Imaging features and ultraearly hematoma growth in intracerebral hemorrhage associated with COVID-19

Background and Purpose Early hematoma expansion (EHE) has been described in the first 48 hours. SHRINC is a phase 2 prospective safety trial whose primary objective is to assess the safety of pioglitazone (PIO) when administered to patients with spontaneous intracerebral hemorrhage (SICH) compared to standard care. A secondary objective is to characterize the changes in hematoma resolution and expansion over time. This prospective study addresses the natural history, clinical impact, and associated risk factors of late hematoma expansion (LEX) by serial magnetic resonance imaging (MRI) after SICH. Methods SHRINC aims to enroll 78 subjects between the ages of 18-80 with a SICH of ≥ 5 ml. This analysis includes the first 42 patients enrolled. Four subjects were excluded because they did not have an MRI after day 2. A baseline CTH was performed followed by an MRI within 24 hours of symptom onset. Hematoma volume (Hv) was measured on FLAIR sequences using a previously published semi-automated range of interest method. LEX was defined as an increase in Hv > 0.5 ml after the 48 hour MRI. Factors associated with LEX were evaluated with logistic regression. Longitudinal analyses were used for measurements taken over the follow up period. Results: Ten (26.3%) of 38 subjects displayed LEX. Eight subjects had LEX between day 2 to 14, and 4 between days 14 to 28. The median initial Hv was 16.1cc in LEX patients and 24.1cc in those without expansion (NEX) (p=0.23). Lower platelet counts (p=0.04) and BUN levels (p=0.03) were associated with LEX in univariate analysis. Multivariate analysis suggested that those with higher BUN levels were less likely to have LEX (OR=0.81; 95%CI 0.65-0.99). Blood pressure and EHE (13.2%) were not associated with LEX. There was no difference in neurological worsening (NIHSS increase ≥ 4), 6 month mRS or death between LEX and NEX. Conclusion: This is the first prospective study to address LEX with serial MRIs. LEX occurs between day 2 to 14 and day 14 to 28. Elevated BUN levels may decrease the likelihood of LEX. A limitation of our study is that the effect of PIO on LEX could not be evaluated because SHRINC is a blinded trial. Further studies will assess the pathophysiology of LEX and its potential implications in clinical trials evaluating hematoma growth and resolution.

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Abstract 2276: Microhemorrhage Burden Increases the Risk of Hematoma Growth in Patients with Intracerebral Hemorrhage

Stroke ◽

10.1161/str.43.suppl_1.a2276 ◽

2012 ◽

Vol 43 (suppl_1) ◽

Author(s):

Joan Martí-Fàbregas ◽

Estrella Morenas ◽

Raquel Delgado-Mederos ◽

Lavinia Dinia ◽

Esther Granell ◽

...

Keyword(s):

Differential Diagnosis ◽

Statistical Analysis ◽

Intracerebral Hemorrhage ◽

Multicentre Study ◽

Symptom Onset ◽

Variable Time ◽

Hematoma Growth ◽

Acute Intracerebral Hemorrhage ◽

Radiological Studies

Introduction Microhemorrhages (MH) are lesions detected on radiological studies resulting from an underlying small-vessel angiopathy. We assesed the hypothesis that the presence of MH increases the risk of hematoma growth (HG) in patients with acute Intracerebral Hemorrhage (ICH). Methods We evaluated a series of patients in a prospective and multicentre study. We included patients with a spontaneous supratentorial ICH within the first 6 hours after symptom onset, that also had a follow-up CT 24-72 hours later and a MRI performed after a variable time after ICH. HG was defined as an increase >33% in the volume of hematoma on the follow-up CT, in comparison with the admission CT. The volume was calculated using the formula AxBxC/2. On MR scans we assessed the presence, number and distribution of MH. After differential diagnosis with other radiological lesions, MH were evaluated on echo-gradient sequences and defined as hypointense rounded lesions with a diameter <10mm. Statistical analysis: Bivariate tests with the whole sample and with the subgroup of patients with less than 3 hours from symptom onset. Results We studied 46 patients, whose mean age was 68.8±11.2 y and 68% were men. Mean baseline volume was 19.1±27.3 cc. We detected MH in 7/15 patients with HG and in 18/31 patients without HG (46.7% vs 58.1%, p=0.53). In the subgroup of patients with 10 MH, the risk of HG was higher than in patients with 0-10 MH (75% vs 28.6%, p=0.067), and this difference was significant when considering only patients with a <3 hours evolution (100% vs 31%, p=0.044). We did not observe any association between risk of HG and distribution of MH. Age and time to CT were equivalent in the two groups (with and without HG), either in the <6 or <3 hours subgroups. Conclusions In conclusion, in patients with hyperacute ICH, the presence of more than 10 MH increases the risk of HG. This is probably an indirect marker of a more severe underlying angiopathy.

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Early Achievement of Blood Pressure Lowering and Hematoma Growth in Acute Intracerebral Hemorrhage: Stroke Acute Management with Urgent Risk-Factor Assessment and Improvement-Intracerebral Hemorrhage Study

Cerebrovascular Diseases ◽

10.1159/000492728 ◽

2018 ◽

Vol 46 (3-4) ◽

pp. 116-122

Author(s):

Yoshitaka Yamaguchi ◽

Masatoshi Koga ◽

Shoichiro Sato ◽

Hiroshi Yamagami ◽

Kenichi Todo ◽

...

