Automated cerebral hemorrhage volume calculation and stability detection using automated software

Introduction

The measurement of intracerebral hemorrhage (ICH) volume is important for management, particularly in evaluating expansion on subsequent imaging. However manual volumetric analysis is time-consuming, especially in busy hospital settings. We aimed to use automated Rapid Hyperdensity software to accurately measure ICH volume across repeated imaging.

Methods

We identified ICH cases, with repeat imaging conducted within 24 hours, from two randomized clinical trials where enrollment was not based on ICH volume. Scans were excluded if there was (1) severe CT artifacts, (2) prior neurosurgical procedures, (3) recent intravenous contrast, or (4) ICH < 1 ml. Manual ICH measurements were conducted by one neuroimaging expert using MIPAV software and compared to the performance of automated software.

Results

127 patients were included with median baseline ICH volume manually measured at 18.18 cc (IQR: 7.31 - 35.71) compared to automated detection of 18.93 cc (IQR: 7.55, 37.88). The two modalities were highly correlated (r = 0.994, p < 0.001). On repeat imaging, the median absolute difference in ICH volume was 0.68cc (IQR: -0.60-4.87) compared to automated detection at 0.68cc (IQR: -0.45-4.63). These absolute differences were also highly correlated (r = 0.941, p < 0.001), with the ability of the automated software to detect ICH expansion with a Sensitivity of 94.12% and Specificity 97.27%.

Conclusion

In our proof-of-concept study, the automated software has high reliability in its ability to quickly determine IPH volume with high sensitivity and specificity and to detect expansion on subsequent imaging.

Abstract TP91: Automated Cerebral Hemorrhage Volume Calculation And Stability Detection Using RAPID Software

Introduction: The measurement of intraparenchymal hemorrhage (IPH) volume is important for management, particularly in evaluating expansion on subsequent imaging. However manual volumetric analysis is time-consuming, especially in busy hospital settings. We aimed to use automated RAPID hyperdensity software to accurately measure IPH volume across repeated imaging.

Methods: We identified primary IPH cases, without evidence of IVH, SDH, or SAH, from two randomized ICH trials where enrollment was not based on IPH volume. Scans were excluded if (1) there was CT acquisition artifact, (2) measured IPH volume was < 0.4ml, or (3) patient underwent a neurosurgical procedure. Repeat imaging, conducted within 12h, was included in a secondary stability analysis. Manual IPH measurements were conducted by one neuroimaging expert using MIPAV software and compared to the performance of the RAPID hyperdensity module.

Results: 149 scans were included with median IPH volume manually measured at 13.3ml (IQR 3.2-27.5) compared to RAPID detection of 18.0ml (IQR 5.1-36.8). The two modalities were highly correlated (Figure 1, r = 0.948, p < 0.001) with a median absolute difference of 3.4ml (IQR 0.2-9.4) and standard error of 0.655. Repeat imaging was available in 65 patients, with a median absolute difference of 0ml (IQR: -2.6-1.5) compared to RAPID detection at 0.1ml (IQR: -2.3-2.7). These absolute differences were also highly correlated (r = 0.878, p < 0.001), with the ability of RAPID to detect a 5ml IPH expansion with a Sensitivity of 98.1% and Specificity 72.7%. Processing time for the software was < 3 minutes.

Conclusion: In our pilot data, the RAPID hyperdensity module has high reliability in its ability to quickly automatically detect IPH volume and high sensitivity to detect expansion on subsequent imaging.

Transcranial direct current stimulation for focal status epilepticus or lateralized periodic discharges in four patients in a critical care setting

OBJECTIVE

Transcranial direct current stimulation (tDCS) has been advocated for various neurological conditions, including epilepsy. A 1-4-mA cathodal current applied to the scalp over a seizure focus can reduce spikes and seizures. This series of four patients with focal status epilepticus is among the first case series to demonstrate benefit of tDCS in the critical care setting.

