Ramadan Fasting and Intracerebral Hematoma: Incidence and Outcomes

Background and Objectives: Fasting over a prescribed period of time is a common religious tradition practiced by several prominent faiths in the world. It is also currently regaining interest as a medical practice, both as preventive and as therapy and/or simple choice of lifestyle. For the first time, we evaluate how Ramadan (an Islamic month) fasting can influence the incidence of intracerebral hematoma and its outcome. Methods: 69 patients with primary intracerebral hemorrhage enrolled in this study, 32 patients were enrolled during Ramadan (18 patients were fasting, 14 patients were not fasting) and 37 patients were enrolled one month later (Shawal) which is not a mandatory fasting month among Muslims. All patients were admitted to Neurology department, Mansoura university hospital. The clinical characteristics and mortality during hospital admission were noticed. They were all assessed using routine lab, CT brain, “National Institutes of Health Stroke Scale” (NIHSS) and “Modified Rankin Scale” (mRS). Results: About 22 percentage of fasting patients with intracerebral hematoma died, 28.6% non-fasting patients died and 20.5% of patients died in the month after Ramadan without significant difference among the three groups (ρ>0.05). Also regarding NIHSS, hematoma expansion and mRS, there was no statistically significant difference among the three groups (ρ>0.05). Conclusion: Ramadan fasting showed neither protective effect nor worsening as regard incidence or bad impact on patients with spontaneous intracerebral hemorrhage.

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Effect of anticoagulant and antiplatelet therapy on the occurrence of primary intracerebral hemorrhage

Medicinski pregled ◽

10.2298/mpns1802042p ◽

2018 ◽

Vol 71 (1-2) ◽

pp. 42-48

Author(s):

Aleksandra Lucic-Prokin ◽

Armin Pakoci ◽

Sanela Popovic ◽

Arsen Uvelin

Keyword(s):

Intracerebral Hemorrhage ◽

Antiplatelet Therapy ◽

Scale Score ◽

Odds Ratio ◽

Oral Anticoagulant ◽

Early Death ◽

National Institutes Of Health ◽

Increased Risk ◽

Significant Difference ◽

First Time

Introduction. The incidence of intracerebral hemorrhage related to oral anticoagulant and antiplatelet therapy has an increasing trend, thus it may be a potential indicator of unvaforable outcome of primary intracerebral hemorrhage. The aim of the study was to determine the effect of these therapies on the occurrence, localization and outcome of primary intracerebral hemorrhage. Material and Methods. A retrospective study included 246 patients with first time diagnosed primary intracerebral hemorrhage. Patients were divided into three groups, according to the drugs they have used. The incidence, anatomical distribution of primary intracerebral hemorrhage and survival/mortality rates were observed in all groups. Results. Antiplatelet therapy was used by 20.3% of patients, 8.2% received antocoagulant therapy, while the rest of 71.5% didn not take these drugs in the premorbid period. The most common risk factor was arterial hypertension (97.2%). In all groups, patients had a tendency for supratentorial hematomas. Only alcohol consumption had a significant impact on the localization of hemorrhage (p < 0,05). There was no statistically significant difference between groups in National Institutes of Health Stroke Scale score on admission and a modified Rankin Scale Score at discharge. Oral anticoagulant users presented with the highest mortality rate in the first 24 hours (odds ratio - 2.5). Patients in other two groups showed a significantly higher survival rate (odds ratio - 1.5). Conclusion. Oral anticoagulant users had significantly higher National Institutes of Health Stroke Scale score on admission with an increased risk for early death. A significantly higher percentage of survival was noted in other two groups. Approximately 2/3 of all patients had poor functional recovery.

