Abstract W P322: Prediction of Intracerebral Hemorrhage Expansion With Clinical, Laboratory, Pharmacologic, and Noncontrast Radiographic Variables

Introduction: Hematoma expansion (HE) is a cause of excess mortality in intracerebral hemorrhage (ICH), and HE is potentially preventable if at-risk patients can be identified. Contrast extravasation on initial computed tomographic angiography (CTA) strongly predicts HE, yet most centers do not integrate CTA into early ICH management. We therefore asked whether other variables available at presentation might be used to predict HE. Methods: We searched the electronic medical records of a large integrated healthcare delivery system to identify patients with a hospitalization discharge diagnosis of ICH during a three year period (2008-2010). HE was defined as ICH volume increase by 1/3 or by 12.5mL, as determined by ABC/2 estimation, within 48 hours of presentation. Pre-specified patient variables including age, gender, medical comorbidities, medication use, and in-hospital vital signs were extracted. Stepwise multivariable logistic regression was performed to model HE in patients with at least two head CT scans (HE group), and HE or death by 48 hours among patients with only one head CT (HE+D group). The area under the receiver operating characteristic curve (AUROC) and pseudo r-squared (pseudo-r2) statistics were used to assess model goodness-of-fit. Results: For the 2 study cohorts, 91/257 (35%) had HE and 163/343 (48%) had HE+D. In stepwise multivariable logistic regression, antithrombotic use (OR = 1.9, P=0.04) and initial mNIHSS (OR = 1.06, P=0.001) were significant predictors in the HE model (AUROC = 0.6712, pseudo-R2 = 0.0641). In the HE+D model, age (OR = 1.02, P=0.02), initial mNIHSS (OR = 1.07, P<0.001), and initial hematoma volume (OR = 1.01, P=0.03) were significant predictors (AUROC = 0.7579, pseudo-R2 = 0.1722). Conclusion: Our model predicting HE+D was better fitted than the HE model. The resemblance to known predictors of ICH mortality in the HE+D model suggests that the improved fit may be driven by mortality rather than HE. CTA contrast extravasation remains the strongest predictor of HE and merits consideration as a standard in early ICH care.

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Peak perihemorrhagic edema correlates with functional outcome in intracerebral hemorrhage

Neurology ◽

10.1212/wnl.0000000000005167 ◽

2018 ◽

Vol 90 (12) ◽

pp. e1005-e1012 ◽

Cited By ~ 27

Author(s):

Bastian Volbers ◽

Antje Giede-Jeppe ◽

Stefan T. Gerner ◽

Jochen A. Sembill ◽

Joji B. Kuramatsu ◽

...

Keyword(s):

Logistic Regression ◽

Intracerebral Hemorrhage ◽

Functional Outcome ◽

Retrospective Cohort ◽

Independent Predictor ◽

Hematoma Expansion ◽

Factors Influencing ◽

Multivariable Logistic Regression ◽

Inflammatory Processes ◽

Perihemorrhagic Edema

ObjectiveTo evaluate the association of perihemorrhagic edema (PHE) evolution and peak edema extent with day 90 functional outcome in patients with intracerebral hemorrhage (ICH) and identify pathophysiologic factors influencing edema evolution.MethodsThis retrospective cohort study included patients with spontaneous supratentorial ICH between January 2006 and January 2014. ICH and PHE volumes were studied using a validated semiautomatic volumetric algorithm. Multivariable logistic regression and propensity score matching (PSM) accounting for age, ICH volume, and location were used for assessing measures associated with functional outcome and PHE evolution. Clinical outcome on day 90 was assessed using the modified Rankin Scale (0–3 = favorable, 4–6 = poor).ResultsA total of 292 patients were included. Median age was 70 years (interquartile range [IQR] 62–78), median ICH volume on admission 17.7 mL (IQR 7.9–40.2). Besides established factors for functional outcome, i.e., ICH volume and location, age, intraventricular hemorrhage, and NIH Stroke Scale score on admission, multivariable logistic regression revealed peak PHE volume (odds ratio [OR] 0.984 [95% confidence interval (CI) 0.973–0.994]) as an independent predictor of day 90 outcome. Peak PHE volume was independently associated with initial PHE increase up to day 3 (OR 1.060 [95% CI 1.018–1.103]) and neutrophil to lymphocyte ratio on day 6 (OR 1.236 [95% CI 1.034–1.477; PSM cohort, n = 124]). Initial PHE increase (PSM cohort, n = 224) was independently related to hematoma expansion (OR 3.647 [95% CI 1.533–8.679]) and fever burden on days 2–3 (OR 1.456 [95% CI 1.103–1.920]).ConclusionOur findings suggest that peak PHE volume represents an independent predictor of functional outcome after ICH. Inflammatory processes and hematoma expansion seem to be involved in PHE evolution and may represent important treatment targets.