METHODS

Patients in the intensive care unit were referred for tDCS treatment when focal status epilepticus or clinically relevant lateralized periodic discharges did not resolve with conventional antiseizure medications and anesthetics. Battery-powered direct cathodal current at 2 mA was delivered by an ActivaDose (Caputron) tDCS device via a saline-soaked sponge on the scalp over the seizure focus. Anode was on the contralateral forehead or shoulder. Treatment was for 30 min, repeated twice in a day, then again 1-4 times more over the next few days.

RESULTS

Three females and one male, aged 34-68 years, were treated. Etiologies of status epilepticus were posterior reversible encephalopathy syndrome in association with immunosuppressants for a liver transplant, perinatal hypoxic-ischemic injury, a prior cardioembolic parietal stroke, and central nervous system lupus. tDCS led to significant reduction of interictal spikes (.78 to .38/s, p < .0001) in three cases and electrographic seizures (3.83/h to 0/h, p < .001) in two cases. Medication reductions were enabled in all cases subsequent to tDCS. The only side effect of tDCS was transient erythema under the sponge in one case. Two patients died of causes unrelated to tDCS, one was discharged to a nursing home, and one became fully responsive as seizures were controlled with tDCS.

SIGNIFICANCE

Spikes and electrographic seizure frequency significantly improved within 1 day of tDCS. Results are potentially confounded by multiple ongoing changes in medications and treatments. These results might encourage further investigation of tDCS in the critical care setting, but verification by controlled studies will be required.

Prognostication of ICU Patients by Providers with and without Neurocritical Care Training

BACKGROUND

Predictions of functional outcome in neurocritical care (NCC) patients impact care decisions. This study compared the predictive values (PVs) of good and poor functional outcome among health care providers with and without NCC training.

METHODS

Consecutive patients who were intubated for  ≥ 72 h with primary neurological illness or neurological complications were prospectively enrolled and followed for 6-month functional outcome. Medical intensive care unit (MICU) attendings, NCC attendings, residents (RES), and nurses (RN) predicted 6-month functional outcome on the modified Rankin scale (mRS). The primary objective was to compare these four groups' PVs of a good (mRS score 0-3) and a poor (mRS score 4-6) outcome prediction.

RESULTS

Two hundred eighty-nine patients were enrolled. One hundred seventy-six had mRS scores predicted by a provider from each group and were included in the primary outcome analysis. At 6 months, 54 (31%) patients had good outcome and 122 (69%) had poor outcome. Compared with other providers, NCC attendings expected better outcomes (p < 0.001). Consequently, the PV of a poor outcome prediction by NCC attendings was higher (96% [95% confidence interval [CI] 89-99%]) than that by MICU attendings (88% [95% CI 80-93%]), RES (82% [95% CI 74-88%]), and RN (85% [95% CI 77-91%]) (p = 0.047, 0.002, and 0.012, respectively). When patients who had withdrawal of life-sustaining therapy (n = 67) were excluded, NCC attendings remained better at predicting poor outcome (NCC 90% [95% CI 75-97%] vs. MICU 73% [95% CI 59-84%], p = 0.064). The PV of a good outcome prediction was similar among groups (MICU 65% [95% CI 52-76%], NCC 63% [95% CI 51-73%], RES 71% [95% CI 55-84%], and RN 64% [95% CI 50-76%]).

CONCLUSIONS

Neurointensivists expected better outcomes than other providers and were better at predicting poor functional outcomes. The PV of a good outcome prediction was modest among all providers.

Reversible Cerebral Vasoconstriction Syndrome in Patients with Coronavirus Disease: A Multicenter Case Series

BACKGROUND AND OBJECTIVES

RCVS (Reversible Cerebral Vasoconstrictive Syndrome) is a condition associated with vasoactive agents that alter endothelial function. There is growing evidence that endothelial inflammation contributes to cerebrovascular disease in patients with coronavirus disease 2019 (COVID-19). In our study, we describe the clinical features, risk factors, and outcomes of RCVS in a multicenter case series of patients with COVID-19.

