston; Department of Neurology (M.S.), Beth Israel Deaconess Medical Center, Boston, MA; Department of Neurology (J.F.M.), Mayo Clinic, Jacksonville, FL; Stroke Program (D.L.B.), Department of Neurology, University of Michigan Health System, Ann Arbor; Departments of Neurology and Public Health Sciences (B.B.W.), University of Virginia Health System, Charlottesville; Department of Neurology (S.L.S.), University of Florida College of Medicine, Jacksonville; Stroke Center (D.L.T.), Harborview Medical Center, University of Washington, Seattle; and University of Cincinnati College of Medicine (M.L.F., S.R.M., R.D., D.W.), OH
| | - Valerie Valant
- From the Center for Human Genetic Research (G.J.F., F.R., H.B.B., T.W.K.B., W.J.D., V.V., M.R.R., L.P.C., A.M.A., K.S., A.V., S.M.G., A.B., J.R., C.D.A.), J. Philip Kistler Stroke Research Center (G.J.F., F.R., H.B.B., T.W.K.B., W.J.D., V.V., M.R.R., A.B., J.R., C.D.A.), Division of Neurocritical Care and Emergency Neurology, Department of Neurology (G.J.F., F.R., H.B.B., T.W.K.B., W.J.D., M.R.R., A.B., J.R., C.D.A.), and Department of Emergency Medicine (J.N.G.), Massachusetts General Hospital, Boston; Program in Medical and Population Genetics (G.J.F., F.R., H.B.B., T.W.K.B., W.J.D., M.R.R., A.B., J.R., C.D.A.), Broad Institute, Cambridge, MA; Department of Epidemiology (G.J.F., P.K.), Harvard School of Public Health, Boston; Department of Neurology (M.S.), Beth Israel Deaconess Medical Center, Boston, MA; Department of Neurology (J.F.M.), Mayo Clinic, Jacksonville, FL; Stroke Program (D.L.B.), Department of Neurology, University of Michigan Health System, Ann Arbor; Departments of Neurology and Public Health Sciences (B.B.W.), University of Virginia Health System, Charlottesville; Department of Neurology (S.L.S.), University of Florida College of Medicine, Jacksonville; Stroke Center (D.L.T.), Harborview Medical Center, University of Washington, Seattle; and University of Cincinnati College of Medicine (M.L.F., S.R.M., R.D., D.W.), OH
| | - Miriam R Raffeld
- From the Center for Human Genetic Research (G.J.F., F.R., H.B.B., T.W.K.B., W.J.D., V.V., M.R.R., L.P.C., A.M.A., K.S., A.V., S.M.G., A.B., J.R., C.D.A.), J. Philip Kistler Stroke Research Center (G.J.F., F.R., H.B.B., T.W.K.B., W.J.D., V.V., M.R.R., A.B., J.R., C.D.A.), Division of Neurocritical Care and Emergency Neurology, Department of Neurology (G.J.F., F.R., H.B.B., T.W.K.B., W.J.D., M.R.R., A.B., J.R., C.D.A.), and Department of Emergency Medicine (J.N.G.), Massachusetts General Hospital, Boston; Program in Medical and Population Genetics (G.J.F., F.R., H.B.B., T.W.K.B., W.J.D., M.R.R., A.B., J.R., C.D.A.), Broad Institute, Cambridge, MA; Department of Epidemiology (G.J.F., P.K.), Harvard School of Public Health, Boston; Department of Neurology (M.S.), Beth Israel Deaconess Medical Center, Boston, MA; Department of Neurology (J.F.M.), Mayo Clinic, Jacksonville, FL; Stroke Program (D.L.B.), Department of Neurology, University of Michigan Health System, Ann Arbor; Departments of Neurology and Public Health Sciences (B.B.W.), University of Virginia Health System, Charlottesville; Department of Neurology (S.L.S.), University of Florida College of Medicine, Jacksonville; Stroke Center (D.L.T.), Harborview Medical Center, University of Washington, Seattle; and University of Cincinnati College of Medicine (M.L.F., S.R.M., R.D., D.W.), OH
| | - Lennox P Chitsike
- From the Center for Human Genetic Research (G.J.F., F.R., H.B.B., T.W.K.B., W.J.D., V.V., M.R.R., L.P.C., A.M.A., K.S., A.V., S.M.G., A.B., J.R., C.D.A.), J. Philip Kistler Stroke Research Center (G.J.F., F.R., H.B.B., T.W.K.B., W.J.D., V.V., M.R.R., A.B., J.R., C.D.A.), Division of Neurocritical Care and Emergency Neurology, Department of Neurology (G.J.F., F.R., H.B.B., T.W.K.B., W.J.D., M.R.R., A.B., J.R., C.D.A.), and Department of Emergency Medicine (J.N.G.), Massachusetts General Hospital, Boston; Program in Medical and Population Genetics (G.J.F., F.R., H.B.B., T.W.K.B., W.J.D., M.R.R., A.B., J.R., C.D.A.), Broad Institute, Cambridge, MA; Department of Epidemiology (G.J.F., P.K.), Harvard School of Public Health, Boston; Department of Neurology (M.S.), Beth Israel Deaconess Medical Center, Boston, MA; Department of Neurology (J.F.M.), Mayo Clinic, Jacksonville, FL; Stroke Program (D.L.B.), Department of Neurology, University of Michigan Health System, Ann Arbor; Departments of Neurology and Public Health Sciences (B.B.W.), University of Virginia Health System, Charlottesville; Department of Neurology (S.L.S.), University of Florida College of Medicine, Jacksonville; Stroke Center (D.L.T.), Harborview Medical Center, University of Washington, Seattle; and University of Cincinnati College of Medicine (M.L.F., S.R.M., R.D., D.W.), OH
| | - Alison M Ayres
- From the Center for Human Genetic Research (G.J.F., F.R., H.B.B., T.W.K.B., W.J.D., V.V., M.R.R., L.P.C., A.M.A., K.S., A.V., S.M.G., A.B., J.R., C.D.A.), J. Philip Kistler Stroke Research Center (G.J.F., F.R., H.B.B., T.W.K.B., W.J.D., V.V., M.R.R., A.B., J.R., C.D.A.), Division of Neurocritical Care and Emergency Neurology, Department of Neurology (G.J.F., F.R., H.B.B., T.W.K.B., W.J.D., M.R.R., A.B., J.R., C.D.A.), and Department of Emergency Medicine (J.N.G.), Massachusetts General Hospital, Boston; Program in Medical and Population Genetics (G.J.F., F.R., H.B.B., T.W.K.B., W.J.D., M.R.R., A.B., J.R., C.D.A.), Broad Institute, Cambridge, MA; Department of Epidemiology (G.J.F., P.K.), Harvard School of Public Health, Boston; Department of Neurology (M.S.), Beth Israel Deaconess Medical Center, Boston, MA; Department of Neurology (J.F.M.), Mayo Clinic, Jacksonville, FL; Stroke Program (D.L.B.), Department of Neurology, University of Michigan Health System, Ann Arbor; Departments of Neurology and Public Health Sciences (B.B.W.), University of Virginia Health System, Charlottesville; Department of Neurology (S.L.S.), University of Florida College of Medicine, Jacksonville; Stroke Center (D.L.T.), Harborview Medical Center, University of Washington, Seattle; and University of Cincinnati College of Medicine (M.L.F., S.R.M., R.D., D.W.), OH
| | - Kristin Schwab
- From the Center for Human Genetic Research (G.J.F., F.R., H.B.B., T.W.K.B., W.J.D., V.V., M.R.R., L.P.C., A.M.A., K.S., A.V., S.M.G., A.B., J.R., C.D.A.), J. Philip Kistler Stroke Research Center (G.J.F., F.R., H.B.B., T.W.K.B., W.J.D., V.V., M.R.R., A.B., J.R., C.D.A.), Division of Neurocritical Care and Emergency Neurology, Department of Neurology (G.J.F., F.R., H.B.B., T.W.K.B., W.J.D., M.R.R., A.B., J.R., C.D.A.), and Department of Emergency Medicine (J.N.G.), Massachusetts General Hospital, Boston; Program in Medical and Population Genetics (G.J.F., F.R., H.B.B., T.W.K.B., W.J.D., M.R.R., A.B., J.R., C.D.A.), Broad Institute, Cambridge, MA; Department of Epidemiology (G.J.F., P.K.), Harvard School of Public Health, Boston; Department of Neurology (M.S.), Beth Israel Deaconess Medical Center, Boston, MA; Department of Neurology (J.F.M.), Mayo Clinic, Jacksonville, FL; Stroke Program (D.L.B.), Department of Neurology, University of Michigan Health System, Ann Arbor; Departments of Neurology and Public Health Sciences (B.B.W.), University of Virginia Health System, Charlottesville; Department of Neurology (S.L.S.), University of Florida College of Medicine, Jacksonville; Stroke Center (D.L.T.), Harborview Medical Center, University of Washington, Seattle; and University of Cincinnati College of Medicine (M.L.F., S.R.M., R.D., D.W.), OH
| | - Joshua N Goldstein
- From the Center for Human Genetic Research (G.J.F., F.R., H.B.B., T.W.K.B., W.J.D., V.V., M.R.R., L.P.C., A.M.A., K.S., A.V., S.M.G., A.B., J.R., C.D.A.), J. Philip Kistler Stroke Research Center (G.J.F., F.R., H.B.B., T.W.K.B., W.J.D., V.V., M.R.R., A.B., J.R., C.D.A.), Division of Neurocritical Care and Emergency Neurology, Department of Neurology (G.J.F., F.R., H.B.B., T.W.K.B., W.J.D., M.R.R., A.B., J.R., C.D.A.), and Department of Emergency Medicine (J.N.G.), Massachusetts General Hospital, Boston; Program in Medical and Population Genetics (G.J.F., F.R., H.B.B., T.W.K.B., W.J.D., M.R.R., A.B., J.R., C.D.A.), Broad Institute, Cambridge, MA; Department of Epidemiology (G.J.F., P.K.), Harvard School of Public Health, Boston; Department of Neurology (M.S.), Beth Israel Deaconess Medical Center, Boston, MA; Department of Neurology (J.F.M.), Mayo Clinic, Jacksonville, FL; Stroke Program (D.L.B.), Department of Neurology, University of Michigan Health System, Ann Arbor; Departments of Neurology and Public Health Sciences (B.B.W.), University of Virginia Health System, Charlottesville; Department of Neurology (S.L.S.), University of Florida College of Medicine, Jacksonville; Stroke Center (D.L.T.), Harborview Medical Center, University of Washington, Seattle; and University of Cincinnati College of Medicine (M.L.F., S.R.M., R.D., D.W.), OH
| | - Anand Viswanathan
- From the Center for Human Genetic Research (G.J.F., F.R., H.B.B., T.W.K.B., W.J.D., V.V., M.R.R., L.P.C., A.M.A., K.S., A.V., S.M.G., A.B., J.R., C.D.A.), J. Philip Kistler Stroke Research Center (G.J.F., F.R., H.B.B., T.W.K.B., W.J.D., V.V., M.R.R., A.B., J.R., C.D.A.), Division of Neurocritical Care and Emergency Neurology, Department of Neurology (G.J.F., F.R., H.B.B., T.W.K.B., W.J.D., M.R.R., A.B., J.R., C.D.A.), and Department of Emergency Medicine (J.N.G.), Massachusetts General Hospital, Boston; Program in Medical and Population Genetics (G.J.F., F.R., H.B.B., T.W.K.B., W.J.D., M.R.R., A.B., J.R., C.D.A.), Broad Institute, Cambridge, MA; Department of Epidemiology (G.J.F., P.K.), Harvard School of Public Health, Boston; Department of Neurology (M.S.), Beth Israel Deaconess Medical Center, Boston, MA; Department of Neurology (J.F.M.), Mayo Clinic, Jacksonville, FL; Stroke Program (D.L.B.), Department of Neurology, University of Michigan Health System, Ann Arbor; Departments of Neurology and Public Health Sciences (B.B.W.), University of Virginia Health System, Charlottesville; Department of Neurology (S.L.S.), University of Florida College of Medicine, Jacksonville; Stroke Center (D.L.T.), Harborview Medical Center, University of Washington, Seattle; and University of Cincinnati College of Medicine (M.L.F., S.R.M., R.D., D.W.), OH
| | - Steven M Greenberg
- From the Center for Human Genetic Research (G.J.F., F.R., H.B.B., T.W.K.B., W.J.D., V.V., M.R.R., L.P.C., A.M.A., K.S., A.V., S.M.G., A.B., J.R., C.D.A.), J. Philip Kistler Stroke Research Center (G.J.F., F.R., H.B.B., T.W.K.B., W.J.D., V.V., M.R.R., A.B., J.R., C.D.A.), Division of Neurocritical Care and Emergency Neurology, Department of Neurology (G.J.F., F.R., H.B.B., T.W.K.B., W.J.D., M.R.R., A.B., J.R., C.D.A.), and Department of Emergency Medicine (J.N.G.), Massachusetts General Hospital, Boston; Program in Medical and Population Genetics (G.J.F., F.R., H.B.B., T.W.K.B., W.J.D., M.R.R., A.B., J.R., C.D.A.), Broad Institute, Cambridge, MA; Department of Epidemiology (G.J.F., P.K.), Harvard School of Public Health, Boston; Department of Neurology (M.S.), Beth Israel Deaconess Medical Center, Boston, MA; Department of Neurology (J.F.M.), Mayo Clinic, Jacksonville, FL; Stroke Program (D.L.B.), Department of Neurology, University of Michigan Health System, Ann Arbor; Departments of Neurology and Public Health Sciences (B.B.W.), University of Virginia Health System, Charlottesville; Department of Neurology (S.L.S.), University of Florida College of Medicine, Jacksonville; Stroke Center (D.L.T.), Harborview Medical Center, University of Washington, Seattle; and University of Cincinnati College of Medicine (M.L.F., S.R.M., R.D., D.W.), OH
| | - Magdy Selim
- From the Center for Human Genetic Research (G.J.F., F.R., H.B.B., T.W.K.B., W.J.D., V.V., M.R.R., L.P.C., A.M.A., K.S., A.V., S.M.G., A.B., J.R., C.D.A.), J. Philip Kistler Stroke Research Center (G.J.F., F.R., H.B.B., T.W.K.B., W.J.D., V.V., M.R.R., A.B., J.R., C.D.A.), Division of Neurocritical Care and Emergency Neurology, Department of Neurology (G.J.F., F.R., H.B.B., T.W.K.B., W.J.D., M.R.R., A.B., J.R., C.D.A.), and Department of Emergency Medicine (J.N.G.), Massachusetts General Hospital, Boston; Program in Medical and Population Genetics (G.J.F., F.R., H.B.B., T.W.K.B., W.J.D., M.R.R., A.B., J.R., C.D.A.), Broad Institute, Cambridge, MA; Department of Epidemiology (G.J.F., P.K.), Harvard School of Public Health, Boston; Department of Neurology (M.S.), Beth Israel Deaconess Medical Center, Boston, MA; Department of Neurology (J.F.M.), Mayo Clinic, Jacksonville, FL; Stroke Program (D.L.B.), Department of Neurology, University of Michigan Health System, Ann Arbor; Departments of Neurology and Public Health Sciences (B.B.W.), University of Virginia Health System, Charlottesville; Department of Neurology (S.L.S.), University of Florida College of Medicine, Jacksonville; Stroke Center (D.L.T.), Harborview Medical Center, University of Washington, Seattle; and University of Cincinnati College of Medicine (M.L.F., S.R.M., R.D., D.W.), OH