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Hematoma Hounsfield units and expansion of intracerebral hemorrhage: A potential marker of hemostatic clot contraction

International Journal of Stroke ◽

10.1177/1747493019895703 ◽

2020 ◽

pp. 174749301989570 ◽

Cited By ~ 1

Author(s):

Han-Gil Jeong ◽

Jae Seung Bang ◽

Beom Joon Kim ◽

Hee-Joon Bae ◽

Moon-Ku Han

Keyword(s):

Computed Tomography ◽

Logistic Regression ◽

Intracerebral Hemorrhage ◽

Hematoma Expansion ◽

P Value ◽

Discrimination Power ◽

Multivariable Logistic Regression ◽

C Statistic ◽

Potential Marker ◽

Clot Contraction

Background Clot contraction reinforces hemostasis by providing an impermeable barrier and contractile force. Since computed tomography attenuation of intracerebral hemorrhage is largely determined by the density of red blood cells, clot contraction can be reflected in an increase of Hounsfield unit (HU) of hematoma. Aims We hypothesized that hematoma expansion is inversely associated with mean HU of intracerebral hemorrhage at presentation. Methods Eighty-nine consecutive spontaneous intracerebral hemorrhage patients with onset to first computed tomography within 24 h were included. Hematomas were segmented using semiautomated planimetry to measure the volume and mean HU. Hematoma expansion was defined as an increase in hematoma volume by over 33% or 6 mL. Multivariable logistic regression was performed for hematoma expansion. The discrimination power of mean HU for hematoma expansion was assessed using C-statistic. Results The computed tomography attenuation of hematoma at presentation was 57.5 ± 3.3 HU and the volume was 16.9 ± 23.2 mL. Hematoma expansion occurred in 37.1% of patients. The computed tomography attenuation of hematoma was lower in patients with hematoma expansion than with no expansion (55.7 ± 2.9 HU vs. 58.6 ± 3.1 HU, p-value < 0.01). Multivariable logistic regression revealed that the mean HU of hematoma was inversely associated with hematoma expansion (adjusted odds ratio, 0.64; 95% confidence interval, 0.51–0.80). The C-statistic of the model with four known predictors increased from 0.66 to 0.84 after incorporating mean HU (p-value < 0.01). Conclusions Intracerebral hemorrhage with lower mean HU of hematoma at presentation is more likely to undergo hematoma expansion. This finding suggests the potential presence of clot contraction process that reinforces hemostasis in intracerebral hemorrhage.

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Liver fibrosis indices associated with substantial hematoma expansion in Chinese patients with primary intracerebral hemorrhage

BMC Neurology ◽

10.1186/s12883-021-02494-0 ◽

2021 ◽

Vol 21 (1) ◽

Author(s):

Huan Wang ◽

Jiongxing Wu ◽

Xue Yang ◽

Junfeng Liu ◽

Wendan Tao ◽

...