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Impact of COVID-19 on stroke admissions, treatments, and outcomes at a comprehensive stroke centre in the United Kingdom

Neurological Sciences ◽

10.1007/s10072-020-04775-x ◽

2020 ◽

Author(s):

Nishita Padmanabhan ◽

Indira Natarajan ◽

Rachel Gunston ◽

Marko Raseta ◽

Christine Roffe

Keyword(s):

National Institutes Of Health ◽

University Hospital ◽

Stroke Severity ◽

Stroke Patients ◽

Stroke Treatment ◽

Patient Demographics ◽

The United Kingdom ◽

Significant Difference ◽

Ischaemic Attack ◽

Provision Of Care

Abstract Introduction The coronavirus disease (COVID-19) pandemic has changed routine clinical practice worldwide with major impacts on the provision of care and treatment for stroke patients. Methods This retrospective observational study included all patients admitted to the Royal Stoke University Hospital in Stoke-on-Trent, UK, with a stroke or transient ischaemic attack between March 15th and April 14th, 2020 (COVID). Patient demographics, characteristics of the stroke, treatment details and logistics were compared with patients admitted in the corresponding weeks in the year before (2019). Results There was a 39.5% (n = 101 vs n = 167) reduction in admissions in the COVID cohort compared with 2019 with more severe strokes (median National Institutes of Health Stroke Scale (NIHSS) 7 vs 4, p = 0.02), and fewer strokes with no visible acute pathology (21.8 vs 37.1%, p = 0.01) on computed tomography. There was no statistically significant difference in the rates of thrombolysis (10.9 vs 13.2%, p = 0.72) and/or thrombectomy (5.9 vs 4.8%, p = 0.90) and no statistically significant difference in time from stroke onset to arrival at hospital (734 vs 576 min, p = 0.34), door-to-needle time for thrombolysis (54 vs 64 min, p = 0.43) and door-to-thrombectomy time (181 vs 445 min, p = 0.72). Thirty-day mortality was not significantly higher in the COVID year (10.9 vs 8.9%, p = 0.77). None of the 7 stroke patients infected with COVID-19 died. Conclusions During the COVID-19 pandemic, the number of stroke admissions fell, and stroke severity increased. There was no statistically significant change in the delivery of thrombolysis and mechanical thrombectomy and no increase in mortality.

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Lesional and perilesional tissue characterization by automated image processing in a novel gyrencephalic animal model of peracute intracerebral hemorrhage

Journal of Cerebral Blood Flow & Metabolism ◽

10.1177/0271678x18802119 ◽

2018 ◽

Vol 39 (12) ◽

pp. 2521-2535 ◽

Cited By ~ 6

Author(s):

Johannes Boltze ◽

Fabienne Ferrara ◽

Atticus H Hainsworth ◽

Leslie R Bridges ◽

Marietta Zille ◽

...

Keyword(s):

White Matter ◽

Animal Models ◽

Intracerebral Hemorrhage ◽

Autologous Blood ◽

Hematoma Expansion ◽

Intracerebral Hematoma ◽

Cerebral White Matter ◽

Large Animal ◽

Adult Sheep ◽

Large Animal Models

Intracerebral hemorrhage (ICH) is an important stroke subtype, but preclinical research is limited by a lack of translational animal models. Large animal models are useful to comparatively investigate key pathophysiological parameters in human ICH. To (i) establish an acute model of moderate ICH in adult sheep and (ii) an advanced neuroimage processing pipeline for automatic brain tissue and hemorrhagic lesion determination; 14 adult sheep were assigned for stereotactically induced ICH into cerebral white matter under physiological monitoring. Six hours after ICH neuroimaging using 1.5T MRI including structural as well as perfusion and diffusion, weighted imaging was performed before scarification and subsequent neuropathological investigation including immunohistological staining. Controlled, stereotactic application of autologous blood caused a space-occupying intracerebral hematoma of moderate severity, predominantly affecting white matter at 5 h post-injection. Neuroimage post-processing including lesion probability maps enabled automatic quantification of structural alterations including perilesional diffusion and perfusion restrictions. Neuropathological and immunohistological investigation confirmed perilesional vacuolation, axonal damage, and perivascular blood as seen after human ICH. The model and imaging platform reflects key aspects of human ICH and enables future translational research on hematoma expansion/evacuation, white matter changes, hematoma evacuation, and other aspects.

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Imaging of Contrast Medium Extravasation in Anticoagulation-Associated Intracerebral Hemorrhage With Dual-Energy Computed Tomography

Stroke ◽

10.1161/strokeaha.113.001224 ◽

2013 ◽

Vol 44 (10) ◽

pp. 2883-2890 ◽

Cited By ~ 14

Author(s):

Sae-Yeon Won ◽

Frieder Schlunk ◽

Julien Dinkel ◽

Hulya Karatas ◽

Wendy Leung ◽

...

