The ‘swirl sign’ as a marker for haematoma expansion and outcome in intra-cranial haemorrhage: A meta-analysis

IntroductionThe characteristics and natural history of acute non-vitamin K antagonists oral anticoagulants (NOAC)-associated intracerebral haemorrhage (ICH) are largely unknown. We performed a comprehensive systematic review and meta-analysis to compare baseline ICH volume, haematoma expansion and clinical outcomes between NOAC-ICH versus vitamin K antagonists-ICH (VKA-ICH).MethodsWe searched PubMed and conference abstracts for observational studies comparing baseline characteristics and outcomes in patients with NOAC-ICH versus VKA-ICH using an appropriate keyword/MeSH term search strategy. Data were extracted following PRISMA and MOOSE guidelines. The main outcome measures were mortality and unfavourable functional outcome (modified Rankin Score: 4–6) at discharge and at 3 months, as well as ICH volumes and haematoma expansion rates in the two groups. Random-effects models with DerSimonian-Laird weights were used for pooled estimates calculation.ResultsTwelve studies including 393 NOAC-ICH and 3482 VKA-ICH were pooled in meta-analysis. There was no difference in mean ICH-volume between the two groups (standard mean difference: −0.24; 95% CI −0.52 to 0.04, p=0.093). The rates of haematoma expansion were comparable in NOAC-ICH versus VKA-ICH (OR: 0.76; 95% CI 0.49 to 1.19, p=0.236). We did not find any difference between patients with NOAC-ICH versus VKA-ICH in all-cause mortality at discharge (OR: 0.66; 95% CI 0.42 to 1.05, p=0.077) and unfavourable functional outcome at discharge (OR: 0.77; 95% CI 0.41 to 1.44, p=0.413). The 3-month outcome was also comparable between the two ICH groups. Moderate-to-substantial statistical heterogeneity was noted.ConclusionOur results confirm that ICH volume, haematoma expansion, mortality and functional outcome appear to be similar for NOAC-ICH versus VKA-ICH. Large prospective cohorts and updated meta-analyses are needed to provide more precise estimates.

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Haemostatic therapy in spontaneous intracerebral haemorrhage patients with high-risk of haematoma expansion by CT marker: a systematic review and meta-analysis of randomised trials

Stroke and Vascular Neurology ◽

10.1136/svn-2021-000941 ◽

2021 ◽

pp. svn-2021-000941

Author(s):

Ximing Nie ◽

Jingyi Liu ◽

Dacheng Liu ◽

Qi Zhou ◽

Wanying Duan ◽

...

Keyword(s):

High Risk ◽

Functional Outcome ◽

Intracerebral Haemorrhage ◽

Meta Analysis ◽

Cochrane Library ◽

Primary Analysis ◽

Haemostatic Agents ◽

Haematoma Expansion ◽

Reduction Of Mortality ◽

Randomised Controlled

Background and purposeCurrent randomised controlled trials (RCTs) showed an uncertain benefit of haemostatic therapy on preventing haematoma expansion and improving the outcome in patients with intracerebral haemorrhage (ICH). This meta-analysis aims to systematically evaluate the effect of haemostatic agents on the prevention of haemorrhage growth in patients with high-risk spontaneous ICH predicted by CT signs in RCTs.MethodsA comprehensive search of PubMed, EMBASE and Cochrane library from 1 January 2005 to 30 June 2021 was conducted. RCTs that compared haemostatic agents with placebo for the treatment of spontaneous patients with ICH with high-risk haemorrhage growth were included. The primary endpoint was haematoma expansion at 24 hours. Other major endpoints of interest included 90-day functional outcome and mortality.ResultsThe meta-analysis included four RCTs that randomised 2666 patients with ICH with high-risk haemorrhage growth. Haemostatic therapy reduced the rate of haematoma expansion at a marginally statistically significant level when compared with placebo (OR 0.84; 95% CI 0.70 to 1.00; p=0.051). Subgroup analysis for patients with black hole sign on CT revealed a significant reduction of haematoma expansion with haemostatic therapy (OR 0.61; 95% CI 0.39 to 0.94; p=0.03). However, both the primary analysis and subgroup analyses showed that haemostatic therapy could not reduce the rate of poor functional outcome (modified Rankin Scale >3) or death.ConclusionsHaemostatic therapy showed a marginally significant benefit in reducing early haematoma expansion in patients with high-risk spontaneous ICH predicted by markers on CT scan. However, no significant improvement in functional outcome or reduction of mortality was observed.

