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Romero JM, Rojas-Serrano LF. Current Evaluation of Intracerebral Hemorrhage. Radiol Clin North Am 2023; 61:479-490. [PMID: 36931764 DOI: 10.1016/j.rcl.2023.01.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/22/2023]
Abstract
Advanced imaging is currently critical in diagnosing, predicting, and managing intracerebral hemorrhage. MD CT angiography has occupied the first line of evaluating patients with a clinical diagnosis of a stroke, given its rapid acquisition time, high resolution of vascular structures, and sensitivity for secondary causes of ICH.
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Affiliation(s)
- Javier M Romero
- Radiology Department, Massachusetts General Hospital, Harvard Medical School, 55 Fruit Street, Gray Building, 241G, MA 02114, USA.
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2
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MRI spot sign in acute intracerebral hemorrhage: an independent biomarker of hematoma expansion and poor functional outcome. J Neurol 2023; 270:1531-1542. [PMID: 36434128 DOI: 10.1007/s00415-022-11498-w] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2022] [Revised: 11/17/2022] [Accepted: 11/18/2022] [Indexed: 11/27/2022]
Abstract
BACKGROUND In acute intracerebral hemorrhage (ICH), the prognostic value of the MRI spot sign on hematoma expansion (HE) and poor functional outcome is poorly known. METHODS We retrospectively included patients admitted over a 4-year period for an acute ICH in a single institution using MRI as the first-line imaging tool. The presence and number of MRI spot signs on contrast-enhanced T1-weighted imaging was evaluated by one neuroradiologist, blinded from outcomes. The primary outcome was HE, defined as > 6 mL or > 33% ICH volume growth from initial MRI to 24-48 h follow-up imaging; the secondary outcome was poor 3-month modified Rankin score (4-6). RESULTS Overall, 147 patients were included, and 62% had a spot sign. Among the 130 patients with follow-up imaging, 24% experienced HE. HE occurred in 6%, 21% and 43% patients with 0, 1 and ≥ 2 spots, respectively (P < 0.001). The MRI spot sign was independently associated with HE (adjusted OR 6.15 [95% CI 1.60-23.65]; P = 0.008), with a dose-dependent effect. The negative and positive predictive values of the spot sign for HE were 0.94 and 0.35, respectively. Poor functional outcome occurred in 27%, 32% and 71% patients with 0, 1 and ≥ 2 spots, respectively (P < 0.001). In multivariable analysis, the presence of ≥ 2 spots was independently associated with poor functional outcome (adjusted OR 3.67 [95% CI 1.21-11.10]; P = 0.024). CONCLUSION The MRI spot sign is an independent biomarker of HE, and the presence of ≥ 2 spots is independently associated with poor 3-month outcome. The lack of spot sign is highly predictive of a favorable evolution.
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3
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Morotti A, Boulouis G, Dowlatshahi D, Li Q, Shamy M, Al-Shahi Salman R, Rosand J, Cordonnier C, Goldstein JN, Charidimou A. Intracerebral haemorrhage expansion: definitions, predictors, and prevention. Lancet Neurol 2023; 22:159-171. [PMID: 36309041 DOI: 10.1016/s1474-4422(22)00338-6] [Citation(s) in RCA: 21] [Impact Index Per Article: 21.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2022] [Revised: 08/04/2022] [Accepted: 08/09/2022] [Indexed: 12/05/2022]
Abstract
Haematoma expansion affects a fifth of patients within 24 h of the onset of acute intracerebral haemorrhage and is associated with death and disability, which makes it an appealing therapeutic target. The time in which active intervention can be done is short as expansion occurs mostly within the first 3 h after onset. Baseline haemorrhage volume, antithrombotic treatment, and CT angiography spot signs are each associated with increased risk of haematoma expansion. Non-contrast CT features are promising predictors of haematoma expansion, but their potential contribution to current models is under investigation. Blood pressure lowering and haemostatic treatment minimise haematoma expansion but have not led to improved functional outcomes in randomised clinical trials. Ultra-early enrolment and selection of participants on the basis of non-contrast CT imaging markers could focus future clinical trials to show clinical benefit in people at high risk of expansion or investigate heterogeneity of treatment effects in clinical trials with broad inclusion criteria.
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Affiliation(s)
- Andrea Morotti
- Neurology Unit, Department of Neurological Sciences and Vision, Azienda Socio Sanitaria Territoriale Spedali Civili, Brescia, Italy.
| | - Gregoire Boulouis
- Diagnostic and Interventional Neuroradiology Department, University Hospital of Tours, Tours, France
| | - Dar Dowlatshahi
- Department of Medicine, Division of Neurology, University of Ottawa and Ottawa Hospital Research Institute, Ottawa ON, Canada
| | - Qi Li
- Department of Neurology, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Michel Shamy
- Department of Medicine, Division of Neurology, University of Ottawa and Ottawa Hospital Research Institute, Ottawa ON, Canada
| | | | - Jonathan Rosand
- Division of Neurocritical Care, Massachusetts General Hospital, Boston, MA, USA; Henry and Allison McCance Center for Brain Health, Massachusetts General Hospital, Boston, MA, USA
| | - Charlotte Cordonnier
- Universite Lille, Inserm, CHU Lille, U1172, LilNCog, Lille Neuroscience and Cognition, F-59000 Lille, France
| | - Joshua N Goldstein
- Division of Neurocritical Care, Massachusetts General Hospital, Boston, MA, USA; Department of Emergency Medicine, Massachusetts General Hospital, Boston, MA, USA
| | - Andreas Charidimou
- Department of Neurology, Boston University Medical Center, Boston University School of Medicine, Boston, MA, USA
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4
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The Predictive Accuracy of the Delayed Spot Sign for Haematoma Expansion in Spontaneous Supratentorial Intracerebral Haemorrhage: A Systematic Review and Meta-Analysis. J Stroke Cerebrovasc Dis 2022; 31:106379. [DOI: 10.1016/j.jstrokecerebrovasdis.2022.106379] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2021] [Revised: 01/24/2022] [Accepted: 01/29/2022] [Indexed: 11/17/2022] Open
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5
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Anderson CS. Intracerebral Hemorrhage. Stroke 2022. [DOI: 10.1016/b978-0-323-69424-7.00028-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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6
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Yi P, Xu M, Chen P, Luo Y, Wang D, Wang H, Wang C. Eliminating vascular interference from the Spot Sign contributes to predicting hematoma expansion in individuals with spontaneous cerebral hemorrhages. Acta Neurol Belg 2021; 121:521-528. [PMID: 31734794 DOI: 10.1007/s13760-019-01244-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2019] [Accepted: 11/07/2019] [Indexed: 10/25/2022]
Abstract
The computed tomography angiography (CTA) Spot Sign is an effective means of predicting hematoma expansion (HE) in the context of spontaneous intracerebral hemorrhage (ICH). We investigated whether continuous CTA source images could differentiate the Spot Sign and blood vessels in the hematoma, and whether it would improve Spot Sign accuracy as an HE predictor. We screened for the presence of CTA Spot Sign in individuals affected by spontaneous ICH within 24 h of symptom development. Based on our findings, we determined the sensitivity, specificity, and positive/negative predictive values of this sign as a predictor of HE both on its own and following the exclusion of blood vessels. In addition, a receiver-operating characteristic approach was used to assess the accuracy of Spot Sign with and without elimination of vascular interference. A total of 265 patients were included in this study. The Spot Sign was observed in 100 patients, including in 29 patients wherein it was confirmed to be blood vessels as determined based upon continuous CTA source images. With respect to predicting HE, Spot Sign sensitivity, specificity, positive predictive values, and negative predictive values were 57%, 71%, 48% and 78%, respectively. Following the exclusion of blood vessels, these values were 57%, 87%, 68% and 81%, respectively. Spot Sign area under the curve after excluding blood vessels was 0.718, which was higher than that of the Spot Sign (0.638). After continuous CTA, source images are used to exclude blood vessels in the hematoma, the Spot Sign is thus more accurate in predicting HE.
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7
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Different criteria for defining "spot sign" in intracerebral hemorrhage show different abilities to predict hematoma expansion and clinical outcomes: a systematic review and meta-analysis. Neurosurg Rev 2021; 44:3059-3068. [PMID: 33608829 DOI: 10.1007/s10143-021-01503-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2020] [Revised: 01/11/2021] [Accepted: 02/12/2021] [Indexed: 10/22/2022]
Abstract
The "spot sign" is a well-known radiological marker used for predicting hematoma expansion and clinical outcomes in patients with intracerebral hemorrhage (ICH). We performed a meta-analysis to assess the predictive accuracy of spot sign, depending on the criteria used to identify them.We conducted a systematic review of clinical studies that clearly stated their definition of spot sign and that were indexed in the Cochrane Library, MEDLINE, EMBASE, and the China National Knowledge Infrastructure databases. We collected data on computed tomography (CT) parameters, spot sign diagnostic criteria, hematoma expansion, and clinical outcomes.Based on the eligibility criteria, we included 17 studies in this systematic review. CT imaging modality, type, time from symptom onset to CT, time from contrast infusion to scan, slice thickness, tube current, and tube electric discharge showed variation across studies. Three different definitions of the spot sign were applied: (1) a hyperdense spot within the hematoma; (2) one or more focal areas/regions of contrast pooling of any size and morphology that occurred within a hemorrhage, were discontinuous from the normal or abnormal vasculature adjacent to the hemorrhage, and showed an attenuation rate ≥ 120 UH; or (3) serpiginous or spot-like contrast density on CTA images that occurred within the hematoma margin, showed twice the density of the hematoma background, and did not contact vessels outside the hematoma. Three definitions for the spot sign were identified, all of which were associated with hematoma expansion, mortality, and unfavorable functional outcome. Subgroup analyses based on these definitions showed that spot sign identified using the second definition were more likely to be associated with hematoma expansion (OR 18.31, 95% CI 9.11-36.8) and unfavorable functional outcomes (OR 8.78, 95% CI 3.24-23.79), while those identified using the third definition were associated with increased risk of mortality (OR 6.88, 95% CI 1.43-33.13).Clinical studies identify spot sign using different CT protocols and criteria. These differences affect the ability of spot sign to predict hematoma expansion and clinical outcomes in ICH patients.
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8
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Is the detectability of the spot sign on CT angiography depending on slice thickness and reconstruction type? Clin Neurol Neurosurg 2021; 203:106559. [PMID: 33618171 DOI: 10.1016/j.clineuro.2021.106559] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2021] [Revised: 02/08/2021] [Accepted: 02/09/2021] [Indexed: 10/22/2022]
Abstract
OBJECTIVE The spot sign is a validated imaging marker widely used in CT angiography (CTA) to detect active bleeding and a higher risk of hematoma expansion in patients with intracerebral hemorrhage (ICH). The aim of this study was to investigate the detectability of spot signs on thin multiplanar projection reconstruction (MPR) images compared to thicker maximum intensity projection (MIP) images. METHODS In this retrospective analysis, we assessed imaging data of 146 patients with primary hypertensive/microangiopathic ICH who received emergency non-contrast computed tomography (NCCT) and CTA. Two experienced radiologists, blinded to each other, evaluated images of thin (1 mm) MPR images and thick (3 mm) MIP images on the presence of spot signs and performed a consensus reading. Kappa tests were used for data comparison. RESULTS In total, spot signs were observed in 27 cases (=18.5 %) in both thin MPR and thick MIP slices. Detectability of the spot sign did not differ in 1 mm MPR images and 3 mm MIP images (Cohen's kappa, 1.0; p = 0.00). Also, when the readings of the two radiologists were analyzed separately, results for MPR and MIP slices were similar (MPR: Cohen's kappa, 0.81, p = 0.00; MIP: Cohen's kappa, 0.74; p = 0.00). CONCLUSION No significant difference in the detectability of the spot sign could be demonstrated when comparing 1 mm MPR images with 3 mm MIP images.
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9
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Peeters MTJ, Kort KJDD, Houben R, Henneman WJP, Oostenbrugge RJV, Staals J, Postma AA. Dual-Energy CT Angiography Improves Accuracy of Spot Sign for Predicting Hematoma Expansion in Intracerebral Hemorrhage. J Stroke 2021; 23:82-90. [PMID: 33600705 PMCID: PMC7900388 DOI: 10.5853/jos.2020.03531] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2020] [Accepted: 10/22/2020] [Indexed: 12/30/2022] Open
Abstract
Background and Purpose Spot sign (SS) on computed tomography angiography (CTA) is associated with hematoma expansion (HE) and poor outcome after intracerebral hemorrhage (ICH). However, its predictive performance varies across studies, possibly because differentiating hyperdense hemorrhage from contrast media is difficult. We investigated whether dual-energy-CTA (DE-CTA), which can separate hemorrhage from iodinated contrast, improves the diagnostic accuracy of SS for predicting HE.
Methods Primary ICH patients undergoing DE-CTA (both arterial as well as delayed venous phase) and follow-up computed tomography were prospectively included between 2014 and 2019. SS was assessed on both arterial and delayed phase images of the different DE-CTA datasets, i.e., conventional-like mixed images, iodine images, and fusion images. Diagnostic accuracy of SS for prediction of HE was determined on all datasets. The association between SS and HE, and between SS and poor outcome (modified Rankin Scale at 3 months ≥3) was assessed with multivariable logistic regression, using the dataset with highest diagnostic accuracy.
Results Of 139 included patients, 47 showed HE (33.8%). Sensitivity of SS for HE was 32% (accuracy 0.72) on conventional-like mixed arterial images which increased to 76% (accuracy 0.80) on delayed fusion images. Presence of SS on delayed fusion images was independently associated with HE (odds ratio [OR], 17.5; 95% confidence interval [CI], 6.14 to 49.82) and poor outcome (OR, 3.84; 95% CI, 1.16 to 12.73).
Conclusions Presence of SS on DE-CTA, in particular on delayed phase fusion images, demonstrates higher diagnostic performance in predicting HE compared to conventional-like mixed imaging, and it is associated with poor outcome.