MATERIALS AND METHODS

Multicenter retrospective case series. We collected clinical characteristics, imaging, and outcomes of patients with RCVS and COVID-19 identified at each participating site.

RESULTS

Ten patients were identified, 7 women, ages 21 - 62 years. Risk factors included use of vasoconstrictive agents in 7 and history of migraine in 2. Presenting symptoms included thunderclap headache in 5 patients with recurrent headaches in 4. Eight were hypertensive on arrival to the hospital. Symptoms of COVID-19 included fever in 2, respiratory symptoms in 8, and gastrointestinal symptoms in 1. One patient did not have systemic COVID-19 symptoms. MRI showed subarachnoid hemorrhage in 3 cases, intraparenchymal hemorrhage in 2, acute ischemic stroke in 4, FLAIR hyperintensities in 2, and no abnormalities in 1 case. Neurovascular imaging showed focal segment irregularity and narrowing concerning for vasospasm of the left MCA in 4 cases and diffuse, multifocal narrowing of the intracranial vasculature in 6 cases. Outcomes varied, with 2 deaths, 2 remaining in the ICU, and 6 surviving to discharge with modified Rankin scale (mRS) scores of 0 (n=3), 2 (n=2), and 3 (n=1).

CONCLUSIONS

Our series suggests that patients with COVID-19 may be at risk for RCVS, particularly in the setting of additional risk factors such as exposure to vasoactive agents. There was variability in the symptoms and severity of COVID-19, clinical characteristics, abnormalities on imaging, and mRS scores. However, a larger study is needed to validate a causal relationship between RCVS and COVID-19.

Standardized Nomenclature for Modified Rankin Scale Global Disability Outcomes: Consensus Recommendations From Stroke Therapy Academic Industry Roundtable XI

The modified Rankin Scale (mRS), a 7-level, clinician-reported, measure of global disability, is the most widely employed outcome scale in acute stroke trials. The scale's original development preceded the advent of modern clinimetrics, but substantial subsequent work has been performed to enable the mRS to meet robust contemporary scale standards. Prior research and consensus recommendations have focused on modernizing 2 aspects of the mRS: operationalized assignment of scale scores and statistical analysis of scale distributions. Another important characteristic of the mRS still requiring elaboration and specification to contemporary clinimetric standards is the Naming of scale outcomes. Recent clinical trials have used a bewildering variety, often mutually contradictory, of rubrics to describe scale states. Understanding of the meaning of mRS outcomes by clinicians, patients, and other clinical trial stakeholders would be greatly enhanced by use of a harmonized, uniform set of labels for the distinctive mRS outcomes that would be used consistently across trials. This statement advances such recommended rubrics, developed by the Stroke Therapy Academic Industry Roundtable collaboration using an iterative, mixed-methods process. Specific guidance is provided for health state terms (eg, Symptomatic but Nondisabled for mRS score 1; requires constant care for mRS score 5) and valence terms (eg, excellent for mRS score 1; very poor for mRS score 5) to employ for 23 distinct numeric mRS outcomes, including: all individual 7 mRS levels; all 12 positive and negative dichotomized mRS ranges, positive and negative sliding dichotomies; and utility-weighted analysis of the mRS.

Automated Cerebral Hemorrhage Detection Using RAPID

BACKGROUND AND PURPOSE

Intracranial hemorrhage (ICH) is an important event that is diagnosed on head NCCT. Increased NCCT utilization in busy hospitals may limit timely identification of ICH. RAPID ICH is an automated hybrid 2D-3D convolutional neural network application designed to detect ICH that may allow for expedited ICH diagnosis. We determined the accuracy of RAPID ICH for ICH detection and ICH volumetric quantification on NCCT.

MATERIALS AND METHODS

NCCT scans were evaluated for ICH by RAPID ICH. Consensus detection of ICH by 3 neuroradiology experts was used as the criterion standard for RAPID ICH comparison. ICH volume was also automatically determined by RAPID ICH in patients with intraparenchymal or intraventricular hemorrhage and compared with manually segmented ICH volumes by a single neuroradiology expert. ICH detection accuracy, sensitivity, specificity, positive predictive value, negative predictive value, and positive and negative likelihood ratios by RAPID ICH were determined.

