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

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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Perihematomal edema as predictor of outcome in spontaneous intracerebral hemorrhage

Journal of Neurosciences in Rural Practice ◽

10.4103/0976-3147.127873 ◽

2014 ◽

Vol 5 (01) ◽

pp. 48-54 ◽

Cited By ~ 14

Author(s):

Mani Gupta ◽

Rajesh Verma ◽

Anit Parihar ◽

Ravindra K. Garg ◽

Maneesh K. Singh ◽

...

Keyword(s):

Intracerebral Hemorrhage ◽

Clinical Laboratory ◽

Negative Impact ◽

Univariate Analysis ◽

High Rate ◽

Controlled Study ◽

Spontaneous Intracerebral Hemorrhage ◽

Hematoma Volume ◽

Poor Outcome ◽

Perihematomal Edema

ABSTRACT Background: Spontaneous intracerebral hemorrhage (SICH) is a form of cerebrovascular accident with a very high rate of morbidity and mortality. The determinants of prognosis include the demographic, clinical, laboratory, and radiologic factors. It is long known that the hematoma size has a negative impact on the outcome in SICH. The influence of perihematomal edema (PHE) is not established to the extent same as that of hematoma volume. Hence, we planned this study to determine as to what role does PHE plays in the outcome in SICH. Aim of the Study: To evaluate the prognostic influence of absolute and relative edema (ratio of absolute edema to hematoma volume) in the patients of SICH. Materials and Methods: This is a prospective case-controlled study. A total of 44 patients were enrolled after excluding the confounding factors. The patients were evaluated and their disability was assessed using modified Rankin scale (MRS). The imaging was done in the interval between 24 and 72 h and the hematoma volume, absolute edema volume, and the relative edema were calculated. The outcome was reassessed at 12 weeks and defined as favorable if MRS < 3. Results: A total of 69 patients were found to be having SICH on imaging; however, 25 patients were excluded as they had one of the criterion for exclusion. Hence, only 44 patients were included in the study. On univariate analysis, none of the demographic characteristics of the patients, vascular risk factors, presenting complaints, blood pressure, Glasgow coma scale, and MRS at admission, laboratory parameters were not significantly different in the two outcome groups. The hematoma volume was significantly higher in the poor outcome group (P < 0.0001) and the relative edema was associated with a favorable outcome at 12 weeks (P < 0.0001). On multivariate logistic regression, the hematoma volume and relative edema were found to have effect on the outcome similar to that seen on univariate analysis. Conclusion: In SICH, a larger hematoma volume is a predictor of poor outcome and a relative edema is associated with a better functional status.

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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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Black Hole Sign Predicts Poor Outcome in Patients with Intracerebral Hemorrhage

Cerebrovascular Diseases ◽

10.1159/000486163 ◽

2018 ◽

Vol 45 (1-2) ◽

pp. 48-53 ◽

Cited By ~ 7

Author(s):

Qi Li ◽

Wen-Song Yang ◽

Sheng-Li Chen ◽

Fu-Rong Lv ◽

Fa-Jin Lv ◽

...

Keyword(s):