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Affiliation(s)
- Michaël T J Peeters
- Department of Neurology and Cardiovascular Research Institute Maastricht, Maastricht University Medical Center, Maastricht, Netherlands
| | - Kim J D de Kort
- Department of Neurology and Cardiovascular Research Institute Maastricht, Maastricht University Medical Center, Maastricht, Netherlands
| | - Rik Houben
- Department of Neurology and Cardiovascular Research Institute Maastricht, Maastricht University Medical Center, Maastricht, Netherlands
| | - Wouter J P Henneman
- Department of Radiology and Nuclear Medicine, MHeNS School for Mental Health and Neuroscience, Maastricht University Medical Center, Maastricht, Netherlands
| | - Robert J van Oostenbrugge
- Department of Neurology and Cardiovascular Research Institute Maastricht, Maastricht University Medical Center, Maastricht, Netherlands
| | - Julie Staals
- Department of Neurology and Cardiovascular Research Institute Maastricht, Maastricht University Medical Center, Maastricht, Netherlands
| | - Alida A Postma
- Department of Radiology and Nuclear Medicine, MHeNS School for Mental Health and Neuroscience, Maastricht University Medical Center, Maastricht, Netherlands
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Li Z, You M, Long C, Bi R, Xu H, He Q, Hu B. Hematoma Expansion in Intracerebral Hemorrhage: An Update on Prediction and Treatment. Front Neurol 2020; 11:702. [PMID: 32765408 PMCID: PMC7380105 DOI: 10.3389/fneur.2020.00702] [Citation(s) in RCA: 39] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2020] [Accepted: 06/09/2020] [Indexed: 12/15/2022] Open
Abstract
Intracerebral hemorrhage (ICH) is the most lethal type of stroke, but there is no specific treatment. After years of effort, neurologists have found that hematoma expansion (HE) is a vital predictor of poor prognosis in ICH patients, with a not uncommon incidence ranging widely from 13 to 38%. Herein, the progress of studies on HE after ICH in recent years is updated, and the topics of definition, prevalence, risk factors, prediction score models, mechanisms, treatment, and prospects of HE are covered in this review. The risk factors and prediction score models, including clinical, imaging, and laboratory characteristics, are elaborated in detail, but limited by sensitivity, specificity, and inconvenience to clinical practice. The management of HE is also discussed from bench work to bed practice. However, the upmost problem at present is that there is no treatment for HE proven to definitely improve clinical outcomes. Further studies are needed to identify more accurate predictors and effective treatment to reduce HE.
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Affiliation(s)
- Zhifang Li
- Department of Neurology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Mingfeng You
- Department of Neurology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Chunnan Long
- Department of Neurology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Rentang Bi
- Department of Neurology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Haoqiang Xu
- Department of Neurology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Quanwei He
- Department of Neurology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Bo Hu
- Department of Neurology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
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11
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Lv XN, Li Q. Imaging predictors for hematoma expansion in patients with intracerebral hemorrhage: A current review. BRAIN HEMORRHAGES 2020. [DOI: 10.1016/j.hest.2020.05.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
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12
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Is four-dimensional CT angiography as effective as digital subtraction angiography in the detection of the underlying causes of intracerebral haemorrhage: a systematic review. Neuroradiology 2020; 62:273-281. [PMID: 31901972 PMCID: PMC7044254 DOI: 10.1007/s00234-019-02349-z] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2019] [Accepted: 12/15/2019] [Indexed: 01/30/2023]
Abstract
PURPOSE To determine whether the sensitivity and specificity of four-dimensional CTA (4D-CTA) are equivalent to digital subtraction angiography (DSA) in the detection of underlying vascular abnormalities in patients with intracerebral haemorrhage (ICH). METHODS A systematic review of studies comparing 4D-CTA with DSA in the detection of the underlying structural causes of ICH was performed on the literature published between 1998 and 2019. RESULTS We identified a total of 237 articles from PubMed, SCOPUS and Web of Science using the following Medical Subject Headings (MeSH) terms: primary intracerebral haemorrhage, 4D-CTA, DSA, cerebral haemorrhage, angiography, digital subtraction, arteriovenous malformations, 4D, CTA, dynamic-CTA and time-resolved CTA. Following the removal of duplicate publications and articles failing to meet our inclusion criteria, there were four articles potentially viable for analysis. Therefore, there were not sufficient studies to provide a statistically meaningful meta-analysis. CONCLUSION The review of current literature has demonstrated that there are few published studies comparing 4D-CTA with DSA in spontaneous ICH, with only four suitable studies identified for potential analysis. However, due to the restricted number of patients and high sensitivity and specificity of 3 studies (100%), performing a meta-analysis was not meaningful. Qualitative analysis of the data concluded that 4D-CTA has the diagnostic potential to replace invasive DSA in certain cases with vascular abnormalities. However, further research studies directly comparing 4D-CTA with DSA using larger prospective patient cohorts are required to strengthen the evidence base.
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Fu F, Sun S, Liu L, Gu H, Su Y, Li Y. Iodine Sign as a Novel Predictor of Hematoma Expansion and Poor Outcomes in Primary Intracerebral Hemorrhage Patients. Stroke 2019; 49:2074-2080. [PMID: 30354984 DOI: 10.1161/strokeaha.118.022017] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background and Purpose- The aim of the study was to investigate the utility of iodine contrast agent leakage (the iodine sign) analyzed by Gemstone spectral imaging in early hematoma formation compared with that of the spot sign for predicting early hematoma expansion (HE) and poor functional outcomes. Methods- From 2014 to 2017, 91 patients with spontaneous intracerebral hemorrhage who underwent spectral computed tomography angiography within 6 hours of spontaneous intracerebral hemorrhage onset were prospectively included in our study. We defined a positive iodine sign as tiny enhancing foci within the hematoma on Gemstone spectral imaging and an iodine concentration inside the foci of >7.82 (100 µg/mL). Univariate and multivariate logistical regression analyses were performed to assess risk factors for HE, and the predictive value of HE was analyzed. Results- Positive spot and iodine signs were present in 38.5% (35/91) and 57.1% (52/91) of the patients, respectively. Using multivariate analysis, the iodine sign independently predicted HE (odds ratio, 53.67; 95% CI, 11.88-242.42; P<0.001) and had a higher sensitivity (91.5% versus 63.8%), negative predictive value (89.7% versus 69.9%), and accuracy (85.7% versus 75.8%) for detecting HE than the spot sign. The iodine sign, but not the spot sign, was significantly related to poor functional outcomes (severely disabled and vegetative state) in all patients (χ2=29.97; P<0.001). Conclusions- The iodine sign is a reliable and sensitive marker for predicting HE and poor functional outcomes. Clinical Trial Registration- URL: https://www.clinicaltrials.gov . Unique identifier: NCT02625948.
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Affiliation(s)
- Fan Fu
- From the Department of Neuroradiology (F.F., Y.S., Y.L.)
| | - Shengjun Sun
- Beijing Tiantan Hospital, Capital Medical University, China; Department of Neuroradiology, Beijing Neurosurgical Institute, China (S.S.)
| | | | - Hongqiu Gu
- Department of Neurology, Tiantan Clinical Trial and Research Center for Stroke, Beijing Tiantan Hospital, Capital Medical University, China (H.G.)
| | - Yaping Su
- From the Department of Neuroradiology (F.F., Y.S., Y.L.)
| | - Yingying Li
- From the Department of Neuroradiology (F.F., Y.S., Y.L.)
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Phan TG, Krishnadas N, Lai VWY, Batt M, Slater LA, Chandra RV, Srikanth V, Ma H. Meta-Analysis of Accuracy of the Spot Sign for Predicting Hematoma Growth and Clinical Outcomes. Stroke 2019; 50:2030-2036. [PMID: 31272327 DOI: 10.1161/strokeaha.118.024347] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Abstract
Background and Purpose- The computed tomography angiographic spot sign refers to contrast leakage within intracerebral hemorrhage (ICH). It has been proposed as a surrogate radiological marker for ICH growth. We conducted a meta-analysis to study the accuracy of the spot sign for predicting ICH growth and mortality. Methods- PubMed, Medline, conference proceedings, and article references in English up to June 2017 were searched for studies reporting "computed tomography angiography" and "spot sign" or "intracerebral hemorrhage" and "spot sign." Each study was ranked on 27 criteria resulting in a quality rating score. Bivariate random effect meta-analysis was used to calculate positive and negative likelihood ratios and area under summary receiver operating characteristics curve for ICH growth and mortality. Hematoma growth was defined using the change in ≥6 mL or ≥33% increase in volume. Results- There were 26 studies describing 5085 patients, including 15 studies not used in previous meta-analyses. Positive likelihood ratio and negative likelihood ratio for ICH growth were 4.85 (95% CI, 3.85-6.02; I2=76.1%) and 0.49 (95% CI, 0.40-0.58) and mortality were 4.65 (95% CI, 3.67-5.90) and 0.55 (95% CI, 0.40-0.69), respectively. For ICH growth, the pooled sensitivity was 0.57 (95% CI, 0.49-0.64) and pooled false positive rate was 0.12 (95% CI, 0.09-0.14). The post-test probability of ICH growth was 0.57. The area under the curve for ICH growth and mortality was 0.86 and 0.87 (CIs are not provided in bivariate method). Meta-regression showed sensitivity of the test to decline significantly with subsequent year of publication (β=-0.148; 95% CI, -0.295 to -0.001; P=0.05). Higher quality assessment is associated with lower false positive rate (β=-0.074; 95% CI, -0.126 to -0.022; P=0.006). Conclusions- The high area under the curve potentially suggests that the spot sign can predict hematoma growth and mortality. Caution is recommended in its application given the heterogeneity across studies, which is appropriate given the data.
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Affiliation(s)
- Thanh G Phan
- From the Clinical Trials, Imaging and Informatics Division, Stroke and Aging Research Group, School of Clinical Sciences at Monash Health, Monash University, Melbourne, Australia (T.G.P., N.K., V.W.Y.L., M.B., H.M.).,Stroke Unit (T.G.P., N.K., V.W.Y.L., M.B., H.M.), Monash Health, Melbourne, Australia
| | - Natasha Krishnadas
- From the Clinical Trials, Imaging and Informatics Division, Stroke and Aging Research Group, School of Clinical Sciences at Monash Health, Monash University, Melbourne, Australia (T.G.P., N.K., V.W.Y.L., M.B., H.M.).,Stroke Unit (T.G.P., N.K., V.W.Y.L., M.B., H.M.), Monash Health, Melbourne, Australia
| | - Vivian Wai Yun Lai
- From the Clinical Trials, Imaging and Informatics Division, Stroke and Aging Research Group, School of Clinical Sciences at Monash Health, Monash University, Melbourne, Australia (T.G.P., N.K., V.W.Y.L., M.B., H.M.)
| | - Michael Batt
- From the Clinical Trials, Imaging and Informatics Division, Stroke and Aging Research Group, School of Clinical Sciences at Monash Health, Monash University, Melbourne, Australia (T.G.P., N.K., V.W.Y.L., M.B., H.M.).,Stroke Unit (T.G.P., N.K., V.W.Y.L., M.B., H.M.), Monash Health, Melbourne, Australia
| | - Lee-Anne Slater
- Diagnostic imaging (L.-A.S., R.V.C.), Monash Health, Melbourne, Australia
| | - Ronil V Chandra
- Diagnostic imaging (L.-A.S., R.V.C.), Monash Health, Melbourne, Australia
| | - Velandai Srikanth
- Department of Medicine, Peninsula Clinical School, Central Clinical School, Monash University, Frankston Hospital, Melbourne, Australia (V.S.)
| | - Henry Ma
- From the Clinical Trials, Imaging and Informatics Division, Stroke and Aging Research Group, School of Clinical Sciences at Monash Health, Monash University, Melbourne, Australia (T.G.P., N.K., V.W.Y.L., M.B., H.M.).,Stroke Unit (T.G.P., N.K., V.W.Y.L., M.B., H.M.), Monash Health, Melbourne, Australia
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15
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Lim JX, Han JX, See AAQ, Lew VH, Chock WT, Ban VF, Pothiawala S, Lim WEH, McAdory LE, James ML, King NKK. External Validation of Hematoma Expansion Scores in Spontaneous Intracerebral Hemorrhage in an Asian Patient Cohort. Neurocrit Care 2018; 30:394-404. [PMID: 30377910 DOI: 10.1007/s12028-018-0631-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
BACKGROUND Hematoma expansion (HE) occurs in approximately one-third of patients with intracerebral hemorrhage (ICH) and is known to be a strong predictor of neurological deterioration as well as poor functional outcome. This study aims to externally validate three risk prediction models of HE (PREDICT, 9-point, and BRAIN scores) in an Asian population. METHODS A prospective cohort of 123 spontaneous ICH patients admitted to a tertiary hospital (certified stroke center) in Singapore was recruited. Logistic recalibrations were performed to obtain updated calibration slopes and intercepts for all models. The discrimination (c-statistic), calibration (Hosmer-Lemeshow test, le Cessie-van Houwelingen-Copas-Hosmer test, Akaike information criterion), overall performance (Brier score, R2), and clinical usefulness (decision curve analysis) of the risk prediction models were examined. RESULTS Overall, the recalibrated PREDICT performed best among the three models in our study cohort based on the novel matrix comprising of Akaike information criterion and c-statistic. The PREDICT model had the highest R2 (0.26) and lowest Brier score (0.14). Decision curve analyses showed that recalibrated PREDICT was more clinically useful than 9-point and BRAIN models over the greatest range of threshold probabilities. The two scores (PREDICT and 9-point) which incorporated computed tomography (CT) angiography spot sign outperformed the one without (BRAIN). CONCLUSIONS To our knowledge, this is the first study to validate HE scores, namely PREDICT, 9-Point and BRAIN, in a multi-ethnic Asian ICH patient population. The PREDICT score was the best performing model in our study cohort, based on the performance metrics employed in this study. Our findings also showed support for CT angiography spot sign as a predictor of outcome after ICH. Although the models assessed are sufficient for risk stratification, the discrimination and calibration are at best moderate and could be improved.
