Family planning considerations in people with multiple sclerosis

Multiple sclerosis is often diagnosed in patients who are planning on having children. Although multiple sclerosis does not negatively influence most pregnancy outcomes, less is known regarding the effects of fetal exposure to novel disease-modifying therapies (DMTs). The withdrawal of some DMTs during pregnancy can modify the natural history of multiple sclerosis, resulting in a substantial risk of pregnancy-related relapse and disability. Drug labels are typically restrictive and favour fetal safety over maternal safety. Emerging data reporting outcomes in neonates exposed to DMTs in utero and through breastfeeding will allow for more careful and individualised treatment decisions. This emerging research is particularly important to guide decision making in women with high disease activity or who are treated with DMTs associated with risk of discontinuation rebound. As increasing data are generated in this field, periodic updates will be required to provide the most up to date guidance on how best to achieve multiple sclerosis stability during pregnancy and post partum, balanced with fetal and newborn safety.

Chronic neuropsychiatric sequelae of SARS-CoV-2: Protocol and methods from the Alzheimer's Association Global Consortium

Introduction

Coronavirus disease 2019 (COVID-19) has caused >3.5 million deaths worldwide and affected >160 million people. At least twice as many have been infected but remained asymptomatic or minimally symptomatic. COVID-19 includes central nervous system manifestations mediated by inflammation and cerebrovascular, anoxic, and/or viral neurotoxicity mechanisms. More than one third of patients with COVID-19 develop neurologic problems during the acute phase of the illness, including loss of sense of smell or taste, seizures, and stroke. Damage or functional changes to the brain may result in chronic sequelae. The risk of incident cognitive and neuropsychiatric complications appears independent from the severity of the original pulmonary illness. It behooves the scientific and medical community to attempt to understand the molecular and/or systemic factors linking COVID-19 to neurologic illness, both short and long term.

Methods

This article describes what is known so far in terms of links among COVID-19, the brain, neurological symptoms, and Alzheimer's disease (AD) and related dementias. We focus on risk factors and possible molecular, inflammatory, and viral mechanisms underlying neurological injury. We also provide a comprehensive description of the Alzheimer's Association Consortium on Chronic Neuropsychiatric Sequelae of SARS-CoV-2 infection (CNS SC2) harmonized methodology to address these questions using a worldwide network of researchers and institutions.

Results

Successful harmonization of designs and methods was achieved through a consensus process initially fragmented by specific interest groups (epidemiology, clinical assessments, cognitive evaluation, biomarkers, and neuroimaging). Conclusions from subcommittees were presented to the whole group and discussed extensively. Presently data collection is ongoing at 19 sites in 12 countries representing Asia, Africa, the Americas, and Europe.

Discussion

The Alzheimer's Association Global Consortium harmonized methodology is proposed as a model to study long-term neurocognitive sequelae of SARS-CoV-2 infection.

Key Points

The following review describes what is known so far in terms of molecular and epidemiological links among COVID-19, the brain, neurological symptoms, and AD and related dementias (ADRD)The primary objective of this large-scale collaboration is to clarify the pathogenesis of ADRD and to advance our understanding of the impact of a neurotropic virus on the long-term risk of cognitive decline and other CNS sequelae. No available evidence supports the notion that cognitive impairment after SARS-CoV-2 infection is a form of dementia (ADRD or otherwise). The longitudinal methodologies espoused by the consortium are intended to provide data to answer this question as clearly as possible controlling for possible confounders. Our specific hypothesis is that SARS-CoV-2 triggers ADRD-like pathology following the extended olfactory cortical network (EOCN) in older individuals with specific genetic susceptibility.The proposed harmonization strategies and flexible study designs offer the possibility to include large samples of under-represented racial and ethnic groups, creating a rich set of harmonized cohorts for future studies of the pathophysiology, determinants, long-term consequences, and trends in cognitive aging, ADRD, and vascular disease.We provide a framework for current and future studies to be carried out within the Consortium. and offers a "green paper" to the research community with a very broad, global base of support, on tools suitable for low- and middle-income countries aimed to compare and combine future longitudinal data on the topic.The Consortium proposes a combination of design and statistical methods as a means of approaching causal inference of the COVID-19 neuropsychiatric sequelae. We expect that deep phenotyping of neuropsychiatric sequelae may provide a series of candidate syndromes with phenomenological and biological characterization that can be further explored. By generating high-quality harmonized data across sites we aim to capture both descriptive and, where possible, causal associations.

Alzheimer’s Association International Cohort Study of Chronic Neuropsychiatric Sequeale of SARS‐CoV‐2 (CNS‐SARS‐CoV‐2)

Background

The pandemic of SARS‐CoV‐2 is focusing all energies on the impact on survival of affected individuals, treatment and prevention, but increasingly attention is focusing on its enduring consequences. We established a global consortium to study a longitudinal representative cohort of individuals, to characterize neurological and neuropsychiatric sequalae from direct viral, immune‐, vascular‐ or accelerated neurodegenerative injury to the central nervous system (CNS).

Method

We propose to characterize the neurobehavioral phenomenology associated with SARS‐CoV‐2 in a large, multinational, longitudinal cohort of post COVID‐19 infection patients following three sampling strategies: 1) Opportunity sample of patients discharged after hospital admission for COVID‐19 related symptoms. 2) A stratified random sample from COVID‐19 testing registries (including asymptomatic and negative participants). 3) Ascertaining COVID‐19 exposure (antibody) status in ongoing longitudinal, community‐based cohort studies that are already collecting biosamples, cognitive, behavioral and neuroimaging data. We will obtain core data within 6 months of discharge or testing. Core characterization will include interviews with the Schedules of Clinical Assessment in Neuropsychiatry (SCAN), neurological exams, emotional reactivity scales and a neurocognitive assessment. Wherever feasible, we will also collect neuroimaging, biosamples and genetic data. Longitudinal follow up will be conducted at 9 and 18 months of the initial evaluation. An mHealth keeping‐in‐touch process will be set up to minimize attrition rates. The population cohorts provide a large, unbiased, normative and validation sample, albeit with more heterogenous outcome ascertainment. They also permit examination of pre‐ and post‐COVID trends in symptoms and biomarkers. Since some ethnic groups, as well as in individuals with blood type A, are at higher risk of COVID‐19 infection and death, a role of genetics in determining susceptibility to infection and poor outcomes seems well supported. We will collect genome‐wide genotypes from our cohort individuals to address the role of ancestry and genetic variation on susceptibility to neuropsychiatric sequelae. High rates of mutation in COVID‐19 strongly suggest that viral infectivity, including neurotropism, may not be uniform across countries affected by the pandemic.

Results

Pending.

Conclusion

Our consortium is in a unique position to address the interaction between genetics (including ancestral DNA), and viral strain variation on CNS sequelae of SARS‐CoV‐2.

Establishment of an internationally agreed minimum data set for acute telestroke

INTRODUCTION

Globally, the use of telestroke programmes for acute care is expanding. Currently, a standardised set of variables for enabling reliable international comparisons of telestroke programmes does not exist. The aim of the study was to establish a consensus-based, minimum dataset for acute telestroke to enable the reliable comparison of programmes, clinical management and patient outcomes.

METHODS

An initial scoping review of variables was conducted, supplemented by reaching out to colleagues leading some of these programmes in different countries. An international expert panel of clinicians, researchers and managers (n = 20) from the Australasia Pacific region, USA, UK and Europe was convened. A modified-Delphi technique was used to achieve consensus via online questionnaires, teleconferences and email.