Keyword(s):

Computed Tomography ◽

Intracerebral Hemorrhage ◽

Contrast Medium ◽

Dual Energy ◽

Hematoma Expansion ◽

Prothrombin Complex Concentrates ◽

Dual Energy Computed Tomography ◽

Warfarin Group ◽

Significant Difference ◽

Contrast Medium Extravasation

Background and Purpose— Contrast medium extravasation (CE) in intracerebral hemorrhage (ICH) is a marker of ongoing bleeding and a predictor of hematoma expansion. The aims of the study were to establish an ICH model in which CE can be quantified, characterized in ICH during warfarin and dabigatran anticoagulation, and to evaluate effects of prothrombin complex concentrates on CE in warfarin-associated ICH. Methods— CD1-mice were pretreated orally with warfarin, dabigatran, or vehicle. Prothrombin complex concentrates were administered in a subgroup of warfarin-treated mice. ICH was induced by stereotactic injection of collagenase VIIs into the right striatum. Contrast agent (350 μL Isovue 370 mg/mL) was injected intravenously after ICH induction (2–3.5 hours). Thirty minutes later, mice were euthanized, and CE was measured by quantifying the iodine content in the hematoma using dual-energy computed tomography. Results— The optimal time point for contrast injection was found to be 3 hours after ICH induction, allowing detection of both an increase and a decrease of CE using dual-energy computed tomography. CE was higher in the warfarin group compared with the controls ( P =0.002). There was no significant difference in CE between dabigatran-treated mice and controls. CE was higher in the sham-treated warfarin group than in the prothrombin complex concentrates–treated warfarin group ( P <0.001). Conclusions— Dual-energy computed tomography allows quantifying CE, as a marker of ongoing bleeding, in a model of anticoagulation-associated ICH. Dabigatran induces less CE in ICH than warfarin and consequently reduces risks of hematoma expansion. This constitutes a potential safety advantage of dabigatran over warfarin. Nevertheless, in case of warfarin anticoagulation, prothrombin complex concentrates reduce this side effect.

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Hemostatic Therapy in Experimental Intracerebral Hemorrhage Associated With the Direct Thrombin Inhibitor Dabigatran

Stroke ◽

10.1161/strokeaha.111.624650 ◽

2011 ◽

Vol 42 (12) ◽

pp. 3594-3599 ◽

Cited By ~ 255

Author(s):

Wei Zhou ◽

Sönke Schwarting ◽

Sergio Illanes ◽

Arthur Liesz ◽

Moritz Middelhoff ◽

...

Keyword(s):

Intracerebral Hemorrhage ◽

Human Factor ◽

Bleeding Time ◽

Factor Viia ◽

Fresh Frozen Plasma ◽

Hematoma Expansion ◽

Intracerebral Hematoma ◽

Fresh Frozen ◽

Hematoma Growth ◽

Frozen Plasma

Background and Purpose— Dabigatran-etexilate (DE) recently has been approved for stroke prevention in atrial fibrillation. However, lack of effective antagonists represents a major concern in the event of intracerebral hemorrhage (ICH). The aims of the present study were to establish a murine model of ICH associated with dabigatran, and to test the efficacy of different hemostatic factors in preventing hematoma growth. Methods— In C57BL/6 mice receiving DE (4.5 or 9.0 mg/kg), in vivo and in vitro coagulation assays and dabigatran plasma levels were measured repeatedly. Thirty minutes after inducing ICH by striatal collagenase injection, mice received an intravenous injection of saline, prothrombin complex concentrate (PCC; 100 U/kg), murine fresh-frozen plasma (200 μL), or recombinant human factor VIIa (8.0 mg/kg). ICH volume was quantified on brain cryosections 24 hours later. Results— DE substantially prolonged tail vein bleeding time and ecarin clotting time for 4 hours corresponding to dabigatran plasma levels. Intracerebral hematoma expansion was observed mainly during the first 3 hours on serial T2* MRI. Anticoagulation with high doses of DE increased the hematoma volume significantly. PCC and, less consistently, fresh-frozen plasma prevented excess hematoma expansion caused by DE, whereas recombinant human factor VIIa was ineffective. Prevention of hematoma growth and reversal of tail vein bleeding time by PCC were dose-dependent. Conclusions— The study provides strong evidence that PCC and, less consistently, fresh-frozen plasma prevent excess intracerebral hematoma expansion in a murine ICH model associated with dabigatran. The efficacy and safety of this strategy must be further evaluated in clinical studies.