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Affiliation(s)
- Jia Xu Lim
- Department of Neurosurgery, National Neuroscience Institute, 11, Jalan Tan Tock Seng, Singapore, 308433, Singapore.,Department of Neurosurgery, Singapore General Hospital, Singapore, Singapore
| | - Julian Xinguang Han
- Department of Neurosurgery, National Neuroscience Institute, 11, Jalan Tan Tock Seng, Singapore, 308433, Singapore.,Department of Neurosurgery, Singapore General Hospital, Singapore, Singapore
| | - Angela An Qi See
- Department of Neurosurgery, National Neuroscience Institute, 11, Jalan Tan Tock Seng, Singapore, 308433, Singapore.,Department of Neurosurgery, Singapore General Hospital, Singapore, Singapore
| | - Voon Hao Lew
- Department of Neurosurgery, National Neuroscience Institute, 11, Jalan Tan Tock Seng, Singapore, 308433, Singapore
| | - Wan Ting Chock
- Department of Neurosurgery, Singapore General Hospital, Singapore, Singapore
| | - Vin Fei Ban
- Department of Neurosurgery, Singapore General Hospital, Singapore, Singapore
| | - Sohil Pothiawala
- Department of Emergency Medicine, Singapore General Hospital, Singapore, Singapore
| | - Winston Eng Hoe Lim
- Department of Diagnostic Radiology, Singapore General Hospital, Singapore, Singapore
| | - Louis Elliot McAdory
- Department of Diagnostic Radiology, Singapore General Hospital, Singapore, Singapore
| | - Michael Lucas James
- Departments of Anesthesiology, Brain Injury Translational Research Center, Duke University, Durham, NC, USA.,Departments of Neurology, Brain Injury Translational Research Center, Duke University, Durham, NC, USA
| | - Nicolas Kon Kam King
- Department of Neurosurgery, National Neuroscience Institute, 11, Jalan Tan Tock Seng, Singapore, 308433, Singapore. .,Department of Neurosurgery, Singapore General Hospital, Singapore, Singapore. .,Duke-NUS Medical School, Singapore, Singapore.
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Cordonnier C, Demchuk A, Ziai W, Anderson CS. Intracerebral haemorrhage: current approaches to acute management. Lancet 2018; 392:1257-1268. [PMID: 30319113 DOI: 10.1016/s0140-6736(18)31878-6] [Citation(s) in RCA: 362] [Impact Index Per Article: 60.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/26/2018] [Revised: 08/04/2018] [Accepted: 08/07/2018] [Indexed: 12/14/2022]
Abstract
Acute spontaneous intracerebral haemorrhage is a life-threatening illness of global importance, with a poor prognosis and few proven treatments. As a heterogeneous disease, certain clinical and imaging features help identify the cause, prognosis, and how to manage the disease. Survival and recovery from intracerebral haemorrhage are related to the site, mass effect, and intracranial pressure from the underlying haematoma, and by subsequent cerebral oedema from perihaematomal neurotoxicity or inflammation and complications from prolonged neurological dysfunction. A moderate level of evidence supports there being beneficial effects of active management goals with avoidance of early palliative care orders, well-coordinated specialist stroke unit care, targeted neurointensive and surgical interventions, early control of elevated blood pressure, and rapid reversal of abnormal coagulation.
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Affiliation(s)
- Charlotte Cordonnier
- University of Lille, Inserm U1171, Degenerative and Vascular Cognitive Disorders, Centre Hospitalier Universitaire Lille, Department of Neurology, Lille, France
| | - Andrew Demchuk
- Department of Clinical Neurosciences, University of Calgary, AB, Canada
| | - Wendy Ziai
- The Johns Hopkins University School of Medicine, Baltimore, MD, United States
| | - Craig S Anderson
- The George Institute for Global Health, University of New South Wales, Sydney, NSW, Australia; Neurology Department, Royal Prince Alfred Hospital, Sydney, NSW, Australia; The George Institute China at Peking University Health Science Center, Beijing, China.
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17
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Xu X, Zhang J, Yang K, Wang Q, Xu B, Chen X. Accuracy of spot sign in predicting hematoma expansion and clinical outcome: A meta-analysis. Medicine (Baltimore) 2018; 97:e11945. [PMID: 30142815 PMCID: PMC6113011 DOI: 10.1097/md.0000000000011945] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
BACKGROUND Spot sign on computed tomography angiography (CTA) has been reported as a risk factor for hematoma expansion (HE) and poor outcome after intracerebral hemorrhage (ICH). We performed a meta-analysis to investigate the predictive accuracy of spot sign for HE, mortality risk, and poor outcome. METHODS We searched PubMed, Embase, and the Cochrane Library for relevant studies. Studies were incorporated if they reported data on relationship between CTA spot sign and HE, mortality or poor outcome. RESULTS Twenty-nine studies were pooled in this meta-analysis. The spot sign occurred in 23.4% patients with spontaneous ICH undergoing CTA scans. It showed a sensitivity of 62% (95% confidence interval [CI] 54-69), with a specificity of 88% (95% CI 85-91). Spot sign was related with increased risk of HE (odds ratios [OR] 8.49, 95% CI 7.28-9.90). In the analysis of association between spot sign and outcome, patients with spot sign had a significant higher risk of in-hospital death (OR 5.08, 95% CI 3.16-8.18) and 3-month death (OR 3.80, 95% CI 2.62-5.52). The spot sign was also a predictor of poor outcome at discharge (OR 6.40, 95% CI 3.41-12.03) and at 3 months (OR 4.44, 95% CI 2.33-8.46). CONCLUSIONS The overall incidence of CTA spot sign in spontaneous ICH patients is substantial. Spot sign demonstrated a good diagnostic performance in predicting HE and was closely associated with increased risk of death and poor outcome.
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Affiliation(s)
- Xinghua Xu
- Department of Neurosurgery
- National Clinical Research Center for Aging and Medicine, Chinese PLA General Hospital, Beijing
| | - Jiashu Zhang
- Department of Neurosurgery
- National Clinical Research Center for Aging and Medicine, Chinese PLA General Hospital, Beijing
| | - Kai Yang
- Department of Neurosurgery, Dongying People's Hospital, Dongying, Shandong, China
| | | | | | - Xiaolei Chen
- Department of Neurosurgery
- National Clinical Research Center for Aging and Medicine, Chinese PLA General Hospital, Beijing
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18
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Iodine concentration: a new, important characteristic of the spot sign that predicts haematoma expansion. Eur Radiol 2018; 28:4343-4349. [PMID: 29675658 DOI: 10.1007/s00330-018-5415-1] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2017] [Revised: 02/22/2018] [Accepted: 03/07/2018] [Indexed: 01/18/2023]
Abstract
OBJECTIVES The computed tomography angiography (CTA) spot sign is a validated predictor of haematoma expansion (HE) in spontaneous intracerebral haemorrhage (SICH). We investigated whether defining the iodine concentration (IC) inside the spot sign and the haematoma on Gemstone spectral imaging (GSI) would improve its sensitivity and specificity for predicting HE. METHODS From 2014 to 2016, we prospectively enrolled 65 SICH patients who underwent single-phase spectral CTA within 6 h. Logistic regression was performed to assess the risk factors for HE. The predictive performance of individual spot sign characteristics was examined via receiver operating characteristic (ROC) analysis. RESULTS The spot sign was detected in 46.1% (30/65) of patients. ROC analysis indicated that IC inside the spot sign had the greatest area under the ROC curve for HE (0.858; 95% confidence interval, 0.727-0.989; p = 0.003). Multivariate analysis found that spot sign with higher IC (i.e. IC > 7.82 100 μg/ml) was an independent predictor of HE (odds ratio = 34.27; 95% confidence interval, 5.608-209.41; p < 0.001) with sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV) of 0.81, 0.75, 0.90 and 0.60, respectively; while the spot sign showed sensitivity, specificity, PPV and NPV of 0.81, 0.79, 0.73 and 0.86. Logistic regression analysis indicated that the IC in haematomas was independently associated with HE (odds ratio = 1.525; 95% confidence interval, 1.041-2.235; p = 0.030). CONCLUSIONS ICs in haematoma and in spot sign were all independently associated with HE. IC analysis in spectral imaging may help to identify SICH patients for targeted haemostatic therapy. KEY POINTS • Iodine concentration in spot sign and haematoma can predict haematoma expansion • Spectral imaging could measure the IC inside the spot sign and haematoma • IC in spot sign improved the positive predictive value (PPV) cf. CTA.
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Graham BR, Menon BK, Coutts SB, Goyal M, Demchuk AM. Computed tomographic angiography in stroke and high-risk transient ischemic attack: Do not leave the emergency department without it! Int J Stroke 2018; 13:673-686. [PMID: 29664350 DOI: 10.1177/1747493018764172] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
Stroke is a major cause of morbidity and mortality worldwide, and effective treatment requires rapid diagnosis and recognition of relevant vascular lesions. In this review we will discuss the usefulness and versatility of computed tomography angiography in the setting of stroke, be it ischemic or hemorrhagic, minor or disabling. Furthermore, we also highlight how we use computed tomography angiography in decision making in transient ischemic attacks, acute disabling ischemic stroke, and hemorrhagic stroke.
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Affiliation(s)
- Brett R Graham
- 1 Department of Clinical Neurosciences, University of Calgary, Canada
| | - Bijoy K Menon
- 1 Department of Clinical Neurosciences, University of Calgary, Canada.,2 Department of Radiology, University of Calgary, Canada.,4 Hotchkiss Brain Institute, University of Calgary, Canada
| | - Shelagh B Coutts
- 1 Department of Clinical Neurosciences, University of Calgary, Canada.,2 Department of Radiology, University of Calgary, Canada.,3 Department of Community Health Sciences, University of Calgary, Canada.,4 Hotchkiss Brain Institute, University of Calgary, Canada
| | - Mayank Goyal
- 1 Department of Clinical Neurosciences, University of Calgary, Canada.,2 Department of Radiology, University of Calgary, Canada.,4 Hotchkiss Brain Institute, University of Calgary, Canada
| | - Andrew M Demchuk
- 1 Department of Clinical Neurosciences, University of Calgary, Canada.,2 Department of Radiology, University of Calgary, Canada.,3 Department of Community Health Sciences, University of Calgary, Canada.,4 Hotchkiss Brain Institute, University of Calgary, Canada
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Wu TC, Chen TY, Shiue YL, Chen JH, Hsieh TJ, Ko CC, Lin CP. Added value of delayed computed tomography angiography in primary intracranial hemorrhage and hematoma size for predicting spot sign. Acta Radiol 2018. [PMID: 28651443 DOI: 10.1177/0284185117718401] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
Background The computed tomography angiography (CTA) spot sign represents active contrast extravasation within acute primary intracerebral hemorrhage (ICH) and is an independent predictor of hematoma expansion (HE) and poor clinical outcomes. The spot sign could be detected on first-pass CTA (fpCTA) or delayed CTA (dCTA). Purpose To investigate the additional benefits of dCTA spot sign in primary ICH and hematoma size for predicting spot sign. Material and Methods This is a retrospective study of 100 patients who underwent non-contrast CT (NCCT) and CTA within 24 h of onset of primary ICH. The presence of spot sign on fpCTA or dCTA, and hematoma size on NCCT were recorded. The spot sign on fpCTA or dCTA for predicting significant HE, in-hospital mortality, and poor clinical outcomes (mRS ≥ 4) are calculated. The hematoma size for prediction of CTA spot sign was also analyzed. Results Only the spot sign on dCTA could predict high risk of significant HE and poor clinical outcomes as on fpCTA ( P < 0.05). With dCTA, there is increased sensitivity and negative predictive value (NPV) for predicting significant HE, in-hospital mortality, and poor clinical outcomes. The XY value (product of the two maximum perpendicular axial dimensions) is the best predictor (area under the curve [AUC] = 0.82) for predicting spot sign on fpCTA or dCTA in the absence of intraventricular and subarachnoid hemorrhage. Conclusion This study clarifies that dCTA imaging could improve predictive performance of CTA in primary ICH. Furthermore, the XY value is the best predictor for CTA spot sign.
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Affiliation(s)
- Te Chang Wu
- Department of Medical Imaging, Chi Mei Medical Center, Tainan, Taiwan
- Department of Biomedical Imaging and Radiological Sciences, National Yang-Ming University, Taipei, Taiwan
- Department of Medical Imaging and Radiological Sciences, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Tai Yuan Chen
- Department of Medical Imaging, Chi Mei Medical Center, Tainan, Taiwan
- Graduate Institute of Medical Sciences, Chang Jung Christian University, Tainan, Taiwan
| | - Yow Ling Shiue
- Institute of Biomedical Science, National Sun Yat-Sen University, Kaohsiung, Taiwan
| | - Jeon Hor Chen
- Department of Radiology, E-DA Hospital, I-Shou University, Kaohsiung, Taiwan
| | - Tsyh-Jyi Hsieh
- Department of Medical Imaging, Chi Mei Medical Center, Tainan, Taiwan
- Department of Medical Imaging and Radiological Sciences, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Ching Chung Ko
- Department of Medical Imaging, Chi Mei Medical Center, Tainan, Taiwan
- Institute of Biomedical Science, National Sun Yat-Sen University, Kaohsiung, Taiwan
| | - Ching Po Lin
- Department of Biomedical Imaging and Radiological Sciences, National Yang-Ming University, Taipei, Taiwan
- Institute of Neuroscience, School of Life Science, National Yang-Ming University, Taipei, Taiwan
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21
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Neutrophil-to-Lymphocyte Ratio Is an Independent Predictor of 30-Day Mortality of Intracerebral Hemorrhage Patients: a Validation Cohort Study. Neurotox Res 2018; 34:347-352. [PMID: 29594812 PMCID: PMC6154212 DOI: 10.1007/s12640-018-9890-6] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2018] [Revised: 03/14/2018] [Accepted: 03/16/2018] [Indexed: 12/11/2022]
Abstract
In a previous study in patients with intracranial hemorrhage (ICH), we found an association between high neutrophil-to-lymphocyte ratio (NLR) with poor short-term mortality. In the current study, this preliminary finding was validated using an independent patient cohort. A total of 181 ICH patients (from January 2016 to December 2017) were included. Diagnosis was confirmed using computed tomography (CT) in all cases. Patient survival (up to 30 days) was compared between subjects with high NLR (above the 7.35 cutoff; n = 74) versus low NLR (≤ 7.35; n = 107) using Kaplan-Meier analysis. A multivariate logistic regression was performed to identify factors that influenced the 30-day mortality. Correlation between NLR with other relevant factors (e.g., C-reactive protein (CRP) and fibrinogen) was examined using Spearman correlation analysis. The 30-day mortality was 19.3% (35/181) in the entire sample, 37.8% (28/74) in the high-NLR group, and 6.5% (7/107) in the low-NLR group (P < 0.001). In comparison to the low-NLR group, the high-NLR group had higher rate of intraventricular hemorrhage (29.7 vs. 16.8%), ICH volume (median 23.9 vs. 6.0 cm3) and ICH score (median 1.5 vs. 0), and lower GCS score (9.4 ± 4.5 vs. 12.9 ± 3.2). An analysis that divided the samples into three equal parts based on NLR also showed increasing 30-day mortality with incremental NLR (1.6, 15.0, and 41.7% from lowest to highest NLR tertile, P for trend < 0.001). Kaplan-Meier curve showed higher 30-day mortality in subjects with high NLR than those with low NLR (P < 0.001 vs. low-NLR group, log-rank test). High NLR (> 7.35) is associated with poor short-term survival in acute ICH patients.