| | - James F Meschia
- From the Center for Human Genetic Research (G.J.F., F.R., H.B.B., T.W.K.B., W.J.D., V.V., M.R.R., L.P.C., A.M.A., K.S., A.V., S.M.G., A.B., J.R., C.D.A.), J. Philip Kistler Stroke Research Center (G.J.F., F.R., H.B.B., T.W.K.B., W.J.D., V.V., M.R.R., A.B., J.R., C.D.A.), Division of Neurocritical Care and Emergency Neurology, Department of Neurology (G.J.F., F.R., H.B.B., T.W.K.B., W.J.D., M.R.R., A.B., J.R., C.D.A.), and Department of Emergency Medicine (J.N.G.), Massachusetts General Hospital, Boston; Program in Medical and Population Genetics (G.J.F., F.R., H.B.B., T.W.K.B., W.J.D., M.R.R., A.B., J.R., C.D.A.), Broad Institute, Cambridge, MA; Department of Epidemiology (G.J.F., P.K.), Harvard School of Public Health, Boston; Department of Neurology (M.S.), Beth Israel Deaconess Medical Center, Boston, MA; Department of Neurology (J.F.M.), Mayo Clinic, Jacksonville, FL; Stroke Program (D.L.B.), Department of Neurology, University of Michigan Health System, Ann Arbor; Departments of Neurology and Public Health Sciences (B.B.W.), University of Virginia Health System, Charlottesville; Department of Neurology (S.L.S.), University of Florida College of Medicine, Jacksonville; Stroke Center (D.L.T.), Harborview Medical Center, University of Washington, Seattle; and University of Cincinnati College of Medicine (M.L.F., S.R.M., R.D., D.W.), OH
| | - Devin L Brown
- From the Center for Human Genetic Research (G.J.F., F.R., H.B.B., T.W.K.B., W.J.D., V.V., M.R.R., L.P.C., A.M.A., K.S., A.V., S.M.G., A.B., J.R., C.D.A.), J. Philip Kistler Stroke Research Center (G.J.F., F.R., H.B.B., T.W.K.B., W.J.D., V.V., M.R.R., A.B., J.R., C.D.A.), Division of Neurocritical Care and Emergency Neurology, Department of Neurology (G.J.F., F.R., H.B.B., T.W.K.B., W.J.D., M.R.R., A.B., J.R., C.D.A.), and Department of Emergency Medicine (J.N.G.), Massachusetts General Hospital, Boston; Program in Medical and Population Genetics (G.J.F., F.R., H.B.B., T.W.K.B., W.J.D., M.R.R., A.B., J.R., C.D.A.), Broad Institute, Cambridge, MA; Department of Epidemiology (G.J.F., P.K.), Harvard School of Public Health, Boston; Department of Neurology (M.S.), Beth Israel Deaconess Medical Center, Boston, MA; Department of Neurology (J.F.M.), Mayo Clinic, Jacksonville, FL; Stroke Program (D.L.B.), Department of Neurology, University of Michigan Health System, Ann Arbor; Departments of Neurology and Public Health Sciences (B.B.W.), University of Virginia Health System, Charlottesville; Department of Neurology (S.L.S.), University of Florida College of Medicine, Jacksonville; Stroke Center (D.L.T.), Harborview Medical Center, University of Washington, Seattle; and University of Cincinnati College of Medicine (M.L.F., S.R.M., R.D., D.W.), OH
| | - Bradford B Worrall
- From the Center for Human Genetic Research (G.J.F., F.R., H.B.B., T.W.K.B., W.J.D., V.V., M.R.R., L.P.C., A.M.A., K.S., A.V., S.M.G., A.B., J.R., C.D.A.), J. Philip Kistler Stroke Research Center (G.J.F., F.R., H.B.B., T.W.K.B., W.J.D., V.V., M.R.R., A.B., J.R., C.D.A.), Division of Neurocritical Care and Emergency Neurology, Department of Neurology (G.J.F., F.R., H.B.B., T.W.K.B., W.J.D., M.R.R., A.B., J.R., C.D.A.), and Department of Emergency Medicine (J.N.G.), Massachusetts General Hospital, Boston; Program in Medical and Population Genetics (G.J.F., F.R., H.B.B., T.W.K.B., W.J.D., M.R.R., A.B., J.R., C.D.A.), Broad Institute, Cambridge, MA; Department of Epidemiology (G.J.F., P.K.), Harvard School of Public Health, Boston; Department of Neurology (M.S.), Beth Israel Deaconess Medical Center, Boston, MA; Department of Neurology (J.F.M.), Mayo Clinic, Jacksonville, FL; Stroke Program (D.L.B.), Department of Neurology, University of Michigan Health System, Ann Arbor; Departments of Neurology and Public Health Sciences (B.B.W.), University of Virginia Health System, Charlottesville; Department of Neurology (S.L.S.), University of Florida College of Medicine, Jacksonville; Stroke Center (D.L.T.), Harborview Medical Center, University of Washington, Seattle; and University of Cincinnati College of Medicine (M.L.F., S.R.M., R.D., D.W.), OH
| | - Scott L Silliman
- From the Center for Human Genetic Research (G.J.F., F.R., H.B.B., T.W.K.B., W.J.D., V.V., M.R.R., L.P.C., A.M.A., K.S., A.V., S.M.G., A.B., J.R., C.D.A.), J. Philip Kistler Stroke Research Center (G.J.F., F.R., H.B.B., T.W.K.B., W.J.D., V.V., M.R.R., A.B., J.R., C.D.A.), Division of Neurocritical Care and Emergency Neurology, Department of Neurology (G.J.F., F.R., H.B.B., T.W.K.B., W.J.D., M.R.R., A.B., J.R., C.D.A.), and Department of Emergency Medicine (J.N.G.), Massachusetts General Hospital, Boston; Program in Medical and Population Genetics (G.J.F., F.R., H.B.B., T.W.K.B., W.J.D., M.R.R., A.B., J.R., C.D.A.), Broad Institute, Cambridge, MA; Department of Epidemiology (G.J.F., P.K.), Harvard School of Public Health, Boston; Department of Neurology (M.S.), Beth Israel Deaconess Medical Center, Boston, MA; Department of Neurology (J.F.M.), Mayo Clinic, Jacksonville, FL; Stroke Program (D.L.B.), Department of Neurology, University of Michigan Health System, Ann Arbor; Departments of Neurology and Public Health Sciences (B.B.W.), University of Virginia Health System, Charlottesville; Department of Neurology (S.L.S.), University of Florida College of Medicine, Jacksonville; Stroke Center (D.L.T.), Harborview Medical Center, University of Washington, Seattle; and University of Cincinnati College of Medicine (M.L.F., S.R.M., R.D., D.W.), OH
| | - David L Tirschwell
- From the Center for Human Genetic Research (G.J.F., F.R., H.B.B., T.W.K.B., W.J.D., V.V., M.R.R., L.P.C., A.M.A., K.S., A.V., S.M.G., A.B., J.R., C.D.A.), J. Philip Kistler Stroke Research Center (G.J.F., F.R., H.B.B., T.W.K.B., W.J.D., V.V., M.R.R., A.B., J.R., C.D.A.), Division of Neurocritical Care and Emergency Neurology, Department of Neurology (G.J.F., F.R., H.B.B., T.W.K.B., W.J.D., M.R.R., A.B., J.R., C.D.A.), and Department of Emergency Medicine (J.N.G.), Massachusetts General Hospital, Boston; Program in Medical and Population Genetics (G.J.F., F.R., H.B.B., T.W.K.B., W.J.D., M.R.R., A.B., J.R., C.D.A.), Broad Institute, Cambridge, MA; Department of Epidemiology (G.J.F., P.K.), Harvard School of Public Health, Boston; Department of Neurology (M.S.), Beth Israel Deaconess Medical Center, Boston, MA; Department of Neurology (J.F.M.), Mayo Clinic, Jacksonville, FL; Stroke Program (D.L.B.), Department of Neurology, University of Michigan Health System, Ann Arbor; Departments of Neurology and Public Health Sciences (B.B.W.), University of Virginia Health System, Charlottesville; Department of Neurology (S.L.S.), University of Florida College of Medicine, Jacksonville; Stroke Center (D.L.T.), Harborview Medical Center, University of Washington, Seattle; and University of Cincinnati College of Medicine (M.L.F., S.R.M., R.D., D.W.), OH
| | - Matthew L Flaherty
- From the Center for Human Genetic Research (G.J.F., F.R., H.B.B., T.W.K.B., W.J.D., V.V., M.R.R., L.P.C., A.M.A., K.S., A.V., S.M.G., A.B., J.R., C.D.A.), J. Philip Kistler Stroke Research Center (G.J.F., F.R., H.B.B., T.W.K.B., W.J.D., V.V., M.R.R., A.B., J.R., C.D.A.), Division of Neurocritical Care and Emergency Neurology, Department of Neurology (G.J.F., F.R., H.B.B., T.W.K.B., W.J.D., M.R.R., A.B., J.R., C.D.A.), and Department of Emergency Medicine (J.N.G.), Massachusetts General Hospital, Boston; Program in Medical and Population Genetics (G.J.F., F.R., H.B.B., T.W.K.B., W.J.D., M.R.R., A.B., J.R., C.D.A.), Broad Institute, Cambridge, MA; Department of Epidemiology (G.J.F., P.K.), Harvard School of Public Health, Boston; Department of Neurology (M.S.), Beth Israel Deaconess Medical Center, Boston, MA; Department of Neurology (J.F.M.), Mayo Clinic, Jacksonville, FL; Stroke Program (D.L.B.), Department of Neurology, University of Michigan Health System, Ann Arbor; Departments of Neurology and Public Health Sciences (B.B.W.), University of Virginia Health System, Charlottesville; Department of Neurology (S.L.S.), University of Florida College of Medicine, Jacksonville; Stroke Center (D.L.T.), Harborview Medical Center, University of Washington, Seattle; and University of Cincinnati College of Medicine (M.L.F., S.R.M., R.D., D.W.), OH
| | - Sharyl R Martini
- From the Center for Human Genetic Research (G.J.F., F.R., H.B.B., T.W.K.B., W.J.D., V.V., M.R.R., L.P.C., A.M.A., K.S., A.V., S.M.G., A.B., J.R., C.D.A.), J. Philip Kistler Stroke Research Center (G.J.F., F.R., H.B.B., T.W.K.B., W.J.D., V.V., M.R.R., A.B., J.R., C.D.A.), Division of Neurocritical Care and Emergency Neurology, Department of Neurology (G.J.F., F.R., H.B.B., T.W.K.B., W.J.D., M.R.R., A.B., J.R., C.D.A.), and Department of Emergency Medicine (J.N.G.), Massachusetts General Hospital, Boston; Program in Medical and Population Genetics (G.J.F., F.R., H.B.B., T.W.K.B., W.J.D., M.R.R., A.B., J.R., C.D.A.), Broad Institute, Cambridge, MA; Department of Epidemiology (G.J.F., P.K.), Harvard School of Public Health, Boston; Department of Neurology (M.S.), Beth Israel Deaconess Medical Center, Boston, MA; Department of Neurology (J.F.M.), Mayo Clinic, Jacksonville, FL; Stroke Program (D.L.B.), Department of Neurology, University of Michigan Health System, Ann Arbor; Departments of Neurology and Public Health Sciences (B.B.W.), University of Virginia Health System, Charlottesville; Department of Neurology (S.L.S.), University of Florida College of Medicine, Jacksonville; Stroke Center (D.L.T.), Harborview Medical Center, University of Washington, Seattle; and University of Cincinnati College of Medicine (M.L.F., S.R.M., R.D., D.W.), OH
| | - Ranjan Deka
- From the Center for Human Genetic Research (G.J.F., F.R., H.B.B., T.W.K.B., W.J.D., V.V., M.R.R., L.P.C., A.M.A., K.S., A.V., S.M.G., A.B., J.R., C.D.A.), J. Philip Kistler Stroke Research Center (G.J.F., F.R., H.B.B., T.W.K.B., W.J.D., V.V., M.R.R., A.B., J.R., C.D.A.), Division of Neurocritical Care and Emergency Neurology, Department of Neurology (G.J.F., F.R., H.B.B., T.W.K.B., W.J.D., M.R.R., A.B., J.R., C.D.A.), and Department of Emergency Medicine (J.N.G.), Massachusetts General Hospital, Boston; Program in Medical and Population Genetics (G.J.F., F.R., H.B.B., T.W.K.B., W.J.D., M.R.R., A.B., J.R., C.D.A.), Broad Institute, Cambridge, MA; Department of Epidemiology (G.J.F., P.K.), Harvard School of Public Health, Boston; Department of Neurology (M.S.), Beth Israel Deaconess Medical Center, Boston, MA; Department of Neurology (J.F.M.), Mayo Clinic, Jacksonville, FL; Stroke Program (D.L.B.), Department of Neurology, University of Michigan Health System, Ann Arbor; Departments of Neurology and Public Health Sciences (B.B.W.), University of Virginia Health System, Charlottesville; Department of Neurology (S.L.S.), University of Florida College of Medicine, Jacksonville; Stroke Center (D.L.T.), Harborview Medical Center, University of Washington, Seattle; and University of Cincinnati College of Medicine (M.L.F., S.R.M., R.D., D.W.), OH
| | - Alessandro Biffi
- From the Center for Human Genetic Research (G.J.F., F.R., H.B.B., T.W.K.B., W.J.D., V.V., M.R.R., L.P.C., A.M.A., K.S., A.V., S.M.G., A.B., J.R., C.D.A.), J. Philip Kistler Stroke Research Center (G.J.F., F.R., H.B.B., T.W.K.B., W.J.D., V.V., M.R.R., A.B., J.R., C.D.A.), Division of Neurocritical Care and Emergency Neurology, Department of Neurology (G.J.F., F.R., H.B.B., T.W.K.B., W.J.D., M.R.R., A.B., J.R., C.D.A.), and Department of Emergency Medicine (J.N.G.), Massachusetts General Hospital, Boston; Program in Medical and Population Genetics (G.J.F., F.R., H.B.B., T.W.K.B., W.J.D., M.R.R., A.B., J.R., C.D.A.), Broad Institute, Cambridge, MA; Department of Epidemiology (G.J.F., P.K.), Harvard School of Public Health, Boston; Department of Neurology (M.S.), Beth Israel Deaconess Medical Center, Boston, MA; Department of Neurology (J.F.M.), Mayo Clinic, Jacksonville, FL; Stroke Program (D.L.B.), Department of Neurology, University of Michigan Health System, Ann Arbor; Departments of Neurology and Public Health Sciences (B.B.W.), University of Virginia Health System, Charlottesville; Department of Neurology (S.L.S.), University of Florida College of Medicine, Jacksonville; Stroke Center (D.L.T.), Harborview Medical Center, University of Washington, Seattle; and University of Cincinnati College of Medicine (M.L.F., S.R.M., R.D., D.W.), OH