RESULTS

Overall, 533 variables were initially identified and harmonised into 159 variables for the expert panel to review. The final dataset included 110 variables covering three themes (service configuration, consultations, patient information) and 12 categories: (1) details about telestroke network/programme (n = 12), (2) details about initiating hospital (n = 10), (3) telestroke consultation (n = 17), (4) patient characteristics (n = 7), (5) presentation to hospital (n = 5), (6) general clinical care within first 24 hours (n = 10), (7) thrombolysis treatment (n = 10), (8) endovascular treatment (n = 13), (9) neurosurgery treatment (n = 8), (10) processes of care beyond 24 hours (n = 7), (11) discharge information (n = 5), (12) post-discharge and follow-up data (n = 6).

DISCUSSION

The acute telestroke minimum dataset provides a recommended set of variables to systematically evaluate acute telestroke programmes in different countries. Adoption is recommended for new and existing services.

Abstract WP462: New or Expanding Ventricular Hemorrhage Predicts Poor Outcome After Intracerebral Hemorrhage

Introduction: Baseline intraventricular hemorrhage (IVH) is a predictor of poor outcome in acute intracerebral hemorrhage (ICH) patients. However, questions remain as to the exact burden that new IVH development, seen on follow-up imaging, or what degree of interval IVH expansion, impacts long term functioning.

Objective: To derive and validate a relationship between IVH change and long term outcome.

Methods: Fractional polynomial analysis was used to test linear and non-linear models of 24-hour IVH change and clinical outcome using data from the multicenter PREDICT study. The primary outcome was mRS 4-6 at 90 days. Dichotomous thresholds were derived via assessment of the selected model and diagnostic accuracy measures were calculated. Independent predictors of poor outcome were determined via multivariable logistic regression. The developed model and all derived thresholds were validated in an independent single center cohort.

Results: Of the 256 patients from PREDICT, 127 (49.6%) had mRS scores of 4-6 at 90 days. 24-hour IVH change and the primary outcome fit a non-linear relationship, where minimal increases in IVH were associated with a high probability of poor outcome (Figure 1). Mean IVH expansion was 8.6 mL. IVH expansion greater than 1 mL (n=53, Sens 33%, Spec 92%, PPV 79%, NPV 58%, aOR 2.77 [95% CI: 1.12-6.89]) and development of any new IVH (n= 74, Sens 43%, Spec 85%, PPV 74%, NPV 60%, aOR 2.17 [95% CI: 1.02-4.63]) strongly predicted mRS 4-6 at 90 days. The model and developed thresholds reproduced well in a validation cohort of 170 patients.

Conclusion: IVH expansion as minimal as 1 mL, or any new IVH is strongly predictive of poor outcome. This can aid in prognostication, be incorporated into definitions of hematoma expansion for future ICH treatment trials, or even imply that IVH treatment is a therapeutic target that may lead to improved outcomes.

Do Intracerebral Hemorrhage Nonexpanders Actually Expand Into the Ventricular Space?

BACKGROUND AND PURPOSE

The computed tomographic angiography spot sign as a predictor of hematoma expansion is limited by its modest sensitivity and positive predictive value. It is possible that hematoma expansion in spot-positive patients is missed because of decompression of intracerebral hemorrhage (ICH) into the ventricular space. We hypothesized that revising hematoma expansion definitions to include intraventricular hemorrhage (IVH) expansion will improve the predictive performance of the spot sign. Our objectives were to determine the proportion of ICH nonexpanders who actually have IVH expansion, determine the proportion of false-positive spot signs that have IVH expansion, and compare the known predictive performance of the spot sign to a revised definition incorporating IVH expansion.

METHODS

We analyzed patients from the multicenter PREDICT ICH spot sign study. We defined hematoma expansion as ≥6 mL or ≥33% ICH expansion or >2 mL IVH expansion and compared spot sign performance using this revised definition with the conventional 6 mL/33% definition using receiver operating curve analysis.

RESULTS

Of 311 patients, 213 did not meet the 6-mL/33% expansion definition (nonexpanders). Only 13 of 213 (6.1%) nonexpanders had ≥2 mL IVH expansion. Of the false-positive spot signs, 4 of 40 (10%) had >2 mL ventricular expansion. The area under the curve for spot sign to predict significant ICH expansion was 0.65 (95% confidence interval, 0.58-0.72), which was no different than when IVH expansion was added to the definition (area under the curve, 0.66; 95% confidence interval, 0.58-0.71).

CONCLUSIONS

Although IVH expansion does indeed occur in a minority of ICH nonexpanders, its inclusion into a revised hematoma expansion definition does not alter the predictive performance of the spot sign.

Location of intracerebral haemorrhage predicts haematoma expansion

Introduction

The role of intracerebral haemorrhage location in haematoma expansion remains unclear. Our objective was to assess the effect of lobar versus non-lobar haemorrhage on haematoma expansion and clinical outcome.

Patients and methods

We analysed data from the prospective PREDICT study where patients with intracerebral haemorrhage presenting to hospital under 6 h of symptom onset received baseline computed tomography (CT), CT angiogram, 24 h follow-up CT, and 90-day mRS. Intracerebral haemorrhage location was categorised as lobar versus non-lobar, and primary outcomes were significant haematoma expansion (>6 ml) and poor clinical outcome (mRS > 3). Multivariable regression was used to adjust for relevant covariates. The primary analysis population was divided by spot sign status and the effect of haemorrhage location was compared to haematoma expansion in exploratory post hoc analysis.

Results

Among 302 patients meeting the inclusion criteria, lobar haemorrhage was associated with increased haematoma expansion >6 ml (p = 0.003), poor clinical outcome (p = 0.011) and mortality (p = 0.017). When adjusted for covariates, lobar haemorrhage independently predicted significant haematoma expansion (aOR 2.2 (95% CI: 1.1-4.3), p = 0.021) and poor clinical outcome (aOR 2.6 (95% CI: 1.2-5.6), p = 0.019). Post hoc analysis showed that patients who were spot sign negative had a higher degree of haematoma expansion with baseline lobar haemorrhage (lobar 26% versus deep 11%; p = 0.01). No significant associations were observed in spot-positive patients (lobar 52% versus deep 47%; p = 0.69).

Discussion and Conclusion

Haematoma expansion is more likely to occur with lobar intracerebral haemorrhage and haemorrhage location is associated with poor clinical outcome. As expansion is a promising therapeutic target, hemorrhage location may be helpful for prognostication and as a selection tool in future ICH clinical trials.

Abstract WP372: The Acute ICH Growth Score: Simple and Accurate Predictor of Hematoma Expansion in Patients with Acute Intracerebral Hemorrhage

Background and Purpose: Acute intracerebral hemorrhage (ICH) hematoma expansion predicts high mortality and morbidity, occurring in a third of patients presenting with this condition. Recent studies correlated ultra-early hematoma growth and hematoma morphologic appearance with ICH expansion. Our purpose was to develop simple and clinically useful score that would predict ICH hematoma expansion accurately.

Methods: This cohort included patients with primary or anticoagulation-associated ICH patients presenting <6 hours post ictus prospectively enrolled in the PREDICT study. Patients underwent baseline CT, CT angiography and 24-hour CT for hematoma expansion analysis. A risk score model was developed for predicting hematoma expansion (> 6 ml or > 33%). A 7-point acute ICH growth score was based on ultra-early hematoma growth > 5 mL/hour (yes=1), irregular morphology (yes=1), density heterogeneity (yes=1), presence of fluid-blood levels (yes=1), spot sign (yes=1), and use of anticoagulation (yes=2). Discrimination of the expansion score was assessed.

Results: We retrospectively studied 301 primary or anticoagulation-associated intracerebral hemorrhage patients. The 7-point acute ICH growth score demonstrated good discrimination for hematoma expansion>6 mL or 33% (area under the curve of 0.76). Median and significant HE are shown in the table below (p<0.001).

