CT Scan Hematoma Volume: A Surrogate Endpoint for the Effect of Treatment in Intracerebral Hemorrhage

Background: Incidence of acute intracerebral hemorrhage (ICH) increases with age, but there is a lack of information about ICH characteristics in the oldest-old (age ≥85 years). In particular, there is a need for information about hematoma volume, which is included in most clinical scales for prediction of mortality in ICH patients. Many of these scales also assume that, independent of ICH characteristics, the oldest-old have a higher mortality than younger elderly patients (age 65-74 years). However, supporting evidence from cohort studies is limited. We investigated ICH characteristics of oldest-old subjects compared to young (<65 years), young-old (65-74 years) and old-old (75-84 years) subjects. We also investigated whether age is an independent mortality predictor in elderly (age ≥65 years) subjects with acute ICH. Methods: We retrospectively collected clinical and neuroimaging data of 383 subjects (age 34-104 years) with acute supratentorial primary ICH who were admitted to an Italian Stroke Unit (SU) between October 2007 and December 2014. Measured ICH characteristics included hematoma location, volume and intraventricular extension of hemorrhage on admission CT scan; admission Glasgow Coma Scale ≤8 and hematoma expansion (HE) measured on follow-up CT-scans obtained after 24 h. General linear models and logistic models were used to investigate the association of age with ICH characteristics. These models were adjusted for pre-admission characteristics, hematoma location and time from symptom onset to admission CT scan. Limited to elderly subjects, Cox models were used to investigate the association of age with in-SU and 1-year mortality: the model for in-SU mortality adjusted for pre-admission and ICH admission characteristics and the model for 1-year mortality additionally adjusted for functional status and disposition at SU discharge. Results: Independent of pre-admission characteristics, hematoma location and time from symptom onset to admission CT-scan, oldest-old subjects had the highest admission hematoma volume (p < 0.01). Age was unrelated to all other ICH characteristics including HE. In elderly patients, multivariable adjusted risk of in-SU and 1-year mortality did not vary across age categories. Conclusions: Oldest-old subjects with acute supratentorial ICH have higher admission hematoma volume than young and young-old subjects but do not differ for other ICH characteristics. When taking into account confounding from ICH characteristics, risk of in-SU and 1-year mortality in elderly subjects with acute supratentorial ICH does not differ across age categories. Our findings question use of age as an independent criterion for stratification of mortality risk in elderly subjects with acute ICH.

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Evaluation of Volumetric Change of Intracerebral Hemorrhage in Patients Treated with Thrombolysis for Intraventricular Hemorrhage

Neurocritical Care ◽

10.1007/s12028-020-01054-7 ◽

2020 ◽

Author(s):

Franziska Staub-Bartelt ◽

Jasper Hans van Lieshout ◽

Thomas Beez ◽

Rainer Kram ◽

Daniel Hänggi ◽

...

Keyword(s):

Basal Ganglia ◽

Intracerebral Hemorrhage ◽

Ct Scan ◽

Intraventricular Hemorrhage ◽

Volume Reduction ◽

Percentage Reduction ◽

Hematoma Volume ◽

Group A ◽

Group B ◽

Lysis Therapy

Abstract Background Intraventricular hemorrhage (IVH) is often caused by irruption of intracerebral hemorrhage (ICH) of basal ganglia or thalamus into the ventricular system. Instillation of recombinant tissue plasminogen activator (rtPA) via an external ventricular drainage (EVD) has been shown to effectively decrease IVH volumes while the impact of rtPA instillation on ICH volumes remains unclear. In this series, we analyzed volumetric changes of ICH in patients with and without intrathecal lysis therapy. Methods Between 01/2013 and 01/2019, 36 patients with IVH caused by hemorrhage of basal ganglia, thalamus or brain stem were treated with rtPA via an EVD (Group A). Initial volumes were determined in the first available computed tomography (CT) scan, final volumes in the last CT scan before discharge. During the same period, 41 patients with ICH without relevant IVH were treated without intrathecal lysis therapy at our neurocritical care unit (Group B). Serial CT scans were evaluated separately for changes in ICH volumes for both cohorts using OsiriX DICOM viewer. The Wilcoxon signed-rank test was performed for statistical analysis in not normally distributed variables. Results Median initial volume of ICH for treatment Group A was 6.5 ml and was reduced to 5.0 ml after first instillation of rtPA (p < 0.01). Twenty-six patients received a second treatment with rtPA (ICH volume reduction 4.5 to 3.3 ml, p < 0.01) and of this cohort further 16 patients underwent a third treatment (ICH volume reduction 3.0 ml to 1.5 ml, p < 0.01). Comparison of first and last CT scan in Group A confirmed an overall median percentage reduction of 91.7% (n = 36, p < 0.01) of ICH volumes and hematoma resolution in Group A was significantly more effective compared to non-rtPA group, Group B (percentage reduction = 68%) independent of initial hematoma volume in the regression analysis (p = 0.07, mean 11.1, 95%CI 7.7–14.5). There were no adverse events in Group A related to rtPA instillation. Conclusion Intrathecal lysis therapy leads to a significant reduction in the intraparenchymal hematoma volume with faster clot resolution compared to the spontaneous hematoma resorption. Furthermore, intrathecal rtPA application had no adverse effect on ICH volume.

