Y Stenting in Wide-Necked Bifurcation Aneurysms: A Single-Center Experience

Stent-assisted coiling is an endovascular means of managing wide-necked bifurcation aneurysms. In spite of the wide availability of various newer devices in managing such difficult aneurysms, the Y stenting offers a safe and cost-effective alternative to treat such cases in resource poor settings. This article provides an insight of our initial six cases of Y stent-assisted coiling along with their follow-up over a period of 6 months with no recanalization in any case. It also highlights the various technical aspects involved in such cases. One case had recurrent subdural hematoma probably due to use of antiplatelets and another patient had sudden dip in level of consciousness probably due to hematoma expansion that might also have been due to antiplatelet usage. However, none of the cases had any issues regarding stent migration, malapposition, and dissection. In our experience, Neuroform Atlas stent used for Y stenting offers a safe and technically easy alternative to various newer bifurcation devices.

Imaging markers of intracerebral hemorrhage expansion in patients with unclear symptom onset

Background: Hematoma expansion (HE) is common and associated with poor outcome in intracerebral hemorrhage (ICH) with unclear symptom onset (USO). Aims: We tested the association between non-contrast computed tomography (NCCT) markers and HE in this population. Methods: Retrospective analysis of patients with primary spontaneous ICH admitted at five centers in the United States and Italy. Baseline NCCT was analyzed for presence of the following markers: intrahematoma hypodensities, heterogeneous density, blend sign, and irregular shape. Variables associated with HE (hematoma growth > 6 mL and/or > 33% from baseline to follow-up imaging) were explored with multivariable logistic regression. Results: Of 2074 patients screened, we included 646 subjects (median age = 75, 53.9% males), of whom 178 (27.6%) had HE. Hypodensities (odds ratio (OR) = 2.67, 95% confidence interval (CI) = 1.79–3.98), heterogeneous density (OR = 2.16, 95% CI = 1.46–3.21), blend sign (OR = 2.28, 95% CI = 1.38–3.75) and irregular shape (OR = 1.82, 95% CI = 1.21–2.75) were independently associated with a higher risk of HE, after adjustment for confounders (ICH volume, anticoagulation, and time from last seen well (LSW) to NCCT). Hypodensities had the highest sensitivity for HE (0.69), whereas blend sign was the most specific marker (0.90). All NCCT markers were more frequent in early presenters (time from LSW to NCCT ⩽ 6 h, n = 189, 29.3%), and more sensitive in this population as well (hypodensities had 0.77 sensitivity). Conclusion: NCCT markers are associated with HE in ICH with USO. These findings require prospective replication and suggest that NCCT features may help the stratification of HE in future studies on USO patients.

External Validation Study On The Value of Deep Learning Algorithm For The Prediction of Hematoma Expansion From Noncontrast CT Scans

Background: Hematoma expansion is an independent predictor of patient outcome and mortality. The early diagnosis of hematoma expansion is crucial for selecting clinical treatment options This study aims to explore the value of a deep learning algorithm for the prediction of hematoma expansion from noncontrast Computed tomography（NCCT） scan through external validation.Methods: 102 NCCT images of Hypertensive intracerebral hemorrhage (HICH) patients diagnosed in our hospital were retrospectively reviewed. The initial Computed tomography (CT) scan images were evaluated by a commercial Artificial intelligence (AI) software using deep learning algorithm and radiologists respectively to predict hematoma expansion and the corresponding sensitivity and specificity of the two groups were calculated and compared, Pair-wise comparisons were conducted among gold standard hematoma expansion diagnosis time, AI software diagnosis time and doctors’ reading time.Results: Among 102 HICH patients, The sensitivity, specificity and accuracy of predicting hematoma expansion in the AI group were higher than those in the doctor group（80.0% vs 66.7%,73.6% vs 58.3%,75.5% vs 60.8%）,with statistically significant difference (p<0.05).The AI diagnosis time (2.8 ± 0.3s) and the doctors’ diagnosis time (11.7 ± 0.3s) were both significantly shorter than the gold standard diagnosis time (14.5 ± 8.8h) (p <0.05), AI diagnosis time was significantly shorter than that of doctors (p<0.05).Conclusions: Deep learning algorithm could effectively predict hematoma expansion at an early stage from the initial CT scan images of HICH patients after onset with high sensitivity and specificity and greatly shortened diagnosis time, which provides a new, accurate, easy-to-use and fast method for the early prediction of hematoma expansion.