Conclusions: In a multicenter prospective study, the ICH expansion score demonstrate good correlation with hematoma expansion, and included recently reported variables such as morphology and ultraearly growth.

Evaluation of Ictal Consciousness in Temporal and Extra Temporal Epilepsy: Observations from a Tertiary Care Hospital in India

Background and Purpose

Differences in consciousness during seizures depend on the location of the seizure onset.

Methods

The present study evaluates ictal consciousness using the ictal consciousness inventory (ICI) in drug refractory mesial temporal (MTLE), neocortical temporal (NTLE) and extra temporal epilepsy (ETLE). This was a cross sectional cohort study with 45 patients with mesial temporal epilepsy, 47 with extra temporal and 11 patients with neocortical temporal epilepsy. The ICI a 20 item questionnaire was used to calculate the scores for level (L, question 1–10) and content (C, question 11–20) of consciousness.

Results

The patients in mesial temporal group had higher ICI-L scores, p = 0.0129 as compared to the extra temporal group, but no difference was observed in the content of consciousness. The ICI-L and C scores were not different in the mesial temporal and the neocortical temporal group (p = 0.53 and 0.65) respectively.

Conclusions

Patients with mesial temporal epilepsy had a higher level of consciousness than the extra temporal group but there was no difference in the content. Also there was no difference in the level and content of consciousness between mesial and the neocortical temporal group.

Re-presenting Protest and Resistance on Stage: Avvai

This article asks how theatre practice may be gendered using not just protest but also resistance as a way of addressing women's oppression. Drawing upon her long experience as a theatre activist, the author traces the various experiments that were made to 'explore alternative images, symbols, metaphors and representation which help construct various forms of [female] subjec tivity' in Tamil theatre. The most recent of these is Avvai, written by Inquilab and directed by the author. In this revisionist account, the historical/mythic poet Avvai, contrary to the prevalent image of her as an old, wise, celibate woman, is rendered as a young, sensuous, creative, 'free' person, a wandering bard. Through a particular understanding of the Sangam era in Tamil his tory, Avvai's inner world as woman, poet and performer, and her external world of community and of politics are represented in ways that satisfy the requirements of a theatre of feminist resistance.

Ultraearly hematoma growth in active intracerebral hemorrhage

OBJECTIVE

To determine the association of ultraearly hematoma growth (uHG) with the CT angiography (CTA) spot sign, hematoma expansion, and clinical outcomes in patients with acute intracerebral hemorrhage (ICH).

METHODS

We analyzed data from 231 patients enrolled in the multicenter Predicting Haematoma Growth and Outcome in Intracerebral Haemorrhage Using Contrast Bolus CT study. uHG was defined as baseline ICH volume/onset-to-CT time (mL/h). The spot sign was used as marker of active hemorrhage. Outcome parameters included significant hematoma expansion (>33% or >6 mL, primary outcome), rate of hematoma expansion, early neurologic deterioration, 90-day mortality, and poor outcome.

RESULTS

uHG was higher in spot sign patients (p < 0.001) and in patients scanned earlier (p < 0.001). Both uHG >4.7 mL/h (p = 0.002) and the CTA spot sign (p = 0.030) showed effects on rate of hematoma expansion but not its interaction (2-way analysis of variance, p = 0.477). uHG >4.7 mL/h improved the sensitivity of the spot sign in the prediction of significant hematoma expansion (73.9% vs 46.4%), early neurologic deterioration (67.6% vs 35.3%), 90-day mortality (81.6% vs 44.9%), and poor outcome (72.8% vs 29.8%), respectively. uHG was independently related to significant hematoma expansion (odds ratio 1.06, 95% confidence interval 1.03-1.10) and clinical outcomes.

CONCLUSIONS

uHG is a useful predictor of hematoma expansion and poor clinical outcomes in patients with acute ICH. The combination of high uHG and the spot sign is associated with a higher rate of hematoma expansion, highlighting the need for very fast treatment in ICH patients.

Stroke and Thrombolysis in Developing Countries

Summary of review

The epidemiology of stroke is well investigated in the developed world; however, in the developing world stroke is less well documented. Most of the available stroke data from these countries are hospital-based. Stroke thrombolysis is currently used in few developing countries like Brazil, Argentina, Senegal, Iran, Pakistan, China, Thailand, and India. The two main barriers for implementation of thrombolysis therapy in developing countries are the high cost of tissue plasminogen activator and lack of proper infrastructure. Most of the centers with the infrastructure to deliver thrombolysis for stroke are predominantly private sector, and only available in urban areas.

Conclusion

Until a more cost-effective thrombolytic agent and the proper infrastructure for widespread use of thrombolysis therapy are available, developing nations should focus on primary and secondary stroke prevention strategies and the establishment of stroke units wherever possible. Such multi-faceted approaches will be more cost-effective for developing countries than the use of thrombolysis.

Abstract WMP92: Location of Hemorrhage Predicts Hematoma Expansion and Poor Clinical Outcome

Background: Baseline volume, spot sign, and coagulation status all predict early hematoma expansion (HE) in intracerebral hemorrhage (ICH). However, the role of ICH location on HE remains unclear. We hypothesized that lobar-located ICH would facilitate HE as it provides a larger potential volume for expansion as compared to deep locations. However, due to the close proximity of critical structures and increased risk of ventricular rupture, we also hypothesized that deep ICH would have a paradoxically increased risk of mortality and morbidity. Our objective was to assess the effect of lobar vs. non-lobar hemorrhage on HE and clinical outcome.

Methods: We analyzed data from the prospective multicentre PREDICT study where patients with ICH presenting to hospital under 6 hours of symptom onset received a baseline CT, CTA, 24 hour follow-up CT, and 90-d mRS. ICH location was categorized as lobar vs deep, and primary outcomes were significant HE (>6mL) and poor clinical outcome (mRS >3). Multivariable regression with stepwise selection was used to adjust for relevant covariates. Sensitivity analysis was conducted by expanding the inclusion criteria to include patients who died or were treated with Factor VIIa and/or surgery prior to follow-up CT.

Results: Among 302 patients meeting the inclusion criteria, lobar hemorrhage was associated with increased hematoma expansion >6mL (p=0.003), poor clinical outcome (p=0.011) and mortality (p=0.017). When adjusted for covariates, lobar hemorrhage independently predicted significant hematoma expansion (aOR 2.3 [95% CI: 1.2-4.4], p=0.02). Sensitivity analysis included a total of 353 patients and lobar location was no longer significantly associated with poor outcome (p=0.198). This appeared to be related to a higher proportion of IVH in the excluded population (33% Primary vs. 65% Excluded, p<0.001).

Conclusion: Lobar hemorrhage led to expansion and poor clinical outcome in the primary analysis population. Sensitivity analysis of the excluded population revealed that deep bleeds are associated with a higher degree of mortality and morbidity, likely due to a higher frequency of IVH. Our findings suggest that baseline ICH location should be considered for risk stratification algorithms.

Small intracerebral hemorrhages have a low spot sign prevalence and are less likely to expand

Background

Hematoma expansion is a major predictor of morbidity and mortality after intracerebral hemorrhage (ICH). Both baseline hematoma volume and the CT-angiogram (CTA) spot sign predict hematoma expansion. Because the CTA spot sign may represent foci of active hemorrhage, we hypothesized that patients with smaller baseline hematoma volumes are less likely to be spot sign positive, and therefore less likely to expand.

Aim

We sought to validate our prior finding that small hematomas are unlikely to expand, and to determine the relationship between baseline hematoma volume, spot sign status, and risk of hematoma expansion.