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Does the Volume and Localization of Intracerebral Hematoma Affect Short-Term Prognosis of Patients with Intracerebral Hemorrhage?

ISRN Neuroscience ◽

10.1155/2013/327968 ◽

2013 ◽

Vol 2013 ◽

pp. 1-3 ◽

Cited By ~ 5

Author(s):

Denisa Salihović ◽

Dževdet Smajlović ◽

Omer Ć. Ibrahimagić

Keyword(s):

Mortality Rate ◽

Intracerebral Hemorrhage ◽

Ct Scan ◽

Statistical Significance ◽

Age Groups ◽

Intraventricular Haemorrhage ◽

Intracerebral Hematoma ◽

Hematoma Volume ◽

Short Term

The aim of this study was to determine whether volume and localization of intracerebral hematoma affects the six-month prognosis of patients with intracerebral hemorrhage (ICH). Patients and Methods. The study included 75 patients with ICH of both sex and all age groups. ICH, based on CT scan findings, was divided in the following groups: lobar, subcortical, infratentorial, intraventricular haemorrhage and multiple hematomas. Volume of intracerebral hematoma was calculated according to formula . Intracerebral hematomas, according to the volume, are divided in three groups (0–29 mL, 30–60 mL, and >60 mL). Results. The highest mortality rate was recorded in the group with multiple hematomas (41%), while the lowest in infratentorial (12.8%). The best six-month survival was in patients with a volume up to 29 mL, 30 of them (64%) survived. The highest mortality rate was recorded in patients with the hematoma volume >60 mL (85%). Kaplan-Meier’s analysis showed that there was statistical significance between the size of the hematoma and the six-month survival (). More than half of patients (61.1%) who survived 6 months after ICH were functionally independent (Rankin scale ≤2). Conclusion The volume of hematoma significantly affects six-month prognosis in patients with intracerebral hemorrhage, while localization does not.

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Epidemiology of Intra-Cerebral Hemorrhage in Young Adult Patients

JUXTA: Jurnal Ilmiah Mahasiswa Kedokteran Universitas Airlangga ◽

10.20473/juxta.v11i22020.65-68 ◽

2020 ◽

Vol 11 (2) ◽

pp. 65

Author(s):

Melisa Melisa ◽

Asra Al Fauzi ◽

Anggraini Dwi Sensusiati

Keyword(s):

Young Adults ◽

Young Adult ◽

Basal Ganglia ◽

Intracerebral Hemorrhage ◽

Ct Scan ◽

General Hospital ◽

Medical Records ◽

Descriptive Study ◽

Hematoma Volume ◽

Observational Descriptive Study

Introduction: This study aimed to define the CT scan imaging of young adult intracerebral hemorrhage (ICH) patients in Dr. Soetomo General Hospital, Surabaya.Methods: This was an observational descriptive study. The data were collected retrospectively with medical records of 18 to 45 years old ICH patients who were treated in Dr. Soetomo General Hospital, Surabaya between 2014 and 2017. The collected data were then presented into tables.Results: 207 patients were identified in this study. The locations of the ICH were basal ganglia (45.89%), lobar (41.55%), thalamus (10.63%), brainstem (8.7%), cerebellum (4.83%), and others (3.86%). The volume of ICH varied from less than 30 cc (66.67%), 30 to 59 cc (27.54%), and more than 60 cc (5.8%). Conclusion: The CT scan imaging of young adults ICH mainly had hematoma volume less than 30 cc and was mostly located in basal ganglia area then followed by lobar area.

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Intracerebral Hematoma, Perihemorrhagic Edema and Urinary Excreted Cysteinyl Leukotrienes Correlation Study

Macedonian Medical Review ◽

10.2478/mmr-2014-0017 ◽

2014 ◽

Vol 68 (2) ◽

pp. 85-88

Author(s):

Natalija Dolnenec-Baneva ◽

Dijana Nikodijevic ◽

Gordana Kiteva-Trenchevska ◽

Igor Petrov ◽

Dragana Petrovska-Cvetkovska ◽

...