RESULTS

We included 308 studies. RAPID ICH correctly identified 151/158 ICH cases and 143/150 ICH-negative cases, which resulted in high sensitivity (0.956, CI: 0.911-0.978), specificity (0.953, CI: 0.907-0.977), positive predictive value (0.956, CI: 0.911-0.978), and negative predictive value (0.953, CI: 0.907-0.977) for ICH detection. The positive likelihood ratio (20.479, CI 9.928-42.245) and negative likelihood ratio (0.046, CI 0.023-0.096) for ICH detection were similarly favorable. RAPID ICH volumetric quantification for intraparenchymal and intraventricular hemorrhages strongly correlated with expert manual segmentation (correlation coefficient r = 0.983); the median absolute error was 3 mL.

CONCLUSIONS

RAPID ICH is highly accurate in the detection of ICH and in the volumetric quantification of intraparenchymal and intraventricular hemorrhages.

Catecholamine-induced cerebral vasospasm and multifocal infarctions in pheochromocytoma

SUMMARY

We report the case of a 76-year-old male with a remote history of papillary thyroid cancer who developed severe paroxysmal headaches in the setting of episodic hypertension. Brain imaging revealed multiple lesions, initially of inconclusive etiology, but suspicious for metastatic foci. A search for the primary malignancy revealed an adrenal tumor, and biochemical testing confirmed the diagnosis of a norepinephrine-secreting pheochromocytoma. Serial imaging demonstrated multiple cerebral infarctions of varying ages, evidence of vessel narrowing and irregularities in the anterior and posterior circulations, and hypoperfusion in watershed areas. An exhaustive work-up for other etiologies of stroke including thromboembolic causes or vasculitis was unremarkable. There was resolution of symptoms, absence of new infarctions, and improvement in vessel caliber after adequate alpha-adrenergic receptor blockade for the management of pheochromocytoma. This clinicoradiologic constellation of findings suggested that the etiology of the multiple infarctions was reversible cerebral vasoconstriction syndrome (RCVS). Pheochromocytoma remains a poorly recognized cause of RCVS. Unexplained multifocal cerebral infarctions in the setting of severe hypertension should prompt the consideration of a vasoactive tumor as the driver of cerebrovascular dysfunction. A missed or delayed diagnosis has the potential for serious neurologic morbidity for an otherwise treatable condition.

LEARNING POINTS

The constellation of multifocal watershed cerebral infarctions of uncertain etiology in a patient with malignant hypertension should trigger the consideration of undiagnosed catecholamine secreting tumors, such as pheochromocytomas and paragangliomas. Reversible cerebral vasoconstriction syndrome is a serious but reversible cerebrovascular manifestation of pheochromocytomas that may lead to strokes (ischemic and hemorrhagic), seizures, and cerebral edema. Alpha-adrenergic receptor blockade can reverse cerebral vasoconstriction and prevent further cerebral ischemia and infarctions. Early diagnosis of catecholamine secreting tumors has the potential for reducing neurologic morbidity and mortality in patients presenting with cerebrovascular complications.

Guidelines for the Acute Treatment of Cerebral Edema in Neurocritical Care Patients

BACKGROUND

Acute treatment of cerebral edema and elevated intracranial pressure is a common issue in patients with neurological injury. Practical recommendations regarding selection and monitoring of therapies for initial management of cerebral edema for optimal efficacy and safety are generally lacking. This guideline evaluates the role of hyperosmolar agents (mannitol, HTS), corticosteroids, and selected non-pharmacologic therapies in the acute treatment of cerebral edema. Clinicians must be able to select appropriate therapies for initial cerebral edema management based on available evidence while balancing efficacy and safety.