Keyword(s):

Logistic Regression ◽

Liver Fibrosis ◽

Intracerebral Hemorrhage ◽

Chinese Population ◽

Binary Logistic Regression ◽

Chinese Patients ◽

Hematoma Expansion ◽

West China Hospital ◽

West China ◽

Increased Risk

Abstract Background Whether liver fibrosis is associated with increased risk for substantial hematoma expansion (HE) after intracerebral hemorrhage (ICH) is still uncertain. We evaluated the association between various liver fibrosis indices and substantial HE in a Chinese population with primary ICH. Methods Primary ICH patients admitted to West China Hospital within 24 h of onset between January 2015 and June 2018 were consecutively enrolled. Six liver fibrosis indices were calculated, including aspartate aminotransferase (AST)-platelet ratio index (APRI), AST/alanine aminotransferase ratio-platelet ratio index (AARPRI), fibrosis-4 (FIB-4), modified fibrosis-4 (mFIB-4), fibrosis quotient (FibroQ) and Forns index. Substantial HE was defined as an increase of more than 33% or 6 mL from baseline ICH volume. The association of each fibrosis index with substantial HE was analyzed using binary logistic regression. Results Of 436 patients enrolled, about 85% showed largely normal results on standard hepatic assays and coagulation parameters. Substantial HE occurred in 115 (26.4%) patients. After adjustment, AARPRI (OR 1.26, 95% CI 1.00-1.57) and FIB-4 (OR 1.15, 95% CI 1.02-1.30) were independently associated with substantial HE in ICH patients within 24 h of onset, respectively. In ICH patients within 6 h of onset, each of the following indices was independently associated with substantial HE: APRI (OR 2.64, 95% CI 1.30-5,36), AARPRI (OR 1.55, 95% CI 1.09-2.21), FIB-4 (OR 1.35, 95% CI 1.08-1.68), mFIB-4 (OR 1.09, 95% CI 1.01-1.18), FibroQ (OR 1.08, 95% CI 1.00-1.16) and Forns index (OR 1.37, 95% CI 1.10-1.69). Conclusions Liver fibrosis indices are independently associated with higher risk of substantial HE in Chinese patients with primary ICH, which suggesting that subclinical liver fibrosis could be routinely assessed in such patients to identify those at high risk of substantial HE.

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Abstract W P323: Development of a Nomogram to Predict Hematoma Expansion in Patients with Spontaneous Intracerebral Hemorrhage

Stroke ◽

10.1161/str.46.suppl_1.wp323 ◽

2015 ◽

Vol 46 (suppl_1) ◽

Author(s):

Xiaoying Yao ◽

Magdy Selim ◽

Ye Xu ◽

Erica Siwila-Sackman

Keyword(s):

Intracerebral Hemorrhage ◽

Clinical Laboratory ◽

External Validation ◽

Treatment Decision ◽

Hematoma Expansion ◽

Absolute Increase ◽

Discrimination Ability ◽

Predicted Probability ◽

Patients At Risk

Background: Early identification of intracerebral hemorrhage (ICH) patients at risk of significant hematoma expansion (SHE) could facilitate the selection of appropriate patients who are likely to benefit from therapies aiming to minimize ICH growth. Nomograms have been proved to have superior individualized disease-related risk estimations of given outcomes. This study aims to develop a normogram that can be performed during the hyperacute phase to predict the risk of SHE in patients with spontaneous ICH. Methods: We reviewed clinical, laboratory, and radiological data from 237 patients diagnosed with spontaneous ICH who had baseline head CT within 12 hours of symptom onset and follow-up CT during the following 72 hours. SHE was defined as an absolute increase in ICH volume > 6ml or an increase greater than 33% from baseline to follow-up CT. To construct the nomogram, we performed logistic regression analyses to determine the predictors of SHE. Each predictor was assigned a point in the graphic interface of a nomogram, and the points were summed up to determine the predicted probability of SHE for a specific ICH patient. Results: SHE occurred in 74 patients (31.2%). The final model to predict SHE, presented as a nomogram, included: time from onset to baseline CT scan (< 3h vs 3-12h), dementia, current smoking, antiplatelet use, serum creatinine level, Glasgow Comma Scale score, and presence of subarachnoid hemorrhage on baseline CT. The model had satisfactory discrimination ability with a bootstrap corrected c index of 0.77 (95% CI, 0.75-0.82) and good calibration. The in-hospital mortality was higher in patients with SHE (42% vs. 15%; p <0.001). Conclusion: We developed and internally validated a novel nomogram model which accurately predicts the possibility of SHE based on seven easily obtainable parameters. This could be useful for treatment decision and stratification. External validation of our nomogram is warranted before its application to other populations.