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22
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Lei C, Geng J, Chen C, Chang X. Accuracy of the Blend Sign on Computed Tomography as a Predictor of Hematoma Growth after Spontaneous Intracerebral Hemorrhage: A Systematic Review. J Stroke Cerebrovasc Dis 2018. [PMID: 29525078 DOI: 10.1016/j.jstrokecerebrovasdis.2018.01.032] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022] Open
Abstract
BACKGROUND Hematoma growth is a strong independent predictor of poor outcome after intracerebral hemorrhage. However, there is no gold standard to accurately predict hematoma growth. Several noncontrast computed tomographic markers associated with hematoma growth have been reported recently. Blend sign, which is a new marker, has been reported in several studies and seems a particularly promising marker but lacks a standardized evaluation so far. METHODS A systematic review of published literature on blend sign and hematoma growth and clinical outcomes was conducted. Systematic review of best practices was followed, and study quality was assessed. RESULTS The 6 studies involved 1573 participants in this review. The prevalence of blend sign ranged from 8.70% to 38.46%. The sensitivity of blend sign to predict hematoma growth varied from 13.0% to 42.86%; the specificity varied from 88.51% to 95.5%. Blend sign showed lower sensitivity but superior specificity for prediction of hematoma growth. Four studies indicated that the presence of blend sign was an independent predictor of hematoma growth. Four studies showed that the prevalence of blend sign was significantly higher in patients with hematoma growth compared with those without hematoma growth (odds ratio, 9.33; 95% confidence interval, 5.20-16.74). CONCLUSION There was an association between blend sign and hematoma growth, but this finding is tentative in light of the fact that the number of included studies was relatively small.
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Affiliation(s)
- Chunyan Lei
- Department of Neurology, First Affiliated Hospital of Kunming Medical University, Kunming, China.
| | - Jia Geng
- Department of Neurology, First Affiliated Hospital of Kunming Medical University, Kunming, China
| | - Chun Chen
- Department of Neurology, First Affiliated Hospital of Kunming Medical University, Kunming, China
| | - Xiaolong Chang
- Department of Neurology, First Affiliated Hospital of Kunming Medical University, Kunming, China
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Combination of Intra-Hematomal Hypodensity on CT and BRAIN Scoring Improves Prediction of Hemorrhage Expansion in ICH. Neurocrit Care 2018; 29:40-46. [DOI: 10.1007/s12028-018-0507-y] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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24
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Rodriguez-Luna D, Coscojuela P, Rodriguez-Villatoro N, Juega JM, Boned S, Muchada M, Pagola J, Rubiera M, Ribo M, Tomasello A, Demchuk AM, Goyal M, Molina CA. Multiphase CT Angiography Improves Prediction of Intracerebral Hemorrhage Expansion. Radiology 2017; 285:932-940. [DOI: 10.1148/radiol.2017162839] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Affiliation(s)
- David Rodriguez-Luna
- From the Stroke Unit, Departments of Neurology (D.R.L., N.R.V., J.M.J., S.B., M.M, J.P., M. Rubiera, M. Ribo, C.A.M.) and Neuroradiology (P.C., A.T.), Vall d’Hebron University Hospital, Vall d’Hebron Research Institute, Autonomous University of Barcelona, Ps Vall d’Hebron 119, 08035 Barcelona, Spain; and Calgary Stroke Program, Department of Clinical Neurosciences and Radiology, Hotchkiss Brain Institute, University of Calgary, Calgary, AB, Canada (A.M.D., M.G.)
| | - Pilar Coscojuela
- From the Stroke Unit, Departments of Neurology (D.R.L., N.R.V., J.M.J., S.B., M.M, J.P., M. Rubiera, M. Ribo, C.A.M.) and Neuroradiology (P.C., A.T.), Vall d’Hebron University Hospital, Vall d’Hebron Research Institute, Autonomous University of Barcelona, Ps Vall d’Hebron 119, 08035 Barcelona, Spain; and Calgary Stroke Program, Department of Clinical Neurosciences and Radiology, Hotchkiss Brain Institute, University of Calgary, Calgary, AB, Canada (A.M.D., M.G.)
| | - Noelia Rodriguez-Villatoro
- From the Stroke Unit, Departments of Neurology (D.R.L., N.R.V., J.M.J., S.B., M.M, J.P., M. Rubiera, M. Ribo, C.A.M.) and Neuroradiology (P.C., A.T.), Vall d’Hebron University Hospital, Vall d’Hebron Research Institute, Autonomous University of Barcelona, Ps Vall d’Hebron 119, 08035 Barcelona, Spain; and Calgary Stroke Program, Department of Clinical Neurosciences and Radiology, Hotchkiss Brain Institute, University of Calgary, Calgary, AB, Canada (A.M.D., M.G.)
| | - Jesús M. Juega
- From the Stroke Unit, Departments of Neurology (D.R.L., N.R.V., J.M.J., S.B., M.M, J.P., M. Rubiera, M. Ribo, C.A.M.) and Neuroradiology (P.C., A.T.), Vall d’Hebron University Hospital, Vall d’Hebron Research Institute, Autonomous University of Barcelona, Ps Vall d’Hebron 119, 08035 Barcelona, Spain; and Calgary Stroke Program, Department of Clinical Neurosciences and Radiology, Hotchkiss Brain Institute, University of Calgary, Calgary, AB, Canada (A.M.D., M.G.)
| | - Sandra Boned
- From the Stroke Unit, Departments of Neurology (D.R.L., N.R.V., J.M.J., S.B., M.M, J.P., M. Rubiera, M. Ribo, C.A.M.) and Neuroradiology (P.C., A.T.), Vall d’Hebron University Hospital, Vall d’Hebron Research Institute, Autonomous University of Barcelona, Ps Vall d’Hebron 119, 08035 Barcelona, Spain; and Calgary Stroke Program, Department of Clinical Neurosciences and Radiology, Hotchkiss Brain Institute, University of Calgary, Calgary, AB, Canada (A.M.D., M.G.)
| | - Marián Muchada
- From the Stroke Unit, Departments of Neurology (D.R.L., N.R.V., J.M.J., S.B., M.M, J.P., M. Rubiera, M. Ribo, C.A.M.) and Neuroradiology (P.C., A.T.), Vall d’Hebron University Hospital, Vall d’Hebron Research Institute, Autonomous University of Barcelona, Ps Vall d’Hebron 119, 08035 Barcelona, Spain; and Calgary Stroke Program, Department of Clinical Neurosciences and Radiology, Hotchkiss Brain Institute, University of Calgary, Calgary, AB, Canada (A.M.D., M.G.)
| | - Jorge Pagola
- From the Stroke Unit, Departments of Neurology (D.R.L., N.R.V., J.M.J., S.B., M.M, J.P., M. Rubiera, M. Ribo, C.A.M.) and Neuroradiology (P.C., A.T.), Vall d’Hebron University Hospital, Vall d’Hebron Research Institute, Autonomous University of Barcelona, Ps Vall d’Hebron 119, 08035 Barcelona, Spain; and Calgary Stroke Program, Department of Clinical Neurosciences and Radiology, Hotchkiss Brain Institute, University of Calgary, Calgary, AB, Canada (A.M.D., M.G.)
| | - Marta Rubiera
- From the Stroke Unit, Departments of Neurology (D.R.L., N.R.V., J.M.J., S.B., M.M, J.P., M. Rubiera, M. Ribo, C.A.M.) and Neuroradiology (P.C., A.T.), Vall d’Hebron University Hospital, Vall d’Hebron Research Institute, Autonomous University of Barcelona, Ps Vall d’Hebron 119, 08035 Barcelona, Spain; and Calgary Stroke Program, Department of Clinical Neurosciences and Radiology, Hotchkiss Brain Institute, University of Calgary, Calgary, AB, Canada (A.M.D., M.G.)
| | - Marc Ribo
- From the Stroke Unit, Departments of Neurology (D.R.L., N.R.V., J.M.J., S.B., M.M, J.P., M. Rubiera, M. Ribo, C.A.M.) and Neuroradiology (P.C., A.T.), Vall d’Hebron University Hospital, Vall d’Hebron Research Institute, Autonomous University of Barcelona, Ps Vall d’Hebron 119, 08035 Barcelona, Spain; and Calgary Stroke Program, Department of Clinical Neurosciences and Radiology, Hotchkiss Brain Institute, University of Calgary, Calgary, AB, Canada (A.M.D., M.G.)
| | - Alejandro Tomasello
- From the Stroke Unit, Departments of Neurology (D.R.L., N.R.V., J.M.J., S.B., M.M, J.P., M. Rubiera, M. Ribo, C.A.M.) and Neuroradiology (P.C., A.T.), Vall d’Hebron University Hospital, Vall d’Hebron Research Institute, Autonomous University of Barcelona, Ps Vall d’Hebron 119, 08035 Barcelona, Spain; and Calgary Stroke Program, Department of Clinical Neurosciences and Radiology, Hotchkiss Brain Institute, University of Calgary, Calgary, AB, Canada (A.M.D., M.G.)
| | - Andrew M. Demchuk
- From the Stroke Unit, Departments of Neurology (D.R.L., N.R.V., J.M.J., S.B., M.M, J.P., M. Rubiera, M. Ribo, C.A.M.) and Neuroradiology (P.C., A.T.), Vall d’Hebron University Hospital, Vall d’Hebron Research Institute, Autonomous University of Barcelona, Ps Vall d’Hebron 119, 08035 Barcelona, Spain; and Calgary Stroke Program, Department of Clinical Neurosciences and Radiology, Hotchkiss Brain Institute, University of Calgary, Calgary, AB, Canada (A.M.D., M.G.)
| | - Mayank Goyal
- From the Stroke Unit, Departments of Neurology (D.R.L., N.R.V., J.M.J., S.B., M.M, J.P., M. Rubiera, M. Ribo, C.A.M.) and Neuroradiology (P.C., A.T.), Vall d’Hebron University Hospital, Vall d’Hebron Research Institute, Autonomous University of Barcelona, Ps Vall d’Hebron 119, 08035 Barcelona, Spain; and Calgary Stroke Program, Department of Clinical Neurosciences and Radiology, Hotchkiss Brain Institute, University of Calgary, Calgary, AB, Canada (A.M.D., M.G.)
| | - Carlos A. Molina
- From the Stroke Unit, Departments of Neurology (D.R.L., N.R.V., J.M.J., S.B., M.M, J.P., M. Rubiera, M. Ribo, C.A.M.) and Neuroradiology (P.C., A.T.), Vall d’Hebron University Hospital, Vall d’Hebron Research Institute, Autonomous University of Barcelona, Ps Vall d’Hebron 119, 08035 Barcelona, Spain; and Calgary Stroke Program, Department of Clinical Neurosciences and Radiology, Hotchkiss Brain Institute, University of Calgary, Calgary, AB, Canada (A.M.D., M.G.)
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Predictive Value of CTA Spot Sign on Hematoma Expansion in Intracerebral Hemorrhage Patients. BIOMED RESEARCH INTERNATIONAL 2017; 2017:4137210. [PMID: 28852647 PMCID: PMC5567448 DOI: 10.1155/2017/4137210] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/03/2017] [Revised: 06/21/2017] [Accepted: 07/12/2017] [Indexed: 01/03/2023]
Abstract
Hematoma expansion (HE) occurs in approximately one-third of patients with intracerebral hemorrhage and leads to high rates of mortality and morbidity. Currently, contrast extravasation within hematoma, termed the spot sign on computed tomography angiography (CTA), has been identified as a strong independent predictor of early hematoma expansion. Past studies indicate that the spot sign is a dynamic entity and is indicative of active hemorrhage. Furthermore, to enhance the spot sign's accuracy of predicting HE, spot parameters observed on CTA or dynamic CTA were used for its quantification. In addition, spot signs detected on multiphase CTA and dynamic CTA are shown to have higher sensitivity and specificity when compared with simple standardized spot sign detection in recent studies. Based on the spot sign, novel methods such as leakage sign and rate of contrast extravasation were explored to redefine HE prediction in combination with clinical characteristics and spot sign on CTA to assist clinical judgment. The spot sign is an accepted independent predictor of active hemorrhage and is used in both secondary intracerebral hemorrhage and the process of surgical assessment for hemorrhagic risk in patients with ischemic stroke. Spot sign predicts patients at high risk for hematoma expansion.
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Phantom-based standardization of CT angiography images for spot sign detection. Neuroradiology 2017; 59:839-844. [PMID: 28730267 DOI: 10.1007/s00234-017-1857-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2017] [Accepted: 05/22/2017] [Indexed: 10/19/2022]
Abstract
PURPOSE The CT angiography (CTA) spot sign is a strong predictor of hematoma expansion in intracerebral hemorrhage (ICH). However, CTA parameters vary widely across centers and may negatively impact spot sign accuracy in predicting ICH expansion. We developed a CT iodine calibration phantom that was scanned at different institutions in a large multicenter ICH clinical trial to determine the effect of image standardization on spot sign detection and performance. METHODS A custom phantom containing known concentrations of iodine was designed and scanned using the stroke CT protocol at each institution. Custom software was developed to read the CT volume datasets and calculate the Hounsfield unit as a function of iodine concentration for each phantom scan. CTA images obtained within 8 h from symptom onset were analyzed by two trained readers comparing the calibrated vs. uncalibrated density cutoffs for spot sign identification. ICH expansion was defined as hematoma volume growth >33%. RESULTS A total of 90 subjects qualified for the study, of whom 17/83 (20.5%) experienced ICH expansion. The number of spot sign positive scans was higher in the calibrated analysis (67.8 vs 38.9% p < 0.001). All spot signs identified in the non-calibrated analysis remained positive after calibration. Calibrated CTA images had higher sensitivity for ICH expansion (76 vs 52%) but inferior specificity (35 vs 63%) compared with uncalibrated images. CONCLUSION Normalization of CTA images using phantom data is a feasible strategy to obtain consistent image quantification for spot sign analysis across different sites and may improve sensitivity for identification of ICH expansion.