METHODS

The Neurocritical Care Society recruited experts in neurocritical care, nursing, and pharmacy to create a panel in 2017. The group generated 16 clinical questions related to initial management of cerebral edema in various neurological insults using the PICO format. A research librarian executed a comprehensive literature search through July 2018. The panel screened the identified articles for inclusion related to each specific PICO question and abstracted necessary information for pertinent publications. The panel used GRADE methodology to categorize the quality of evidence as high, moderate, low, or very low based on their confidence that the findings of each publication approximate the true effect of the therapy.

RESULTS

The panel generated recommendations regarding initial management of cerebral edema in neurocritical care patients with subarachnoid hemorrhage, traumatic brain injury, acute ischemic stroke, intracerebral hemorrhage, bacterial meningitis, and hepatic encephalopathy.

CONCLUSION

The available evidence suggests hyperosmolar therapy may be helpful in reducing ICP elevations or cerebral edema in patients with SAH, TBI, AIS, ICH, and HE, although neurological outcomes do not appear to be affected. Corticosteroids appear to be helpful in reducing cerebral edema in patients with bacterial meningitis, but not ICH. Differences in therapeutic response and safety may exist between HTS and mannitol. The use of these agents in these critical clinical situations merits close monitoring for adverse effects. There is a dire need for high-quality research to better inform clinicians of the best options for individualized care of patients with cerebral edema.

Prognostic value of diffusion-weighted MRI for post-cardiac arrest coma

OBJECTIVE

To validate quantitative diffusion-weighted imaging (DWI) MRI thresholds that correlate with poor outcome in comatose cardiac arrest survivors, we conducted a clinician-blinded study and prospectively obtained MRIs from comatose patients after cardiac arrest.

METHODS

Consecutive comatose post-cardiac arrest adult patients were prospectively enrolled. MRIs obtained within 7 days after arrest were evaluated. The clinical team was blinded to the DWI MRI results and followed a prescribed prognostication algorithm. Apparent diffusion coefficient (ADC) values and thresholds differentiating good and poor outcome were analyzed. Poor outcome was defined as a Glasgow Outcome Scale score of ≤2 at 6 months after arrest.

RESULTS

Ninety-seven patients were included, and 75 patients (77%) had MRIs. In 51 patients with MRI completed by postarrest day 7, the prespecified threshold of >10% of brain tissue with an ADC <650 ×10^-6 mm²/s was highly predictive for poor outcome with a sensitivity of 0.63 (95% confidence interval [CI] 0.42-0.80), a specificity of 0.96 (95% CI 0.77-0.998), and a positive predictive value (PPV) of 0.94 (95% CI 0.71-0.997). The mean whole-brain ADC was higher among patients with good outcomes. Receiver operating characteristic curve analysis showed that ADC <650 ×10^-6 mm²/s had an area under the curve of 0.79 (95% CI 0.65-0.93, p < 0.001). Quantitative DWI MRI data improved prognostication of both good and poor outcomes.

CONCLUSIONS

This prospective, clinician-blinded study validates previous research showing that an ADC <650 ×10^-6 mm²/s in >10% of brain tissue in an MRI obtained by postarrest day 7 is highly specific for poor outcome in comatose patients after cardiac arrest.

Natural history and prognostic value of corticospinal tract Wallerian degeneration in intracerebral hemorrhage

BACKGROUND

The purpose of this study was to define the incidence, imaging characteristics, natural history, and prognostic implication of corticospinal tract Wallerian degeneration (CST-WD) in spontaneous intracerebral hemorrhage (ICH) using serial MR imaging.