| | - Peter Kraft
- From the Center for Human Genetic Research (G.J.F., F.R., H.B.B., T.W.K.B., W.J.D., V.V., M.R.R., L.P.C., A.M.A., K.S., A.V., S.M.G., A.B., J.R., C.D.A.), J. Philip Kistler Stroke Research Center (G.J.F., F.R., H.B.B., T.W.K.B., W.J.D., V.V., M.R.R., A.B., J.R., C.D.A.), Division of Neurocritical Care and Emergency Neurology, Department of Neurology (G.J.F., F.R., H.B.B., T.W.K.B., W.J.D., M.R.R., A.B., J.R., C.D.A.), and Department of Emergency Medicine (J.N.G.), Massachusetts General Hospital, Boston; Program in Medical and Population Genetics (G.J.F., F.R., H.B.B., T.W.K.B., W.J.D., M.R.R., A.B., J.R., C.D.A.), Broad Institute, Cambridge, MA; Department of Epidemiology (G.J.F., P.K.), Harvard School of Public Health, Boston; Department of Neurology (M.S.), Beth Israel Deaconess Medical Center, Boston, MA; Department of Neurology (J.F.M.), Mayo Clinic, Jacksonville, FL; Stroke Program (D.L.B.), Department of Neurology, University of Michigan Health System, Ann Arbor; Departments of Neurology and Public Health Sciences (B.B.W.), University of Virginia Health System, Charlottesville; Department of Neurology (S.L.S.), University of Florida College of Medicine, Jacksonville; Stroke Center (D.L.T.), Harborview Medical Center, University of Washington, Seattle; and University of Cincinnati College of Medicine (M.L.F., S.R.M., R.D., D.W.), OH
| | - Daniel Woo
- From the Center for Human Genetic Research (G.J.F., F.R., H.B.B., T.W.K.B., W.J.D., V.V., M.R.R., L.P.C., A.M.A., K.S., A.V., S.M.G., A.B., J.R., C.D.A.), J. Philip Kistler Stroke Research Center (G.J.F., F.R., H.B.B., T.W.K.B., W.J.D., V.V., M.R.R., A.B., J.R., C.D.A.), Division of Neurocritical Care and Emergency Neurology, Department of Neurology (G.J.F., F.R., H.B.B., T.W.K.B., W.J.D., M.R.R., A.B., J.R., C.D.A.), and Department of Emergency Medicine (J.N.G.), Massachusetts General Hospital, Boston; Program in Medical and Population Genetics (G.J.F., F.R., H.B.B., T.W.K.B., W.J.D., M.R.R., A.B., J.R., C.D.A.), Broad Institute, Cambridge, MA; Department of Epidemiology (G.J.F., P.K.), Harvard School of Public Health, Boston; Department of Neurology (M.S.), Beth Israel Deaconess Medical Center, Boston, MA; Department of Neurology (J.F.M.), Mayo Clinic, Jacksonville, FL; Stroke Program (D.L.B.), Department of Neurology, University of Michigan Health System, Ann Arbor; Departments of Neurology and Public Health Sciences (B.B.W.), University of Virginia Health System, Charlottesville; Department of Neurology (S.L.S.), University of Florida College of Medicine, Jacksonville; Stroke Center (D.L.T.), Harborview Medical Center, University of Washington, Seattle; and University of Cincinnati College of Medicine (M.L.F., S.R.M., R.D., D.W.), OH
| | - Jonathan Rosand
- From the Center for Human Genetic Research (G.J.F., F.R., H.B.B., T.W.K.B., W.J.D., V.V., M.R.R., L.P.C., A.M.A., K.S., A.V., S.M.G., A.B., J.R., C.D.A.), J. Philip Kistler Stroke Research Center (G.J.F., F.R., H.B.B., T.W.K.B., W.J.D., V.V., M.R.R., A.B., J.R., C.D.A.), Division of Neurocritical Care and Emergency Neurology, Department of Neurology (G.J.F., F.R., H.B.B., T.W.K.B., W.J.D., M.R.R., A.B., J.R., C.D.A.), and Department of Emergency Medicine (J.N.G.), Massachusetts General Hospital, Boston; Program in Medical and Population Genetics (G.J.F., F.R., H.B.B., T.W.K.B., W.J.D., M.R.R., A.B., J.R., C.D.A.), Broad Institute, Cambridge, MA; Department of Epidemiology (G.J.F., P.K.), Harvard School of Public Health, Boston; Department of Neurology (M.S.), Beth Israel Deaconess Medical Center, Boston, MA; Department of Neurology (J.F.M.), Mayo Clinic, Jacksonville, FL; Stroke Program (D.L.B.), Department of Neurology, University of Michigan Health System, Ann Arbor; Departments of Neurology and Public Health Sciences (B.B.W.), University of Virginia Health System, Charlottesville; Department of Neurology (S.L.S.), University of Florida College of Medicine, Jacksonville; Stroke Center (D.L.T.), Harborview Medical Center, University of Washington, Seattle; and University of Cincinnati College of Medicine (M.L.F., S.R.M., R.D., D.W.), OH
| | - Christopher D Anderson
- From the Center for Human Genetic Research (G.J.F., F.R., H.B.B., T.W.K.B., W.J.D., V.V., M.R.R., L.P.C., A.M.A., K.S., A.V., S.M.G., A.B., J.R., C.D.A.), J. Philip Kistler Stroke Research Center (G.J.F., F.R., H.B.B., T.W.K.B., W.J.D., V.V., M.R.R., A.B., J.R., C.D.A.), Division of Neurocritical Care and Emergency Neurology, Department of Neurology (G.J.F., F.R., H.B.B., T.W.K.B., W.J.D., M.R.R., A.B., J.R., C.D.A.), and Department of Emergency Medicine (J.N.G.), Massachusetts General Hospital, Boston; Program in Medical and Population Genetics (G.J.F., F.R., H.B.B., T.W.K.B., W.J.D., M.R.R., A.B., J.R., C.D.A.), Broad Institute, Cambridge, MA; Department of Epidemiology (G.J.F., P.K.), Harvard School of Public Health, Boston; Department of Neurology (M.S.), Beth Israel Deaconess Medical Center, Boston, MA; Department of Neurology (J.F.M.), Mayo Clinic, Jacksonville, FL; Stroke Program (D.L.B.), Department of Neurology, University of Michigan Health System, Ann Arbor; Departments of Neurology and Public Health Sciences (B.B.W.), University of Virginia Health System, Charlottesville; Department of Neurology (S.L.S.), University of Florida College of Medicine, Jacksonville; Stroke Center (D.L.T.), Harborview Medical Center, University of Washington, Seattle; and University of Cincinnati College of Medicine (M.L.F., S.R.M., R.D., D.W.), OH.
| | | |
Collapse
|
23
|
Brouwers HB, Raffeld MR, van Nieuwenhuizen KM, Falcone GJ, Ayres AM, McNamara KA, Schwab K, Romero JM, Velthuis BK, Viswanathan A, Greenberg SM, Ogilvy CS, van der Zwan A, Rinkel GJE, Goldstein JN, Klijn CJM, Rosand J. CT angiography spot sign in intracerebral hemorrhage predicts active bleeding during surgery. Neurology 2014; 83:883-9. [PMID: 25098540 DOI: 10.1212/wnl.0000000000000747] [Citation(s) in RCA: 45] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
OBJECTIVE To determine whether the CT angiography (CTA) spot sign marks bleeding complications during and after surgery for spontaneous intracerebral hemorrhage (ICH). METHODS In a 2-center study of consecutive spontaneous ICH patients who underwent CTA followed by surgical hematoma evacuation, 2 experienced readers (blinded to clinical and surgical data) reviewed CTAs for spot sign presence. Blinded raters assessed active intraoperative and postoperative bleeding. The association between spot sign and active intraoperative bleeding, postoperative rebleeding, and residual ICH volumes was evaluated using univariable and multivariable logistic regression. RESULTS A total of 95 patients met inclusion criteria: 44 lobar, 17 deep, 33 cerebellar, and 1 brainstem ICH; ≥1 spot sign was identified in 32 patients (34%). The spot sign was the only independent marker of active bleeding during surgery (odds ratio [OR] 3.4; 95% confidence interval [CI] 1.3-9.0). Spot sign (OR 4.1; 95% CI 1.1-17), female sex (OR 6.9; 95% CI 1.7-37), and antiplatelet use (OR 4.6; 95% CI 1.2-21) were predictive of postoperative rebleeding. Larger residual hematomas and postoperative rebleeding were associated with higher discharge case fatality (OR 3.4; 95% CI 1.1-11) and a trend toward increased case fatality at 3 months (OR 2.9; 95% CI 0.9-8.8). CONCLUSIONS The CTA spot sign is associated with more intraoperative bleeding, more postoperative rebleeding, and larger residual ICH volumes in patients undergoing hematoma evacuation for spontaneous ICH. The spot sign may therefore be useful to select patients for future surgical trials.
Collapse
Affiliation(s)
- H Bart Brouwers
- From the Center for Human Genetic Research (H.B.B., M.R.R., G.J.F., J.R.) and the Departments of Neurology, Neurosurgery, Radiology, and Emergency Medicine (H.B.B., M.R.R., G.J.F., A.M.A., K.A.M., K.S., J.M.R., A.V., S.M.G., C.S.O., J.N.G., J.R.), Massachusetts General Hospital, Harvard Medical School, Boston; and the Department of Neurology & Neurosurgery, Brain Center Rudolf Magnus, and Department of Radiology (H.B.B., K.M.v.N., B.K.V., A.v.d.Z., G.J.E.R., C.J.M.K.), University Medical Center Utrecht, Utrecht University, the Netherlands.
| | - Miriam R Raffeld
- From the Center for Human Genetic Research (H.B.B., M.R.R., G.J.F., J.R.) and the Departments of Neurology, Neurosurgery, Radiology, and Emergency Medicine (H.B.B., M.R.R., G.J.F., A.M.A., K.A.M., K.S., J.M.R., A.V., S.M.G., C.S.O., J.N.G., J.R.), Massachusetts General Hospital, Harvard Medical School, Boston; and the Department of Neurology & Neurosurgery, Brain Center Rudolf Magnus, and Department of Radiology (H.B.B., K.M.v.N., B.K.V., A.v.d.Z., G.J.E.R., C.J.M.K.), University Medical Center Utrecht, Utrecht University, the Netherlands
| | - Koen M van Nieuwenhuizen
- From the Center for Human Genetic Research (H.B.B., M.R.R., G.J.F., J.R.) and the Departments of Neurology, Neurosurgery, Radiology, and Emergency Medicine (H.B.B., M.R.R., G.J.F., A.M.A., K.A.M., K.S., J.M.R., A.V., S.M.G., C.S.O., J.N.G., J.R.), Massachusetts General Hospital, Harvard Medical School, Boston; and the Department of Neurology & Neurosurgery, Brain Center Rudolf Magnus, and Department of Radiology (H.B.B., K.M.v.N., B.K.V., A.v.d.Z., G.J.E.R., C.J.M.K.), University Medical Center Utrecht, Utrecht University, the Netherlands
| | - Guido J Falcone
- From the Center for Human Genetic Research (H.B.B., M.R.R., G.J.F., J.R.) and the Departments of Neurology, Neurosurgery, Radiology, and Emergency Medicine (H.B.B., M.R.R., G.J.F., A.M.A., K.A.M., K.S., J.M.R., A.V., S.M.G., C.S.O., J.N.G., J.R.), Massachusetts General Hospital, Harvard Medical School, Boston; and the Department of Neurology & Neurosurgery, Brain Center Rudolf Magnus, and Department of Radiology (H.B.B., K.M.v.N., B.K.V., A.v.d.Z., G.J.E.R., C.J.M.K.), University Medical Center Utrecht, Utrecht University, the Netherlands
| | - Alison M Ayres
- From the Center for Human Genetic Research (H.B.B., M.R.R., G.J.F., J.R.) and the Departments of Neurology, Neurosurgery, Radiology, and Emergency Medicine (H.B.B., M.R.R., G.J.F., A.M.A., K.A.M., K.S., J.M.R., A.V., S.M.G., C.S.O., J.N.G., J.R.), Massachusetts General Hospital, Harvard Medical School, Boston; and the Department of Neurology & Neurosurgery, Brain Center Rudolf Magnus, and Department of Radiology (H.B.B., K.M.v.N., B.K.V., A.v.d.Z., G.J.E.R., C.J.M.K.), University Medical Center Utrecht, Utrecht University, the Netherlands
| | - Kristen A McNamara
- From the Center for Human Genetic Research (H.B.B., M.R.R., G.J.F., J.R.) and the Departments of Neurology, Neurosurgery, Radiology, and Emergency Medicine (H.B.B., M.R.R., G.J.F., A.M.A., K.A.M., K.S., J.M.R., A.V., S.M.G., C.S.O., J.N.G., J.R.), Massachusetts General Hospital, Harvard Medical School, Boston; and the Department of Neurology & Neurosurgery, Brain Center Rudolf Magnus, and Department of Radiology (H.B.B., K.M.v.N., B.K.V., A.v.d.Z., G.J.E.R., C.J.M.K.), University Medical Center Utrecht, Utrecht University, the Netherlands
| | - Kristin Schwab
- From the Center for Human Genetic Research (H.B.B., M.R.R., G.J.F., J.R.) and the Departments of Neurology, Neurosurgery, Radiology, and Emergency Medicine (H.B.B., M.R.R., G.J.F., A.M.A., K.A.M., K.S., J.M.R., A.V., S.M.G., C.S.O., J.N.G., J.R.), Massachusetts General Hospital, Harvard Medical School, Boston; and the Department of Neurology & Neurosurgery, Brain Center Rudolf Magnus, and Department of Radiology (H.B.B., K.M.v.N., B.K.V., A.v.d.Z., G.J.E.R., C.J.M.K.), University Medical Center Utrecht, Utrecht University, the Netherlands
| | - Javier M Romero
- From the Center for Human Genetic Research (H.B.B., M.R.R., G.J.F., J.R.) and the Departments of Neurology, Neurosurgery, Radiology, and Emergency Medicine (H.B.B., M.R.R., G.J.F., A.M.A., K.A.M., K.S., J.M.R., A.V., S.M.G., C.S.O., J.N.G., J.R.), Massachusetts General Hospital, Harvard Medical School, Boston; and the Department of Neurology & Neurosurgery, Brain Center Rudolf Magnus, and Department of Radiology (H.B.B., K.M.v.N., B.K.V., A.v.d.Z., G.J.E.R., C.J.M.K.), University Medical Center Utrecht, Utrecht University, the Netherlands