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Abstract W P257: Predictors of the CT Angiography Spot Sign in Deep and Lobar Intracerebral Hemorrhage

Stroke ◽

10.1161/str.45.suppl_1.wp257 ◽

2014 ◽

Vol 45 (suppl_1) ◽

Author(s):

Farid Radmanesh ◽

Guido J Falcone ◽

Christopher D Anderson ◽

Thomas W Battey ◽

Alison M Ayres ◽

...

Keyword(s):

Logistic Regression ◽

Intracerebral Hemorrhage ◽

Ct Angiography ◽

Cerebral Amyloid Angiopathy ◽

Symptom Onset ◽

Hematoma Expansion ◽

Amyloid Angiopathy ◽

Spot Sign ◽

Increased Risk ◽

Cerebral Amyloid

Objectives: Intracerebral hemorrhage (ICH) patients with CT angiography (CTA) spot sign are at increased risk of hematoma expansion and poor outcome. Since ICH is often the acute manifestation of a chronic cerebral vasculopathy, we investigated whether different clinical or imaging characteristics predict spot sign presence in patients with different underlying vasculopathies. Using ICH location as a surrogate for hypertension-related ICH and cerebral amyloid angiopathy-related ICH, we identified risk factors associated with spot sign. METHODS: We retrospectively analyzed a prospective cohort of consecutive spontaneous ICH patients with available CTA. Spot sign presence was ascertained by two independent readers blinded to clinical data. We assessed potential predictors of spot sign be performing uni- and multivariable logistic regression, analyzing deep and lobar ICH separately. RESULTS: 649 patients were eligible, 291 (45%) deep and 358 (55%) lobar ICH. Median time from symptom onset to CTA was 4.5 (IQR 5.2) and 5.7 (IQR 7.4) hours in patients with deep and lobar ICH, respectively. At least one spot sign was present in 76 (26%) deep and 103 (29%) lobar ICH patients. In mutivariable logistic regression, independent predictors of spot sign in deep ICH were warfarin (OR 2.82 [95%CI 1.06-7.57]; p=0.03), time from symptom onset to CTA (OR 0.9 [95%CI 0.81-0.97]; p=0.02), and baseline ICH volume (OR 1.27 [95%CI 1.14-1.43]; p=2.5E-5; per 10 mL increase). Predictors of spot sign in lobar ICH were preexisting dementia (OR 2.7 [95%CI 1.15-6.43]; p=0.02), warfarin (OR 4.01 [95%CI 1.78-9.29]; p=0.009), and baseline ICH volume (OR 1.27 [95%CI 1.17-1.39]; p=5.4E-8; per 10 mL increase). As expected, spot sign presence was a strong predictor of hematoma expansion in both deep (OR 3.52 [95%CI 1.72-7.2]; p=0.0005) and lobar ICH (OR 6.53 [95%CI 3.23-13.44]; p=2.2E-7). CONCLUSIONS: The most potent associations with spot sign are shared by deep and lobar ICH, suggesting that ICH caused by different vasculopathic processes share biological features. The relationship between preexisting dementia and spot sign in lobar ICH, but not deep ICH, suggests that ICH occurring in the context of more advanced cerebral amyloid angiopathy may be more likely to have prolonged bleeding.

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CONTRAST EXTRAVASATION ON CT ANGIOGRAPHY PREDICTS HEMATOMA EXPANSION IN INTRACEREBRAL HEMORRHAGE

Neurology ◽

10.1212/01.wnl.0000278894.44311.0b ◽

2007 ◽

Vol 69 (6) ◽

pp. 617-617 ◽

Cited By ~ 7

Author(s):

Y. Murai ◽

Y. Ikeda ◽

A. Teramoto ◽

J. N. Goldstein ◽

S. M. Greenberg ◽

...

Keyword(s):

Intracerebral Hemorrhage ◽

Ct Angiography ◽

Hematoma Expansion ◽

Contrast Extravasation

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Rate of Contrast Extravasation on Computed Tomographic Angiography Predicts Hematoma Expansion and Mortality in Primary Intracerebral Hemorrhage

Stroke ◽

10.1161/strokeaha.115.009659 ◽

2015 ◽

Vol 46 (9) ◽

pp. 2498-2503 ◽

Cited By ~ 20

Author(s):

H. Bart Brouwers ◽

Thomas W.K. Battey ◽

Hayley H. Musial ◽

Viesha A. Ciura ◽

Guido J. Falcone ◽

...