Methods

Data were from the prospective PREDICT ICH study. Patients presenting within 6 h of symptom onset with completed baseline CT, CTA, and follow-up CT were included. Baseline hematoma volume was categorized a priori (<3 mL, 3–10 mL, 10–20 mL, >20 mL). The primary outcome was significant hematoma expansion (≥6 mL, ≥12.5 mL or ≥33%) and secondary outcomes were early neurological worsening, good clinical outcome (modified Rankin Scale 0–3), and mortality at 90 days.

Results

Among 315 patients meeting the inclusion criteria, baseline hematoma volume category predicted absolute hematoma expansion ( p < 0.001), spot sign prevalence ( p < 0.001), early neurologic worsening ( p = 0.002), clinical outcome ( p < 0.001), and mortality ( p < 0.001). Very small hematomas (<3 mL) were unlikely to be spot positive (7.7%), unlikely to expand (2.6%), and were associated with a 73% chance of good clinical outcome. Spot sign appeared to be most predictive of expansion in the 3–10 mL baseline hematoma volume category.

Conclusion

Very small hematomas are unlikely to expand and have a low spot sign prevalence. Hemostatic therapy trials may be best targeted at hemorrhages >3 mL in volume.

Perihematomal Edema Is Greater in the Presence of a Spot Sign but Does Not Predict Intracerebral Hematoma Expansion

BACKGROUND AND PURPOSE

Perihematomal edema volume may be related to intracerebral hemorrhage (ICH) volume at baseline and, consequently, with hematoma expansion. However, the relationship between perihematomal edema and hematoma expansion has not been well established. We aimed to investigate the relationship among baseline perihematomal edema, the computed tomographic angiography spot sign, hematoma expansion, and clinical outcome in patients with acute ICH.

METHODS

Predicting Hematoma Growth and Outcome in Intracerebral Hemorrhage Using Contrast Bolus CT (PREDICT) was a prospective observational cohort study of ICH patients presenting within 6 hours from onset. Patients underwent computed tomography and computed tomographic angiography scans at baseline and 24-hour computed tomography scan. A post hoc analysis of absolute perihematomal edema and relative perihematomal edema (absolute perihematomal edema divided by ICH) volumes was performed on baseline computed tomography scans (n=353). Primary outcome was significant hematoma expansion (>6 mL or >33%). Secondary outcomes were early neurological deterioration, 90-day mortality, and poor outcome.

RESULTS

Absolute perihematomal edema volume was higher in spot sign patients (24.5 [11.5-41.8] versus 12.6 [6.9-22] mL; P<0.001), but it was strongly correlated with ICH volume (ρ=0.905; P<0.001). Patients who experienced significant hematoma expansion had higher absolute perihematomal edema volume (18.4 [10-34.6] versus 11.8 [6.5-22] mL; P<0.001) but similar relative perihematomal edema volume (1.09 [0.89-1.37] versus 1.12 [0.88-1.54]; P=0.400). Absolute perihematomal edema volume and poorer outcomes were higher by tertiles of ICH volume, and perihematomal edema volume did not independently predict significant hematoma expansion.

CONCLUSIONS

Perihematomal edema volume is greater at baseline in the presence of a spot sign. However, it is strongly correlated with ICH volume and does not independently predict hematoma expansion.

Intracerebral Hematoma Morphologic Appearance on Noncontrast Computed Tomography Predicts Significant Hematoma Expansion

Background and Purpose—

Hematoma expansion in intracerebral hemorrhage is associated with higher morbidity and mortality. The computed tomography (CT) angiographic spot sign is highly predictive of expansion, but other morphological features of intracerebral hemorrhage such as fluid levels, density heterogeneity, and margin irregularity may also predict expansion, particularly in centres where CT angiography is not readily available.

Methods—

Baseline noncontrast CT scans from patients enrolled in the Predicting Hematoma Growth and Outcome in Intracerebral Hemorrhage Using Contrast Bolus CT (PREDICT) study were assessed for the presence of fluid levels and degree of density heterogeneity and margin irregularity using previously validated scales. Presence and grade of these metrics were correlated with the presence of hematoma expansion as defined by the PREDICT study on 24-hour follow-up scan.

Results—

Three hundred eleven patients were included in the analysis. The presence of fluid levels and increasing heterogeneity and irregularity were associated with 24-hour hematoma expansion ( P =0.021, 0.003 and 0.049, respectively) as well as increases in absolute hematoma size. Fluid levels had the highest positive predictive value (50%; 28%–71%), whereas margin irregularity had the highest negative predictive value (78%; 71%–85). Noncontrast metrics had comparable predictive values as spot sign for expansion when controlled for vitamin K, antiplatelet use, and baseline National Institutes of Health Stroke Scale, although in a combined area under the receiver-operating characteristic curve model, spot sign remained the most predictive.

Conclusions—

Fluid levels, density heterogeneity, and margin irregularity on noncontrast CT are associated with hematoma expansion at 24 hours. These markers may assist in prediction of outcomes in scenarios where CT angiography is not readily available and may be of future help in refining the predictive value of the CT angiography spot sign.

Validation of the 9-Point and 24-Point Hematoma Expansion Prediction Scores and Derivation of the PREDICT A/B Scores

Background and Purpose—

Nine- and 24-point prediction scores have recently been published to predict hematoma expansion (HE) in acute intracerebral hemorrhage. We sought to validate these scores and perform an independent analysis of HE predictors.

Methods—

We retrospectively studied 301 primary or anticoagulation-associated intracerebral hemorrhage patients presenting <6 hours post ictus prospectively enrolled in the Predicting Hematoma Growth and Outcome in Intracerebral Hemorrhage Using Contrast Bolus Computed Tomography (PREDICT) study. Patients underwent baseline computed tomography angiography and 24-hour noncontrast computed tomography follow-up for HE analysis. Discrimination and calibration of the 9- and 24-point scores was assessed. Independent predictors of HE were identified using multivariable regression and incorporated into the PREDICT A/B scores, which were then compared with existing scores.

Results—

The 9- and 24-point HE scores demonstrated acceptable discrimination for HE>6 mL or 33% and >6 mL, respectively (area under the curve of 0.706 and 0.755, respectively). The 24-point score demonstrated appropriate calibration in the PREDICT cohort (χ 2 statistic, 11.5; P =0.175), whereas the 9-point score demonstrated poor calibration (χ 2 statistic, 34.3; P <0.001). Independent HE predictors included spot sign number, time from onset, warfarin use or international normalized ratio >1.5, Glasgow Coma Scale, and National Institutes of Health Stroke Scale and were included in PREDICT A/B scores. PREDICT A showed improved discrimination compared with both existing scores, whereas performance of PREDICT B varied by definition of expansion.

Conclusions—

The 9- and 24-point expansion scores demonstrate acceptable discrimination in an independent multicenter cohort; however, calibration was suboptimal for the 9-point score. The PREDICT A score showed improved discrimination for HE prediction but requires independent validation.

Serum uric acid in new and recent onset primary hypertension

Introduction:

Hyperuricemia is common among adults with prehypertension, especially when the microalbuminuria is present. Hyperuricemia precedes the development of hypertension.

Aim:

(1) To find the association of hyperuricemia in new-onset hypertensive patients. (2) To find the association of hyperuricemia in hypertensive patients with regard to gender and risk factors such as smoking and central obesity.

Material and Methods:

A total of 50 adults aged between 20 and 50 years who had mild early hypertension were selected for the study. Fifty controls without hypertension were enrolled and investigated.

Results:

The association between uric acid (UA) and hypertension was analyzed using Student's t-test and statistical difference were assessed using Pearson coefficient. The study showed a significant difference in UA between the hypertensive subjects and the normotensive controls. There was not a significant difference between waist abnormality, smoking and UA in cases. Males have a higher degree of hyperuricemia than females in hypertensive patients.