| | - Birgitta K Velthuis
- From the Center for Human Genetic Research (H.B.B., M.R.R., G.J.F., J.R.) and the Departments of Neurology, Neurosurgery, Radiology, and Emergency Medicine (H.B.B., M.R.R., G.J.F., A.M.A., K.A.M., K.S., J.M.R., A.V., S.M.G., C.S.O., J.N.G., J.R.), Massachusetts General Hospital, Harvard Medical School, Boston; and the Department of Neurology & Neurosurgery, Brain Center Rudolf Magnus, and Department of Radiology (H.B.B., K.M.v.N., B.K.V., A.v.d.Z., G.J.E.R., C.J.M.K.), University Medical Center Utrecht, Utrecht University, the Netherlands
| | - Anand Viswanathan
- From the Center for Human Genetic Research (H.B.B., M.R.R., G.J.F., J.R.) and the Departments of Neurology, Neurosurgery, Radiology, and Emergency Medicine (H.B.B., M.R.R., G.J.F., A.M.A., K.A.M., K.S., J.M.R., A.V., S.M.G., C.S.O., J.N.G., J.R.), Massachusetts General Hospital, Harvard Medical School, Boston; and the Department of Neurology & Neurosurgery, Brain Center Rudolf Magnus, and Department of Radiology (H.B.B., K.M.v.N., B.K.V., A.v.d.Z., G.J.E.R., C.J.M.K.), University Medical Center Utrecht, Utrecht University, the Netherlands
| | - Steven M Greenberg
- From the Center for Human Genetic Research (H.B.B., M.R.R., G.J.F., J.R.) and the Departments of Neurology, Neurosurgery, Radiology, and Emergency Medicine (H.B.B., M.R.R., G.J.F., A.M.A., K.A.M., K.S., J.M.R., A.V., S.M.G., C.S.O., J.N.G., J.R.), Massachusetts General Hospital, Harvard Medical School, Boston; and the Department of Neurology & Neurosurgery, Brain Center Rudolf Magnus, and Department of Radiology (H.B.B., K.M.v.N., B.K.V., A.v.d.Z., G.J.E.R., C.J.M.K.), University Medical Center Utrecht, Utrecht University, the Netherlands
| | - Christopher S Ogilvy
- From the Center for Human Genetic Research (H.B.B., M.R.R., G.J.F., J.R.) and the Departments of Neurology, Neurosurgery, Radiology, and Emergency Medicine (H.B.B., M.R.R., G.J.F., A.M.A., K.A.M., K.S., J.M.R., A.V., S.M.G., C.S.O., J.N.G., J.R.), Massachusetts General Hospital, Harvard Medical School, Boston; and the Department of Neurology & Neurosurgery, Brain Center Rudolf Magnus, and Department of Radiology (H.B.B., K.M.v.N., B.K.V., A.v.d.Z., G.J.E.R., C.J.M.K.), University Medical Center Utrecht, Utrecht University, the Netherlands
| | - Albert van der Zwan
- From the Center for Human Genetic Research (H.B.B., M.R.R., G.J.F., J.R.) and the Departments of Neurology, Neurosurgery, Radiology, and Emergency Medicine (H.B.B., M.R.R., G.J.F., A.M.A., K.A.M., K.S., J.M.R., A.V., S.M.G., C.S.O., J.N.G., J.R.), Massachusetts General Hospital, Harvard Medical School, Boston; and the Department of Neurology & Neurosurgery, Brain Center Rudolf Magnus, and Department of Radiology (H.B.B., K.M.v.N., B.K.V., A.v.d.Z., G.J.E.R., C.J.M.K.), University Medical Center Utrecht, Utrecht University, the Netherlands
| | - Gabriel J E Rinkel
- From the Center for Human Genetic Research (H.B.B., M.R.R., G.J.F., J.R.) and the Departments of Neurology, Neurosurgery, Radiology, and Emergency Medicine (H.B.B., M.R.R., G.J.F., A.M.A., K.A.M., K.S., J.M.R., A.V., S.M.G., C.S.O., J.N.G., J.R.), Massachusetts General Hospital, Harvard Medical School, Boston; and the Department of Neurology & Neurosurgery, Brain Center Rudolf Magnus, and Department of Radiology (H.B.B., K.M.v.N., B.K.V., A.v.d.Z., G.J.E.R., C.J.M.K.), University Medical Center Utrecht, Utrecht University, the Netherlands
| | - Joshua N Goldstein
- From the Center for Human Genetic Research (H.B.B., M.R.R., G.J.F., J.R.) and the Departments of Neurology, Neurosurgery, Radiology, and Emergency Medicine (H.B.B., M.R.R., G.J.F., A.M.A., K.A.M., K.S., J.M.R., A.V., S.M.G., C.S.O., J.N.G., J.R.), Massachusetts General Hospital, Harvard Medical School, Boston; and the Department of Neurology & Neurosurgery, Brain Center Rudolf Magnus, and Department of Radiology (H.B.B., K.M.v.N., B.K.V., A.v.d.Z., G.J.E.R., C.J.M.K.), University Medical Center Utrecht, Utrecht University, the Netherlands
| | - Catharina J M Klijn
- From the Center for Human Genetic Research (H.B.B., M.R.R., G.J.F., J.R.) and the Departments of Neurology, Neurosurgery, Radiology, and Emergency Medicine (H.B.B., M.R.R., G.J.F., A.M.A., K.A.M., K.S., J.M.R., A.V., S.M.G., C.S.O., J.N.G., J.R.), Massachusetts General Hospital, Harvard Medical School, Boston; and the Department of Neurology & Neurosurgery, Brain Center Rudolf Magnus, and Department of Radiology (H.B.B., K.M.v.N., B.K.V., A.v.d.Z., G.J.E.R., C.J.M.K.), University Medical Center Utrecht, Utrecht University, the Netherlands
| | - Jonathan Rosand
- From the Center for Human Genetic Research (H.B.B., M.R.R., G.J.F., J.R.) and the Departments of Neurology, Neurosurgery, Radiology, and Emergency Medicine (H.B.B., M.R.R., G.J.F., A.M.A., K.A.M., K.S., J.M.R., A.V., S.M.G., C.S.O., J.N.G., J.R.), Massachusetts General Hospital, Harvard Medical School, Boston; and the Department of Neurology & Neurosurgery, Brain Center Rudolf Magnus, and Department of Radiology (H.B.B., K.M.v.N., B.K.V., A.v.d.Z., G.J.E.R., C.J.M.K.), University Medical Center Utrecht, Utrecht University, the Netherlands
| |
Collapse
|
24
|
Radmanesh F, Falcone GJ, Anderson CD, Battey TWK, Ayres AM, Vashkevich A, McNamara KA, Schwab K, Romero JM, Viswanathan A, Greenberg SM, Goldstein JN, Rosand J, Brouwers HB. Risk factors for computed tomography angiography spot sign in deep and lobar intracerebral hemorrhage are shared. Stroke 2014; 45:1833-5. [PMID: 24876264 PMCID: PMC4116606 DOI: 10.1161/strokeaha.114.005276] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND AND PURPOSE Patients with intracerebral hemorrhage (ICH) who present with a spot sign on computed tomography angiography are at increased risk of hematoma expansion and poor outcome. Because primary ICH is the acute manifestation of chronic cerebral small vessel disease, we investigated whether different clinical or imaging characteristics predict spot sign presence, using ICH location as a surrogate for arteriolosclerosis- and cerebral amyloid angiopathy-related ICH. METHODS Patients with primary ICH and available computed tomography angiography at presentation were included. Predictors of spot sign were assessed using uni- and multivariable regression, stratified by ICH location. RESULTS Seven hundred forty-one patients were eligible, 335 (45%) deep and 406 (55%) lobar ICH. At least one spot sign was present in 76 (23%) deep and 102 (25%) lobar ICH patients. In multivariable regression, warfarin (odds ratio [OR], 2.42; 95% confidence interval [CI], 1.01-5.71; P=0.04), baseline ICH volume (OR, 1.20; 95% CI, 1.09-1.33, per 10 mL increase; P<0.001), and time from symptom onset to computed tomography angiography (OR, 0.89; 95% CI, 0.80-0.96, per hour; P=0.009) were associated with the spot sign in deep ICH. Predictors of spot sign in lobar ICH were warfarin (OR, 3.95; 95% CI, 1.87-8.51; P<0.001) and baseline ICH volume (OR, 1.20; 95% CI, 1.10-1.31, per 10 mL increase; P<0.001). CONCLUSIONS The most potent associations with spot sign are shared between deep and lobar ICH, suggesting that the acute bleeding process that arises in the setting of different chronic small vessel diseases shares commonalities.
Collapse
Affiliation(s)
- Farid Radmanesh
- From the Center for Human Genetic Research, Massachusetts General Hospital, Boston, MA (F.R., G.J.F., C.D.A., T.W.K.B., J.R., H.B.B.); Division of Neurocritical Care and Emergency Neurology, Department of Neurology, Massachusetts General Hospital, Boston, MA (F.R., G.J.F., C.D.A., T.W.K.B., J.R., H.B.B.); J. Philip Kistler Stroke Research Center, Massachusetts General Hospital, Boston, MA (F.R., G.J.F., C.D.A., T.W.K.B., A.M.A., A. Vashkevich, K.A.M., K.S., A. Viswanathan, S.M.G., J.R., H.B.B.); Departments of Radiology (J.M.R.) and Emergency Medicine (J.N.G.), Massachusetts General Hospital, Boston, MA; and Department of Neurosurgery, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands (H.B.B.)
| | - Guido J Falcone
- From the Center for Human Genetic Research, Massachusetts General Hospital, Boston, MA (F.R., G.J.F., C.D.A., T.W.K.B., J.R., H.B.B.); Division of Neurocritical Care and Emergency Neurology, Department of Neurology, Massachusetts General Hospital, Boston, MA (F.R., G.J.F., C.D.A., T.W.K.B., J.R., H.B.B.); J. Philip Kistler Stroke Research Center, Massachusetts General Hospital, Boston, MA (F.R., G.J.F., C.D.A., T.W.K.B., A.M.A., A. Vashkevich, K.A.M., K.S., A. Viswanathan, S.M.G., J.R., H.B.B.); Departments of Radiology (J.M.R.) and Emergency Medicine (J.N.G.), Massachusetts General Hospital, Boston, MA; and Department of Neurosurgery, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands (H.B.B.)
| | - Christopher D Anderson
- From the Center for Human Genetic Research, Massachusetts General Hospital, Boston, MA (F.R., G.J.F., C.D.A., T.W.K.B., J.R., H.B.B.); Division of Neurocritical Care and Emergency Neurology, Department of Neurology, Massachusetts General Hospital, Boston, MA (F.R., G.J.F., C.D.A., T.W.K.B., J.R., H.B.B.); J. Philip Kistler Stroke Research Center, Massachusetts General Hospital, Boston, MA (F.R., G.J.F., C.D.A., T.W.K.B., A.M.A., A. Vashkevich, K.A.M., K.S., A. Viswanathan, S.M.G., J.R., H.B.B.); Departments of Radiology (J.M.R.) and Emergency Medicine (J.N.G.), Massachusetts General Hospital, Boston, MA; and Department of Neurosurgery, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands (H.B.B.)
| | - Thomas W K Battey
- From the Center for Human Genetic Research, Massachusetts General Hospital, Boston, MA (F.R., G.J.F., C.D.A., T.W.K.B., J.R., H.B.B.); Division of Neurocritical Care and Emergency Neurology, Department of Neurology, Massachusetts General Hospital, Boston, MA (F.R., G.J.F., C.D.A., T.W.K.B., J.R., H.B.B.); J. Philip Kistler Stroke Research Center, Massachusetts General Hospital, Boston, MA (F.R., G.J.F., C.D.A., T.W.K.B., A.M.A., A. Vashkevich, K.A.M., K.S., A. Viswanathan, S.M.G., J.R., H.B.B.); Departments of Radiology (J.M.R.) and Emergency Medicine (J.N.G.), Massachusetts General Hospital, Boston, MA; and Department of Neurosurgery, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands (H.B.B.)
| | - Alison M Ayres
- From the Center for Human Genetic Research, Massachusetts General Hospital, Boston, MA (F.R., G.J.F., C.D.A., T.W.K.B., J.R., H.B.B.); Division of Neurocritical Care and Emergency Neurology, Department of Neurology, Massachusetts General Hospital, Boston, MA (F.R., G.J.F., C.D.A., T.W.K.B., J.R., H.B.B.); J. Philip Kistler Stroke Research Center, Massachusetts General Hospital, Boston, MA (F.R., G.J.F., C.D.A., T.W.K.B., A.M.A., A. Vashkevich, K.A.M., K.S., A. Viswanathan, S.M.G., J.R., H.B.B.); Departments of Radiology (J.M.R.) and Emergency Medicine (J.N.G.), Massachusetts General Hospital, Boston, MA; and Department of Neurosurgery, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands (H.B.B.)
| | - Anastasia Vashkevich
- From the Center for Human Genetic Research, Massachusetts General Hospital, Boston, MA (F.R., G.J.F., C.D.A., T.W.K.B., J.R., H.B.B.); Division of Neurocritical Care and Emergency Neurology, Department of Neurology, Massachusetts General Hospital, Boston, MA (F.R., G.J.F., C.D.A., T.W.K.B., J.R., H.B.B.); J. Philip Kistler Stroke Research Center, Massachusetts General Hospital, Boston, MA (F.R., G.J.F., C.D.A., T.W.K.B., A.M.A., A. Vashkevich, K.A.M., K.S., A. Viswanathan, S.M.G., J.R., H.B.B.); Departments of Radiology (J.M.R.) and Emergency Medicine (J.N.G.), Massachusetts General Hospital, Boston, MA; and Department of Neurosurgery, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands (H.B.B.)
| | - Kristen A McNamara
- From the Center for Human Genetic Research, Massachusetts General Hospital, Boston, MA (F.R., G.J.F., C.D.A., T.W.K.B., J.R., H.B.B.); Division of Neurocritical Care and Emergency Neurology, Department of Neurology, Massachusetts General Hospital, Boston, MA (F.R., G.J.F., C.D.A., T.W.K.B., J.R., H.B.B.); J. Philip Kistler Stroke Research Center, Massachusetts General Hospital, Boston, MA (F.R., G.J.F., C.D.A., T.W.K.B., A.M.A., A. Vashkevich, K.A.M., K.S., A. Viswanathan, S.M.G., J.R., H.B.B.); Departments of Radiology (J.M.R.) and Emergency Medicine (J.N.G.), Massachusetts General Hospital, Boston, MA; and Department of Neurosurgery, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands (H.B.B.)