Keyword(s):

Intracerebral Hemorrhage ◽

Computed Tomographic Angiography ◽

Hematoma Expansion ◽

Contrast Extravasation ◽

Computed Tomographic ◽

Tomographic Angiography

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Hematoma expansion is more frequent in deep than lobar intracerebral hemorrhage

Neurology ◽

10.1212/wnl.0000000000010990 ◽

2020 ◽

Vol 95 (24) ◽

pp. e3386-e3393

Author(s):

David Roh ◽

Amelia Boehme ◽

Codi Young ◽

William Roth ◽

Jose Gutierrez ◽

...

Keyword(s):

Logistic Regression ◽

Intracerebral Hemorrhage ◽

Confidence Intervals ◽

Symptom Onset ◽

Subgroup Analysis ◽

Intraventricular Hemorrhage ◽

Hematoma Expansion ◽

Relative Growth ◽

Racial Variations ◽

Poor Outcomes

ObjectiveTo test the hypothesis that patients with deep intracerebral hemorrhage (ICH) would encounter hematoma expansion (HE) more frequently compared to patients with lobar ICH.MethodsPatients with ICH with neuroimaging to calculate HE were analyzed from the multicenter Ethnic/Racial Variations of Intracerebral Hemorrhage (ERICH) cohort. Patients with laboratory coagulopathy or preceding anticoagulant use were excluded to assess relationships of ICH location alone (deep vs lobar) with HE, defined as >33% relative growth. Odds ratios (ORs) and 95% confidence intervals (CIs) for these relationships were estimated with logistic regression. Sensitivity and specificity determined HE thresholds best associated with poor 3-month outcomes (modified Rankin score 4-6) stratified by location.ResultsThere were 1,049 patients with deep and 408 patients with lobar ICH analyzed. Deep ICH locations were more likely to have HE (adjusted OR 1.57, 95% CI 1.08–2.29) after adjustment for age, sex, race, baseline hematoma size, and intraventricular hemorrhage. However, this difference was nonsignificant (adjusted OR 1.35, 95% CI 0.81–2.24) after controlling for time from symptom onset to admission CT in a subgroup analysis of 729 patients with these data. Yet, the threshold of HE best associated with poor outcomes was smaller in deep (30%) compared to lobar (50%) ICH.ConclusionsWhile HE was more frequent in deep than lobar ICH, this could be due to differences in symptom onset to admission CT times in our cohort. However, patients with deep ICH appear particularly vulnerable to the deleterious effects of small volumes of HE. Further studies should clarify whether ICH location needs to be considered in HE treatment paradigms.

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Early Predictors of the Increase in Perihematomal Edema Volume After Intracerebral Hemorrhage: A Retrospective Analysis From the Risa-MIS-ICH Study

Frontiers in Neurology ◽

10.3389/fneur.2021.700166 ◽

2021 ◽

Vol 12 ◽

Author(s):

Gengzhao Ye ◽

Shuna Huang ◽

Renlong Chen ◽

Yan Zheng ◽

Wei Huang ◽

...

Keyword(s):