Conclusion:

Serum UA is strongly associated with blood pressure (BP) in new and recent onset primary hypertension. The remarkable association of UA with BP in adults is consistent with recent animal model data and the hypothesis that the UA might have a pathogenic role in the development of hypertension.

Health problems and stress in Information Technology and Business Process Outsourcing employees

Stress is high in software profession because of their nature of work, target, achievements, night shift, over work load. 1. To study the demographic profile of the employees. 2. To access the level of job stress and quality of life of the respondents. 3. To study in detail the health problems of the employees. All employees working in IT and BPO industry for more than two years were included into the study. A detailed questionnaire of around 1000 IT and BPO employees including their personal details, stress score by Holmes and Rahe to assess the level of stress and master health checkup profile were taken and the results were analysed. Around 56% had musculoskeletal symptoms. 22% had newly diagnosed hypertension,10% had diabetes, 36% had dyslipidemia, 54% had depression, anxiety and insomnia, 40% had obesity. The stress score was higher in employees who developed diabetes, hypertension and depression. Early diagnosis of stress induced health problems can be made out by stress scores, intense lifestyle modification, diet advice along with psychological counselling would reduce the incidence of health problems in IT sector and improve the quality of work force.

Abstract W MP25: Intravenous Thrombolysis in India: The Indo-US Stroke Project

Background: There is limited information concerning stroke thrombolysis in developing countries like India. We investigated the frequency, barriers and outcomes after thrombolysis in 5 high-volume hospitals across India.

Methods: The Indo-US Stroke Registry and Infrastructure Development Project, jointly funded by NINDS and the Indian Department of Biotechnology, currently include 5 geographically diverse centers in North and South India and one in Boston, USA. Trained MD co-investigators and research coordinators prospectively collect data on consecutive adult patients with imaging-confirmed ischemic stroke <2 weeks after symptom onset. Data is entered into a central web-based electronic database.

Results: From Nov-2012 to July-2014, 1944 patients were enrolled. Two hundred and eighty six were eligible for tPA. A total of 215 patients (11% of the total cohort and 75% of tPA-eligible patients) received thrombolysis including 139 of 188 patients who arrived <3h after onset and 76 of 98 who arrived between 3-4.5 h. Mean age was 59±15 years (range 48-69 years) and 68% were male. Stroke risk factors included hypertension (75%), diabetes (48%), hyperlipidemia (18%), coronary artery disease (27%), rheumatic heart disease (12%), atrial fibrillation (9%) and myocardial infarction (10%).The median NIHSS score was 10 (Interquartile range: 6-14). Hospital arrival was via EMS (3%), private transportation (50%) and transfer from another hospital (49%). Symptomatic intracranial hemorrhage was documented in 15 patients. Barriers of thrombolysis among patients otherwise eligible for thrombolysis included inability to afford tPA (n=15), patients/family refusal (n=32), delay in stroke diagnosis (n=6), and/or other in-hospital delays (n=9).

Conclusions: Thrombolysis is frequently administered in large academic hospitals in India, with acceptable safety. The relative lack of ambulance services, delay in arrival and diagnosis, and high cost of tPA are opportunities for infrastructure development.

Abstract 93: Do Intracerebral Hemorrhage “Non-Expanders” Actually Expand into the Ventricular Space?

Background: The CT-angiography spot sign as a predictor of hematoma expansion (HE) is limited by its modest sensitivity and PPV. Spot sign studies restrict HE definitions to the parenchymal component of ICH and do not consistently evaluate intraventricular hemorrhage (IVH) expansion. Decompression of ICH into the ventricular space can lead to underestimation of HE and overestimation of false-positive spot signs. We hypothesized that a proportion of ICH “non-expanders” expand into the ventricular space and including IVH expansion in HE definitions will improve the predictive performance of the spot sign. Our objectives were: 1) determine the proportion of ICH “non-expanders” who have IVH expansion, 2) determine the proportion of “false-positive” spot signs that have IVH expansion, 3) compare the known predictive performance of the spot sign to its performance when using an HE definition incorporating IVH expansion, and 4) explore the predictors of IVH expansion.

Methods: We analyzed patients from the multicenter PREDICT ICH spot sign study. We defined HE as ≥6mL or ≥33% ICH expansion or >2ml IVH expansion, and compared the performance of this new definition with the conventional 6mL/33% parenchymal definition using ROC analysis. We used regression analysis to determine the predictors of IVH expansion.

Results: Of 315 patients with complete imaging, 215 did not meet the 6mL/33% expansion definition ("non-expanders"). Only 14/215 (6.5%) of “non-expanders” had ≥2mL IVH expansion. Of the “false positive” spot signs, 4/39 (10.3%) had >2mL ventricular expansion. The AUC for spot sign to predict significant ICH expansion was 0.65 [95% CI 0.58-0.72], which was no different then when IVH expansion was added to the HE definition: AUC 0.64 [95% CI 0.58-0.71]. Predictors for IVH expansion included IVH at baseline (aOR 2.5, p=0.013), elevated INR (aOR 2.5, p=0.011), and spot sign (aOR 5.9, p<0.001).

Conclusions: IVH expansion occurs in a small minority of “non-expanders”, and only 10% of “false positive” post signs actually expended in the ventricular space. Furthermore, revising HE definitions to include IVH expansion did not alter the predictive performance of the spot sign.

Inverse relationship between stigma and quality of life in India: is epilepsy a disabling neurological condition?

OBJECTIVE

Stigma associated with epilepsy has negative effects on psychosocial outcomes, affecting quality of life (QOL) and increasing disease burden in persons with epilepsy (PWEs). The aim of our study was to measure the impact of stigma on the QOL of PWEs and the prevalence of neurological disability due to stigmatized epilepsy.

METHOD

A prospective observational study with a sample of 208 PWEs was conducted. Neuropsychological Tests used were the Indian Disability Evaluation Assessment Scale (IDEAS) to measure disability, the Dysfunctional Analysis Questionnaire (DAQ) to measure QOL, and the Stigma Scale for Epilepsy (SSE) to assess stigma.

RESULTS

Spearman correlation was calculated, and stigma (SSE) was highly significant with QOL (DAQ) (0.019) and disability due to stigmatized epilepsy (IDEAS) (0.011).

CONCLUSION

The present study supports the global perception of stigma associated with epilepsy and its negative impact on their overall QOL and its contribution to the escalation of the disease burden.

Abstract T MP86: Quality of Stroke Care in India: the Indo-US Stroke Project

Background: There is limited information concerning the quality of care and outcomes after stroke in developing countries like India. We investigated stroke quality in 5 high-volume academic tertiary hospitals across India, using quality measures derived from the AHA GWTG-Stroke program.

Methods: The Indo-US Stroke Registry and Infrastructure Development Project, jointly funded by NINDS and the Indian Department of Biotechnology, currently has 5 centers in India and one in the US. Trained MD co-investigators and research coordinators prospectively collect data on consecutive adult patients admitted with imaging-confirmed ischemic stroke <2 weeks after symptom onset. Data is entered into a central web-based electronic database.

Results: From 11/12 to 6/13, 967 patients were enrolled across the 5 Indian centers. Mean age 59.7±14y (range 20-92), 66% males. Eighty-four (8.7%) arrived within 3h and 50 (5.2%) arrived 3.0-4.5h after onset and proved eligible for thrombolysis; of these, 104 (78%) received IV or IA thrombolysis. NIHSS was documented prospectively in 39%, retrospectively in 41%, and not obtained in 20%. Before the end of Day 2, 91% received antithrombotic therapy and 46% received DVT prophylaxis. Dysphagia screening prior to oral intake was completed in 760 patients (79%), of whom 34% failed the screen and 24% remained NPO during hospitalization. In-hospital complications included pneumonia (16%), DVT/PE (4%), and UTI (14%; nearly all had indwelling Foley catheters). LDL cholesterol was documented in 86%. Discharge medications included antiplatelets (85%), anticoagulants (22%), and lipid lowering agents (76%). Of 105 patients with atrial fibrillation, 59 (44%) were discharged on anticoagulation. Discharge education included information about stroke risk factors and awareness (93%), emergent evaluation for new symptoms (53%), prescribed medications (93%), smoking cessation counseling (13%). In-hospital mortality was 6%, 40% were assessed for rehabilitation but 83.5% were discharged home .