Black Hole ◽

Logistic Regression ◽

Intracerebral Hemorrhage ◽

Ct Scan ◽

Functional Outcome ◽

Multivariate Logistic Regression Analysis ◽

Hematoma Expansion ◽

Poor Functional Outcome ◽

Poor Outcome ◽

Prognostic Stratification

Background: In spontaneous intracerebral hemorrhage (ICH), black hole sign has been proposed as a promising imaging marker that predicts hematoma expansion in patients with ICH. The aim of our study was to investigate whether admission CT black hole sign predicts hematoma growth in patients with ICH. Methods: From July 2011 till February 2016, patients with spontaneous ICH who underwent baseline CT scan within 6 h of symptoms onset and follow-up CT scan were recruited into the study. The presence of black hole sign on admission non-enhanced CT was independently assessed by 2 readers. The functional outcome was assessed using the modified Rankin Scale (mRS) at 90 days. Univariate and multivariable logistic regression analyses were performed to assess the association between the presence of the black hole sign and functional outcome. Results: A total of 225 patients (67.6% male, mean age 60.3 years) were included in our study. Black hole sign was identified in 32 of 225 (14.2%) patients on admission CT scan. The multivariate logistic regression analysis demonstrated that age, intraventricular hemorrhage, baseline ICH volume, admission Glasgow Coma Scale score, and presence of black hole sign on baseline CT independently predict poor functional outcome at 90 days. There are significantly more patients with a poor functional outcome (defined as mRS ≥4) among patients with black hole sign than those without (84.4 vs. 32.1%, p < 0.001; OR 8.19, p = 0.001). Conclusions: The CT black hole sign independently predicts poor outcome in patients with ICH. Early identification of black hole sign is useful in prognostic stratification and may serve as a potential therapeutic target for anti-expansion clinical trials.

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Early Perihematomal Edema Expansion: Definition, Significance, and Association with Outcomes after Intracerebral Hemorrhage

Oxidative Medicine and Cellular Longevity ◽

10.1155/2021/6249509 ◽

2021 ◽

Vol 2021 ◽

pp. 1-7

Author(s):

Xin-Ni Lv ◽

Zuo-Qiao Li ◽

Lan Deng ◽

Wen-Song Yang ◽

Yu-Lun Li ◽

...

Keyword(s):

Intracerebral Hemorrhage ◽

Functional Outcome ◽

Scale Score ◽

Ct Scans ◽

Absolute Increase ◽

Poor Outcome ◽

Perihematomal Edema ◽

Logistic Regression Procedure ◽

Admission Glasgow Coma Scale

Objective. To investigate the association between early perihematomal edema (PHE) expansion and functional outcome in patients with intracerebral hemorrhage (ICH). Methods. Patients with ICH who underwent initial computed tomography (CT) scans within 6 hours after the onset of symptoms and follow-up CT scans within 24 ± 12 hours were included. Absolute PHE increase was defined as the absolute increase in PHE volume from baseline to 24 hours. A receiver-operating characteristic (ROC) curve was generated to determine the cutoff value for early PHE expansion, which was operationally defined as an absolute increase in PHE volume of >6 mL. The outcome of interest was 3-month poor outcome defined as modified Rankin scale score of ≥4. A multivariable logistic regression procedure was used to assess the association between early PHE expansion and outcome after ICH. Results. In 233 patients with ICH, 89 (38.2%) patients had poor outcome at 3-month follow-up. Early PHE expansion was observed in 56 of 233 (24.0%) patients. Patients with early PHE expansion were more likely to have poor functional outcome than those without (43.8% vs. 11.8%, p < 0.001 ). After adjusting for age, admission systolic blood pressure, admission Glasgow Coma Scale score, baseline ICH volume and the presence of intraventricular hemorrhage, and time from onset to CT, early PHE expansion was associated with poor outcome (adjusted odds ratio, 4.25; 95% confidence interval, 1.70–10.60; p = 0.002 ). Conclusions. The early PHE expansion was not uncommon in patients with ICH and was correlated with poor outcome following ICH.

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Abstract W P326: Comparison of Spontaneous Intracerebral Hemorrhage Outcomes in Patients with Warfarin and Antiplatelet Medication Use

Stroke ◽

10.1161/str.46.suppl_1.wp326 ◽

2015 ◽

Vol 46 (suppl_1) ◽

Author(s):

Santosh Murthy ◽

Yogesh Moradiya ◽

Jesse Dawson ◽

Kennedy Lees ◽

Daniel F Hanley ◽

...