Keyword(s):

Intracerebral Hemorrhage ◽

Brain Edema ◽

Correlation Study ◽

Intracerebral Hematoma ◽

Moderate Correlation ◽

Hematoma Volume ◽

Cysteinyl Leukotrienes ◽

Edema Volume ◽

Perihemorrhagic Edema

AbstractIntroduction.Several mechanisms in formation of perihemorrhagic edema are activated after contact of brain tissue-extravasated blood in intracerebral hemorrhage. Cysteinyl leukotrienes (cysLT) (C4, D4, E4) are included in this process as significant edema factors and they determine the neurological deficit and outcome. The study aim was a 5-day follow-up (admission/3 day/5 day) of urinary cysLT, hematoma volume, edema volume values and their correlation in patients after spontaneous, primary supratentorial intracerebral hemorrhage.Methods.An enzyme immunoassay was used for urinary cysLT measured in 62 patients and 80 healthy controls. Hematoma and edema volumes were visualized and measured by computed tomography and mathematically calculated with a special spheroid shape formula (V=AxBxC/2).Results.CysLT of hemorrhagic patients (1842.20±1413.2, 1181.54±906.2, 982.30±774.2pg/ml/mg creatinine) were significantly excreted (p<0.01). Brain edema (12.86±13.5, 22.38±21.1, 28.45±29.4cm3) was significantly increased (p<0.01). Hematoma volume values (13.05±14.5, 13.13±14.7, 12.99±14.7cm3) were not significant (p>0.05). A high correlation (multiple regression) between cysLT, hematoma and edema was found on the 3rdday (R=0.6) and a moderate correlation at admission (R=0.3) and on the 5thday (R=0.3).Conclusion.In our 5-day follow-up study a significant cysLT brain synthesis and significant brain edema progression versus constant hematoma volume values in hemorrhagic patients was found. A high correlation between cysLT, hematoma and edema volume was found on the 3rdday, a moderate correlation on admission and on the 5thday, which means that high cysLT and hematoma values were associated with high/moderate edema values.

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Anti-inflammatory genes in PBMCs post-spontaneous intracerebral hemorrhage

Translational Neuroscience ◽

10.1515/tnsci-2021-0003 ◽

2021 ◽

Vol 12 (1) ◽

pp. 58-66

Author(s):

Doan Nguyen ◽

Vi Tran ◽

Alireza Shirazian ◽

Cruz Velasco-Gonzalez ◽

Ifeanyi Iwuchukwu

Keyword(s):

Intracerebral Hemorrhage ◽

Negative Correlation ◽

Mononuclear Cells ◽

Inflammatory Cells ◽

Favorable Outcome ◽

Hospital Length Of Stay ◽

Spontaneous Intracerebral Hemorrhage ◽

Hematoma Volume ◽

Peripheral Blood Mononuclear ◽

Anti Inflammatory

Abstract Background Neuroinflammation is important in the pathophysiology of spontaneous intracerebral hemorrhage (ICH) and peripheral inflammatory cells play a role in the clinical evolution and outcome. Methodology Blood samples from ICH patients (n = 20) were collected at admission for 5 consecutive days for peripheral blood mononuclear cells (PBMCs). Frozen PBMCs were used for real-time PCR using Taqman probes (NFKB1, SOD1, PPARG, IL10, NFE2L2, and REL) and normalized to GAPDH. Data on hospital length of stay and modified Rankin score (MRS) were collected with 90-day MRS ≤ 3 as favorable outcome. Statistical analysis of clinical characteristics to temporal gene expression from early to delayed timepoints was compared for MRS groups (favorable vs unfavorable) and hematoma volume. Principle findings and results IL10, SOD1, and REL expression were significantly higher at delayed timepoints in PBMCs of ICH patients with favorable outcome. PPARG and REL increased between timepoints in patients with favorable outcome. NFKB1 expression was not sustained, but significantly decreased from higher levels at early onset in patients with unfavorable outcome. IL10 expression showed a negative correlation in patients with high hematoma volume (>30 mL). Conclusions and significance Anti-inflammatory, pro-survival regulators were highly expressed at delayed time points in ICH patients with a favorable outcome, and IL10 expression showed a negative correlation to high hematoma volume.