METHODS AND RESULTS

Consecutive ICH patients with supratentorial ICH prospectively underwent serial MRIs at 2, 7, 14, and 21 days. MRIs were analyzed by independent raters for the presence and topographical distribution of CST-WD on diffusion-weighted imaging (DWI). Baseline demographics, hematoma characteristics, ICH score, and admission National Institute of Health Stroke Score (NIHSS) were systematically recorded. Functional outcome at 3 months was assessed by the modified Rankin Scale (mRS) and the motor-NIHSS. Twenty-seven patients underwent 93 MRIs; 88 of these were serially obtained in the first month. In 13 patients (48%), all with deep ICH, CST-WD changes were observed after a median of 7 days (interquartile range, 7 to 8) as reduced diffusion on DWI and progressed rostrocaudally along the CST. CST-WD changes evolved into T2-hyperintense areas after a median of 11 days (interquartile range, 6 to 14) and became atrophic on MRIs obtained after 3 months. In univariate analyses, the presence of CST-WD was associated with poor functional outcome (ie, mRS 4 to 6; P=0.046) and worse motor-NIHSS (5 versus 1, P=0.001) at 3 months.

CONCLUSIONS

Wallerian degeneration along the CST is common in spontaneous supratentorial ICH, particularly in deep ICH. It can be detected 1 week after ICH on DWI and progresses rostrocaudally along the CST over time. The presence of CST-WD is associated with poor motor and functional recovery after ICH.

Magnetic resonance imaging profile of blood-brain barrier injury in patients with acute intracerebral hemorrhage

Background

Spontaneous intracerebral hemorrhage (ICH) is associated with blood–brain barrier (BBB) injury, which is a poorly understood factor in ICH pathogenesis, potentially contributing to edema formation and perihematomal tissue injury. We aimed to assess and quantify BBB permeability following human spontaneous ICH using dynamic contrast‐enhanced magnetic resonance imaging (DCE MRI). We also investigated whether hematoma size or location affected the amount of BBB leakage.

Methods and Results

Twenty‐five prospectively enrolled patients from the Diagnostic Accuracy of MRI in Spontaneous intracerebral Hemorrhage (DASH) study were examined using DCE MRI at 1 week after symptom onset. Contrast agent dynamics in the brain tissue and general tracer kinetic modeling were used to estimate the forward leakage rate (K^trans) in regions of interest (ROI) in and surrounding the hematoma and in contralateral mirror–image locations (control ROI). In all patients BBB permeability was significantly increased in the brain tissue immediately adjacent to the hematoma, that is, the hematoma rim, compared to the contralateral mirror ROI (P<0.0001). Large hematomas (>30 mL) had higher K^trans values than small hematomas (P<0.005). K^trans values of lobar hemorrhages were significantly higher than the K^trans values of deep hemorrhages (P<0.005), independent of hematoma volume. Higher K^trans values were associated with larger edema volumes.

Conclusions

BBB leakage in the brain tissue immediately bordering the hematoma can be measured and quantified by DCE MRI in human ICH. BBB leakage at 1 week is greater in larger hematomas as well as in hematomas in lobar locations and is associated with larger edema volumes.

Intracranial hypotension producing reversible coma: a systematic review, including three new cases

Intracranial hypotension is a disorder of CSF hypovolemia due to iatrogenic or spontaneous spinal CSF leakage. Rarely, positional headaches may progress to coma, with frequent misdiagnosis. The authors review reported cases of verified intracranial hypotension-associated coma, including 3 previously unpublished cases, totaling 29. Most patients presented with headache prior to neurological deterioration, with positional symptoms elicited in almost half. Eight patients had recently undergone a spinal procedure such as lumbar drainage. Diagnostic workup almost always began with a head CT scan. Subdural collections were present in 86%; however, intracranial hypotension was frequently unrecognized as the underlying cause. Twelve patients underwent one or more procedures to evacuate the collections, sometimes with transiently improved mental status. However, no patient experienced lasting neurological improvement after subdural fluid evacuation alone, and some deteriorated further. Intracranial hypotension was diagnosed in most patients via MRI studies, which were often obtained due to failure to improve after subdural hematoma (SDH) evacuation. Once the diagnosis of intracranial hypotension was made, placement of epidural blood patches was curative in 85% of patients. Twenty-seven patients (93%) experienced favorable outcomes after diagnosis and treatment; 1 patient died, and 1 patient had a morbid outcome secondary to duret hemorrhages. The literature review revealed that numerous additional patients with clinical histories consistent with intracranial hypotension but no radiological confirmation developed SDH following a spinal procedure. Several such patients experienced poor outcomes, and there were multiple deaths. To facilitate recognition of this treatable but potentially life-threatening condition, the authors propose criteria that should prompt intracranial hypotension workup in the comatose patient and present a stepwise management algorithm to guide the appropriate diagnosis and treatment of these patients.