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Accuracy of swirl sign for predicting hematoma enlargement in intracerebral hemorrhage: a meta-analysis

Journal of the Neurological Sciences ◽

10.1016/j.jns.2019.02.032 ◽

2019 ◽

Vol 399 ◽

pp. 155-160 ◽

Cited By ~ 4

Author(s):

Zhiyuan Yu ◽

Jun Zheng ◽

Maiyue He ◽

Rui Guo ◽

Lu Ma ◽

...

Keyword(s):

Intracerebral Hemorrhage ◽

Meta Analysis ◽

Hematoma Enlargement ◽

Swirl Sign

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Heterogeneity Signs on Noncontrast Computed Tomography Predict Hematoma Expansion after Intracerebral Hemorrhage: A Meta-Analysis

BioMed Research International ◽

10.1155/2018/6038193 ◽

2018 ◽

Vol 2018 ◽

pp. 1-9 ◽

Cited By ~ 1

Author(s):

Danfeng Zhang ◽

Jigang Chen ◽

Qiang Xue ◽

Bingying Du ◽

Ya Li ◽

...

Keyword(s):

Computed Tomography ◽

Intracerebral Hemorrhage ◽

Meta Analysis ◽

Cochrane Library ◽

Hematoma Expansion ◽

Random Effects Model ◽

Poor Outcome ◽

Increased Risk ◽

Noncontrast Computed Tomography ◽

Swirl Sign

Background and Purpose. Hematoma expansion (HE) is related to clinical deterioration after intracerebral hemorrhage (ICH) and noncontrast computed tomography (NCCT) signs are indicated as predictors for HE but with inconsistent conclusions. We aim to clarify the correlations of NCCT heterogeneity signs with HE by meta-analysis of related studies. Methods. PubMed, Embase, and Cochrane library were searched for eligible studies exploring the relationships between NCCT heterogeneity signs (hypodensity, mixed density, swirl sign, blend sign, and black hole sign) and HE. Poor outcome and mortality were considered as secondary outcomes. Odds ratio (OR) and its 95% confidence intervals (CIs) were selected as the effect size and combined using random effects model. Results. Fourteen studies were included, involving 3240 participants and 435 HEs. The summary results suggested statistically significant correlations of heterogeneity signs with HE (OR, 5.17; 95% CI, 3.72–7.19, P<0.001), poor outcome (OR, 3.60; 95% CI, 1.98–6.54, P<0.001), and mortality (OR, 4.64; 95%, 2.96–7.27, P<0.001). Conclusions. Our findings suggested that hematoma heterogeneity signs on NCCT were positively associated with the increased risk of HE, poor outcome, and mortality rate in ICH.

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CT SWIRL SIGN IN SPONTANEOUS INTRA-CEREBRAL HAEMORRHAGE AND ASSOCIATION WITH HAEMATOMA EXPANSION

10.26226/morressier.5f5a58d42c3338b5c13cd125 ◽

2020 ◽

Author(s):

Anusha Apparau ◽

Norlisah Mohd Ramli ◽

Kartini Rahmat ◽

Khairul Azmi Abd Kadir ◽

Jeannie Wong Hsiu Ding

Keyword(s):

Cerebral Haemorrhage ◽

Haematoma Expansion ◽

Swirl Sign

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Meta-analysis of haematoma volume, haematoma expansion and mortality in intracerebral haemorrhage associated with oral anticoagulant use

Journal of Neurology ◽

10.1007/s00415-019-09536-1 ◽

2019 ◽

Vol 266 (12) ◽

pp. 3126-3135 ◽

Cited By ~ 9

Author(s):

David J. Seiffge ◽

Martina B. Goeldlin ◽

Turgut Tatlisumak ◽

Philippe Lyrer ◽

Urs Fischer ◽

...