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Effect of Nursing Care Strategy on Functional Outcomes among Patients after First Time Stroke

Evidence-Based Nursing Research ◽

10.47104/ebnrojs3.v1i2.69 ◽

2019 ◽

Vol 1 (2) ◽

pp. 13

Author(s):

Marwa M. Ali ◽

Rasha F. Mohamed ◽

Amina A. Mahmoud

Keyword(s):

Nursing Care ◽

Functional Outcomes ◽

Intervention Group ◽

Depression Scale ◽

Knowledge Score ◽

University Hospital ◽

Control Group ◽

Significant Difference ◽

Functional Disabilities ◽

First Time

Context: Strokes are life-changing events not merely affect a person physically but also emotionally as it may result in physical disabilities, which lead to functional disabilities as difficulties carrying out daily activities as working, walking, talking, eating, bathing, with loss of energy in addition to depressive status as a result of functional disabilities. Daily nursing care strategies are essential to stroke management. Since, it can overcome spasticity and hemiplegia through sustained stretching by various positioning, repetitive performance of a specific movement, and teaching patient to use and adapt the affected limb during functional activities. Aim: The aim of this study is to evaluate the effect of nursing care strategy on functional outcomes among patients after the first-time stroke. Methods: A quasi-experimental design used to conduct the current study in neurology department to be followed through neurology outpatient clinic at Benha University Hospital. During the period from the beginning of February 2018 till the beginning of January 2019.Subjects: Purposive sample of 171 patients to be at the end of study period (Intervention group 72 & control group 69), recruited according to the study formula based on the total number admitted to the study settings during 2017. Tools: Two tools utilized for data collection, (1)Structured interviewing questionnaire for patients, (II)Functional outcomes scales, involving: Modified Ashworth scale, Modified Barthel index, as well as the Center for Epidemiologic Studies Depression Scale (CES-D Scale). Results: Showed that there was highly statistically significant difference in term of increased knowledge score among the intervention group compared to controls, as well as a significantly lower degree of spasticity, a higher level of independence in performing activity of daily living (ADL), besides, lower depression score among intervention group compared to controls. It also showed a significant correlation between the degree of spasticity with both of independence in performing ADL and degree of depression among intervention group after nursing care strategy implementation. Conclusion: The nursing care strategy was effective in improving patients’ knowledge as well as the functional outcomes among intervention group revealing a significant correlation between the degree of spasticity with both independence in performing ADL and degree of depression. The study suggested continuous education and training program planned and offered regularly to stroke patients in the neurology and rehabilitation unit. Also recommended written, a simple booklet about stroke and its management should be provided & be available for patients and their families (relatives).

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Clinical Strategies Against Early Hematoma Expansion Following Intracerebral Hemorrhage

Frontiers in Neuroscience ◽

10.3389/fnins.2021.677744 ◽

2021 ◽

Vol 15 ◽

Author(s):

Kanta Tanaka ◽

Kazunori Toyoda

Keyword(s):