Conclusions: These early data provide insights about stroke quality of care in large academic Indian hospitals, and suggest underuse of guideline-based care. Opportunities exist for establishing programs like GWTG-Stroke in India.

Abstract T P266: Training and Certification of Research Teams Across Countries: The INDO-US Project Experience

Background: The Indo-US Stroke Registry and Infrastructure Development Project, jointly funded by NINDS and the Indian Dept. of Biotechnology, currently includes 5 academic tertiary hospitals in India and 1 in USA. The aim is to develop high-quality stroke centers in India, modeled after the US center.

Methods: From Jun’12-Jun’13, 5 Indian PIs (one per center) hired 19 research coordinators or fellows and one project manager across all sites. The US collaborators developed a web-based registry with data variables/definitions consistent with the NINDS Stroke Common Data Elements and the AHA GWTG-Stroke Projects. Before launch of prospective data collection, the US PI and project manager trained the Indian collaborators as follows: (a) coordinator training via 2 video-conferences/web discussions and 1 interactive telephone training session for data entry, NIHSS and mRS certification, stroke classification, and imaging data (b) 2 teleconferences for MD training on data definitions, stroke subtypes using an automated web-based system, and image analysis (c) Data entry, logic check and query resolution for all co-investigators via 6 sessions using teleconference and remote computer access (d) Recently, we developed video training modules. Enrollment progress reports were sent out monthly. Post-launch, we conducted 5 teleconferences (one every 2 months) to resolve queries. In April ’13, site monitoring and audit visits were conducted by the Project managers. We compared our experience before and after the in-person site monitoring visit.

Results: After the in-person site monitoring visit in April ’13, enrollment improved by 150% (27 patients per month in May-June 2013, vs. an average of 17 per month from Nov-2012 to May-2013). The in-person site visit resulted in significantly better data quality, with a 60% decrease in data entry errors. Research coordinators unanimously expressed a better understanding of consent procedures, regulatory aspects, and accurate data collection.

Conclusion: Cross-country research collaboration requires extensive resources for training and certification purposes. In-person site visits appear essential for improving data quality and should be conducted in addition to video, telephone and web-based training.

Abstract 30: Association of Fluid Levels, Density Heterogeneity and Irregular Margins on Baseline Non-Contrast Computerized Tomography With Significant Hematoma Expansion in Intracerebral Hemorrhage

Introduction: The PREDICT study confirmed that the spot sign was a valid predictor of expansion in intracerebral hemorrhage (ICH) at 24h, with a positive predictive value (PPV) of 61%. This technique requires access to computed tomography angiography (CTA). Other markers may enhance the ability to predict expansion in ICH, or be useful in cases where multimodal imaging is not available. Previous studies have suggested that markers on non-contrast computed tomography (NCCT) such as density heterogeneity within the hematoma, irregularity of external margins, or internal fluid levels are associated with hematoma expansion (HE).

Methods: Baseline NCCT scans of patients enrolled in PREDICT were examined for the presence of internal fluid levels (defined as a change within the hematoma resulting in a linear interface between two discrete fluid densities) and for the presence of hematoma density heterogeneity and margin irregularity (using an ordinal scale of 1-5 defined, published and validated previously). The association of each marker with median 24h absolute growth and with significant HE (defined as an increase in hematoma size of 6 mL or 33% measured 24h from baseline) were determined.

Results: Fluid levels were present in 29 (8.3%) of 351 eligible patients. The presence of fluid levels were associated with significant HE at 24h (χ2 =7.64, df=1, p<0.01) and with a trend toward increased median absolute ICH volume at 24h (6.4 mL vs. 0.9 mL, p=0.09). The PPV for fluid levels was 52% (95% CI 46-57) for significant HE. Increased density heterogeneity (p<0.01) and margin irregularity (p<0.01) were both associated with increased median absolute ICH volume at 24h. Increased density heterogeneity was associated with significant HE (χ2 =20.0, df=4, p<0.01); increased margin irregularity had a trend toward association with significant HE (χ2 =8.69, df=4, p=0.06).

Conclusions: Density heterogeneity and fluid levels are associated with significant HE at 24h, and margin irregularity is associated with increased median hematoma size. These markers may be useful for predicting significant HE in ICH in cases where CTA is unavailable to identify the presence of a spot sign. They may also provide additional variables to incorporate into risk scores for hematoma expansion.

Abstract 31: Ultraearly Hematoma Growth: Multicenter External Validation of the Adjustment of Intracerebral Hemorrhage Volume by Onset-to-imaging Time

Background: The impact of baseline intracerebral hemorrhage (ICH) volume on hematoma growth (HG) and clinical outcome may vary widely depending on the onset-to-imaging time (OIT). We previously reported that the adjustment of initial ICH volume by OIT (coined as ultraearly HG, uHG) is a powerful tool for outcome prediction in acute ICH. We aimed to validate our previous findings in a multicenter external cohort and to assess the relationship between uHG and the CTA spot-sign.

Methods: The PREDICT study was a prospective, observational cohort study of consecutive ICH patients <6 hours. Patients underwent baseline and 24-hour CT scans, and CTA for the blinded detection of spot sign. uHG was defined as the relation between baseline ICH volume/OIT, HG as hematoma expansion >33% or >6 mL, early neurologic deterioration (END) as increase ≥4 points in the NIHSS score or death at 24 hours, and poor outcome as mRS score >2 at 3 months.

Results: Two hundred and thirty-seven patients were included in this study. Median baseline ICH volume was 14.5 (6[[Unable to Display Character: &#8211;]]30.4) mL, median OIT 135 (85.5[[Unable to Display Character: &#8211;]]199) minutes, and median uHG 6.5 (2.5-14.3) mL/h. The spot sign was present in 31.2% of patients. uHG was 2.7-fold higher in spot sign-positive patients (11.1 [5.7-17.7] mL/h vs. 4.1 [1.9-12.3] mL/h, P<0.001). uHG >4.7 mL/h improved the sensitivity-specificity of both baseline ICH volume >10 mL and spot sign in the prediction of HG (73.9%-57.5% vs. 68.1%-54.3% and 48.9%-73.9%), 90-day mortality (82%-56.3% vs. 78%-53.5% and 45.8%-70.8%), and poor outcome (72.9%-80.4% vs. 69.8%-70.6% and 38%-75%), respectively. The median hematoma expansion at 24 hours among spot-positive patients was 3.2 mL in uHG <5 mL/h group, 4.1 mL in uHG 5-10 mL/h group, and 4.8 mL in uHG >10 mL/h group (P<0.001). In adjusted multivariate analyses uHG independently predicted HG (OR 1.08, 95% CI 1.04-1.12), END (OR 1.06, 95% CI 1.02-1.10), 90-day mortality (OR 1.07, 95% CI 1.02-1.11), and poor outcome (OR 1.12, 95% CI 1.02-1.23).

Conclusions: These results validate uHG as a powerful predictor of outcome in acute ICH. uHG is significantly higher in spot sign patients, improves the accuracy of baseline ICH volume and spot sign in the prediction of HG and clinical outcome, and independently predicts HG, END, 90-day mortality, and poor outcome.