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Chen S, Zhao B, Wang W, Shi L, Reis C, Zhang J. Predictors of hematoma expansion predictors after intracerebral hemorrhage. Oncotarget 2017; 8:89348-89363. [PMID: 29179524 PMCID: PMC5687694 DOI: 10.18632/oncotarget.19366] [Citation(s) in RCA: 41] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2017] [Accepted: 06/19/2017] [Indexed: 01/04/2023] Open
Abstract
Despite years of effort, intracerebral hemorrhage (ICH) remains the most devastating form of stroke with more than 40% 30-day mortality worldwide. Hematoma expansion (HE), which occurs in one third of ICH patients, is strongly predictive of worse prognosis and potentially preventable if high-risk patients were identified in the early phase of ICH. In this review, we summarize data from recent studies on HE prediction and classify those potential indicators into four categories: clinical (severity of consciousness disturbance; blood pressure; blood glucose at and after admission); laboratory (hematologic parameters of coagulation, inflammation and microvascular integrity status), radiographic (interval time from ICH onset; baseline volume, shape and density of hematoma; intraventricular hemorrhage; especially the spot sign and modified spot sign) and integrated predictors (9-point or 24-point clinical prediction algorithm and PREDICT A/B). We discuss those predictors’ underlying pathophysiology in HE and present opportunities to develop future therapeutic strategies.
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Affiliation(s)
- Sheng Chen
- Department of Neurosurgery, Second Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, PR China
| | - Binjie Zhao
- Department of Neurosurgery, Second Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, PR China
| | - Wei Wang
- Department of Neurosurgery, Second Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, PR China
| | - Ligen Shi
- Department of Neurosurgery, Second Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, PR China
| | - Cesar Reis
- Department of Physiology and Pharmacology, Loma Linda University, Loma Linda, California, USA.,Department of Preventive Medicine, Loma Linda University, Loma Linda, California, USA
| | - Jianmin Zhang
- Department of Neurosurgery, Second Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, PR China
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Yu Z, Zheng J, Ma L, Guo R, Li M, Wang X, Lin S, Li H, You C. The predictive accuracy of the black hole sign and the spot sign for hematoma expansion in patients with spontaneous intracerebral hemorrhage. Neurol Sci 2017; 38:1591-1597. [DOI: 10.1007/s10072-017-3006-6] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2016] [Accepted: 05/24/2017] [Indexed: 01/01/2023]
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Zheng J, Yu Z, Xu Z, Li M, Wang X, Lin S, Li H, You C. The Accuracy of the Spot Sign and the Blend Sign for Predicting Hematoma Expansion in Patients with Spontaneous Intracerebral Hemorrhage. Med Sci Monit 2017; 23:2250-2257. [PMID: 28498827 PMCID: PMC5437917 DOI: 10.12659/msm.901583] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND Hematoma expansion is associated with poor outcome in intracerebral hemorrhage (ICH) patients. The spot sign and the blend sign are reliable tools for predicting hematoma expansion in ICH patients. The aim of this study was to compare the accuracy of the two signs in the prediction of hematoma expansion. MATERIAL AND METHODS Patients with spontaneous ICH were screened for the presence of the computed tomography angiography (CTA) spot sign and the non-contrast CT (NCCT) blend sign within 6 hours after onset of symptoms. The sensitivity, specificity, and positive and negative predictive values of the spot sign and the blend sign in predicting hematoma expansion were calculated. The accuracy of the spot sign and the blend sign in predicting hematoma expansion was analyzed by receiver-operator analysis. RESULTS A total of 115 patients were enrolled in this study. The spot sign was observed in 25 (21.74%) patients, whereas the blend sign was observed in 22 (19.13%) patients. Of the 28 patients with hematoma expansion, the CTA spot sign was found on admission CT scans in 16 (57.14%) and the NCCT blend sign in 12 (42.86%), respectively. The sensitivity, specificity, positive predictive value, and negative predictive value of the spot sign for predicting hematoma expansion were 57.14%, 89.66%, 64.00%, and 86.67%, respectively. In contrast, the sensitivity, specificity, positive predictive value, and negative predictive value of the blend sign were 42.86%, 88.51%, 54.55%, and 82.80%, respectively. The area under the curve (AUC) of the spot sign was 0.734, which was higher than that of the blend sign (0.657). CONCLUSIONS Both the spot sign and the blend sign seemed to be good predictors for hematoma expansion, and the spot sign appeared to have better predictive accuracy.
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Affiliation(s)
- Jun Zheng
- Department of Neurosurgery, West China Hospital, Sichuan University, Chengdu, Sichuan, China (mainland)
| | - Zhiyuan Yu
- Department of Neurosurgery, West China Hospital, Sichuan University, Chengdu, Sichuan, China (mainland)
| | - Zhao Xu
- Department of Anesthesia, West China Hospital, Sichuan University, Chengdu, Sichuan, China (mainland)
| | - Mou Li
- Department of Radiology, West China Hospital, Sichuan University, Chengdu, Sichuan, China (mainland)
| | - Xiaoze Wang
- Department of Radiology, West China Hospital, Sichuan University, Chengdu, Sichuan, China (mainland)
| | - Sen Lin
- Department of Neurosurgery, West China Hospital, Sichuan University, Chengdu, Sichuan, China (mainland)
| | - Hao Li
- Department of Neurosurgery, West China Hospital, Sichuan University, Chengdu, Sichuan, China (mainland)
| | - Chao You
- Department of Neurosurgery, West China Hospital, Sichuan University, Chengdu, Sichuan, China (mainland)
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Nishiyama J, Sorimachi T, Aoki R, Inoue G, Matsumae M. Occurrence of spot signs from hypodensity areas on precontrast CT in intracerebral hemorrhage. Neurol Res 2017; 39:419-425. [DOI: 10.1080/01616412.2017.1297341] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Affiliation(s)
- Jun Nishiyama
- Department of Neurosurgery, Tokai University, Kanagawa, Japan
| | | | - Rie Aoki
- Department of Neurosurgery, Tokai University, Kanagawa, Japan
| | - Go Inoue
- Department of Neurosurgery, Tokai University, Kanagawa, Japan
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Morotti A, Romero JM, Jessel MJ, Brouwers HB, Gupta R, Schwab K, Vashkevich A, Ayres A, Anderson CD, Gurol ME, Viswanathan A, Greenberg SM, Rosand J, Goldstein JN. Effect of CTA Tube Current on Spot Sign Detection and Accuracy for Prediction of Intracerebral Hemorrhage Expansion. AJNR Am J Neuroradiol 2016; 37:1781-1786. [PMID: 27197985 DOI: 10.3174/ajnr.a4810] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2016] [Accepted: 03/17/2016] [Indexed: 11/07/2022]
Abstract
BACKGROUND AND PURPOSE Reduction of CT tube current is an effective strategy to minimize radiation load. However, tube current is also a major determinant of image quality. We investigated the impact of CTA tube current on spot sign detection and diagnostic performance for intracerebral hemorrhage expansion. MATERIALS AND METHODS We retrospectively analyzed a prospectively collected cohort of consecutive patients with primary intracerebral hemorrhage from January 2001 to April 2015 who underwent CTA. The study population was divided into 2 groups according to the median CTA tube current level: low current (<350 mA) and high current (≥350 mA). CTA first-pass readings for spot sign presence were independently analyzed by 2 readers. Baseline and follow-up hematoma volumes were assessed by semiautomated computer-assisted volumetric analysis. Sensitivity, specificity, positive and negative predictive values, and accuracy of spot sign in predicting hematoma expansion were calculated. RESULTS This study included 709 patients (288 and 421 in the low- and high-current groups, respectively). A higher proportion of low-current scans identified at least 1 spot sign (20.8% versus 14.7%, P = .034), but hematoma expansion frequency was similar in the 2 groups (18.4% versus 16.2%, P = .434). Sensitivity and positive and negative predictive values were not significantly different between the 2 groups. Conversely, high-current scans showed superior specificity (91% versus 84%, P = .015) and overall accuracy (84% versus 77%, P = .038). CONCLUSIONS CTA obtained at high levels of tube current showed better diagnostic accuracy for prediction of hematoma expansion by using spot sign. These findings may have implications for future studies using the CTA spot sign to predict hematoma expansion for clinical trials.
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Affiliation(s)
- A Morotti
- From the Department of Clinical and Experimental Sciences (A.M.), Neurology Clinic, University of Brescia, Brescia, Italy
- J.P. Kistler Stroke Research Center (A.M., M.J.J., K.S., A. Vashkevich, A.A., C.D.A., M.E.G., A. Viswanathan, S.M.G., J.R., J.N.G.)
| | - J M Romero
- Neuroradiology Service, Department of Radiology (J.M.R., R.G.)
| | - M J Jessel
- J.P. Kistler Stroke Research Center (A.M., M.J.J., K.S., A. Vashkevich, A.A., C.D.A., M.E.G., A. Viswanathan, S.M.G., J.R., J.N.G.)
| | - H B Brouwers
- Department of Neurosurgery (H.B.B.), Brain Center Rudolf Magnus, University Medical Center, Utrecht, the Netherlands
| | - R Gupta
- Neuroradiology Service, Department of Radiology (J.M.R., R.G.)
| | - K Schwab
- J.P. Kistler Stroke Research Center (A.M., M.J.J., K.S., A. Vashkevich, A.A., C.D.A., M.E.G., A. Viswanathan, S.M.G., J.R., J.N.G.)
| | - A Vashkevich
- J.P. Kistler Stroke Research Center (A.M., M.J.J., K.S., A. Vashkevich, A.A., C.D.A., M.E.G., A. Viswanathan, S.M.G., J.R., J.N.G.)
| | - A Ayres
- J.P. Kistler Stroke Research Center (A.M., M.J.J., K.S., A. Vashkevich, A.A., C.D.A., M.E.G., A. Viswanathan, S.M.G., J.R., J.N.G.)
| | - C D Anderson
- J.P. Kistler Stroke Research Center (A.M., M.J.J., K.S., A. Vashkevich, A.A., C.D.A., M.E.G., A. Viswanathan, S.M.G., J.R., J.N.G.)
| | - M E Gurol
- J.P. Kistler Stroke Research Center (A.M., M.J.J., K.S., A. Vashkevich, A.A., C.D.A., M.E.G., A. Viswanathan, S.M.G., J.R., J.N.G.)
| | - A Viswanathan
- J.P. Kistler Stroke Research Center (A.M., M.J.J., K.S., A. Vashkevich, A.A., C.D.A., M.E.G., A. Viswanathan, S.M.G., J.R., J.N.G.)
| | - S M Greenberg
- J.P. Kistler Stroke Research Center (A.M., M.J.J., K.S., A. Vashkevich, A.A., C.D.A., M.E.G., A. Viswanathan, S.M.G., J.R., J.N.G.)
| | - J Rosand
- J.P. Kistler Stroke Research Center (A.M., M.J.J., K.S., A. Vashkevich, A.A., C.D.A., M.E.G., A. Viswanathan, S.M.G., J.R., J.N.G.)
- Division of Neurocritical Care and Emergency Neurology (J.R., J.N.G.)
| | - J N Goldstein
- J.P. Kistler Stroke Research Center (A.M., M.J.J., K.S., A. Vashkevich, A.A., C.D.A., M.E.G., A. Viswanathan, S.M.G., J.R., J.N.G.)
- Division of Neurocritical Care and Emergency Neurology (J.R., J.N.G.)
- Department of Emergency Medicine (J.N.G.), Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
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32
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Morotti A, Romero JM, Gupta R, Goldstein JN. Reply. AJNR Am J Neuroradiol 2016; 37:E64. [PMID: 27444941 DOI: 10.3174/ajnr.a4887] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Affiliation(s)
- A Morotti
- Department of Clinical and Experimental Sciences, Neurology Clinic University of Brescia, Brescia, Italy.,J. P. Kistler Stroke Research Center Massachusetts General Hospital, Harvard Medical SchoolBoston, Massachusetts
| | - J M Romero
- Neuroradiology Service, Department of Radiology Massachusetts General Hospital, Harvard Medical School Boston, Massachusetts
| | - R Gupta
- Neuroradiology Service, Department of Radiology Massachusetts General Hospital, Harvard Medical School Boston, Massachusetts
| | - J N Goldstein
- J. P. Kistler Stroke Research Center.,Department of Emergency Medicine Massachusetts General Hospital, Harvard Medical School Boston, Massachusetts
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Rodriguez-Luna D, Coscojuela P, Rubiera M, Hill MD, Dowlatshahi D, Aviv RI, Silva Y, Dzialowski I, Lum C, Czlonkowska A, Boulanger JM, Kase CS, Gubitz G, Bhatia R, Padma V, Roy J, Tomasello A, Demchuk AM, Molina CA. Ultraearly hematoma growth in active intracerebral hemorrhage. Neurology 2016; 87:357-64. [PMID: 27343067 DOI: 10.1212/wnl.0000000000002897] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2015] [Accepted: 02/29/2016] [Indexed: 01/06/2023] Open
Abstract
OBJECTIVE To determine the association of ultraearly hematoma growth (uHG) with the CT angiography (CTA) spot sign, hematoma expansion, and clinical outcomes in patients with acute intracerebral hemorrhage (ICH). METHODS We analyzed data from 231 patients enrolled in the multicenter Predicting Haematoma Growth and Outcome in Intracerebral Haemorrhage Using Contrast Bolus CT study. uHG was defined as baseline ICH volume/onset-to-CT time (mL/h). The spot sign was used as marker of active hemorrhage. Outcome parameters included significant hematoma expansion (>33% or >6 mL, primary outcome), rate of hematoma expansion, early neurologic deterioration, 90-day mortality, and poor outcome. RESULTS uHG was higher in spot sign patients (p < 0.001) and in patients scanned earlier (p < 0.001). Both uHG >4.7 mL/h (p = 0.002) and the CTA spot sign (p = 0.030) showed effects on rate of hematoma expansion but not its interaction (2-way analysis of variance, p = 0.477). uHG >4.7 mL/h improved the sensitivity of the spot sign in the prediction of significant hematoma expansion (73.9% vs 46.4%), early neurologic deterioration (67.6% vs 35.3%), 90-day mortality (81.6% vs 44.9%), and poor outcome (72.8% vs 29.8%), respectively. uHG was independently related to significant hematoma expansion (odds ratio 1.06, 95% confidence interval 1.03-1.10) and clinical outcomes. CONCLUSIONS uHG is a useful predictor of hematoma expansion and poor clinical outcomes in patients with acute ICH. The combination of high uHG and the spot sign is associated with a higher rate of hematoma expansion, highlighting the need for very fast treatment in ICH patients.