| | - Kristin Schwab
- From the Center for Human Genetic Research, Massachusetts General Hospital, Boston, MA (F.R., G.J.F., C.D.A., T.W.K.B., J.R., H.B.B.); Division of Neurocritical Care and Emergency Neurology, Department of Neurology, Massachusetts General Hospital, Boston, MA (F.R., G.J.F., C.D.A., T.W.K.B., J.R., H.B.B.); J. Philip Kistler Stroke Research Center, Massachusetts General Hospital, Boston, MA (F.R., G.J.F., C.D.A., T.W.K.B., A.M.A., A. Vashkevich, K.A.M., K.S., A. Viswanathan, S.M.G., J.R., H.B.B.); Departments of Radiology (J.M.R.) and Emergency Medicine (J.N.G.), Massachusetts General Hospital, Boston, MA; and Department of Neurosurgery, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands (H.B.B.)
| | - Javier M Romero
- From the Center for Human Genetic Research, Massachusetts General Hospital, Boston, MA (F.R., G.J.F., C.D.A., T.W.K.B., J.R., H.B.B.); Division of Neurocritical Care and Emergency Neurology, Department of Neurology, Massachusetts General Hospital, Boston, MA (F.R., G.J.F., C.D.A., T.W.K.B., J.R., H.B.B.); J. Philip Kistler Stroke Research Center, Massachusetts General Hospital, Boston, MA (F.R., G.J.F., C.D.A., T.W.K.B., A.M.A., A. Vashkevich, K.A.M., K.S., A. Viswanathan, S.M.G., J.R., H.B.B.); Departments of Radiology (J.M.R.) and Emergency Medicine (J.N.G.), Massachusetts General Hospital, Boston, MA; and Department of Neurosurgery, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands (H.B.B.)
| | - Anand Viswanathan
- From the Center for Human Genetic Research, Massachusetts General Hospital, Boston, MA (F.R., G.J.F., C.D.A., T.W.K.B., J.R., H.B.B.); Division of Neurocritical Care and Emergency Neurology, Department of Neurology, Massachusetts General Hospital, Boston, MA (F.R., G.J.F., C.D.A., T.W.K.B., J.R., H.B.B.); J. Philip Kistler Stroke Research Center, Massachusetts General Hospital, Boston, MA (F.R., G.J.F., C.D.A., T.W.K.B., A.M.A., A. Vashkevich, K.A.M., K.S., A. Viswanathan, S.M.G., J.R., H.B.B.); Departments of Radiology (J.M.R.) and Emergency Medicine (J.N.G.), Massachusetts General Hospital, Boston, MA; and Department of Neurosurgery, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands (H.B.B.)
| | - Steven M Greenberg
- From the Center for Human Genetic Research, Massachusetts General Hospital, Boston, MA (F.R., G.J.F., C.D.A., T.W.K.B., J.R., H.B.B.); Division of Neurocritical Care and Emergency Neurology, Department of Neurology, Massachusetts General Hospital, Boston, MA (F.R., G.J.F., C.D.A., T.W.K.B., J.R., H.B.B.); J. Philip Kistler Stroke Research Center, Massachusetts General Hospital, Boston, MA (F.R., G.J.F., C.D.A., T.W.K.B., A.M.A., A. Vashkevich, K.A.M., K.S., A. Viswanathan, S.M.G., J.R., H.B.B.); Departments of Radiology (J.M.R.) and Emergency Medicine (J.N.G.), Massachusetts General Hospital, Boston, MA; and Department of Neurosurgery, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands (H.B.B.)
| | - Joshua N Goldstein
- From the Center for Human Genetic Research, Massachusetts General Hospital, Boston, MA (F.R., G.J.F., C.D.A., T.W.K.B., J.R., H.B.B.); Division of Neurocritical Care and Emergency Neurology, Department of Neurology, Massachusetts General Hospital, Boston, MA (F.R., G.J.F., C.D.A., T.W.K.B., J.R., H.B.B.); J. Philip Kistler Stroke Research Center, Massachusetts General Hospital, Boston, MA (F.R., G.J.F., C.D.A., T.W.K.B., A.M.A., A. Vashkevich, K.A.M., K.S., A. Viswanathan, S.M.G., J.R., H.B.B.); Departments of Radiology (J.M.R.) and Emergency Medicine (J.N.G.), Massachusetts General Hospital, Boston, MA; and Department of Neurosurgery, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands (H.B.B.)
| | - Jonathan Rosand
- From the Center for Human Genetic Research, Massachusetts General Hospital, Boston, MA (F.R., G.J.F., C.D.A., T.W.K.B., J.R., H.B.B.); Division of Neurocritical Care and Emergency Neurology, Department of Neurology, Massachusetts General Hospital, Boston, MA (F.R., G.J.F., C.D.A., T.W.K.B., J.R., H.B.B.); J. Philip Kistler Stroke Research Center, Massachusetts General Hospital, Boston, MA (F.R., G.J.F., C.D.A., T.W.K.B., A.M.A., A. Vashkevich, K.A.M., K.S., A. Viswanathan, S.M.G., J.R., H.B.B.); Departments of Radiology (J.M.R.) and Emergency Medicine (J.N.G.), Massachusetts General Hospital, Boston, MA; and Department of Neurosurgery, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands (H.B.B.)
| | - H Bart Brouwers
- From the Center for Human Genetic Research, Massachusetts General Hospital, Boston, MA (F.R., G.J.F., C.D.A., T.W.K.B., J.R., H.B.B.); Division of Neurocritical Care and Emergency Neurology, Department of Neurology, Massachusetts General Hospital, Boston, MA (F.R., G.J.F., C.D.A., T.W.K.B., J.R., H.B.B.); J. Philip Kistler Stroke Research Center, Massachusetts General Hospital, Boston, MA (F.R., G.J.F., C.D.A., T.W.K.B., A.M.A., A. Vashkevich, K.A.M., K.S., A. Viswanathan, S.M.G., J.R., H.B.B.); Departments of Radiology (J.M.R.) and Emergency Medicine (J.N.G.), Massachusetts General Hospital, Boston, MA; and Department of Neurosurgery, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands (H.B.B.).
| |
Collapse
|
25
|
Brouwers HB, Chang Y, Falcone GJ, Cai X, Ayres AM, Battey TWK, Vashkevich A, McNamara KA, Valant V, Schwab K, Orzell SC, Bresette LM, Feske SK, Rost NS, Romero JM, Viswanathan A, Chou SHY, Greenberg SM, Rosand J, Goldstein JN. Predicting hematoma expansion after primary intracerebral hemorrhage. JAMA Neurol 2014; 71:158-64. [PMID: 24366060 DOI: 10.1001/jamaneurol.2013.5433] [Citation(s) in RCA: 226] [Impact Index Per Article: 22.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
IMPORTANCE Many clinical trials focus on restricting hematoma expansion following acute intracerebral hemorrhage (ICH), but selecting those patients at highest risk of hematoma expansion is challenging. OBJECTIVE To develop a prediction score for hematoma expansion in patients with primary ICH. DESIGN, SETTING, AND PARTICIPANTS Prospective cohort study at 2 urban academic medical centers among patients having primary ICH with available baseline and follow-up computed tomography for volumetric analysis (817 patients in the development cohort and 195 patients in the independent validation cohort). MAIN OUTCOMES AND MEASURES Hematoma expansion was assessed using semiautomated software and was defined as more than 6 mL or 33% growth. Covariates were tested for association with hematoma expansion using univariate and multivariable logistic regression. A 9-point prediction score was derived based on the regression estimates and was subsequently tested in the independent validation cohort. RESULTS Hematoma expansion occurred in 156 patients (19.1%). In multivariable analysis, predictors of expansion were as follows: warfarin sodium use, the computed tomography angiography spot sign, and shorter time to computed tomography (≤ 6 vs >6 hours) (P < .001 for all), as well as baseline ICH volume (<30 [reference], 30-60 [P = .03], and >60 [P = .005] mL). The incidence of hematoma expansion steadily increased with higher scores. In the independent validation cohort (n = 195), our prediction score performed well and showed strong association with hematoma expansion (odds ratio, 4.59; P < .001 for a high vs low score). The C statistics for the score were 0.72 for the development cohort and 0.77 for the independent validation cohort. CONCLUSIONS AND RELEVANCE A 9-point prediction score for hematoma expansion was developed and independently validated. The results open a path for individualized treatment and trial design in ICH aimed at patients at highest risk of hematoma expansion with maximum potential for therapeutic benefit.
Collapse
Affiliation(s)
- H Bart Brouwers
- Center for Human Genetic Research, Massachusetts General Hospital, Harvard Medical School, Boston2Division of Neurocritical Care and Emergency Neurology, Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston3Hemorrhagic S
| | - Yuchiao Chang
- Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston
| | - Guido J Falcone
- Center for Human Genetic Research, Massachusetts General Hospital, Harvard Medical School, Boston2Division of Neurocritical Care and Emergency Neurology, Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston3Hemorrhagic S
| | - Xuemei Cai
- Department of Neurology, Brigham and Women's Hospital, Harvard Medical School, Boston
| | - Alison M Ayres
- Hemorrhagic Stroke Research Group, Massachusetts General Hospital, Harvard Medical School, Boston4J. Philip Kistler Stroke Research Center, Massachusetts General Hospital, Harvard Medical School, Boston
| | - Thomas W K Battey
- Center for Human Genetic Research, Massachusetts General Hospital, Harvard Medical School, Boston3Hemorrhagic Stroke Research Group, Massachusetts General Hospital, Harvard Medical School, Boston4J. Philip Kistler Stroke Research Center, Massachusetts Gen
| | - Anastasia Vashkevich
- Hemorrhagic Stroke Research Group, Massachusetts General Hospital, Harvard Medical School, Boston4J. Philip Kistler Stroke Research Center, Massachusetts General Hospital, Harvard Medical School, Boston
| | - Kristen A McNamara
- Hemorrhagic Stroke Research Group, Massachusetts General Hospital, Harvard Medical School, Boston4J. Philip Kistler Stroke Research Center, Massachusetts General Hospital, Harvard Medical School, Boston
| | - Valerie Valant
- Center for Human Genetic Research, Massachusetts General Hospital, Harvard Medical School, Boston3Hemorrhagic Stroke Research Group, Massachusetts General Hospital, Harvard Medical School, Boston4J. Philip Kistler Stroke Research Center, Massachusetts Gen
| | - Kristin Schwab
- Hemorrhagic Stroke Research Group, Massachusetts General Hospital, Harvard Medical School, Boston4J. Philip Kistler Stroke Research Center, Massachusetts General Hospital, Harvard Medical School, Boston
| | - Susannah C Orzell
- Department of Neurology, Brigham and Women's Hospital, Harvard Medical School, Boston
| | - Linda M Bresette
- Department of Neurology, Brigham and Women's Hospital, Harvard Medical School, Boston
| | - Steven K Feske
- Department of Neurology, Brigham and Women's Hospital, Harvard Medical School, Boston
| | - Natalia S Rost
- Center for Human Genetic Research, Massachusetts General Hospital, Harvard Medical School, Boston2Division of Neurocritical Care and Emergency Neurology, Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston3Hemorrhagic S
| | - Javier M Romero
- Neuroradiology Service, Department of Radiology, Massachusetts General Hospital, Harvard Medical School, Boston
| | - Anand Viswanathan
- Division of Neurocritical Care and Emergency Neurology, Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston3Hemorrhagic Stroke Research Group, Massachusetts General Hospital, Harvard Medical School, Boston4J. Philip Kis
| | - Sherry H-Y Chou
- Department of Neurology, Brigham and Women's Hospital, Harvard Medical School, Boston
| | - Steven M Greenberg
- Hemorrhagic Stroke Research Group, Massachusetts General Hospital, Harvard Medical School, Boston4J. Philip Kistler Stroke Research Center, Massachusetts General Hospital, Harvard Medical School, Boston
| | - Jonathan Rosand
- Center for Human Genetic Research, Massachusetts General Hospital, Harvard Medical School, Boston2Division of Neurocritical Care and Emergency Neurology, Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston3Hemorrhagic S
| | - Joshua N Goldstein
- Division of Neurocritical Care and Emergency Neurology, Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston3Hemorrhagic Stroke Research Group, Massachusetts General Hospital, Harvard Medical School, Boston4J. Philip Kis
| |
Collapse
|
26
|
Woo D, Falcone GJ, Devan WJ, Brown WM, Biffi A, Howard TD, Anderson CD, Brouwers HB, Valant V, Battey TWK, Radmanesh F, Raffeld MR, Baedorf-Kassis S, Deka R, Woo JG, Martin LJ, Haverbusch M, Moomaw CJ, Sun G, Broderick JP, Flaherty ML, Martini SR, Kleindorfer DO, Kissela B, Comeau ME, Jagiella JM, Schmidt H, Freudenberger P, Pichler A, Enzinger C, Hansen BM, Norrving B, Jimenez-Conde J, Giralt-Steinhauer E, Elosua R, Cuadrado-Godia E, Soriano C, Roquer J, Kraft P, Ayres AM, Schwab K, McCauley JL, Pera J, Urbanik A, Rost NS, Goldstein JN, Viswanathan A, Stögerer EM, Tirschwell DL, Selim M, Brown DL, Silliman SL, Worrall BB, Meschia JF, Kidwell CS, Montaner J, Fernandez-Cadenas I, Delgado P, Malik R, Dichgans M, Greenberg SM, Rothwell PM, Lindgren A, Slowik A, Schmidt R, Langefeld CD, Rosand J. Meta-analysis of genome-wide association studies identifies 1q22 as a susceptibility locus for intracerebral hemorrhage. Am J Hum Genet 2014; 94:511-21. [PMID: 24656865 PMCID: PMC3980413 DOI: 10.1016/j.ajhg.2014.02.012] [Citation(s) in RCA: 200] [Impact Index Per Article: 20.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2013] [Accepted: 02/24/2014] [Indexed: 11/25/2022] Open
Abstract
Intracerebral hemorrhage (ICH) is the stroke subtype with the worst prognosis and has no established acute treatment. ICH is classified as lobar or nonlobar based on the location of ruptured blood vessels within the brain. These different locations also signal different underlying vascular pathologies. Heritability estimates indicate a substantial genetic contribution to risk of ICH in both locations. We report a genome-wide association study of this condition that meta-analyzed data from six studies that enrolled individuals of European ancestry. Case subjects were ascertained by neurologists blinded to genotype data and classified as lobar or nonlobar based on brain computed tomography. ICH-free control subjects were sampled from ambulatory clinics or random digit dialing. Replication of signals identified in the discovery cohort with p < 1 × 10(-6) was pursued in an independent multiethnic sample utilizing both direct and genome-wide genotyping. The discovery phase included a case cohort of 1,545 individuals (664 lobar and 881 nonlobar cases) and a control cohort of 1,481 individuals and identified two susceptibility loci: for lobar ICH, chromosomal region 12q21.1 (rs11179580, odds ratio [OR] = 1.56, p = 7.0 × 10(-8)); and for nonlobar ICH, chromosomal region 1q22 (rs2984613, OR = 1.44, p = 1.6 × 10(-8)). The replication included a case cohort of 1,681 individuals (484 lobar and 1,194 nonlobar cases) and a control cohort of 2,261 individuals and corroborated the association for 1q22 (p = 6.5 × 10(-4); meta-analysis p = 2.2 × 10(-10)) but not for 12q21.1 (p = 0.55; meta-analysis p = 2.6 × 10(-5)). These results demonstrate biological heterogeneity across ICH subtypes and highlight the importance of ascertaining ICH cases accordingly.