Role of heparin and low-molecular-weight heparins in the management of acute ischemic stroke

The numerous large-scale randomized clinical trials performed during the last decade on either unfractionated heparin, or low molecular weight heparin have not been able to demonstrate undisputed benefits in patients with acute ischemic stroke, compared with no treatment or aspirin. However, a large number of these trials, including the International Stroke Trial and Chinese Acute Stroke Trial, exhibit severe methodological limitations and need to be interpreted with caution. Knowledge of thromboembolism pathophysiology and clinical experience leads to the theory that heparins will prevent red thrombus formation, propagation and embolism. Heparins effectively prevent venous thrombosis and pulmonary embolism. More trials are needed to test heparins in patients whose cardiocerebrovascular lesions are better defined by newer neuroimaging techniques. The efficacy of heparins has not been adequately tested in patients with defined stroke subtypes and occlusive vascular lesions. Heparins should not be indiscriminately given to all patients with acute ischemic stroke. High-quality, randomized trials that adequately study heparin use in patients using modern technology for vascular lesions and stroke subtypes are lacking, and need to be performed.

Spot sign number is the most important spot sign characteristic for predicting hematoma expansion using first-pass computed tomography angiography: analysis from the PREDICT study

BACKGROUND AND PURPOSE

The spot sign score (SSS) provides risk stratification for hematoma expansion in acute intracerebral hemorrhage; however, external validation is needed. We sought to validate the SSS and assess prognostic performance of individual spot characteristics associated with hematoma expansion from a prospective multicenter intracerebral hemorrhage study.

METHODS

Two hundred twenty-eight intracerebral hemorrhage patients within 6 hours after ictus were enrolled in the Predicting Hematoma Growth and Outcome in Intracerebral Hemorrhage Using Contrast Bolus CT (PREDICT) study, a multicenter prospective intracerebral hemorrhage cohort study. Patients were evaluated with baseline noncontrast computerized tomography, computerized tomography angiography, and 24-hour follow-up computerized tomography. Primary outcome was significant hematoma expansion (>6 mL or >33%) and secondary outcome was absolute and relative expansion. Blinded computerized tomography angiography spot sign characterization and SSS calculation were independently performed by 2 neuroradiologists and a radiology resident. Diagnostic performance of the SSS and individual spot characteristics were examined with multivariable regression, receiver operating characteristic analysis, and tests for trend.

RESULTS

SSS and spot number independently predicted significant, absolute, and relative hematoma expansion (P<0.05 each) and demonstrated near perfect interobserver agreement (κ=0.82 and κ=0.85, respectively). Incremental risk of hematoma expansion among spot-positive patients was not identified for SSS (P trend=0.720) but was demonstrated for spot number (P trend=0.050). Spot number and SSS demonstrated similar area under the curve (0.69 versus 0.68; P=0.306) for hematoma expansion.

CONCLUSIONS

Multicenter external validation of the SSS demonstrates that the spot number alone provides similar prediction but improved risk stratification of hematoma expansion compared with the SSS.

Abstract 115: Venous Phase Acquisition Is the Best Bolus Timing to Increase Spot Sign Detection in ICH, But Frequency and Extent of Hematoma Expansion Are Greater in Spot Signs Detected in the Arterial Phase of CTA

Background: Although the PREDICT study validated the spot sign for predicting significant hematoma expansion (HE) in acute intracerebral hemorrhage (ICH), the sensitivity was 51% and PPV 61%. Recent studies suggest that second pass imaging can increase the yield of contrast extravasation. The present analysis aimed to determine the frequency of spot sign depending on the phase of image acquisition, and whether an early phase spot sign has greater HE compared to later phases.

Methods: The PREDICT study was a multicentric, prospective, observational cohort study of ICH patients presented <6 hours. A blinded neurologist measured the Hounsfield units of an arterial and venous structure at three levels on CTA source images. The nearest structure to ICH was chosen to classify each study into the phase of acquisition. CTA were classified in 10 phases from early triggering to steady state, including arterial peak (5), arterial-venous equilibrium (6), and venous peak (7). Significant HE was defined as ICH enlargement >33% or >6mL at 24 hours.

Results: Overall (n=378), 77.5% of CTA were acquired in arterial phases. The spot sign occurred in 29.6%, and there was a trend to more frequent detection in the venous phases (37.6% vs. 27.3%, p=0.066) and in later image acquisition phases (p=0.141; Fig). HE analysis was limited to 318 patients: 26.7% presented spot sign and 32.4% experienced significant HE. In spot-sign positive group, there was a trend that HE occurred more frequently in earlier image acquisition phases (p=0.193, Fig). Similarly, median total hematoma enlargement (ICH+IVH) was greater in earlier phases (p=0.041; Fig).

Conclusions: This analysis highlights improved spot sign detection with later image acquisition in venous phase of CTA. However spot signs identified in the arterial phase are associated with more frequent hematoma expansion and greater extent. A two phase CTA is optimal in ICH patients and should include image acquisition in the arterial and venous phases.

Abstract WP293: Baseline Perihematomal Edema is Greater in the Presence of a CTA Spot Sign but Does Not Predict Hematoma Expansion Independent of ICH Volume

Background: Similarly to intracerebral hemorrhage (ICH), perihematomal edema (PHE) increases with time from onset. A small degree of PHE relative to ICH may suggest a very early timepoint from onset or actively bleeding ICH and therefore predict a higher likelihood of hematoma expansion (HE). The relationship between PHE, ICH and HE has not however been established. Therefore, we aimed to investigate the link between PHE and ICH by time and their relationship with the CTA spot sign and HE.

Methods: The PREDICT study was a multicentric, prospective, observational cohort study of ICH patients <6 hours. All study cohort subjects with available baseline CT scan images (n=377) were included in this analysis. Volumes and diameters of total lesion, ICH and PHE were measured systematically by two blinded investigators, respectively. Diameter measurements were taken in the axial CT slice with the largest ICH area. Significant HE was defined as ICH enlargement >33% or >6mL at 24 hours.

Results: Correlation between volume and diameter measurements was strong for total lesion (r=0.9; p<0.001) and ICH (r=0.88; p<0.001), but moderate for PHE (r=0.43; p<0.001). PHE represented a half of the total lesion volume at baseline (Table). PHE volume and diameter were not related to time from onset to baseline CT, although PHE/ICH diameter (p=0.017) and volume (p=0.061) ratios were higher the later the baseline CT scan was performed. Spot-sign patients (29.7%) had more baseline PHE, ICH and total lesion than spot-negative patients (Table). HE analysis was limited to 322 patients with follow-up CT before rFVIIa or surgical intervention. HE patients (32%) presented with higher PHE, ICH and total lesion volumes (Table). Baseline PHE diameter and volume ratios however did not predict subsequent HE.

Conclusion: Edema represents about half of total lesion volume in acute ICH. Edema and ICH are larger in the presence of a CTA spot sign. Edema alone does not predict subsequent hematoma expansion.

A comparative study of caregiver burden in psychiatric illness and chronic medical illness

BACKGROUND

Caregivers of individuals suffering from psychiatric illness are at risk of being subjected to mental health consequences such as depression, anxiety and burnout. Community-based studies proved that 18-47% of caregivers land in depression. The caregiver burden can be quantified into objective, subjective and demand burdens. There is paucity of data comparing the caregiver burden of psychiatric patients and that of chronic medical illness patients.

AIMS AND OBJECTIVES

(1) To compare the caregiver burden in psychiatric illness and chronic medical illness. (2) To study the association of caregiver burden with demographic factors like age, gender, duration of caregiving.

MATERIALS AND METHODS

The study included two groups of caregivers, each of 50 members. Group 1 consisted of caregivers of psychiatric patients and group 2 consisted of caregivers of chronic medical illness patients. The Montgomery Borgatta Caregiver Burden scale was used to assess the burden in terms of objective, subjective and demand burdens.