Keyword(s):

Vitamin K ◽

Intracerebral Haemorrhage ◽

Meta Analysis ◽

Vitamin K Antagonists ◽

Oral Anticoagulants ◽

Age Difference ◽

Haematoma Volume ◽

Haematoma Expansion ◽

Reported Data ◽

Volume Difference

Abstract Objective To obtain precise estimates of age, haematoma volume, secondary haematoma expansion (HE) and mortality for patients with intracerebral haemorrhage (ICH) taking oral anticoagulants [Vitamin K antagonists (VKA-ICH) or non-Vitamin K antagonist oral anticoagulants (NOAC-ICH)] and those not taking oral anticoagulants (non-OAC ICH) at ICH symptom onset. Methods We conducted a systematic review and meta-analysis of studies comparing VKA-ICH or NOAC-ICH or both with non-OAC ICH. Primary outcomes were haematoma volume (in ml), HE, and mortality (in-hospital and 3-month). We calculated odds ratios (ORs) using the Mantel–Haenszel random-effects method and corresponding 95% confidence intervals (95%CI) and determined the mean ICH volume difference. Results We identified 19 studies including data from 16,546 patients with VKA-ICH and 128,561 patients with non-OAC ICH. Only 2 studies reported data on 4943 patients with NOAC-ICH. Patients with VKA-ICH were significantly older than patients with non-OAC ICH (mean age difference: 5.55 years, 95%CI 4.03–7.07, p < 0.0001, I2 = 92%, p < 0.001). Haematoma volume was significantly larger in VKA-ICH with a mean difference of 9.66 ml (95%CI 6.24–13.07 ml, p < 0.00001; I2 = 42%, p = 0.05). HE occurred significantly more often in VKA-ICH (OR 2.96, 95%CI 1.74–4.97, p < 0.00001; I2 = 65%). VKA-ICH was associated with significantly higher in-hospital mortality (VKA-ICH: 32.8% vs. non-OAC ICH: 22.4%; OR 1.83, 95%CI 1.61–2.07, p < 0.00001, I2 = 20%, p = 0.27) and 3-month mortality (VKA-ICH: 47.1% vs. non-OAC ICH: 25.5%; OR 2.24, 95%CI 1.52–3.31, p < 0.00001, I2 = 71%, p = 0.001). We did not find sufficient data for a meta-analysis comparing NOAC-ICH and non-OAC-ICH. Conclusion This meta-analysis confirms, refines and expands findings from prior studies. We provide precise estimates of key prognostic factors and outcomes for VKA-ICH, which has larger haematoma volume, increased rate of HE and higher mortality compared to non-OAC ICH. There are insufficient data on NOACs.

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Appendix 3. Meta-analysis Methods

Issues in Toxicology - Formaldehyde ◽

10.1039/9781788010269-00357 ◽

2018 ◽

pp. 357-368

Keyword(s):

Meta Analysis ◽

Analysis Methods

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The effects of low-ratio n-6/n-3 PUFA on biomarkers of inflammation: a systematic review and meta-analysis

Food & Function ◽

10.1039/d0fo01976c ◽

2021 ◽

Author(s):

Yali Wei ◽

Yan Meng ◽

Na Li ◽

Qian Wang ◽

Liyong Chen

Keyword(s):

Systematic Review ◽

Fatty Acid ◽

Polyunsaturated Fatty Acid ◽

Meta Analysis ◽

Chain Polyunsaturated Fatty Acid ◽

Inflammation Markers ◽

Pufa Supplementation ◽

Long Chain

The purpose of the systematic review and meta-analysis was to determine if low-ratio n-6/n-3 long-chain polyunsaturated fatty acid (PUFA) supplementation affects serum inflammation markers based on current studies.

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