Diabetes Mellitus ◽

Black Hole ◽

Intracerebral Hemorrhage ◽

Clinical Laboratory ◽

Characteristic Curve ◽

Hematoma Expansion ◽

Hematoma Volume ◽

Absolute Increase ◽

Poor Outcome ◽

Perihematomal Edema

Background and Purpose: Perihematomal edema (PHE) is associated with poor functional outcomes after intracerebral hemorrhage (ICH). Early identification of risk factors associated with PHE growth may allow for targeted therapeutic interventions.Methods: We used data contained in the risk stratification and minimally invasive surgery in acute intracerebral hemorrhage (Risa-MIS-ICH) patients: a prospective multicenter cohort study. Patients' clinical, laboratory, and radiological data within 24 h of admission were obtained from their medical records. The absolute increase in PHE volume from baseline to day 3 was defined as iPHE volume. Poor outcome was defined as modified Rankin Scale (mRS) of 4 to 6 at 90 days. Binary logistic regression was used to assess the relationship between iPHE volume and poor outcome. The receiver operating characteristic curve was used to find the best cutoff. Linear regression was used to identify variables associated with iPHE volume (ClinicalTrials.gov Identifier: NCT03862729).Results: One hundred ninety-seven patients were included in this study. iPHE volume was significantly associated with poor outcome [P = 0.003, odds ratio (OR) 1.049, 95% confidence interval (CI) 1.016–1.082] after adjustment for hematoma volume. The best cutoff point of iPHE volume was 7.98 mL with a specificity of 71.4% and a sensitivity of 47.5%. Diabetes mellitus (P = 0.043, β = 7.66 95% CI 0.26–15.07), black hole sign (P = 0.002, β = 18.93 95% CI 6.84–31.02), and initial ICH volume (P = 0.018, β = 0.20 95% CI 0.03–0.37) were significantly associated with iPHE volume. After adjusting for hematoma expansion, the black hole sign could still independently predict the increase of PHE (P < 0.001, β = 21.62 95% CI 10.10–33.15).Conclusions: An increase of PHE volume >7.98 mL from baseline to day 3 may lead to poor outcome. Patients with diabetes mellitus, black hole sign, and large initial hematoma volume result in more PHE growth, which should garner attention in the treatment.

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Liver Fibrosis Indices Associated with Substantial Hematoma Expansion in Chinese Patients with Primary Intracerebral Hemorrhage

10.21203/rs.3.rs-666991/v1 ◽

2021 ◽

Author(s):

Huan Wang ◽

Jiongxing Wu ◽

Xue Yang ◽

Junfeng Liu ◽

Wendan Tao ◽

...

Keyword(s):

Logistic Regression ◽

Liver Fibrosis ◽

Intracerebral Hemorrhage ◽

Chinese Population ◽

Binary Logistic Regression ◽

Chinese Patients ◽

Hematoma Expansion ◽

West China Hospital ◽

West China ◽

Increased Risk

Abstract Background: Whether liver fibrosis is associated with increased risk for substantial hematoma expansion (HE) after intracerebral hemorrhage (ICH) is still uncertain. We evaluated the association between various liver fibrosis indices and substantial HE in a Chinese population with primary ICH.Methods: Primary ICH patients admitted to West China Hospital within 24 hours of onset between January 2015 and June 2018 were consecutively enrolled. Six liver fibrosis indices were calculated, including aspartate aminotransferase (AST)-platelet ratio index (APRI), AST/alanine aminotransferase ratio-platelet ratio index (AARPRI), fibrosis-4 (FIB-4), modified fibrosis-4 (mFIB-4), fibrosis quotient (FibroQ) and Forns index. Substantial HE was defined as an increase of more than 33% or 6 mL from baseline ICH volume. The association of each fibrosis index with substantial HE was analyzed using binary logistic regression. Results: Of 436 patients enrolled, about 85% showed largely normal results on standard hepatic assays and coagulation parameters. Substantial HE occurred in 115 (26.4%) patients. After adjustment, AARPRI (OR 1.26, 95% CI 1.00-1.57) and FIB-4 (OR 1.15, 95% CI 1.02-1.30) were independently associated with substantial HE in ICH patients within 24h of onset, respectively. In ICH patients within 6h of onset, each of the following indices was independently associated with substantial HE: APRI (OR 2.63, 95% CI 1.30-5,34), AARPRI (OR 1.55, 95% CI 1.09-2.22), FIB-4 (OR 1.35, 95% CI 1.08-1.69), mFIB-4 (OR 1.09, 95% CI 1.01-1.18), FibroQ (OR 1.08, 95% CI 1.00-1.16) and Forns index (OR 1.37, 95% CI 1.10-1.69). Conclusions: Liver fibrosis indices are independently associated with higher risk of substantial HE in Chinese patients with primary ICH, which suggesting that subclinical liver fibrosis could be routinely assessed in such patients to identify those at high risk of substantial HE.

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