Keyword(s):

Intracerebral Hemorrhage ◽

Functional Outcomes ◽

Intraventricular Hemorrhage ◽

Hematoma Expansion ◽

Spontaneous Intracerebral Hemorrhage ◽

Hematoma Volume ◽

Computed Tomographic ◽

Warfarin Group ◽

Antiplatelet Medication ◽

Perihematomal Edema

Background: Use of antiplatelet medications and warfarin has been associated with poor clinical outcomes in spontaneous intracerebral hemorrhage (ICH). However, a head to head comparison between these groups has not been performed. We compared ICH outcomes among patients on these medications. Methods: In this cohort study, we analyzed 987 patients with ICH from the Virtual International Stroke Trials Archive. Patients with ICH presented within six-hours of symptom onset had baseline clinical, radiological data, and computed tomographic scan at 72 hours. Hematoma expansion was defined as interval increase in size by >33%. Main outcome variables were 90-day mortality, and modified Rankin Score (mRS) at 90 days dichotomized into 0-3 vs 4-6. Results: Of 987 ICH patients 154 had prior antiplatelet use, 30 had warfarin, and 803 had neither of the two medications. The warfarin group had significantly higher age (p<0.001) and higher prevalence of atrial fibrillation (p<0.001). Of the ICH characteristics, comparing warfarin, antiplatelet and no warfarin/antiplatelet cohorts, the warfarin group had lower Glasgow coma scale (GCS) scores (p=0.049), higher intraventricular hemorrhage (IVH) rate (p=0.010), and more hydrocephalus (p<0.001). Hematoma expansion at 72 hours was significantly higher with warfarin use (p=0.003), while the ratio of perihematomal edema volume to hematoma volume at 72 hours was lowest with warfarin use (p<0.001). In the logistic regression model adjusted for age, sex, race, hematoma volume, perihematomal edema, GCS, IVH and hydrocephalus; warfarin patients had significantly lower odds of achieving mRS 0-3 (OR: 0.23, 95% CI: 0.06-0.83, p=0.025), while the antiplatelet group had similar functional outcomes compared to no warfarin/antiplatelet use (OR: 0.75, 95% CI: 0.46-1.23, p=0.260). The 90-day mortality outcomes were not significantly different across the three groups (18.7% to 40.3%, p=0.520). Conclusion: Warfarin use is associated with a higher incidence of hydrocephalus, intraventricular hemorrhage and hematoma expansion, but lesser perihematomal edema relative to the hematoma volume. Warfarin associated ICH appears to be independently associated with worse functional outcomes but not with 90-day mortality in ICH.

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Abstract P416: Remote Ischemic Conditioning Reduces Perihematomal Edema After Intracerebral Hemorrhage: First Proof-Of-Concept Randomized Controlled Trial

Stroke ◽

10.1161/str.52.suppl_1.p416 ◽

2021 ◽

Vol 52 (Suppl_1) ◽

Author(s):

Zhao Wenbo ◽

Fang Jiang ◽

Sijie Li ◽

Yuchuan Ding ◽

Xunming Ji

Keyword(s):