Cerebral Microbleeds and Acute Hematoma Characteristics in the ATACH-2 and MISTIE III Trials

Background and Objectives:To study the relationship between the presence of cerebral microbleeds (CMBs) and acute hematoma characteristics among patients with primary intracerebral hemorrhage (ICH).Methods:We pooled individual patient data from the Antihypertensive Treatment of Acute Cerebral Hemorrhage (ATACH-2) trial and the Minimally Invasive Surgery Plus Alteplase for Intracerebral Hemorrhage Evacuation phase 3 trial (MISTIE III). We included subjects with a brain magnetic resonance imaging (MRI) scan. Exposure was the presence of a CMB. The co-primary outcomes were admission ICH volume and hematoma expansion. Mixed-effects linear and logistic regression models were used, with demographics and comorbidities considered fixed effects, and the study cohort treated as a random effect. Additional analyses assessed the relationship between CMB topography and number, and hematoma characteristics.Results:Of the 1,499 ICH patients enrolled in the parent trials, 466 (31.1%) were included in this analysis, and 231 (49.6%) patients had CMBs. In adjusted models, presence of CMBs was associated with smaller ICH volume (Beta, -0.26; 95% CI, -0.44 to -0.08), and lower odds of hematoma expansion (OR, 0.65; 95% CI 0.40-0.95; P=0.04). The strength of association between CMBs and hematoma characteristics increased with increasing number of CMBs. The location of the CMBs and the severity of leukoaraiosis did not modify these results.Discussion:In a pooled cohort of ICH patients, our results are consistent with the hypothesis that more severe underlying small vessel disease, as represented by CMBs, leads to smaller baseline hematoma volumes and reduced hematoma expansion. Underlying cerebral small vessel disease may be of prognostic significance after ICH.Classification of Evidence:This study provides Class II evidence that the presence of microbleeds on MRI is associated with a smaller ICH volume at presentation and a lower rate of hematoma expansion on follow-up imaging.

Early Tranexamic Acid in Intracerebral Hemorrhage: A Meta-Analysis of Randomized Controlled Trials

Objective: Intracranial hemorrhage (ICH) is a common complication of traumatic brain, in which tranexamic acid has been recommended as an additional therapy to prevent a second bleeding. However, the effect of early administration of tranexamic acid for ICH patients remains controversial.Methods: A systematic search was performed in Cochrane Library, Medline, Embase, and Web of Science. Poor outcome refers to significant hemorrhage growth, new intracranial hemorrhage, new focal cerebral ischaemic lesions, the need for neurosurgery, or death. Study heterogeneity and publication bias were estimated.Results: Seven randomized controlled trials involving 3,192 participants were included in our meta-analysis. Tranexamic acid administration in ICH patients was associated with better outcomes of hematoma expansion (odd ratios [OR] 0.79; 95% confidence interval (CI) CI, 0.67–0.93; I2 = 0%; P = 0.006) and growth of hemorrhagic lesions (weighted mean difference [WMD], −1.97 ml; 95% CI, −2.94 to −1.00; I2 = 14%; P &lt; 0.001) than the placebo. No difference was found between the mortality, poor outcome, neurosurgical intervention, new bleeding, and the duration of hospital stay. Moreover, no publication bias was found.Conclusion: Our analysis reveals that the early treatment with tranexamic acid can significantly reduce the incidence of hematoma expansion and the volume of hemorrhagic lesion, but does not exert considerable effects on mortality, poor outcome, neurosurgery, rebleeding, and the duration of stay.

Higher Cerebral Blood Flow Predicts Early Hematoma Expansion in Patients With Intracerebral Hemorrhage: A Clinical Study

The early hematoma expansion of intracerebral hemorrhage (ICH) indicates a poor prognosis. This paper studies the relationship between cerebral blood flow (CBF) around the hematoma and hematoma expansion (HE) in the acute stage of intracerebral hemorrhage. A total of 50 patients with supratentorial cerebral hemorrhage were enrolled in this study. They underwent baseline whole-brain CTP within 6 h after intracerebral hemorrhage, and non-contrast CT within 24 h. Absolute hematoma growth and relative hematoma growth were calculated, respectively. A relative growth of Hematoma volume &gt;33% was considered to be hematoma expansion. The Ipsilateral peri-edema CBF and Ipsilateral edema CBF were calculated by CTP maps in patients with and without hematoma expansion, respectively. In this study the incidence of hematoma expansion in the early stage of supratentorial cerebral hemorrhage was 32%; The CBF of the hematoma expansion group was higher than that of the patients without hematoma expansion (23.5 ± 12.5 vs. 15.1 ± 7.4, P = 0.004). After adjusting for age, gender, Symptom onset to NCCT and Baseline hematoma volume, ipsilateral peri-edema CBF was still an independent risk factor for early HE (or = 1.095, 95% CI = 1.01–1.19, P = 0.024). Here, we concluded that higher cerebral blood flow predicts early hematoma expansion in patients with intracerebral hemorrhage.