Blood Pressure ◽

Intracerebral Hemorrhage ◽

Stroke Onset ◽

Factor Vii ◽

Hematoma Expansion ◽

Thrombin Inhibitor ◽

Small Magnitude ◽

Hematoma Enlargement ◽

Significant Difference ◽

Hematoma Growth

Hematoma volume is the strongest predictor of morbidity and mortality after intracerebral hemorrhage. Protection against early hematoma growth is therefore the mainstay of therapeutic intervention for acute intracerebral hemorrhage, but the current armamentarium is restricted to early blood pressure lowering and emergent reversal for anticoagulant agents. Although intensive lowering of systolic blood pressure to <140 mmHg appears likely to prevent hematoma growth, two recent randomized trials, INTERACT-2 and ATACH-2, demonstrated non-significant trends of reduced hematoma enlargement by intensive blood pressure control, with only a small magnitude of benefit or no benefit for clinical outcomes. While oral anticoagulants can be immediately reversed by prothrombin complex concentrate, or the newly developed idarucizumab for direct thrombin inhibitor or andexanet for factor Xa inhibitors, the situation regarding reversal of antiplatelet agents is not yet quite as advanced. However, considering at most the approximately 10% rate of anticoagulant use among patients with intracerebral hemorrhage, what is most essential for patients with intracerebral hemorrhage in general is early hemostatic therapy. Tranexamic acid may safely reduce hematoma expansion, but its hemostatic effect was insufficient to be translated into improved functional outcomes in the TICH-2 randomized trial with 2,325 participants. In this context, recombinant activated factor VII (rFVIIa) is a candidate to be added to the armory against hematoma enlargement. The FAST, a phase 3 trial that compared doses of 80 and 20 μg/kg rFVIIa with placebo in 841 patients within 4 h after the stroke onset, showed a significant reduction in hematoma growth with rFVIIa treatment, but demonstrated no significant difference in the proportion of patients with severe disability or death. However, a post hoc analysis of the FAST trial suggested a benefit of rFVIIa in a target subgroup of younger patients without extensive bleeding at baseline when treated earlier after stroke onset. The FASTEST trial is now being prepared to determine this potential benefit of rFVIIa, reflecting the pressing need to develop therapeutic strategies against hematoma enlargement, a powerful but modifiable prognostic factor in patients with intracerebral hemorrhage.

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Abstract WP415: Cigarette Smoking as Risk Factor for Hematoma Expansion in Primary Intracerebral Hemorrhage: Analysis From a Randomized Clinical Trial

Stroke ◽

10.1161/str.51.suppl_1.wp415 ◽

2020 ◽

Vol 51 (Suppl_1) ◽

Author(s):

Shahram Majidi ◽

Lydia Foster ◽

Christopher P Kellner ◽

Jose I Suarez ◽

Adnan I Qureshi ◽

...

Keyword(s):

Risk Factor ◽

Cigarette Smoking ◽

Intracerebral Hemorrhage ◽

Smoking Status ◽

Hematoma Expansion ◽

Primary Analysis ◽

Significant Difference ◽

Former Smokers ◽

Gcs Score ◽

The Impact

Background: Cigarette smoking is a well-known risk factor for ischemic and hemorrhagic stroke. We evaluated the impact of smoking status on hematoma expansion and clinical outcome in patients with primary intracerebral hemorrhage (ICH). Methods: This is a post hoc exploratory analysis of Antihypertensive Treatment at Acute Cerebral Hemorrhage(ATACH)-2 trial. Patients with ICH were randomized into intensive blood pressure lowering(SBP: <139 mmHg) versus Baseline characteristics were compared based on smoking status. Analysis of outcome measures was adjusted for covariates included in the ATACH-2 primary analysis or those associated with smoking status. Results: Of total of 914 patients in the trial with known smoking status, 439 (48%) patients were ever-smokers (264 current smokers and 175 former smokers). Current and former smokers were younger and more likely to be male. There was no difference in the baseline Glasgow Coma Scale(GCS) score and initial hematoma size based on smoking status. Ever-smokers had higher rate of thalamic hemorrhage (42% vs 34%) and intraventricular hemorrhage (29% vs 23%); this rate was highest among former smokers (49% and 35%, respectively). Ever-smokers had higher rate of hematoma expansion in 24 hour [adjusted RR (95% CI): 1.46; (1.05 -2.03)] compared to non-smokers after adjusting for confounding factors. There was no significant difference in the rate of death and disability at 90 days between the two groups [adjusted RR; (95% CI): 1.18; (0.93 -1.50)]. Conclusions: Our analysis demonstrates cigarette smoking as an independent predictor for hematoma expansion. There was no significant difference in death and disability based on smoking status.

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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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