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Affiliation(s)
- David Rodriguez-Luna
- From the Stroke Unit, Departments of Neurology (D.R.-L., M.R., C.A.M.) and Neuroradiology (P.C., A.T.), Vall d'Hebron University Hospital and Vall d'Hebron Research Institute, Barcelona, Spain; Calgary Stroke Program (M.D.H., A.M.D.), Department of Clinical Neurosciences, Department of Radiology, Hotchkiss Brain Institute, University of Calgary; Department of Medicine, Neurology (D.D.), and Department of Diagnostic Imaging, Neuroradiology Section (C.L.), The Ottawa Hospital, University of Ottawa, Ottawa Hospital Research Institute; Division of Neuroradiology and Department of Medical Imaging (R.I.A.), Sunnybrook Health Sciences Centre, University of Toronto, Canada; Department of Neurology (Y.S.), Dr Josep Trueta University Hospital, Institut d'Investigació Biomèdica Girona Foundation, Spain; Department of Neurology (I.D.), University of Dresden, Germany; 2nd Department of Neurology (A.C.), Institute of Psychiatry and Neurology of Warsaw, Poland; Charles LeMoyne Hospital (J.-M.B.), University of Sherbrooke, Montreal, Canada; Department of Neurology (C.S.K.), Boston Medical Center, MA; Department of Neurology (G.G.), Dalhousie University, Halifax, Canada; Department of Neurology (R.B., V.P.), All India Institute of Medical Sciences, New Delhi; and AMRI Hospital Kolkata (J.R.), India.
| | - Pilar Coscojuela
- From the Stroke Unit, Departments of Neurology (D.R.-L., M.R., C.A.M.) and Neuroradiology (P.C., A.T.), Vall d'Hebron University Hospital and Vall d'Hebron Research Institute, Barcelona, Spain; Calgary Stroke Program (M.D.H., A.M.D.), Department of Clinical Neurosciences, Department of Radiology, Hotchkiss Brain Institute, University of Calgary; Department of Medicine, Neurology (D.D.), and Department of Diagnostic Imaging, Neuroradiology Section (C.L.), The Ottawa Hospital, University of Ottawa, Ottawa Hospital Research Institute; Division of Neuroradiology and Department of Medical Imaging (R.I.A.), Sunnybrook Health Sciences Centre, University of Toronto, Canada; Department of Neurology (Y.S.), Dr Josep Trueta University Hospital, Institut d'Investigació Biomèdica Girona Foundation, Spain; Department of Neurology (I.D.), University of Dresden, Germany; 2nd Department of Neurology (A.C.), Institute of Psychiatry and Neurology of Warsaw, Poland; Charles LeMoyne Hospital (J.-M.B.), University of Sherbrooke, Montreal, Canada; Department of Neurology (C.S.K.), Boston Medical Center, MA; Department of Neurology (G.G.), Dalhousie University, Halifax, Canada; Department of Neurology (R.B., V.P.), All India Institute of Medical Sciences, New Delhi; and AMRI Hospital Kolkata (J.R.), India
| | - Marta Rubiera
- From the Stroke Unit, Departments of Neurology (D.R.-L., M.R., C.A.M.) and Neuroradiology (P.C., A.T.), Vall d'Hebron University Hospital and Vall d'Hebron Research Institute, Barcelona, Spain; Calgary Stroke Program (M.D.H., A.M.D.), Department of Clinical Neurosciences, Department of Radiology, Hotchkiss Brain Institute, University of Calgary; Department of Medicine, Neurology (D.D.), and Department of Diagnostic Imaging, Neuroradiology Section (C.L.), The Ottawa Hospital, University of Ottawa, Ottawa Hospital Research Institute; Division of Neuroradiology and Department of Medical Imaging (R.I.A.), Sunnybrook Health Sciences Centre, University of Toronto, Canada; Department of Neurology (Y.S.), Dr Josep Trueta University Hospital, Institut d'Investigació Biomèdica Girona Foundation, Spain; Department of Neurology (I.D.), University of Dresden, Germany; 2nd Department of Neurology (A.C.), Institute of Psychiatry and Neurology of Warsaw, Poland; Charles LeMoyne Hospital (J.-M.B.), University of Sherbrooke, Montreal, Canada; Department of Neurology (C.S.K.), Boston Medical Center, MA; Department of Neurology (G.G.), Dalhousie University, Halifax, Canada; Department of Neurology (R.B., V.P.), All India Institute of Medical Sciences, New Delhi; and AMRI Hospital Kolkata (J.R.), India
| | - Michael D Hill
- From the Stroke Unit, Departments of Neurology (D.R.-L., M.R., C.A.M.) and Neuroradiology (P.C., A.T.), Vall d'Hebron University Hospital and Vall d'Hebron Research Institute, Barcelona, Spain; Calgary Stroke Program (M.D.H., A.M.D.), Department of Clinical Neurosciences, Department of Radiology, Hotchkiss Brain Institute, University of Calgary; Department of Medicine, Neurology (D.D.), and Department of Diagnostic Imaging, Neuroradiology Section (C.L.), The Ottawa Hospital, University of Ottawa, Ottawa Hospital Research Institute; Division of Neuroradiology and Department of Medical Imaging (R.I.A.), Sunnybrook Health Sciences Centre, University of Toronto, Canada; Department of Neurology (Y.S.), Dr Josep Trueta University Hospital, Institut d'Investigació Biomèdica Girona Foundation, Spain; Department of Neurology (I.D.), University of Dresden, Germany; 2nd Department of Neurology (A.C.), Institute of Psychiatry and Neurology of Warsaw, Poland; Charles LeMoyne Hospital (J.-M.B.), University of Sherbrooke, Montreal, Canada; Department of Neurology (C.S.K.), Boston Medical Center, MA; Department of Neurology (G.G.), Dalhousie University, Halifax, Canada; Department of Neurology (R.B., V.P.), All India Institute of Medical Sciences, New Delhi; and AMRI Hospital Kolkata (J.R.), India
| | - Dar Dowlatshahi
- From the Stroke Unit, Departments of Neurology (D.R.-L., M.R., C.A.M.) and Neuroradiology (P.C., A.T.), Vall d'Hebron University Hospital and Vall d'Hebron Research Institute, Barcelona, Spain; Calgary Stroke Program (M.D.H., A.M.D.), Department of Clinical Neurosciences, Department of Radiology, Hotchkiss Brain Institute, University of Calgary; Department of Medicine, Neurology (D.D.), and Department of Diagnostic Imaging, Neuroradiology Section (C.L.), The Ottawa Hospital, University of Ottawa, Ottawa Hospital Research Institute; Division of Neuroradiology and Department of Medical Imaging (R.I.A.), Sunnybrook Health Sciences Centre, University of Toronto, Canada; Department of Neurology (Y.S.), Dr Josep Trueta University Hospital, Institut d'Investigació Biomèdica Girona Foundation, Spain; Department of Neurology (I.D.), University of Dresden, Germany; 2nd Department of Neurology (A.C.), Institute of Psychiatry and Neurology of Warsaw, Poland; Charles LeMoyne Hospital (J.-M.B.), University of Sherbrooke, Montreal, Canada; Department of Neurology (C.S.K.), Boston Medical Center, MA; Department of Neurology (G.G.), Dalhousie University, Halifax, Canada; Department of Neurology (R.B., V.P.), All India Institute of Medical Sciences, New Delhi; and AMRI Hospital Kolkata (J.R.), India
| | - Richard I Aviv
- From the Stroke Unit, Departments of Neurology (D.R.-L., M.R., C.A.M.) and Neuroradiology (P.C., A.T.), Vall d'Hebron University Hospital and Vall d'Hebron Research Institute, Barcelona, Spain; Calgary Stroke Program (M.D.H., A.M.D.), Department of Clinical Neurosciences, Department of Radiology, Hotchkiss Brain Institute, University of Calgary; Department of Medicine, Neurology (D.D.), and Department of Diagnostic Imaging, Neuroradiology Section (C.L.), The Ottawa Hospital, University of Ottawa, Ottawa Hospital Research Institute; Division of Neuroradiology and Department of Medical Imaging (R.I.A.), Sunnybrook Health Sciences Centre, University of Toronto, Canada; Department of Neurology (Y.S.), Dr Josep Trueta University Hospital, Institut d'Investigació Biomèdica Girona Foundation, Spain; Department of Neurology (I.D.), University of Dresden, Germany; 2nd Department of Neurology (A.C.), Institute of Psychiatry and Neurology of Warsaw, Poland; Charles LeMoyne Hospital (J.-M.B.), University of Sherbrooke, Montreal, Canada; Department of Neurology (C.S.K.), Boston Medical Center, MA; Department of Neurology (G.G.), Dalhousie University, Halifax, Canada; Department of Neurology (R.B., V.P.), All India Institute of Medical Sciences, New Delhi; and AMRI Hospital Kolkata (J.R.), India
| | - Yolanda Silva
- From the Stroke Unit, Departments of Neurology (D.R.-L., M.R., C.A.M.) and Neuroradiology (P.C., A.T.), Vall d'Hebron University Hospital and Vall d'Hebron Research Institute, Barcelona, Spain; Calgary Stroke Program (M.D.H., A.M.D.), Department of Clinical Neurosciences, Department of Radiology, Hotchkiss Brain Institute, University of Calgary; Department of Medicine, Neurology (D.D.), and Department of Diagnostic Imaging, Neuroradiology Section (C.L.), The Ottawa Hospital, University of Ottawa, Ottawa Hospital Research Institute; Division of Neuroradiology and Department of Medical Imaging (R.I.A.), Sunnybrook Health Sciences Centre, University of Toronto, Canada; Department of Neurology (Y.S.), Dr Josep Trueta University Hospital, Institut d'Investigació Biomèdica Girona Foundation, Spain; Department of Neurology (I.D.), University of Dresden, Germany; 2nd Department of Neurology (A.C.), Institute of Psychiatry and Neurology of Warsaw, Poland; Charles LeMoyne Hospital (J.-M.B.), University of Sherbrooke, Montreal, Canada; Department of Neurology (C.S.K.), Boston Medical Center, MA; Department of Neurology (G.G.), Dalhousie University, Halifax, Canada; Department of Neurology (R.B., V.P.), All India Institute of Medical Sciences, New Delhi; and AMRI Hospital Kolkata (J.R.), India
| | - Imanuel Dzialowski
- From the Stroke Unit, Departments of Neurology (D.R.-L., M.R., C.A.M.) and Neuroradiology (P.C., A.T.), Vall d'Hebron University Hospital and Vall d'Hebron Research Institute, Barcelona, Spain; Calgary Stroke Program (M.D.H., A.M.D.), Department of Clinical Neurosciences, Department of Radiology, Hotchkiss Brain Institute, University of Calgary; Department of Medicine, Neurology (D.D.), and Department of Diagnostic Imaging, Neuroradiology Section (C.L.), The Ottawa Hospital, University of Ottawa, Ottawa Hospital Research Institute; Division of Neuroradiology and Department of Medical Imaging (R.I.A.), Sunnybrook Health Sciences Centre, University of Toronto, Canada; Department of Neurology (Y.S.), Dr Josep Trueta University Hospital, Institut d'Investigació Biomèdica Girona Foundation, Spain; Department of Neurology (I.D.), University of Dresden, Germany; 2nd Department of Neurology (A.C.), Institute of Psychiatry and Neurology of Warsaw, Poland; Charles LeMoyne Hospital (J.-M.B.), University of Sherbrooke, Montreal, Canada; Department of Neurology (C.S.K.), Boston Medical Center, MA; Department of Neurology (G.G.), Dalhousie University, Halifax, Canada; Department of Neurology (R.B., V.P.), All India Institute of Medical Sciences, New Delhi; and AMRI Hospital Kolkata (J.R.), India
| | - Cheemun Lum
- From the Stroke Unit, Departments of Neurology (D.R.-L., M.R., C.A.M.) and Neuroradiology (P.C., A.T.), Vall d'Hebron University Hospital and Vall d'Hebron Research Institute, Barcelona, Spain; Calgary Stroke Program (M.D.H., A.M.D.), Department of Clinical Neurosciences, Department of Radiology, Hotchkiss Brain Institute, University of Calgary; Department of Medicine, Neurology (D.D.), and Department of Diagnostic Imaging, Neuroradiology Section (C.L.), The Ottawa Hospital, University of Ottawa, Ottawa Hospital Research Institute; Division of Neuroradiology and Department of Medical Imaging (R.I.A.), Sunnybrook Health Sciences Centre, University of Toronto, Canada; Department of Neurology (Y.S.), Dr Josep Trueta University Hospital, Institut d'Investigació Biomèdica Girona Foundation, Spain; Department of Neurology (I.D.), University of Dresden, Germany; 2nd Department of Neurology (A.C.), Institute of Psychiatry and Neurology of Warsaw, Poland; Charles LeMoyne Hospital (J.-M.B.), University of Sherbrooke, Montreal, Canada; Department of Neurology (C.S.K.), Boston Medical Center, MA; Department of Neurology (G.G.), Dalhousie University, Halifax, Canada; Department of Neurology (R.B., V.P.), All India Institute of Medical Sciences, New Delhi; and AMRI Hospital Kolkata (J.R.), India
| | - Anna Czlonkowska
- From the Stroke Unit, Departments of Neurology (D.R.-L., M.R., C.A.M.) and Neuroradiology (P.C., A.T.), Vall d'Hebron University Hospital and Vall d'Hebron Research Institute, Barcelona, Spain; Calgary Stroke Program (M.D.H., A.M.D.), Department of Clinical Neurosciences, Department of Radiology, Hotchkiss Brain Institute, University of Calgary; Department of Medicine, Neurology (D.D.), and Department of Diagnostic Imaging, Neuroradiology Section (C.L.), The Ottawa Hospital, University of Ottawa, Ottawa Hospital Research Institute; Division of Neuroradiology and Department of Medical Imaging (R.I.A.), Sunnybrook Health Sciences Centre, University of Toronto, Canada; Department of Neurology (Y.S.), Dr Josep Trueta University Hospital, Institut d'Investigació Biomèdica Girona Foundation, Spain; Department of Neurology (I.D.), University of Dresden, Germany; 2nd Department of Neurology (A.C.), Institute of Psychiatry and Neurology of Warsaw, Poland; Charles LeMoyne Hospital (J.-M.B.), University of Sherbrooke, Montreal, Canada; Department of Neurology (C.S.K.), Boston Medical Center, MA; Department of Neurology (G.G.), Dalhousie University, Halifax, Canada; Department of Neurology (R.B., V.P.), All India Institute of Medical Sciences, New Delhi; and AMRI Hospital Kolkata (J.R.), India
| | - Jean-Martin Boulanger