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

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.

INTEnsive ambulance-delivered blood pressure Reduction in hyper-ACute stroke Trial (INTERACT4): study protocol for a randomized controlled trial

Background Early pre-hospital initiation of blood pressure (BP) lowering could improve outcomes for patients with acute stroke, by reducing hematoma expansion in intracerebral hemorrhage (ICH), and time to reperfusion treatment and risk of intracranial hemorrhage in ischemic stroke (IS). We present the design of the fourth INTEnsive ambulance-delivered blood pressure Reduction in hyper-ACute stroke Trial (INTERACT4). Methods A multi-center, ambulance-delivered, prospective, randomized, open-label, blinded endpoint (PROBE) assessed trial of pre-hospital BP lowering in 3116 hypertensive patients with suspected acute stroke at 50+ sites in China. Patients are randomized through a mobile phone digital system to intensive BP lowering to a target systolic BP of < 140 mmHg within 30 min, or guideline-recommended BP management according to local protocols. After the collection of in-hospital clinical and management data and 7-day outcomes, trained blinded assessors conduct telephone or face-to-face assessments of physical function and health-related quality of life in participants at 90 days. The primary outcome is the physical function on the modified Rankin scale at 90 days, analyzed as an ordinal outcome with 7 categories. The sample size was estimated to provide 90% power (α = 0.05) to detect a 22% reduction in the odds of a worse functional outcome using ordinal logistic regression. Discussion INTERACT4 is a pragmatic clinical trial to provide reliable evidence on the effectiveness and safety of ambulance-delivered hyperacute BP lowering in patients with suspected acute stroke. Trial registration ClinicalTrials.gov NCT03790800. Registered on 2 January 2019; Chinese Trial Registry ChiCTR1900020534. Registered on 7 January 2019. All items can be found in this protocol paper.

Noncontrast Computed Tomography Markers of Cerebral Hemorrhage Expansion: Diagnostic Accuracy Meta-Analysis

Background and purpose Assess the diagnostic accuracy of noncontrast computed tomography (NCCT) markers of hematoma expansion in patients with primary intracerebral hemorrhage. Methods We performed a meta-analysis of observational studies and randomized controlled trials with available data for calculation of sensitivity and specificity of NCCT markers for hematoma expansion (absolute growth >6 or 12.5 mL and/or relative growth >33%). The following NCCT markers were analyzed: irregular shape, island sign (shape-related features); hypodensity, heterogeneous density, blend sign, black hole sign, and swirl sign (density-related features). Pooled accuracy values for each marker were derived from hierarchical logistic regression models. Results A total of 10,363 subjects from 23 eligible studies were included. Significant risk of bias of included studies was noted. Hematoma expansion frequency ranged from 7% to 40%, mean intracerebral hemorrhage volume from 9 to 27.8 ml, presence of NCCT markers from 9% (island sign) to 82% (irregular shape). Among shape features, sensitivity ranged from 0.32 (95%CI = 0.20–0.47) for island sign to 0.68 (95%CI = 0.57–0.77) for irregular shape, specificity ranged from 0.47 (95%CI = 0.36–0.59) for irregular shape to 0.92 (95%CI = 0.85–0.96) for island sign; among density features sensitivity ranged from 0.28 (95%CI = 0.21–0.35) for black hole sign to 0.63 (95%CI = 0.44–0.78) for hypodensity, specificity ranged from 0.65 (95%CI = 0.56–0.73) for heterogeneous density to 0.89 (95%CI = 0.85–0.92) for blend sign. Conclusion Diagnostic accuracy of NCCT markers remains suboptimal for implementation in clinical trials although density features performed better than shape-related features. This analysis may help in better tailoring patients’ selection for hematoma expansion targeted trials.