Collapse
Affiliation(s)
- Daniel Woo
- Department of Neurology and Rehabilitation Medicine, University of Cincinnati College of Medicine, Cincinnati, OH 45267, USA.
| | - Guido J Falcone
- Center for Human Genetic Research, Massachusetts General Hospital, Boston, MA 02114, USA; Division of Neurocritical Care and Emergency Neurology, Department of Neurology, Massachusetts General Hospital, Boston, MA 02114, USA; The J. Philip Kistler Stroke Research Center, Massachusetts General Hospital, Boston, MA 02114, USA; Program in Medical and Population Genetics, Broad Institute, Cambridge, MA 02141, USA; Department of Epidemiology, Harvard School of Public Health, Boston, MA 02115, USA
| | - William J Devan
- Center for Human Genetic Research, Massachusetts General Hospital, Boston, MA 02114, USA; Division of Neurocritical Care and Emergency Neurology, Department of Neurology, Massachusetts General Hospital, Boston, MA 02114, USA; The J. Philip Kistler Stroke Research Center, Massachusetts General Hospital, Boston, MA 02114, USA; Program in Medical and Population Genetics, Broad Institute, Cambridge, MA 02141, USA
| | - W Mark Brown
- Center for Public Health Genomics and Department of Biostatistical Sciences, Wake Forest University, Winston-Salem, NC 27157, USA
| | - Alessandro Biffi
- Center for Human Genetic Research, Massachusetts General Hospital, Boston, MA 02114, USA; Division of Neurocritical Care and Emergency Neurology, Department of Neurology, Massachusetts General Hospital, Boston, MA 02114, USA; The J. Philip Kistler Stroke Research Center, Massachusetts General Hospital, Boston, MA 02114, USA; Program in Medical and Population Genetics, Broad Institute, Cambridge, MA 02141, USA
| | - Timothy D Howard
- Center for Public Health Genomics and Department of Biostatistical Sciences, Wake Forest University, Winston-Salem, NC 27157, USA
| | - Christopher D Anderson
- Center for Human Genetic Research, Massachusetts General Hospital, Boston, MA 02114, USA; Division of Neurocritical Care and Emergency Neurology, Department of Neurology, Massachusetts General Hospital, Boston, MA 02114, USA; The J. Philip Kistler Stroke Research Center, Massachusetts General Hospital, Boston, MA 02114, USA; Program in Medical and Population Genetics, Broad Institute, Cambridge, MA 02141, USA
| | - H Bart Brouwers
- Center for Human Genetic Research, Massachusetts General Hospital, Boston, MA 02114, USA; Division of Neurocritical Care and Emergency Neurology, Department of Neurology, Massachusetts General Hospital, Boston, MA 02114, USA; The J. Philip Kistler Stroke Research Center, Massachusetts General Hospital, Boston, MA 02114, USA; Program in Medical and Population Genetics, Broad Institute, Cambridge, MA 02141, USA
| | - Valerie Valant
- Center for Human Genetic Research, Massachusetts General Hospital, Boston, MA 02114, USA; Division of Neurocritical Care and Emergency Neurology, Department of Neurology, Massachusetts General Hospital, Boston, MA 02114, USA; The J. Philip Kistler Stroke Research Center, Massachusetts General Hospital, Boston, MA 02114, USA; Program in Medical and Population Genetics, Broad Institute, Cambridge, MA 02141, USA
| | - Thomas W K Battey
- Center for Human Genetic Research, Massachusetts General Hospital, Boston, MA 02114, USA; Division of Neurocritical Care and Emergency Neurology, Department of Neurology, Massachusetts General Hospital, Boston, MA 02114, USA; The J. Philip Kistler Stroke Research Center, Massachusetts General Hospital, Boston, MA 02114, USA; Program in Medical and Population Genetics, Broad Institute, Cambridge, MA 02141, USA
| | - Farid Radmanesh
- Center for Human Genetic Research, Massachusetts General Hospital, Boston, MA 02114, USA; Division of Neurocritical Care and Emergency Neurology, Department of Neurology, Massachusetts General Hospital, Boston, MA 02114, USA; The J. Philip Kistler Stroke Research Center, Massachusetts General Hospital, Boston, MA 02114, USA; Program in Medical and Population Genetics, Broad Institute, Cambridge, MA 02141, USA
| | - Miriam R Raffeld
- Center for Human Genetic Research, Massachusetts General Hospital, Boston, MA 02114, USA; Division of Neurocritical Care and Emergency Neurology, Department of Neurology, Massachusetts General Hospital, Boston, MA 02114, USA; The J. Philip Kistler Stroke Research Center, Massachusetts General Hospital, Boston, MA 02114, USA; Program in Medical and Population Genetics, Broad Institute, Cambridge, MA 02141, USA
| | - Sylvia Baedorf-Kassis
- Center for Human Genetic Research, Massachusetts General Hospital, Boston, MA 02114, USA; Division of Neurocritical Care and Emergency Neurology, Department of Neurology, Massachusetts General Hospital, Boston, MA 02114, USA; The J. Philip Kistler Stroke Research Center, Massachusetts General Hospital, Boston, MA 02114, USA; Program in Medical and Population Genetics, Broad Institute, Cambridge, MA 02141, USA
| | - Ranjan Deka
- Department of Environmental Health, University of Cincinnati College of Medicine, Cincinnati, OH 45267, USA
| | - Jessica G Woo
- Division of Biostatistics and Epidemiology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH 45229, USA
| | - Lisa J Martin
- Division of Human Genetics, Cincinnati Children's Hospital Medical Center, Cincinnati, OH 45229, USA
| | - Mary Haverbusch
- Department of Neurology and Rehabilitation Medicine, University of Cincinnati College of Medicine, Cincinnati, OH 45267, USA
| | - Charles J Moomaw
- Department of Neurology and Rehabilitation Medicine, University of Cincinnati College of Medicine, Cincinnati, OH 45267, USA
| | - Guangyun Sun
- Department of Environmental Health, University of Cincinnati College of Medicine, Cincinnati, OH 45267, USA
| | - Joseph P Broderick
- Department of Neurology and Rehabilitation Medicine, University of Cincinnati College of Medicine, Cincinnati, OH 45267, USA
| | - Matthew L Flaherty
- Department of Neurology and Rehabilitation Medicine, University of Cincinnati College of Medicine, Cincinnati, OH 45267, USA
| | - Sharyl R Martini
- Department of Neurology and Rehabilitation Medicine, University of Cincinnati College of Medicine, Cincinnati, OH 45267, USA
| | - Dawn O Kleindorfer
- Department of Neurology and Rehabilitation Medicine, University of Cincinnati College of Medicine, Cincinnati, OH 45267, USA
| | - Brett Kissela
- Department of Neurology and Rehabilitation Medicine, University of Cincinnati College of Medicine, Cincinnati, OH 45267, USA
| | - Mary E Comeau
- Center for Public Health Genomics and Department of Biostatistical Sciences, Wake Forest University, Winston-Salem, NC 27157, USA
| | - Jeremiasz M Jagiella
- Department of Neurology, Jagiellonian University Medical College, Krakow 31-008, Poland
| | - Helena Schmidt
- Institute of Molecular Biology and Medical Biochemistry, Medical University Graz, Graz 8010, Austria
| | - Paul Freudenberger
- Institute of Molecular Biology and Medical Biochemistry, Medical University Graz, Graz 8010, Austria
| | - Alexander Pichler
- Department of Neurology, Medical University of Graz, Graz 8036, Austria
| | - Christian Enzinger
- Department of Neurology, Medical University of Graz, Graz 8036, Austria; Division of Neuroradiology, Department of Radiology, Medical University of Graz, Graz 8036, Austria
| | - Björn M Hansen
- Department of Clinical Sciences Lund, Neurology, Lund University, Lund 221 85, Sweden; Department of Neurology, Skåne University Hospital, Lund 221 85, Sweden
| | - Bo Norrving
- Department of Clinical Sciences Lund, Neurology, Lund University, Lund 221 85, Sweden; Department of Neurology, Skåne University Hospital, Lund 221 85, Sweden
| | - Jordi Jimenez-Conde
- Department of Neurology, Neurovascular Research Unit, Institut Hospital del Mar d'Investigacions Mèdiques, Universitat Autonoma de Barcelona/DCEXS-UPF, Barcelona 08003, Spain; Cardiovascular Epidemiology and Genetics Research Group, Institut Hospital del Mar d'Investigacions Mèdiques, Barcelona 08003, Spain
| | - Eva Giralt-Steinhauer
- Department of Neurology, Neurovascular Research Unit, Institut Hospital del Mar d'Investigacions Mèdiques, Universitat Autonoma de Barcelona/DCEXS-UPF, Barcelona 08003, Spain; Cardiovascular Epidemiology and Genetics Research Group, Institut Hospital del Mar d'Investigacions Mèdiques, Barcelona 08003, Spain
| | - Roberto Elosua
- Department of Neurology, Neurovascular Research Unit, Institut Hospital del Mar d'Investigacions Mèdiques, Universitat Autonoma de Barcelona/DCEXS-UPF, Barcelona 08003, Spain; Cardiovascular Epidemiology and Genetics Research Group, Institut Hospital del Mar d'Investigacions Mèdiques, Barcelona 08003, Spain
| | - Elisa Cuadrado-Godia
- Department of Neurology, Neurovascular Research Unit, Institut Hospital del Mar d'Investigacions Mèdiques, Universitat Autonoma de Barcelona/DCEXS-UPF, Barcelona 08003, Spain; Cardiovascular Epidemiology and Genetics Research Group, Institut Hospital del Mar d'Investigacions Mèdiques, Barcelona 08003, Spain
| | - Carolina Soriano
- Department of Neurology, Neurovascular Research Unit, Institut Hospital del Mar d'Investigacions Mèdiques, Universitat Autonoma de Barcelona/DCEXS-UPF, Barcelona 08003, Spain; Cardiovascular Epidemiology and Genetics Research Group, Institut Hospital del Mar d'Investigacions Mèdiques, Barcelona 08003, Spain
| | - Jaume Roquer
- Department of Neurology, Neurovascular Research Unit, Institut Hospital del Mar d'Investigacions Mèdiques, Universitat Autonoma de Barcelona/DCEXS-UPF, Barcelona 08003, Spain; Cardiovascular Epidemiology and Genetics Research Group, Institut Hospital del Mar d'Investigacions Mèdiques, Barcelona 08003, Spain
| | - Peter Kraft
- Department of Epidemiology, Harvard School of Public Health, Boston, MA 02115, USA
| | - Alison M Ayres
- The J. Philip Kistler Stroke Research Center, Massachusetts General Hospital, Boston, MA 02114, USA
| | - Kristin Schwab
- The J. Philip Kistler Stroke Research Center, Massachusetts General Hospital, Boston, MA 02114, USA
| | - Jacob L McCauley
- John P. Hussman Institute for Human Genomics, University of Miami, Miller School of Medicine, Miami, FL 33136, USA
| | - Joanna Pera
- Department of Neurology, Jagiellonian University Medical College, Krakow 31-008, Poland
| | - Andrzej Urbanik
- Department of Radiology, Jagiellonian University Medical College, Krakow 31-008, Poland
| | - Natalia S Rost
- Center for Human Genetic Research, Massachusetts General Hospital, Boston, MA 02114, USA; Division of Neurocritical Care and Emergency Neurology, Department of Neurology, Massachusetts General Hospital, Boston, MA 02114, USA; The J. Philip Kistler Stroke Research Center, Massachusetts General Hospital, Boston, MA 02114, USA; Program in Medical and Population Genetics, Broad Institute, Cambridge, MA 02141, USA
| | - Joshua N Goldstein
- Department of Emergency Medicine, Massachusetts General Hospital, Boston, MA 02114, USA
| | - Anand Viswanathan
- The J. Philip Kistler Stroke Research Center, Massachusetts General Hospital, Boston, MA 02114, USA
| | | | - David L Tirschwell
- Stroke Center, Harborview Medical Center, University of Washington, Seattle, WA 98104, USA
| | - Magdy Selim
- Department of Neurology, Stroke Division, Beth Israel Deaconess Medical Center, Boston, MA 02215, USA
| | - Devin L Brown
- Stroke Program, Department of Neurology, University of Michigan Health System, Ann Arbor, MI 48109, USA
| | - Scott L Silliman
- Department of Neurology, University of Florida College of Medicine, Jacksonville, FL 32209, USA
| | - Bradford B Worrall
- Department of Neurology and Public Health Sciences, University of Virginia Health System, Charlottesville, VA 22908, USA
| | - James F Meschia
- Department of Neurology, Mayo Clinic, Jacksonville, FL 32224, USA
| | - Chelsea S Kidwell
- Department of Neurology, University of Arizona, Tucson, AZ 85724, USA
| | - Joan Montaner
- Neurovascular Research Laboratory and Neurovascular Unit, Institut de Recerca, Hospital Vall d'Hebron, Universitat Autonoma de Barcelona, Barcelona 08035, Spain
| | - Israel Fernandez-Cadenas
- Neurovascular Research Laboratory and Neurovascular Unit, Institut de Recerca, Hospital Vall d'Hebron, Universitat Autonoma de Barcelona, Barcelona 08035, Spain; Stroke Pharmacogenomics and Genetics, Fundació Docència i Recerca Mútuaterrassa, Barcelona 08010, Spain
| | - Pilar Delgado
- Neurovascular Research Laboratory and Neurovascular Unit, Institut de Recerca, Hospital Vall d'Hebron, Universitat Autonoma de Barcelona, Barcelona 08035, Spain
| | - Rainer Malik
- Institute for Stroke and Dementia Research, Klinikum der Universität München, Ludwig-Maximilians-University, Munich 80539, Germany; Munich Cluster for Systems Neurology (Synergy), Munich 80539, Germany
| | - Martin Dichgans
- Institute for Stroke and Dementia Research, Klinikum der Universität München, Ludwig-Maximilians-University, Munich 80539, Germany; Munich Cluster for Systems Neurology (Synergy), Munich 80539, Germany
| | - Steven M Greenberg
- The J. Philip Kistler Stroke Research Center, Massachusetts General Hospital, Boston, MA 02114, USA
| | - Peter M Rothwell
- Stroke Prevention Research Unit, Nuffield Department of Clinical Neuroscience, University of Oxford, Oxford OX3 9DU, UK
| | - Arne Lindgren
- Department of Clinical Sciences Lund, Neurology, Lund University, Lund 221 85, Sweden; Department of Neurology, Skåne University Hospital, Lund 221 85, Sweden
| | - Agnieszka Slowik
- Department of Neurology, Jagiellonian University Medical College, Krakow 31-008, Poland
| | - Reinhold Schmidt
- Department of Neurology, Medical University of Graz, Graz 8036, Austria
| | - Carl D Langefeld
- Center for Public Health Genomics and Department of Biostatistical Sciences, Wake Forest University, Winston-Salem, NC 27157, USA
| | - Jonathan Rosand
- Center for Human Genetic Research, Massachusetts General Hospital, Boston, MA 02114, USA; Division of Neurocritical Care and Emergency Neurology, Department of Neurology, Massachusetts General Hospital, Boston, MA 02114, USA; The J. Philip Kistler Stroke Research Center, Massachusetts General Hospital, Boston, MA 02114, USA; Program in Medical and Population Genetics, Broad Institute, Cambridge, MA 02141, USA.
| |
Collapse
|
27
|
Boulouis G, Dumas A, Betensky RA, Brouwers HB, Fotiadis P, Vashkevich A, Ayres A, Schwab K, Romero JM, Smith EE, Viswanathan A, Goldstein JN, Rosand J, Gurol ME, Greenberg SM. Anatomic pattern of intracerebral hemorrhage expansion: relation to CT angiography spot sign and hematoma center. Stroke 2014; 45:1154-6. [PMID: 24603066 PMCID: PMC3984947 DOI: 10.1161/strokeaha.114.004844] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND AND PURPOSE We sought to identify baseline determinants of the anatomic pattern of hematoma expansion in patients with intracerebral hemorrhage and spot sign. METHODS We coregistered baseline and follow-up CT scans from 15 intracerebral hemorrhage patients and measured growth at each surface node from baseline to follow-up hematoma. We analyzed the effects of proximity to the spot sign or hematoma center on distance of expansion, controlling for covariates. RESULTS There was substantial node-to-node variation in the extent of expansion around each hematoma surface (mean coefficient of variation for expansion distance, 0.43; 95% confidence interval, 0.39-0.48), indicating nonuniform expansion. Closer proximity to the hematoma center was independently associated with increased expansion (0.185 mm greater expansion for each 1 mm closer to the center; P<0.0001). Closer proximity to the spot sign was not independently associated with increased expansion in models including both terms. CONCLUSIONS Hemorrhages expand nonuniformly around their surface with a tendency for greater expansion closer to their center. These findings provide a novel framework for analyzing mechanisms underlying hemorrhage growth and response to treatment.