- From the Stroke Unit, Departments of Neurology (D.R.-L., M.R., C.A.M.) and Neuroradiology (P.C., A.T.), Vall d'Hebron University Hospital and Vall d'Hebron Research Institute, Barcelona, Spain; Calgary Stroke Program (M.D.H., A.M.D.), Department of Clinical Neurosciences, Department of Radiology, Hotchkiss Brain Institute, University of Calgary; Department of Medicine, Neurology (D.D.), and Department of Diagnostic Imaging, Neuroradiology Section (C.L.), The Ottawa Hospital, University of Ottawa, Ottawa Hospital Research Institute; Division of Neuroradiology and Department of Medical Imaging (R.I.A.), Sunnybrook Health Sciences Centre, University of Toronto, Canada; Department of Neurology (Y.S.), Dr Josep Trueta University Hospital, Institut d'Investigació Biomèdica Girona Foundation, Spain; Department of Neurology (I.D.), University of Dresden, Germany; 2nd Department of Neurology (A.C.), Institute of Psychiatry and Neurology of Warsaw, Poland; Charles LeMoyne Hospital (J.-M.B.), University of Sherbrooke, Montreal, Canada; Department of Neurology (C.S.K.), Boston Medical Center, MA; Department of Neurology (G.G.), Dalhousie University, Halifax, Canada; Department of Neurology (R.B., V.P.), All India Institute of Medical Sciences, New Delhi; and AMRI Hospital Kolkata (J.R.), India
| | - Carlos S Kase
- From the Stroke Unit, Departments of Neurology (D.R.-L., M.R., C.A.M.) and Neuroradiology (P.C., A.T.), Vall d'Hebron University Hospital and Vall d'Hebron Research Institute, Barcelona, Spain; Calgary Stroke Program (M.D.H., A.M.D.), Department of Clinical Neurosciences, Department of Radiology, Hotchkiss Brain Institute, University of Calgary; Department of Medicine, Neurology (D.D.), and Department of Diagnostic Imaging, Neuroradiology Section (C.L.), The Ottawa Hospital, University of Ottawa, Ottawa Hospital Research Institute; Division of Neuroradiology and Department of Medical Imaging (R.I.A.), Sunnybrook Health Sciences Centre, University of Toronto, Canada; Department of Neurology (Y.S.), Dr Josep Trueta University Hospital, Institut d'Investigació Biomèdica Girona Foundation, Spain; Department of Neurology (I.D.), University of Dresden, Germany; 2nd Department of Neurology (A.C.), Institute of Psychiatry and Neurology of Warsaw, Poland; Charles LeMoyne Hospital (J.-M.B.), University of Sherbrooke, Montreal, Canada; Department of Neurology (C.S.K.), Boston Medical Center, MA; Department of Neurology (G.G.), Dalhousie University, Halifax, Canada; Department of Neurology (R.B., V.P.), All India Institute of Medical Sciences, New Delhi; and AMRI Hospital Kolkata (J.R.), India
| | - Gord Gubitz
- From the Stroke Unit, Departments of Neurology (D.R.-L., M.R., C.A.M.) and Neuroradiology (P.C., A.T.), Vall d'Hebron University Hospital and Vall d'Hebron Research Institute, Barcelona, Spain; Calgary Stroke Program (M.D.H., A.M.D.), Department of Clinical Neurosciences, Department of Radiology, Hotchkiss Brain Institute, University of Calgary; Department of Medicine, Neurology (D.D.), and Department of Diagnostic Imaging, Neuroradiology Section (C.L.), The Ottawa Hospital, University of Ottawa, Ottawa Hospital Research Institute; Division of Neuroradiology and Department of Medical Imaging (R.I.A.), Sunnybrook Health Sciences Centre, University of Toronto, Canada; Department of Neurology (Y.S.), Dr Josep Trueta University Hospital, Institut d'Investigació Biomèdica Girona Foundation, Spain; Department of Neurology (I.D.), University of Dresden, Germany; 2nd Department of Neurology (A.C.), Institute of Psychiatry and Neurology of Warsaw, Poland; Charles LeMoyne Hospital (J.-M.B.), University of Sherbrooke, Montreal, Canada; Department of Neurology (C.S.K.), Boston Medical Center, MA; Department of Neurology (G.G.), Dalhousie University, Halifax, Canada; Department of Neurology (R.B., V.P.), All India Institute of Medical Sciences, New Delhi; and AMRI Hospital Kolkata (J.R.), India
| | - Rohit Bhatia
- From the Stroke Unit, Departments of Neurology (D.R.-L., M.R., C.A.M.) and Neuroradiology (P.C., A.T.), Vall d'Hebron University Hospital and Vall d'Hebron Research Institute, Barcelona, Spain; Calgary Stroke Program (M.D.H., A.M.D.), Department of Clinical Neurosciences, Department of Radiology, Hotchkiss Brain Institute, University of Calgary; Department of Medicine, Neurology (D.D.), and Department of Diagnostic Imaging, Neuroradiology Section (C.L.), The Ottawa Hospital, University of Ottawa, Ottawa Hospital Research Institute; Division of Neuroradiology and Department of Medical Imaging (R.I.A.), Sunnybrook Health Sciences Centre, University of Toronto, Canada; Department of Neurology (Y.S.), Dr Josep Trueta University Hospital, Institut d'Investigació Biomèdica Girona Foundation, Spain; Department of Neurology (I.D.), University of Dresden, Germany; 2nd Department of Neurology (A.C.), Institute of Psychiatry and Neurology of Warsaw, Poland; Charles LeMoyne Hospital (J.-M.B.), University of Sherbrooke, Montreal, Canada; Department of Neurology (C.S.K.), Boston Medical Center, MA; Department of Neurology (G.G.), Dalhousie University, Halifax, Canada; Department of Neurology (R.B., V.P.), All India Institute of Medical Sciences, New Delhi; and AMRI Hospital Kolkata (J.R.), India
| | - Vasantha Padma
- From the Stroke Unit, Departments of Neurology (D.R.-L., M.R., C.A.M.) and Neuroradiology (P.C., A.T.), Vall d'Hebron University Hospital and Vall d'Hebron Research Institute, Barcelona, Spain; Calgary Stroke Program (M.D.H., A.M.D.), Department of Clinical Neurosciences, Department of Radiology, Hotchkiss Brain Institute, University of Calgary; Department of Medicine, Neurology (D.D.), and Department of Diagnostic Imaging, Neuroradiology Section (C.L.), The Ottawa Hospital, University of Ottawa, Ottawa Hospital Research Institute; Division of Neuroradiology and Department of Medical Imaging (R.I.A.), Sunnybrook Health Sciences Centre, University of Toronto, Canada; Department of Neurology (Y.S.), Dr Josep Trueta University Hospital, Institut d'Investigació Biomèdica Girona Foundation, Spain; Department of Neurology (I.D.), University of Dresden, Germany; 2nd Department of Neurology (A.C.), Institute of Psychiatry and Neurology of Warsaw, Poland; Charles LeMoyne Hospital (J.-M.B.), University of Sherbrooke, Montreal, Canada; Department of Neurology (C.S.K.), Boston Medical Center, MA; Department of Neurology (G.G.), Dalhousie University, Halifax, Canada; Department of Neurology (R.B., V.P.), All India Institute of Medical Sciences, New Delhi; and AMRI Hospital Kolkata (J.R.), India
| | - Jayanta Roy
- From the Stroke Unit, Departments of Neurology (D.R.-L., M.R., C.A.M.) and Neuroradiology (P.C., A.T.), Vall d'Hebron University Hospital and Vall d'Hebron Research Institute, Barcelona, Spain; Calgary Stroke Program (M.D.H., A.M.D.), Department of Clinical Neurosciences, Department of Radiology, Hotchkiss Brain Institute, University of Calgary; Department of Medicine, Neurology (D.D.), and Department of Diagnostic Imaging, Neuroradiology Section (C.L.), The Ottawa Hospital, University of Ottawa, Ottawa Hospital Research Institute; Division of Neuroradiology and Department of Medical Imaging (R.I.A.), Sunnybrook Health Sciences Centre, University of Toronto, Canada; Department of Neurology (Y.S.), Dr Josep Trueta University Hospital, Institut d'Investigació Biomèdica Girona Foundation, Spain; Department of Neurology (I.D.), University of Dresden, Germany; 2nd Department of Neurology (A.C.), Institute of Psychiatry and Neurology of Warsaw, Poland; Charles LeMoyne Hospital (J.-M.B.), University of Sherbrooke, Montreal, Canada; Department of Neurology (C.S.K.), Boston Medical Center, MA; Department of Neurology (G.G.), Dalhousie University, Halifax, Canada; Department of Neurology (R.B., V.P.), All India Institute of Medical Sciences, New Delhi; and AMRI Hospital Kolkata (J.R.), India
| | - Alejandro Tomasello
- From the Stroke Unit, Departments of Neurology (D.R.-L., M.R., C.A.M.) and Neuroradiology (P.C., A.T.), Vall d'Hebron University Hospital and Vall d'Hebron Research Institute, Barcelona, Spain; Calgary Stroke Program (M.D.H., A.M.D.), Department of Clinical Neurosciences, Department of Radiology, Hotchkiss Brain Institute, University of Calgary; Department of Medicine, Neurology (D.D.), and Department of Diagnostic Imaging, Neuroradiology Section (C.L.), The Ottawa Hospital, University of Ottawa, Ottawa Hospital Research Institute; Division of Neuroradiology and Department of Medical Imaging (R.I.A.), Sunnybrook Health Sciences Centre, University of Toronto, Canada; Department of Neurology (Y.S.), Dr Josep Trueta University Hospital, Institut d'Investigació Biomèdica Girona Foundation, Spain; Department of Neurology (I.D.), University of Dresden, Germany; 2nd Department of Neurology (A.C.), Institute of Psychiatry and Neurology of Warsaw, Poland; Charles LeMoyne Hospital (J.-M.B.), University of Sherbrooke, Montreal, Canada; Department of Neurology (C.S.K.), Boston Medical Center, MA; Department of Neurology (G.G.), Dalhousie University, Halifax, Canada; Department of Neurology (R.B., V.P.), All India Institute of Medical Sciences, New Delhi; and AMRI Hospital Kolkata (J.R.), India
| | - Andrew M Demchuk
- From the Stroke Unit, Departments of Neurology (D.R.-L., M.R., C.A.M.) and Neuroradiology (P.C., A.T.), Vall d'Hebron University Hospital and Vall d'Hebron Research Institute, Barcelona, Spain; Calgary Stroke Program (M.D.H., A.M.D.), Department of Clinical Neurosciences, Department of Radiology, Hotchkiss Brain Institute, University of Calgary; Department of Medicine, Neurology (D.D.), and Department of Diagnostic Imaging, Neuroradiology Section (C.L.), The Ottawa Hospital, University of Ottawa, Ottawa Hospital Research Institute; Division of Neuroradiology and Department of Medical Imaging (R.I.A.), Sunnybrook Health Sciences Centre, University of Toronto, Canada; Department of Neurology (Y.S.), Dr Josep Trueta University Hospital, Institut d'Investigació Biomèdica Girona Foundation, Spain; Department of Neurology (I.D.), University of Dresden, Germany; 2nd Department of Neurology (A.C.), Institute of Psychiatry and Neurology of Warsaw, Poland; Charles LeMoyne Hospital (J.-M.B.), University of Sherbrooke, Montreal, Canada; Department of Neurology (C.S.K.), Boston Medical Center, MA; Department of Neurology (G.G.), Dalhousie University, Halifax, Canada; Department of Neurology (R.B., V.P.), All India Institute of Medical Sciences, New Delhi; and AMRI Hospital Kolkata (J.R.), India
| | - Carlos A Molina
- From the Stroke Unit, Departments of Neurology (D.R.-L., M.R., C.A.M.) and Neuroradiology (P.C., A.T.), Vall d'Hebron University Hospital and Vall d'Hebron Research Institute, Barcelona, Spain; Calgary Stroke Program (M.D.H., A.M.D.), Department of Clinical Neurosciences, Department of Radiology, Hotchkiss Brain Institute, University of Calgary; Department of Medicine, Neurology (D.D.), and Department of Diagnostic Imaging, Neuroradiology Section (C.L.), The Ottawa Hospital, University of Ottawa, Ottawa Hospital Research Institute; Division of Neuroradiology and Department of Medical Imaging (R.I.A.), Sunnybrook Health Sciences Centre, University of Toronto, Canada; Department of Neurology (Y.S.), Dr Josep Trueta University Hospital, Institut d'Investigació Biomèdica Girona Foundation, Spain; Department of Neurology (I.D.), University of Dresden, Germany; 2nd Department of Neurology (A.C.), Institute of Psychiatry and Neurology of Warsaw, Poland; Charles LeMoyne Hospital (J.-M.B.), University of Sherbrooke, Montreal, Canada; Department of Neurology (C.S.K.), Boston Medical Center, MA; Department of Neurology (G.G.), Dalhousie University, Halifax, Canada; Department of Neurology (R.B., V.P.), All India Institute of Medical Sciences, New Delhi; and AMRI Hospital Kolkata (J.R.), India
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Wang B, Yan S, Xu M, Zhang S, Liu K, Hu H, Selim M, Lou M. Timing of Occurrence Is the Most Important Characteristic of Spot Sign. Stroke 2016; 47:1233-1238. [PMID: 27026627 DOI: 10.1161/strokeaha.116.012697] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2016] [Accepted: 03/01/2016] [Indexed: 11/16/2022]
Abstract
BACKGROUND AND PURPOSE Most previous studies have used single-phase computed tomographic angiography to detect the spot sign, a marker for hematoma expansion (HE) in spontaneous intracerebral hemorrhage. We investigated whether defining the spot sign based on timing on perfusion computed tomography (CTP) would improve its specificity for predicting HE. METHODS We prospectively enrolled supratentorial spontaneous intracerebral hemorrhage patients who underwent CTP within 6 hours of onset. Logistic regression was performed to assess the risk factors for HE and poor outcome. Predictive performance of individual CTP spot sign characteristics were examined with receiver operating characteristic analysis. RESULTS Sixty-two men and 21 women with spontaneous intracerebral hemorrhage were included in this analysis. Spot sign was detected in 46% (38/83) of patients. Receiver operating characteristic analysis indicated that the timing of spot sign occurrence on CTP had the greatest area under receiver operating characteristic curve for HE (0.794; 95% confidence interval, 0.630-0.958; P=0.007); the cutoff time was 23.13 seconds. On multivariable analysis, the presence of early-occurring spot sign (ie, spot sign before 23.13 seconds) was an independent predictor not only of HE (odds ratio=28.835; 95% confidence interval, 6.960-119.458; P<0.001), but also of mortality at 3 months (odds ratio =22.377; 95% confidence interval, 1.773-282.334; P=0.016). Moreover, the predictive performance showed that the redefined early-occurring spot sign maintained a higher specificity for HE compared with spot sign (91% versus 74%). CONCLUSIONS Redefining the spot sign based on timing of contrast leakage on CTP to determine early-occurring spot sign improves the specificity for predicting HE and 3-month mortality. The use of early-occurring spot sign could improve the selection of ICH patients for potential hemostatic therapy.