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Admission CT radiomic signatures outperform hematoma volume in predicting baseline clinical severity and functional outcome in the ATACH‐2 trial intracerebral hemorrhage population

European Journal of Neurology ◽

10.1111/ene.15000 ◽

2021 ◽

Author(s):

Stefan P. Haider ◽

Adnan I. Qureshi ◽

Abhi Jain ◽

Hishan Tharmaseelan ◽

Elisa R. Berson ◽

...

Keyword(s):

Intracerebral Hemorrhage ◽

Functional Outcome ◽

Clinical Severity ◽

Hematoma Volume

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Late Neurological Deterioration after Acute Intracerebral Hemorrhage: A post hoc Analysis of the ATACH-2 Trial

Cerebrovascular Diseases ◽

10.1159/000506117 ◽

2020 ◽

Vol 49 (1) ◽

pp. 26-31 ◽

Cited By ~ 1

Author(s):

Shuhei Okazaki ◽

Haruko Yamamoto ◽

Lydia D. Foster ◽

Mayumi Fukuda-Doi ◽

Masatoshi Koga ◽

...

Keyword(s):

Blood Pressure ◽

Intracerebral Hemorrhage ◽

Significant Risk ◽

Blood Pressure Level ◽

Neurological Deterioration ◽

Major Influence ◽

Case Report Form ◽

Hematoma Volume ◽

Systolic Blood Pressure Level ◽

Significant Difference

Background: Neurological deterioration (ND) has a major influence on the prognosis of intracerebral hemorrhage (ICH); however, factors associated with ND occurring after 24 h of ICH onset are unknown. Methods: We performed exploratory analyses of data from the Antihypertensive Treatment of Acute Cerebral Hemorrhage 2 trial, which compared intensive and standard blood pressure lowering treatment in ICH. NDs were captured on the adverse event case report form. Logistic regression analysis was performed to examine the independent predictors of late ND. Results: Among 1,000 participants with acute ICH, 82 patients (8.2%) developed early ND (≤24 h), and 64 (6.4%) had late ND. Baseline hematoma volume (adjusted OR [aOR] per 1-cm3 increase 1.04, 95% CI 1.02–1.06, p < 0.0001), hematoma volume increase in 24 h (aOR 2.24, 95% CI 1.23–4.07, p = 0.008), and the presence of intraventricular hemorrhage (IVH; aOR 2.38, 95% CI 1.32–4.29, p = 0.004) were independent predictors of late ND (vs. no late ND). Late ND was a significant risk factor for poor 90-day outcome (OR 3.46, 95% CI 1.82–6.56). No statistically significant difference in the incidence of late ND was noted between the 2 treatment groups. Conclusions: Initial hematoma volume, early hematoma volume expansion, and IVH are independent predictors of late ND after ICH. Intensive reduction in the systolic blood pressure level does not prevent the development of late ND.

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Abstract WP418: Characteristic of Intracerebral Hemorrhage Related to Direct Oral Anticoagulant versus Warfarin: Results From the PASTA Registry

Stroke ◽

10.1161/str.51.suppl_1.wp418 ◽

2020 ◽

Vol 51 (Suppl_1) ◽

Author(s):

Satoshi Suda ◽

Yasuyuki Iguchi ◽

Shigeru Fujimoto ◽

Yoshiki Yagita ◽

Takayuki Mizunari ◽

...

Keyword(s):