RESULTS AND CONCLUSION

The caregiver burden scores in the caregivers of psychiatric patients were significantly higher than that of chronic medical illness (P<0.0001). The caregiver burden was found to increase with the duration of illness as well as with the age of caregiver. The caregiver burden in the sample population was less as the objective and demand burden did not cross the reference higher value in the given scale, whereas the emotional impact given by the subjective burden was on higher side.

Primary tuberculosis of stomach

Gastric tuberculosis is mostly secondary to pulmonary tuberculosis. Primary and isolated gastric tuberculosis is very rare. A case of primary gastric tuberculosis of stomach in a 45-year-old female, known diabetic and hypertensive who presented to the hospital with epigastric pain and vomiting is being reported. Endoscopy showed a gastric ulcerated nodular lesion and biopsy showed tuberculous granuloma. Repeat endoscopy after a course of antituberculosis treatment showed minimal gastritis and complete resolution of the ulcerated nodular lesion.

Abstract 100: Small Intracerebral Hematomas Have A Low Spot Sign Prevalence And Are Unlikely To Expand

Background: Early intracerebral hemorrhage (ICH) expansion is a major determinant of poor clinical outcome. We previously reported baseline hematoma volume was a predictor of hematoma expansion (HE), and that hematomas <3mL may represent a subgroup with good prognosis. Our objective was to validate our previous findings in a multi-centre prospective observational cohort, and to assess the relationship between baseline hematoma size and the CTA spot-sign. We hypothesized that small hematomas are less likely to expand, and have low spot-sign prevalence.

Methods: The PREDICT study is a prospective, observational cohort study of consecutive patients with acute ICH. Inclusion criteria are age>18, symptom onset <6 hours, and baseline CT and CTA; exclusions are baseline ICH >100ml, planned ICH surgery within 24 hours, known secondary cause of ICH, known renal impairment, GCS<6, or premorbid disability or terminal illness. Scans were reviewed for spot sign presence/absence by a neuroradiologist blinded to outcomes and follow-up imaging. Volumes were measured by planimetry by a neurologist blinded to CTA images and outcomes. The predictor of interest was baseline hematoma volume which was stratified as <3mL, 3-9mL, 10-19mL, 20-29mL and >30mL based on our prior study. Primary outcome was significant HE defined as ≥6mL. We used multivariable models to calculate adjusted odds ratios (aOR) for HE.

Findings: Two-hundred and sixty-eight patients were enrolled from 11 centers in 6 countries: HE analysis was limited to 228 patients with follow-up CT before rFVIIa or surgical intervention. Median baseline hematoma volume was 12.4ml, spot-sign was present in 26.8% of patients, and 25% of patients had HE of ≥6ml. HE and spot sign prevalence increased with increasing baseline hematoma volume (see table ) . Only one patient with volume <3ml had HE; the patient was on warfarin (INR 2.2) but spot negative. Two patients with volumes <3ml were spot positive, but neither had HE. When compared to hematomas >30ml, the aOR for HE was 0.09 for <3ml hematomas, 0.14 for 3-9ml, 0.49 for 10-20ml, and 1.83 for 20-30ml (p<0.001). Associations between baseline hematoma volume and clinical outcomes will be presented.

Discussion: Our results validate baseline hematoma volume as a predictor of HE. Furthermore, spot sign prevalence is associated with baseline hematoma volume. These results can inform ICH trial design and clinical prognostication at the bedside: small hematomas have a low spot sign prevalence and are unlikely to expand ≥6 ml, even when spot positive. Conversely, half of hematomas >30ml are spot positive and will expand.

Abstract 3046: Co-registration and 3D Comparison Reveal a Variable Trajectory of Intracerebral Hemorrhage Expansion in Relation to Spot Sign Location: Analysis from the PREDICT Study

Background: Intracerebral hemorrhage (ICH) expansion can have devastating effects for patients. The spot sign, a form of contrast extravasation, has been shown to predict hemorrhage expansion. However, the relationship between the location of the spot sign within the ICH and the direction of hemorrhage expansion has not been defined. We hypothesized that the spot sign can predict the trajectory of ICH expansion.

Methods: Data from PREDICT, a prospective, observational cohort study coordinated at the University of Calgary, were used to conduct this case series. Non-contrast computed tomography (CT) and CT-angiography data were obtained for each subject. We used segmentation software to outline ICH volume on baseline and follow-up CTs. We then co-registered the scans and volumes in the same space to allow for three-dimensional voxel-to-voxel comparison along the x-, y-, and z-axes. This comparison yielded three points in three-dimensional space: the spot sign center of mass, the baseline ICH center of mass, and the follow-up ICH center of mass. Distances and angles between these points were used to classify four groups of ICH expansion: 1) perpendicular to the spot sign and baseline ICH center of mass; 2) away from the spot sign; 3) toward the spot sign; and, 4) circumferential.

Results: Eighty-two PREDICT study subjects exhibited spot signs. Forty were multiple spot signs and 42 were single spot signs eligible for this analysis. Seven subjects were excluded because of surgery or incomplete imaging. Sixteen subjects were not co-registered because of head motion or insufficient image quality. Nineteen single spot subjects were successfully co-registered. The radius of these 19 hemorrhages was 1.6±0.4 cm (assuming a sphere). The spot sign was located 1.4±0.6 times the length of the radius away from the baseline ICH center of mass. We classified nine co-registered subjects into the four groups because they showed significant hemorrhage expansion defined as ≥6 mL or ≥33% from baseline to follow-up. Four subjects exhibited hemorrhage expansion away from the spot sign, three exhibited circumferential hemorrhage expansion, and two exhibited hemorrhage expansion toward the spot sign. No hemorrhages expanded perpendicular to the spot sign.

Conclusion: The spot sign is generally located in the periphery of the ICH. Hemorrhages do not consistently expand in one specific trajectory from the spot sign. This study suggests that the spot sign location may not be useful to predict the direction of hemorrhage expansion.

Thrombolytic therapy for acute ischemic stroke: 3 h and beyond

The current status of thrombolytic therapy approved by the US Food and Drug Administration is intravenous recombinant plasminogen activator given within 3 h of the onset of ischemic stroke. Intra-arterial therapy is possible for up to 6 h but is not Food and Drug Administration-approved for this purpose. Based on current radiologic methods (i.e., magnetic resonance imaging and perfusion computed tomography scans), it is being increasingly realized that the time window for effective thrombolytic therapy is variable, and salvageable tissue in the form of the ischemic penumbra may exist for longer periods of time and could therefore offer a greater time window based on these imaging studies. Development of an effective neuroprotective drug would greatly enhance the stability of the penumbra and offer further opportunities for extending the time window for reperfusion.

Mania associated with hepatitis B : a case report

Mania following or associated with medical and pharmacological conditions is well known. However there are no reports of mania in a case of acute viral hepatitis B infection. This paper describes a manic disorder in a young female with acute viral hepatitis B infection, without any past or family history of psychiatric illness or associated psychosocial stressors.

Intracerebral haematoma formation in herpes simplex encephalitis: a case report

Acute viral encephalitides have a high mortality and morbidity in all age groups. Early institution of appropriate medical treatment can alter the prognosis dramatically. Imaging studies may be normal or may show a wide variety of subtle findings in the initial stages. Knowledge of the extremely varied clinical as well as radiological expression of the disease is essential to enable timely diagnosis. A case is presented here of histopathologically proven Herpes simplex encephalitis (HSE), wherein a large intracerebral haematoma was seen on imaging studies. Observation of the accompanying subtle findings and knowledge of the variability of expression of this disease helped in reaching the correct diagnosis.