Collapse
Affiliation(s)
- Grégoire Boulouis
- From the Hemorrhagic Stroke Research Program, Department of Neurology (G.B., A.D., H.B.B., P.F., A. Vashkevich, A.A., K.S., A. Viswanathan, M.E.G., S.M.G.), Division of Neuroradiology, Department of Radiology (J.M.R.), Department of Emergency Medicine (J.N.G.), and Division of Neurocritical Care and Emergency Neurology (J.R.), Massachusetts General Hospital, Harvard Medical School, Boston, MA; Department of Biostatistics, Harvard School of Public Health, Boston, MA (R.A.B.); and Department of Clinical Neurosciences and Hotchkiss Brain Institute, University of Calgary, Alberta, Canada (E.E.S.)
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
28
|
Falcone GJ, Biffi A, Brouwers HB, Anderson CD, Battey TWK, Ayres AM, Vashkevich A, Schwab K, Rost NS, Goldstein JN, Viswanathan A, Greenberg SM, Rosand J. Predictors of hematoma volume in deep and lobar supratentorial intracerebral hemorrhage. JAMA Neurol 2013; 70:988-94. [PMID: 23733000 DOI: 10.1001/jamaneurol.2013.98] [Citation(s) in RCA: 110] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
IMPORTANCE Hematoma volume is the strongest predictor of outcome in intracerebral hemorrhage (ICH). Despite known differences in the underlying biology between deep and lobar ICHs, limited data are available on location specificity of factors reported to affect hematoma volume. OBJECTIVE To evaluate whether determinants of ICH volume differ by topography, we sought to estimate location-specific effects for potential predictors of this radiological outcome. DESIGN Prospective cohort study. SETTING Academic medical center. PARTICIPANTS A total of 744 supratentorial primary ICH patients (388 deep and 356 lobar) aged older than 18 years admitted between January 1, 2000, and December 31, 2010. MAIN OUTCOMES AND MEASURES Intracerebral hemorrhage volume measured from the computed tomography scan obtained on presentation to the emergency department. Linear regression analysis, stratified by ICH location, was implemented to identify determinants of log-transformed ICH volume. RESULTS Median ICH volume was larger in lobar hemorrhages (39 mL; interquartile range, 16-75 mL) than in deep hemorrhages (13 mL; interquartile range, 5-40 mL; P < .001). In multivariable linear regression, independent predictors of deep ICH volume were intensity of anticoagulation (β = 0.32; standard error [SE] = 0.08; P < .001; test for trend across 4 categories of the international normalized ratio), history of coronary artery disease (β = 0.33; SE = 0.17; P = .05), male sex (β = 0.28; SE = 0.14; P = .05), and age (β = -0.02; SE = 0.01; P = .001). Independent predictors of lobar ICH volume were intensity of anticoagulation (β = 0.14; SE = 0.06; P = .02) and antiplatelet treatment (β = 0.27; SE = 0.13; P = .03). CONCLUSIONS AND RELEVANCE Predictors of hematoma volume only partially overlap between deep and lobar ICHs. These findings suggest that the mechanisms that determine the extent of bleeding differ for deep and lobar ICHs. Further studies are needed to characterize the specific biological pathways that underlie the observed associations.
Collapse
Affiliation(s)
- Guido J Falcone
- Center for Human Genetic Research, Massachusetts General Hospital, Boston, Massachusetts 02114, USA
| | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
29
|
Romero JM, Brouwers HB, Lu J, Delgado Almandoz JE, Kelly H, Heit J, Goldstein J, Rosand J, Gonzalez RG. Prospective validation of the computed tomographic angiography spot sign score for intracerebral hemorrhage. Stroke 2013; 44:3097-102. [PMID: 24021687 DOI: 10.1161/strokeaha.113.002752] [Citation(s) in RCA: 52] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
BACKGROUND AND PURPOSE Intracerebral hemorrhage (ICH) results in high mortality and morbidity for patients. Previous retrospective studies correlated the spot sign score (SSSc) with ICH expansion, mortality, and clinical outcome among ICH survivors. We performed a prospective study to validate the SSSc for the prediction of ICH expansion, mortality, and clinical outcome among survivors. METHODS We prospectively included consecutive patients with primary ICH presenting to a single institution for a 1.5-year period. All patients underwent baseline noncontrast computed tomography (CT) and multidetector CT angiography performed within 24 hours of admission and a follow-up noncontrast CT within 48 hours after the initial CT. The ICH volume was calculated on the noncontrast CT images using semiautomated software. The SSSc was calculated on the multidetector CT angiographic source images. We assessed in-hospital mortality and modified Rankin Scale at discharge and at 3 months among survivors. A multivariate logistic regression analysis was performed to determine independent predictors of hematoma expansion, in-hospital mortality, and poor clinical outcome. RESULTS A total of 131 patients met the inclusion criteria. Of the 131 patients, a spot sign was detected in 31 patients (24%). In a multivariate analysis, the SSSc predicted significant hematoma expansion (odds ratio, 3.1; 95% confidence interval, 1.77-5.39; P≤0.0001), in-hospital mortality (odds ratio, 4.1; 95% confidence interval, 2.11-7.94; P≤0.0001), and poor clinical outcome (odds ratio, 3; 95% confidence interval, 1.4-4.42; P=0.004). In addition, the SSSc was an accurate grading scale for ICH expansion, modified Rankin Scale at discharge, and in-hospital mortality. CONCLUSIONS The SSSc demonstrated a strong stepwise correlation with hematoma expansion and clinical outcome in patients with primary ICH.
Collapse
Affiliation(s)
- Javier M Romero
- From the Department of Radiology (J.M.R., H.K., J.H., R.G.G.), Department of Emergency Medicine (J.G.), and Department of Neurology (H.B.B., J.R.), Massachusetts General Hospital, Harvard University, Boston, MA; Department of Radiology, Peking Union Medical College Hospital, Beijing, China (J.L.); and Department of Interventional Neuroradiology, Neuroscience Institute, Abbott Northwestern Hospital, Minneapolis, MN (J.D.-A.)
| | | | | | | | | | | | | | | | | |
Collapse
|
30
|
Brouwers HB, Backes D, Kimberly WT, Schwab K, Romero JM, Velthuis BK, Klijn CJM, Ogilvy CS, Regli L, Greenberg SM, Rosand J, Rinkel GJE, Goldstein JN. Computed tomography angiography spot sign does not predict case fatality in aneurysmal subarachnoid hemorrhage with intraparenchymal extension. Stroke 2013; 44:1590-4. [PMID: 23572475 DOI: 10.1161/strokeaha.111.000586] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND AND PURPOSE Many patients with aneurysmal subarachnoid hemorrhage (SAH) with intraparenchymal extension develop early hematoma expansion, which is not explained by aneurysmal rerupture in half of cases. In patients with primary intracerebral hemorrhage, the computed tomography angiography (CTA) spot sign predicts hematoma expansion and poor outcome. We conducted a 2-center prospective cohort study to evaluate whether CTA spot sign predicts case fatality in aneurysmal subarachnoid hemorrhage with intraparenchymal extension. METHODS We studied consecutive patients with aneurysmal subarachnoid hemorrhage with intraparenchymal extension. Two experienced readers, blinded to clinical data, analyzed CTAs for spot sign presence. We assessed the proportion of patients with the CTA spot sign and tested its association with in-hospital and 90-day case fatality, using univariable and multivariable logistic regression. RESULTS In 32 of 236 patients (14%), we found at least 1 spot sign. Acute surgical hematoma evacuation with aneurysm occlusion occurred in 120 patients (51%). The overall in-hospital case fatality rate was 37%. The CTA spot sign was not associated with in-hospital (multivariable odds ratio, 0.51 [95% confidence interval, 0.06-3.26]) or 90-day (multivariable odds ratio, 0.59 [0.21-1.65]) case fatality. CONCLUSIONS The found frequency of CTA spot signs is lower after aneurysmal than primary intracerebral hemorrhage and is not associated with in-hospital or 90-day case fatality in patients with aneurysmal subarachnoid hemorrhage with intraparenchymal extension.
Collapse
Affiliation(s)
- H Bart Brouwers
- Center for Human Genetic Research-Rosand Lab, Massachusetts General Hospital, Harvard Medical School, 185 Cambridge St, CPZN-6818, Boston, MA 02114, USA.
| | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
31
|
Brouwers HB, Greenberg SM. Hematoma expansion following acute intracerebral hemorrhage. Cerebrovasc Dis 2013; 35:195-201. [PMID: 23466430 DOI: 10.1159/000346599] [Citation(s) in RCA: 183] [Impact Index Per Article: 16.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2012] [Accepted: 12/18/2012] [Indexed: 12/20/2022] Open
Abstract
Intracerebral hemorrhage (ICH), the most devastating form of stroke, has no specific therapy proven to improve outcome by randomized controlled trial. Location and baseline hematoma volume are strong predictors of mortality, but are nonmodifiable by the time of diagnosis. Expansion of the initial hematoma is a further marker of poor prognosis that may be at least partly preventable. Several risk factors for hematoma expansion have been identified, including baseline ICH volume, early presentation after symptom onset, anticoagulation, and the CT angiography spot sign. Although the biological mechanisms of hematoma expansion remain unclear, accumulating evidence supports a model of ongoing secondary bleeding from ruptured adjacent vessels surrounding the initial bleeding site. Several large clinical trials testing therapies aimed at preventing hematoma expansion are in progress, including aggressive blood pressure reduction, treatment with recombinant factor VIIa guided by CT angiography findings, and surgical intervention for superficial hematomas without intraventricular extension. Hematoma expansion is so far the only marker of outcome that is amenable to treatment and thus a potentially important therapeutic target.
Collapse
Affiliation(s)
- H Bart Brouwers
- Center for Human Genetic Research, Massachusetts General Hospital, Harvard Medical School, Boston, MA 02114, USA.
| | | |
Collapse
|
32
|
Falcone GJ, Biffi A, Devan WJ, Brouwers HB, Anderson CD, Valant V, Ayres AM, Schwab K, Rost NS, Goldstein JN, Viswanathan A, Greenberg SM, Selim M, Meschia JF, Brown DL, Worrall BB, Silliman SL, Tirschwell DL, Rosand J. Burden of blood pressure-related alleles is associated with larger hematoma volume and worse outcome in intracerebral hemorrhage. Stroke 2013; 44:321-6. [PMID: 23321443 DOI: 10.1161/strokeaha.112.675181] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND AND PURPOSE Intracerebral hemorrhage (ICH) is the acute manifestation of a progressive disease of the cerebral small vessels. The severity of this disease seems to influence not only risk of ICH but also the size of the hematoma. As the burden of high blood pressure-related alleles is associated with both hypertension-related end-organ damage and risk of ICH, we sought to determine whether this burden influences ICH baseline hematoma volume. METHODS Prospective study in subjects of European descent with supratentorial ICH who underwent genome-wide genotyping. Forty-two single nucleotide polymorphisms associated with high blood pressure were identified from a publicly available database. A genetic risk score was constructed based on these single nucleotide polymorphisms. The score was used as the independent variable in univariate and multivariate regression models for admission ICH volume and poor clinical outcome (modified Rankin Scale, 3-6). RESULTS A total of 323 ICH cases were enrolled in the study (135 deep and 188 lobar intracranial hematomas). The blood pressure-based genetic risk score was associated with both baseline hematoma volume and poor clinical outcome specifically in deep ICH. In multivariate regression analyses, each additional SD of the score increased mean deep ICH volume by 28% (or 2.7 mL increase; β=0.28; SE=0.11; P=0.009) and risk of poor clinical outcome by 71% (odds ratio, 1.71; 95% confidence interval, 1.05-2.80; P=0.03). CONCLUSIONS Increasing numbers of high blood pressure-related alleles are associated with mean baseline hematoma volume and poor clinical outcome in ICH. These findings suggest that the small vessel vasculopathy responsible for the occurrence of the hemorrhage also influences its volume.