Intracerebral Hemorrhage ◽

Controlled Trial ◽

Neurological Deterioration ◽

Hematoma Expansion ◽

Control Group ◽

Hematoma Volume ◽

Remote Ischemic Conditioning ◽

Ischemic Conditioning ◽

Significant Difference ◽

Perihematomal Edema

Introduction: The prognosis of intracerebral hemorrhage (ICH) is poor because of the mass effect arising from the hematoma and the associated perihematomal edema (PHE). Remote ischemic conditioning (RIC) has been shown to promote hematoma clearance and reduce PHE in animal models, however it remains unknown whether RIC is safe and effective in reducing PHE in ICH patients. Objective: To evaluate the safety and efficacy of RIC in reducing PHE after ICH. Methods: In this open-label, rater-blind, randomized control trial, 40 subjects with supratentorial ICH (hematoma volume:10-30 ml) diagnosed between 24 to 48 hours of onset were assigned to the RIC group or control group. All subjects received standard background medical therapy. Subjects in the RIC group underwent repeated daily RIC (4 cycles of 5 minutes inflation [200 mmHg] /deflation [0 mmHg] of cuff on one arm) for 7 consecutive days. The primary efficacy outcome was PHE volume at 7 days, and both absolute PHE volume and relative PHE volume (defined as absolute PHE volume divided by hematoma volume) were measured. Safety outcome included death, neurological deterioration, hematoma expansion, and any other severe adverse events. Results: All 40 subjects completed this study. Mean age was 59.3±11.7 years, and 57.5% were male. At baseline, the median National Institutes of Health Stroke Scale score was 9.5 (range 1-28), median Glasgow Come Score was 15 (range 10-15), and mean ICH volume was 13.9±4.5 ml. The mean relative PHE volume was 1.11±0.26 in the control group and 1.05±0.23 in the RIC group at baseline; and 1.49±0.30 vs. 1.33 ±0.32 at Day 3 (p>0.05 each) respectively. After 7 days of treatment, RIC significantly reduced the relative PHE volume as compared to the control (1.77±0.39 vs. 2.02±0.27, p=0.02). The absolute PHE volume and hematoma volume at Day 3 and Day 7 had no significant difference between groups (p>0.05 each). No subject died or suffered from neurological deterioration or hematoma expansion and no adverse event was associated with RIC. Conclusion: RIC seemed to be safe in patients with ICH and induced a significant reduction in the relative PHE volume after 7 day of treatment. These results warrant a further study with large sample to examine the effect of RIC on functional outcome after ICH.

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Comparison of Black Hole Sign, Satellite Sign, and Iodine Sign to Predict Hematoma Expansion in Patients with Spontaneous Intracerebral Hemorrhage

BioMed Research International ◽

10.1155/2021/3919710 ◽

2021 ◽

Vol 2021 ◽

pp. 1-8

Author(s):

Milind Ratna Shakya ◽

Fan Fu ◽

Miao Zhang ◽

Yi Shan ◽

Fan Yu ◽

...

Keyword(s):

Computed Tomography ◽

Black Hole ◽

Intracerebral Hemorrhage ◽

Odds Ratio ◽

Predictive Accuracy ◽

Characteristic Curve ◽

Receiver Operator Characteristic Curve ◽

Hematoma Expansion ◽

Spontaneous Intracerebral Hemorrhage ◽

Significant Difference

Purpose. To discretely and collectively compare black hole sign (BHS) and satellite sign (SS) with recently introduced gemstone spectral imaging-based iodine sign (IS) for predicting hematoma expansion (HE) in spontaneous intracerebral hemorrhage (SICH). Methods. This retrospective study includes 90 patients from 2017 to 2019 who underwent both spectral computed tomography angiography (CTA) as well as noncontrast computed tomography (NCCT) within 6 hours of SICH onset along with subsequent follow-up NCCT scanned within 24 hours. We named the presence of any of BHS or SS as any NCCT sign. Two independent reviewers analyzed all the HE predicting signs. Receiver-operator characteristic curve analysis and logistic regression were performed to compare the predictive performance of HE. Results. A total of 61 patients had HE, out of which IS was seen in 78.7% (48/61) while BHS and SS were seen in 47.5% (29/61) and 41% (25/61), respectively. The area under the curve for BHS, SS, and IS was 63.4%, 67%, and 82.4%, respectively, while for any NCCT sign was 71.5%. There was no significant difference between IS and any NCCT sign ( P = 0.108 ). Multivariate analysis showed IS (odds ratio 68.24; 95% CI 11.76-396.00; P < 0.001 ) and any NCCT sign (odds ratio 19.49; 95% CI 3.99-95.25; P < 0.001 ) were independent predictors of HE whereas BHS (odds ratio 0.34; 95% CI 0.01-38.50; P = 0.534 ) and SS (odds ratio 4.54; 95% CI 0.54-38.50; P = 0.165 ) had no significance. Conclusion. The predictive accuracy of any NCCT sign was better than that of sole BHS and SS. Both any NCCT sign and IS were independent predictors of HE. Although IS had higher predictive accuracy, any NCCT sign may still be regarded as a fair predictor of HE when CTA is not available.

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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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