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Affiliation(s)
- Binli Wang
- Department of Neurology, the 2nd Affiliated Hospital of Zhejiang University, School of Medicine, Hangzhou, China
| | - Shenqiang Yan
- Department of Neurology, the 2nd Affiliated Hospital of Zhejiang University, School of Medicine, Hangzhou, China
| | - Mengjun Xu
- Department of Neurology, the 2nd Affiliated Hospital of Zhejiang University, School of Medicine, Hangzhou, China
| | - Sheng Zhang
- Department of Neurology, the 2nd Affiliated Hospital of Zhejiang University, School of Medicine, Hangzhou, China
| | - Keqin Liu
- Department of Neurology, Hangzhou First People's Hospital, Hangzhou, China
| | - Haitao Hu
- Department of Neurology, the 2nd Affiliated Hospital of Zhejiang University, School of Medicine, Hangzhou, China
| | - Magdy Selim
- Department of Neurology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Min Lou
- Department of Neurology, the 2nd Affiliated Hospital of Zhejiang University, School of Medicine, Hangzhou, China
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Schindlbeck KA, Galinovic I, Fiebach JB. Response to Letter Regarding Article, "Spot Sign in Acute Intracerebral Hemorrhage in Dynamic T1-Weighted Magnetic Resonance Imaging". Stroke 2016; 47:e85. [PMID: 27012740 DOI: 10.1161/strokeaha.116.012941] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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Schindlbeck KA, Santaella A, Galinovic I, Krause T, Rocco A, Nolte CH, Villringer K, Fiebach JB. Spot Sign in Acute Intracerebral Hemorrhage in Dynamic T1-Weighted Magnetic Resonance Imaging. Stroke 2015; 47:417-23. [PMID: 26715459 DOI: 10.1161/strokeaha.115.011570] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2015] [Accepted: 11/18/2015] [Indexed: 11/16/2022]
Abstract
BACKGROUND AND PURPOSE In computed tomographic imaging of acute intracerebral hemorrhage spot sign on computed tomographic angiography has been established as a marker for hematoma expansion and poor clinical outcome. Although, magnetic resonance imaging (MRI) can accurately visualize acute intracerebral hemorrhage, a corresponding MRI marker is lacking to date. METHODS We prospectively examined 50 consecutive patients with acute intracerebral hemorrhage within 24 hours of symptom onset. The MRI protocol consisted of a standard stroke protocol and dynamic contrast-enhanced T1-weighted imaging with a time resolution of 7.07 s/batch. Stroke scores were assessed at admission and at time of discharge. Volume measurements of hematoma size and spot sign were performed with MRIcron. RESULTS Contrast extravasation within sites of the hemorrhage (MRI spot sign) was seen in 46% of the patients. Patients with an MRI spot sign had a significantly shorter time to imaging than those without (P<0.001). The clinical outcome measured by the modified Rankin Scale was significantly worse in patients with spot sign compared with those without (P≤0.001). Hematoma expansion was observed in the spot sign group compared with the nonspot sign group, although the differences were not significant. CONCLUSIONS Spot sign can be detected using MRI on postcontrast T1-weighted and dynamic T1-weighted images. It is associated with worse clinical outcome. The time course of contrast extravasation in dynamic T1 images indicates that these spots represent ongoing bleeding.
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Affiliation(s)
- Katharina A Schindlbeck
- From the Department of Neurology, Charité - Universitätsmedizin Berlin, Berlin, Germany (K.A.S., A.R., C.H.N.); International Graduate Program Medical Neurosciences, Berlin, Germany (A.S.); and Center for Stroke Research Berlin (CSB), Berlin, Germany (I.G., T.K., K.V., J.B.F.).
| | - Anna Santaella
- From the Department of Neurology, Charité - Universitätsmedizin Berlin, Berlin, Germany (K.A.S., A.R., C.H.N.); International Graduate Program Medical Neurosciences, Berlin, Germany (A.S.); and Center for Stroke Research Berlin (CSB), Berlin, Germany (I.G., T.K., K.V., J.B.F.)
| | - Ivana Galinovic
- From the Department of Neurology, Charité - Universitätsmedizin Berlin, Berlin, Germany (K.A.S., A.R., C.H.N.); International Graduate Program Medical Neurosciences, Berlin, Germany (A.S.); and Center for Stroke Research Berlin (CSB), Berlin, Germany (I.G., T.K., K.V., J.B.F.)
| | - Thomas Krause
- From the Department of Neurology, Charité - Universitätsmedizin Berlin, Berlin, Germany (K.A.S., A.R., C.H.N.); International Graduate Program Medical Neurosciences, Berlin, Germany (A.S.); and Center for Stroke Research Berlin (CSB), Berlin, Germany (I.G., T.K., K.V., J.B.F.)
| | - Andrea Rocco
- From the Department of Neurology, Charité - Universitätsmedizin Berlin, Berlin, Germany (K.A.S., A.R., C.H.N.); International Graduate Program Medical Neurosciences, Berlin, Germany (A.S.); and Center for Stroke Research Berlin (CSB), Berlin, Germany (I.G., T.K., K.V., J.B.F.)
| | - Christian H Nolte
- From the Department of Neurology, Charité - Universitätsmedizin Berlin, Berlin, Germany (K.A.S., A.R., C.H.N.); International Graduate Program Medical Neurosciences, Berlin, Germany (A.S.); and Center for Stroke Research Berlin (CSB), Berlin, Germany (I.G., T.K., K.V., J.B.F.)
| | - Kersten Villringer
- From the Department of Neurology, Charité - Universitätsmedizin Berlin, Berlin, Germany (K.A.S., A.R., C.H.N.); International Graduate Program Medical Neurosciences, Berlin, Germany (A.S.); and Center for Stroke Research Berlin (CSB), Berlin, Germany (I.G., T.K., K.V., J.B.F.)
| | - Jochen B Fiebach
- From the Department of Neurology, Charité - Universitätsmedizin Berlin, Berlin, Germany (K.A.S., A.R., C.H.N.); International Graduate Program Medical Neurosciences, Berlin, Germany (A.S.); and Center for Stroke Research Berlin (CSB), Berlin, Germany (I.G., T.K., K.V., J.B.F.)
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Akiyama H, Uchino K, Hasegawa Y. Characteristics of Symptomatic Intracranial Hemorrhage in Patients Receiving Non-Vitamin K Antagonist Oral Anticoagulant Therapy. PLoS One 2015; 10:e0132900. [PMID: 26171862 PMCID: PMC4501739 DOI: 10.1371/journal.pone.0132900] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2015] [Accepted: 06/22/2015] [Indexed: 01/18/2023] Open
Abstract
Objectives The first non-vitamin K antagonist oral anticoagulant (NOAC) introduced to the market in Japan was dabigatran in March 2011, and three more NOACs, rivaroxaban, apixaban, and edoxaban, have since become available. Randomized controlled trials of NOACs have revealed that intracranial hemorrhage (ICH) occurs less frequently with NOACs compared with warfarin. However, the absolute incidence of ICH associated with NOACs has increased with greater use of these anticoagulants, and we wanted to explore the incidence, clinical characteristics, and treatment course of patients with NOACs-associated ICH. Methods We retrospectively analyzed the characteristics of symptomatic ICH patients receiving NOACs between March 2011 and September 2014. Results ICH occurred in 6 patients (5 men, 1 woman; mean ± SD age, 72.8 ± 3.2 years). Mean time to onset was 146.2 ± 111.5 days after starting NOACs. Five patients received rivaroxaban and 1 patient received apixaban. None received dabigatran or edoxaban. Notably, no hematoma expansion was observed within 24 h of onset in the absence of infusion of fresh frozen plasma, activated prothrombin complex concentrate, recombinant activated factor VIIa or hemodialysis. When NOAC therapy was initiated, mean HAS-BLED and PANWARDS scores were 1.5 ± 0.5 and 39.5 ± 7.7, respectively. Mean systolic blood pressure was 137.8 ± 15.9 mmHg within 1 month before spontaneous ICH onset. Conclusion Six symptomatic ICHs occurred early in NOAC therapy but hematoma volume was small and did not expand in the absence of infusion of reversal agents or hemodialysis. The occurrence of ICH during NOAC therapy is possible even when there is acceptable mean systolic blood pressure control (137.8 ± 15.9 mmHg) and HAS-BLED score ≤ 2. Even stricter blood pressure lowering and control within the acceptable range may be advisable to prevent ICH during NOAC therapy.
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Affiliation(s)
- Hisanao Akiyama
- Department of Neurology, St. Marianna University School of Medicine, Kawasaki, Kanagawa, Japan
| | - Kenji Uchino
- Department of Neurology, St. Marianna University School of Medicine, Kawasaki, Kanagawa, Japan
| | - Yasuhiro Hasegawa
- Department of Neurology, St. Marianna University School of Medicine, Kawasaki, Kanagawa, Japan
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Liebeskind DS, Feldmann E. Imaging of cerebrovascular disorders: precision medicine and the collaterome. Ann N Y Acad Sci 2015; 1366:40-8. [PMID: 25922154 DOI: 10.1111/nyas.12765] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2015] [Revised: 03/16/2015] [Accepted: 03/18/2015] [Indexed: 12/29/2022]
Abstract
Imaging of stroke and neurovascular disorders has profoundly enhanced clinical practice and related research during the last 40 years since the introduction of computed tomography (CT) and magnetic resonance imaging (MRI) enabled mapping of the brain. We highlight recent advances in neurovascular imaging. We describe how the convergence of readily available data and new clinical trial paradigms will recast our methods for studying the neurovascular patient. The application of a precision medicine approach to the collaterome, a comprehensive synthesis of neurovascular pathophysiology, will entail novel methods for clinical trial randomization, collection of routine and clinical trial imaging results, data archiving, and analysis.
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Affiliation(s)
- David S Liebeskind
- Neurovascular Imaging Research Core and the University of California, Los Angeles Stroke Center, Los Angeles, California
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Chan S, Conell C, Veerina KT, Rao VA, Flint AC. Prediction of Intracerebral Haemorrhage Expansion with Clinical, Laboratory, Pharmacologic, and Noncontrast Radiographic Variables. Int J Stroke 2015; 10:1057-61. [DOI: 10.1111/ijs.12507] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2014] [Accepted: 02/25/2015] [Indexed: 12/17/2022]
Abstract
Background Hematoma expansion confers excess mortality in intracerebral haemorrhage, and is potentially preventable if at-risk patients can be identified. Contrast extravasation on initial computed tomographic angiography strongly predicts hematoma expansion but is not very sensitive, and most centers have not yet integrated computed tomographic angiography into acute intracerebral haemorrhage management. We therefore asked whether other presentation variables can predict hematoma expansion. Methods We searched the electronic medical records of a large integrated healthcare delivery system to identify patients with a hospitalization discharge diagnosis of intracerebral haemorrhage between the years 2008 and 2010. Hematoma expansion was defined as radiographic increase by 1/3 or by 12·5 ml within 48 h of presentation. Pre-specified patient demographic and clinical presentation variables were extracted. Stepwise multivariable logistic regression was performed to model hematoma expansion. Because some patients may have died from hematoma expansion without a second head computed tomography, we constructed a separate model including patients that died without a second head computed tomography in 48 h, hematoma expansion or death. Results Ninety-one of 257 patients (35%) had hematoma expansion. Antithrombotic use (odds ratio = 1·9, P = 0·04) and initial mNIHSS (modified National Institutes of Health Stroke Scale; odds ratio = 1·06, P = 0·001) were significant predictors in the hematoma expansion model (area under the Receiver–Operator Characteristics curve, AUROC = 0·6712, pseudo- r2 = 0·0641). 163 of 343 patients (48%) had hematoma expansion or death. Age (odds ratio = 1·02, P = 0·02), initial mNIHSS (odds ratio = 1·07, P < 0·001), and initial hematoma volume (odds ratio = 1·01, P = 0·03) were significant predictors of hematoma expansion or death (AUROC = 0·7579, pseudo- r2 = 0·1722). Conclusion Clinical and noncontrast radiographic variables only weakly predict hematoma expansion. Examination of other indicators, such as computed tomographic angiography contrast extravasation (the ‘spot sign’), may prove more valuable in acute intracerebral haemorrhage care.
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Affiliation(s)
- Sheila Chan
- Department of Neuroscience, Kaiser Permanente, Redwood City, CA, USA
| | - Carol Conell
- Division of Research, Kaiser Permanente, Oakland, CA, USA
| | | | - Vivek A. Rao
- Department of Neuroscience, Kaiser Permanente, Redwood City, CA, USA
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