Collapse
Affiliation(s)
- Guido J Falcone
- Center for Human Genetic Research, Massachusetts General Hospital, 185 Cambridge St, CPZN-6818, Boston, MA 02114, USA
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
33
|
Affiliation(s)
- Guido J. Falcone
- From the Center for Human Genetic Research, Massachusetts General Hospital, Boston, MA; Hemorrhagic Stroke Research Group, Massachusetts General Hospital, Boston, MA; Division of Neurocritical Care and Emergency Neurology, Department of Neurology, Massachusetts General Hospital, Boston MA; and Program in Medical and Population Genetics, Broad Institute, Cambridge MA
| | - H. Bart Brouwers
- From the Center for Human Genetic Research, Massachusetts General Hospital, Boston, MA; Hemorrhagic Stroke Research Group, Massachusetts General Hospital, Boston, MA; Division of Neurocritical Care and Emergency Neurology, Department of Neurology, Massachusetts General Hospital, Boston MA; and Program in Medical and Population Genetics, Broad Institute, Cambridge MA
| | - Jonathan Rosand
- From the Center for Human Genetic Research, Massachusetts General Hospital, Boston, MA; Hemorrhagic Stroke Research Group, Massachusetts General Hospital, Boston, MA; Division of Neurocritical Care and Emergency Neurology, Department of Neurology, Massachusetts General Hospital, Boston MA; and Program in Medical and Population Genetics, Broad Institute, Cambridge MA
| |
Collapse
|
34
|
Brouwers HB, Goldstein JN, Romero JM, Rosand J. Clinical applications of the computed tomography angiography spot sign in acute intracerebral hemorrhage: a review. Stroke 2012; 43:3427-32. [PMID: 23132779 DOI: 10.1161/strokeaha.112.664003] [Citation(s) in RCA: 75] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Affiliation(s)
- H Bart Brouwers
- Department of Neurology, J. Philip Kistler Stroke Research Center, Massachusetts General Hospital, Harvard Medical School, 185 Cambridge St, CPZN-6818, Boston, MA 02114, USA.
| | | | | | | |
Collapse
|
35
|
Goldstein JN, Brouwers HB, Romero JM, McNamara K, Schwab K, Greenberg SM, Rosand J. SCORE-IT: the Spot Sign score in restricting ICH growth─an Atach-II ancillary study. J Vasc Interv Neurol 2012; 5:20-25. [PMID: 23230461 PMCID: PMC3517028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Subscribe] [Scholar Register] [Indexed: 06/01/2023]
Abstract
INTRODUCTION The ATACH-II trial is designed to evaluate whether intensive blood pressure reduction can reduce hematoma growth and improve outcome. However, it is difficult to determine, at presentation, which patients are at highest risk of ongoing bleeding, and will receive the most clinical benefit from blood pressure therapy. It may be that improved predictive markers will lead to efficient, personalized selection of optimal therapy. We hypothesize that specific imaging findings on CT angiography (CTA) and MRI will mark those patients who receive the most benefit from intensive blood pressure reduction. METHODS Many patients enrolled in ATACH-II will undergo CTA and/or MRI as part of routine clinical care. We will perform a blinded analysis of these images. For CTA, we will determine the presence of contrast pooling (also termed contrast extravasation or the "Spot Sign"). In addition, we will calculate a Spot Sign Score, a score that includes number of Spot Signs, diameter, and contrast density. For MRI, we will focus on the presence, number, and location of cerebral microbleeds (CMBs) on sensitive T2*-weighted MRI sequences. RESULTS We will test the hypothesis that patients with a Spot Sign will receive clinical benefit from intensive blood pressure reduction. In addition, we will determine whether patients with the highest Spot Sign Scores receive the most benefit from intensive blood pressure reduction. Finally, we will determine whether the absence of CMBs marks those at higher risk for hematoma expansion, and therefore more likely to benefit from treatment. CONCLUSION This ancillary study offers the tremendous opportunity to determine whether imaging findings can risk stratify ICH patients for acute therapies aimed at limiting hematoma growth.
Collapse
Affiliation(s)
- JN Goldstein
- Hemorrhagic Stroke Research Group, Massachusetts General Hospital, Boston, MA, USA
- Division of Neurocritical Care and Emergency Neurology, Department of Neurology, Massachusetts General Hospital, Boston, MA, USA
- Department of Emergency Medicine, Massachusetts General Hospital, Zero Emerson Place, Suite 3B, Boston, MA 02114, USA
| | - HB Brouwers
- Hemorrhagic Stroke Research Group, Massachusetts General Hospital, Boston, MA, USA
- Division of Neurocritical Care and Emergency Neurology, Department of Neurology, Massachusetts General Hospital, Boston, MA, USA
- Center for Human Genetic Research, Massachusetts General Hospital, Boston, MA, USA
| | - JM Romero
- Department of Emergency Medicine, Massachusetts General Hospital, Zero Emerson Place, Suite 3B, Boston, MA 02114, USA
| | - K McNamara
- Hemorrhagic Stroke Research Group, Massachusetts General Hospital, Boston, MA, USA
| | - K Schwab
- Hemorrhagic Stroke Research Group, Massachusetts General Hospital, Boston, MA, USA
| | - SM Greenberg
- Hemorrhagic Stroke Research Group, Massachusetts General Hospital, Boston, MA, USA
- Division of Neurocritical Care and Emergency Neurology, Department of Neurology, Massachusetts General Hospital, Boston, MA, USA
| | - J Rosand
- Hemorrhagic Stroke Research Group, Massachusetts General Hospital, Boston, MA, USA
- Division of Neurocritical Care and Emergency Neurology, Department of Neurology, Massachusetts General Hospital, Boston, MA, USA
- Center for Human Genetic Research, Massachusetts General Hospital, Boston, MA, USA
- Neuroradiology Service, Department of Radiology, Massachusetts General Hospital, Boston, MA, USA
| |
Collapse
|
36
|
Brouwers HB, Biffi A, McNamara KA, Ayres AM, Valant V, Schwab K, Romero JM, Viswanathan A, Greenberg SM, Rosand J, Goldstein JN. Apolipoprotein E genotype is associated with CT angiography spot sign in lobar intracerebral hemorrhage. Stroke 2012; 43:2120-5. [PMID: 22621984 DOI: 10.1161/strokeaha.112.659094] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
BACKGROUND AND PURPOSE The CT angiography (CTA) spot sign predicts hematoma expansion and poor outcome in patients with primary intracerebral hemorrhage (ICH). The biological underpinnings of the spot sign remain poorly understood; it may be that the underlying vasculopathy influences its presence. Therefore, we conducted a study to identify genetic predictors of the spot sign. METHODS In an ongoing prospective cohort study, we analyzed 371 patients with CTA and genetic data available. CTAs were reviewed for the spot sign by 2 experienced readers, blinded to clinical data, according to validated criteria. Analyses were stratified by ICH location. RESULTS In multivariate analysis, patients on warfarin were more likely to have a spot sign regardless of ICH location (OR, 3.85; 95% CI, 1.33-11.13 in deep ICH and OR, 2.86; 95% CI, 1.33-6.13 in lobar ICH). Apolipoprotein E ε2, but not ε4, was associated with the presence of a spot sign in lobar ICH (OR, 2.09; 95% CI, 1.05-4.19). There was no effect for ε2 or ε4 in deep ICH. CONCLUSIONS Patients with ICH on warfarin are more likely to present with a spot sign regardless of ICH location. Among patients with lobar ICH, those who possess the apolipoprotein E ε2 allele are more likely to have a spot sign. Given the established relationship between apolipoprotein E ε2 and vasculopathic changes in cerebral amyloid angiopathy, our findings suggest that both hemostatic factors and vessel pathology influence spot sign presence.
Collapse
Affiliation(s)
- H Bart Brouwers
- Center for Human Genetic Research-Rosand Lab, Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, MA 02114, USA.
| | | | | | | | | | | | | | | | | | | | | |
Collapse
|
37
|
Brouwers HB, Biffi A, Ayres AM, Schwab K, Cortellini L, Romero JM, Rost NS, Viswanathan A, Greenberg SM, Rosand J, Goldstein JN. Apolipoprotein E genotype predicts hematoma expansion in lobar intracerebral hemorrhage. Stroke 2012; 43:1490-5. [PMID: 22535266 DOI: 10.1161/strokeaha.111.643262] [Citation(s) in RCA: 62] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND AND PURPOSE Hematoma volume is the most potent predictor of outcome in spontaneous intracerebral hemorrhage (ICH), and hematoma expansion after hospital presentation occurs in up to 40% of individuals. Among patients with lobar ICH, the apolipoprotein E (APOE) ε2 allele predicts larger hematoma volumes at presentation. We investigated whether the ε2 allele also identifies individuals at increased risk of hematoma expansion. METHODS We analyzed 510 patients with primary ICH and genetic data available from an ongoing prospective cohort study. Baseline and follow-up CT scans were assessed for ICH location and volume using computer-assisted volumetric methods. RESULTS Individuals with lobar ICH who possessed APOE ε2 were at increased risk for hematoma expansion (OR, 2.72; 95% CI, 1.19-6.23; P=0.009). The highest odds of expansion were in patients who qualified for the diagnosis of cerebral amyloid angiopathy-related ICH and carried the APOE ε2 allele (OR, 6.02; 95% CI, 1.60-22.58; P=0.008). There was no effect of ε2 on hematoma expansion in deep ICH and APOE ε4 had no effect on hematoma expansion in lobar or deep ICH. CONCLUSIONS Possession of APOE ε2 predisposes individuals with lobar ICH to hematoma expansion. This effect is even more pronounced in patients with amyloid angiopathy-related ICH, consistent with the ε2 allele's role in vascular amyloid deposition and vessel fragility.
Collapse
Affiliation(s)
- H Bart Brouwers
- Center for Human Genetic Research-Rosand Lab, Massachusetts General Hospital, Harvard Medical School, 185 Cambridge Street, CPZN-6818, Boston, MA 02114, USA.
| | | | | | | | | | | | | | | | | | | | | |
Collapse
|
38
|
Abstract
Intracerebral hemorrhage is a devastating disease, and no specific therapy has been proven to reduce mortality in a randomized controlled trial. However, management in a neuroscience intensive care unit does appear to improve outcomes, suggesting that many available therapies do in fact provide benefit. In the acute phase of intracerebral hemorrhage care, strategies aimed at minimizing ongoing bleeding include reversal of anticoagulation and modest blood pressure reduction. In addition, the monitoring and regulation of glucose levels, temperature, and, in selected cases, intracranial pressure are recommended by many groups. Selected patients may benefit from hematoma evacuation or external ventricular drainage. Ongoing clinical trials are examining aggressive blood pressure management, hemostatic therapy, platelet transfusion, stereotactic hematoma evacuation, and intraventricular thrombolysis. Finally, preventing recurrence of intracerebral hemorrhage is of pivotal importance, and tight blood pressure management is paramount.
Collapse
Affiliation(s)
- H Bart Brouwers
- Division of Neurocritical Care and Emergency Neurology, Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, MA 02114, USA.
| | | |
Collapse
|
39
|
Delgado Almandoz JE, Kelly HR, Schaefer PW, Brouwers HB, Yoo AJ, Stone MJ, Goldstein JN, Rosand J, Lev MH, Gonzalez RG, Romero JM. CT angiography spot sign predicts in-hospital mortality in patients with secondary intracerebral hemorrhage. J Neurointerv Surg 2011; 4:442-7. [PMID: 22003048 DOI: 10.1136/neurintsurg-2011-010061] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
BACKGROUND AND OBJECTIVE The presence of active contrast extravasation during CT angiography, the spot sign, is a potent predictor of in-hospital mortality in patients with primary intracerebral hemorrhage (ICH). However, its predictive value in patients with ICH due to a vascular abnormality, secondary ICH (SICH), is unknown. The aim of this study was to determine the clinical and radiological predictors of a spot sign and in-hospital mortality in patients with SICH. METHODS Two experienced readers independently reviewed CT angiograms performed on 215 consecutive patients presenting to the emergency department with SICH over a 10-year period to assess the presence of spot signs according to strict radiological criteria. Differences in reader interpretation were resolved by consensus. Medical records were reviewed for baseline clinical characteristics and in-hospital mortality. Univariate and multivariate logistic regression analyses were performed to determine the clinical and radiological predictors of a spot sign and in-hospital mortality in patients with SICH. RESULTS Spot signs were identified in 31 of 215 patients with SICH (14.4%), four of which were delayed spot signs (12.9%). Spot signs were most common in patients with arteriovenous fistulas (42%), Moyamoya (40%), elevated admission blood glucose (23%) and large intraventricular hemorrhage volumes (29%). Spot signs were most predictive of in-hospital mortality in patients with aneurysms of the anterior cerebral artery (100%) and anterior communicating artery (75%). In univariate analysis, the presence of a spot sign significantly increased the risk of in-hospital mortality in patients with SICH (38.7%, OR 2.2, 95% CI 1.0 to 4.9, p=0.0497). However, in multivariate logistic regression analysis the admission Glasgow Coma Scale was the only independent predictor of in-hospital mortality in patients with SICH (OR 2.8, 95% CI 1.6 to 5.1, p=0.0004). CONCLUSION The spot sign identifies patients with SICH at increased risk of in-hospital mortality. However, the admission Glasgow Coma Scale was the only independent predictor of in-hospital mortality in this cohort of patients with SICH.
Collapse
|
40
|
Delgado Almandoz JE, Yoo AJ, Stone MJ, Schaefer PW, Oleinik A, Brouwers HB, Goldstein JN, Rosand J, Lev MH, Gonzalez RG, Romero JM. The spot sign score in primary intracerebral hemorrhage identifies patients at highest risk of in-hospital mortality and poor outcome among survivors. Stroke 2009; 41:54-60. [PMID: 19910545 DOI: 10.1161/strokeaha.109.565382] [Citation(s) in RCA: 148] [Impact Index Per Article: 9.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND AND PURPOSE The spot sign score is a potent predictor of hematoma expansion in patients with primary intracerebral hemorrhage (ICH). We aim to determine the accuracy of this scoring system for the prediction of in-hospital mortality and poor outcome among survivors in patients with primary ICH. METHODS Three neuroradiologists retrospectively reviewed CT angiograms (CTAs) performed in 573 consecutive patients who presented to our Emergency Department with primary ICH over a 9-year period to determine the presence and scoring of spot signs according to strict criteria. Baseline ICH and intraventricular hemorrhage volumes were independently determined by computer-assisted volumetric analysis. Medical records were independently reviewed for baseline clinical characteristics and modified Rankin Scale (mRS) at hospital discharge and 3-month follow-up. Poor outcome among survivors was defined as a mRS > or =4 at 3-month follow-up. RESULTS We identified spot signs in 133 of 573 CTAs (23.2%), 11 of which were delayed spot signs (8.3%). The presence of any spot sign increased the risk of in-hospital mortality (55.6%, OR 4.0, 95% CI 2.6 to 5.9, P<0.0001) and poor outcome among survivors at 3-month follow-up (50.8%, OR 2.5, 95% CI 1.4 to 4.3, P<0.0014). The spot sign score successfully predicted an escalating risk of both outcome measures. In multivariate analysis, the spot sign score was an independent predictor of in-hospital mortality (OR 1.5, 95% CI 1.2 to 1.9, P<0.0002) and poor outcome among survivors at 3-month follow-up (OR 1.6, 95% CI 1.1 to 2.1, P<0.0065). CONCLUSIONS The spot sign score is an independent predictor of in-hospital mortality and poor outcome among survivors in primary ICH.
Collapse
Affiliation(s)
- Josser E Delgado Almandoz
- Division of Neuroradiology, Mallinckrodt Institute of Radiology, Washington University School of Medicine, Campus Box 8131, 510 S Kingshighway Blvd, Saint Louis, MO 63110, USA.
| | | | | | | | | | | | | | | | | | | | | |
Collapse
|