Intracerebral Hemorrhage ◽

Oral Anticoagulant ◽

Hematoma Expansion ◽

Direct Oral Anticoagulant ◽

Registry Study ◽

Stroke Patients ◽

Hematoma Volume ◽

Imaging Characteristics ◽

Warfarin Treatment ◽

Patient Enrollment

Background and Purpose: The characteristics of direct oral anticoagulant (DOAC)-related intracerebral hemorrhage (ICH) have not been fully clarified. We planned to recruit patients prospectively and to investigate the characteristics and outcomes in patients with ICH receiving direct oral anticoagulant (DOAC) and warfarin treatment. Methods: The prospective analysis of stroke patients taking anticoagulants (PASTA) registry study is an observational, multicenter, prospective registry of stroke patients receiving OAC. Patient enrollment started in April 2016 at 25 tertiary centers across Japan. We compared imaging, clinical characteristics, and discharge modified Rankin Scale (mRS) between DOAC- and warfarin-related ICH patients with atrial fibrillation (AF). Results: A total of 154 patients (51 women; median age 77 [quartiles 69-87] years) were analyzed. Of these, 111 patients (72%) received prior DOAC treatment and the remaining 43 (28%) received prior warfarin treatment (Fig. A, B and C). There were no relevant differences in clinical and hematoma characteristics between DOAC- and warfarin-related ICH regarding baseline hematoma volume (median [quartiles]: DOAC, 11 [5-23] mL vs. warfarin, 12 [5-30] mL; P =0.95), rate of hematoma expansion (DOAC, 12/111 [11%] vs. warfarin, 4/43 [9%]; P =0.80), rate of subcortical hemorrhage (DOAC, 15/111 [11%] vs. warfarin, 10/43 [9%]; P =0.80) and the proportion of patients with unfavorable outcome (mRS, 4-6: DOAC 76/108 [70%] vs. warfarin 23/38 [61%]; P =0.26). Cerebral microbleeds (CMBs) were detected more frequently in DOAC group than in warfarin (47/76 [62%] vs. 11/32 [34%]; P <0.01). Subgroup analyses showed that type of DOAC agent did not result in relevant differences in imaging characteristics or outcome (Fig. D and E). Conclusions: Our results showed that there were no significant differences in hematoma characteristics and functional outcome among AF patients with DOAC- or warfarin-related ICH.

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Abstract 3543: Imaging Correlates of Early Neurologic Deterioration among Patients with Intracerebral Hemorrhage

Stroke ◽

10.1161/str.43.suppl_1.a3543 ◽

2012 ◽

Vol 43 (suppl_1) ◽

Author(s):

Nerses Sanossian ◽

Adrian M Burgos ◽

David S Liebeskind ◽

Sidney Starkman ◽

Pablo Villablanca ◽

...

Keyword(s):

Intracerebral Hemorrhage ◽

Hematoma Expansion ◽

Hematoma Volume ◽

Phase 3 ◽

Neurologic Deterioration ◽

Irregular Border ◽

History Of ◽

Initial Imaging ◽

Fazekas Scale ◽

Frequent Presence

Background: Early neurologic deterioration (END) occurs commonly in intracerebral hemorrhage (ICH) patients being transported by EMS ambulances, but the imaging correlates of END have not been previously delineated. Methods: We analyzed consecutive ICH patients in the Field Administration of Stroke Therapy - Magnesium (FAST-MAG) Trial, a phase 3, multicenter of paramedic-initiated magnesium sulfate vs. placebo for stroke patients presenting within 2 hours of symptom onset. END was defined as a 2-point or greater decrease in the Glasgow Coma Scale (GCS) from paramedic evaluation to ED evaluation. Baseline imaging studies were independently analyzed by 2 neurologists for ICH location, volume, presence of intraventricular hemorrhage (IVH), heterogeneity (defined as >20 point difference in Hounsfield units), irregular hematoma borders, multilobulated appearance, and substantial edema (defined as >0.5cm thickness). Leukoaraiosis was graded using the Fazekas scale for periventricular and deep white matter changes (0-3 for each). Results: Among 127 patients, mean age was 66 (SD 14) years, 34% were women, 35% were Hispanic ethnicity, 83% white, and 84% had a history of HTN. Patients were evaluated by paramedics a median of 23 (IQR 16, 39) minutes after last known well time (LKWT). At that time, the median GCS was 15 (IQR 15-15) and mean SBP/DBP was 177/95 (SD 34/22). Initial post-arrival brain imaging was performed a median of 94 (IQR 77, 117) min after LKWT. Post-arrival study GCS scores were obtained at a median of 108 (IQR 70, 144) min after LWKT. Early neurologic deterioration occurred in 37 (29%) patients. Among these patients, median first ED GCS was 3 (IQR 3-10). On first imaging, compared with neurologically stable patients, END patients had larger hematoma volume (33 cc v 16 cc, p<0.0001), and more frequent presence of intraventricular extension (45% v 20%, p=0.003), midline shift (58% v 22%), substantial edema (54% v 26%, p=0.038), heterogeneous density (50% v 22%, p=0.006), multilobulated appearance (44% v 18%, p=0.002), and irregular border (39% v 14%, p=0.010). Leukoaraiosis and cortical v subcortical location did not affect rates of END. In multivariate analysis, hematoma volume and presence of IVH were imaging findings independently associated with early neurologic deterioration. Conclusions: About 3 in 10 patients with hyperacute ICH neurologically deteriorate during the prehospital and early emergency department course, often before neuroimaging is obtained. Patients with early neurologic deterioration have larger hematoma volume and occurrence of IVH on initial imaging. These findings suggest hematoma expansion prior to ED arrival drives early neurologic deterioration in ICH and emphasize the need for prehospital interventions.

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