Keyword(s):

Blood Pressure ◽

Risk Factor ◽

Intracerebral Hemorrhage ◽

Acute Management ◽

Acute Hypertension ◽

Risk Factor Assessment ◽

Significant Difference ◽

Pressure Lowering ◽

Hematoma Growth ◽

Multicenter Prospective Observational Study

Background: Previous studies have revealed that hematoma growth mainly occurs during the first 6 h after the onset of spontaneous intracerebral hemorrhage (ICH). Early lowering of blood pressure (BP) may be beneficial for preventing hematoma growth. However, relationships between timing of BP lowering and hematoma growth in ICH remain unclear. We investigated associations between timing of BP lowering and hematoma growth for ICH. Methods: The Stroke Acute Management with Urgent Risk-factor Assessment and Improvement (SAMURAI)-ICH Study was a multicenter, prospective, observational study investigating the safety and feasibility of early (within 3 h from onset) reduction of systolic BP (SBP) to < 160 mm Hg with intravenous nicardipine for acute hypertension in cases of spontaneous ICH. The present study was a post hoc analysis of the SAMURAI-ICH study. We examined relationships between time from onset, imaging, and initiation of treatment to target SBP achievement and hematoma growth (absolute growth ≥6 mL) in ICH patients. Target SBP achievement was defined as the time at which SBP first became < 160 mm Hg. Results: Among 211 patients, hematoma growth was seen in 31 patients (14.7%). The time from imaging to target SBP and time from treatment to target SBP were significantly shorter in patients without hematoma growth than in those with (p = 0.043 and p = 0.032 respectively), whereas no significant difference was seen in time from onset to SBP < 160 mm Hg between groups (p = 0.177). Patients in the lower quartiles of time from imaging to target SBP and time from treatment to target SBP showed lower incidences of hematoma growth (p trend = 0.023 and 0.037 respectively). The lowest quartile of time from imaging to target SBP (< 38 min) was negatively associated with hematoma growth on multivariable logistic regression (OR 0.182; 95% CI 0.038–0.867; p = 0.032). Conclusions: Early achievement of target SBP < 160 mm Hg is associated with a lower risk of hematoma growth in ICH.

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Earlier Blood Pressure-Lowering and Greater Attenuation of Hematoma Growth in Acute Intracerebral Hemorrhage

Stroke ◽

10.1161/strokeaha.112.651422 ◽

2012 ◽

Vol 43 (8) ◽

pp. 2236-2238 ◽

Cited By ~ 22

Author(s):

Hisatomi Arima ◽

Yining Huang ◽

Ji Guang Wang ◽

Emma Heeley ◽

Candice Delcourt ◽

...

Keyword(s):

Blood Pressure ◽

Intracerebral Hemorrhage ◽

Blood Pressure Lowering ◽

Pressure Lowering ◽

Hematoma Growth ◽

Acute Intracerebral Hemorrhage

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Ultra‐Early Blood Pressure Reduction Attenuates Hematoma Growth and Improves Outcome in Intracerebral Hemorrhage

Annals of Neurology ◽

10.1002/ana.25793 ◽

2020 ◽

Vol 88 (2) ◽

pp. 388-395 ◽

Cited By ~ 2

Author(s):

Qi Li ◽

Andrew D. Warren ◽

Adnan I. Qureshi ◽

Andrea Morotti ◽

Guido J. Falcone ◽

...

Keyword(s):

Blood Pressure ◽

Intracerebral Hemorrhage ◽

Blood Pressure Reduction ◽

Pressure Reduction ◽

Hematoma Growth

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Association between neutrophil to lymphocyte ratio and blood glucose level at admission in patients with spontaneous intracerebral hemorrhage

Scientific Reports ◽

10.1038/s41598-019-52214-5 ◽

2019 ◽

Vol 9 (1) ◽

Cited By ~ 2

Author(s):

Fan Zhang ◽

Yanming Ren ◽

Wei Fu ◽

Yuelong Wang ◽

Juan Qian ◽

...

Keyword(s):

Regression Analysis ◽

Blood Glucose ◽

Intracerebral Hemorrhage ◽

Blood Glucose Level ◽

Glucose Level ◽

Inflammatory Responses ◽

Neutrophil To Lymphocyte Ratio ◽

Secondary Brain Injury ◽

Imaging Features ◽

Lymphocyte Ratio

Abstract Previous studies indicated that both inflammatory responses and hyperglycemia are involved in the similar pathophysiological mechanisms after onset of intracerebral hemorrhage (ICH). However the relationship between hyperglycemia and inflammation remains unknown. We aim to evaluate the associations of hyperglycemia with inflammation and neutrophil to lymphocyte ratio (NLR) in patients with ICH. Patients with acute ICH were retrospectively enrolled. Clinical characteristics and imaging features were obtained. The associations between outcome and laboratory biomarkers were assessed by multivariable logistic regression analysis. Spearman analysis and multiple linear regression analysis were performed to estimate the association of NLR and serum glucose. 175 patients were enrolled. Poor outcome occurred in 86 patients at 30 days. Elevated blood glucose level (BGL) and NLR were strongly associated with outcome in patients with ICH. Moreover, combined NLR-BGL exhibited a better predictive accuracy compared with the peripheral leukocyte counts. Furthermore, there was a robust association between BGL and NLR. We first demonstrated both of NLR and BGL were independently associated with each other. Our results indicate that inflammatory responses and the pathological process of hyperglycemia may influence each other by several complex pathological mechanisms and have a mutual promoting effect to secondary brain injury.

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