Abstract 3220: Does Multimodality MRI have Added Benefit in the Diagnosis and Management of “Classic” Hypertensive Intracerebral Hemorrhage?

Introduction: It is unclear whether MRI adds benefit to non-contrast head CT (CT) in the diagnosis and management of patients with “classic” hypertensive intracerebral hemorrhage (HICH) on CT, and whether this additive information justifies MRI costs. We sought to answer this question using a prospective cohort of 159 consecutive patients with spontaneous ICH who systematically underwent CT and multimodality MRI.

Methods: ICH etiology was classified in one of 12 predefined categories along with diagnostic certainty (highly probable, likely and possible), by two blinded neuroradiologists based on CT review (“CT diagnosis”). Two other blinded neuroradiologists reviewed in addition the MRI and determined the most likely diagnosis (“MRI diagnosis”). The “final” diagnosis was used as the reference standard and was assigned by two external, independent and blinded ICH clinician-experts who evaluated all clinical and imaging data including the initial and a 3 month MRI, CT angiography, contrast angiography, pathology and follow-up clinic visits, as available.

Results: Of 159 patients, 86 (54%) had HICH as the final diagnosis. CT and MRI correctly identified 63 (73%) and 78 (91%) of these patients, respectively (P=0.005). Notably, MRI correctly classified eight of nine patients (89%) who had an “unknown” diagnosis by CT. Conversely, 74 patients were classified as HICH by the blinded CT review, and 64 (86%) of these patients had HICH as the final diagnosis. If the CT diagnosis was categorized as highly probable HICH (n=42), then it was almost always correct (98%). If the CT was categorized as likely (n=18) or possible (n=14) HICH, then it was correct in only 72% of cases. MRI increased diagnostic yield in the likely and possible categories by identifying one cavernous malformation (3%) and by improving diagnostic confidence in 19 patients (59%). MRI was wrong in three instances, all in the highly probable category (4%) by incorrectly classifying the etiology of intracerebral hemorrhage due to a possible vascular malformation (n=2) or coagulopathy (n=1).

Conclusions: MRI is more accurate in correctly classifying hypertensive intracerebral hemorrhage than non contrast CT. MRI has significant additive yield over non contrast CT by improving diagnosis and diagnostic confidence in patients for whom the CT diagnosis is of intermediate or low certainty, but not for those diagnosed with a hypertensive intracerebral hemorrhage with high confidence.

Abstract 105: Diagnostic Accuracy of MRI in Spontaneous Intra-cerebral Hemorrhage (DASH) - Final Results

Background: The optimal diagnostic evaluation for patients with a spontaneous intracerebral hemorrhage (ICH) or intraventricular hemorrhage (IVH) remains controversial. We aimed to assess the utility of early magnetic resonance imaging (MRI) in the diagnosis and management of these patients.

Methods: Consecutive patients with spontaneous ICH or IVH were prospectively enrolled in this NIH funded study. Patients were excluded if they had a known (pre-existing) ICH source, a known inability to undergo MRI (e.g. pacemaker) or a Glasgow coma scale score ≤5. In addition to non-contrast brain CT and laboratory testing (including a toxicology screen and EKG), patients underwent gadolinium-enhanced MRI/MRA. Catheter angiography was pursued if the patient met pre-specified criteria. Survivors returned for a 90 day follow-up clinic visit with a repeat MRI. Based on clinical admission data and the initial head CT a presumed ICH cause was assigned by the treating neurocritical care/stroke neurologist. A choice was made out of 12 pre-specified etiologies. After subsequent review of the MRI, the neurologist was given the opportunity to modify the presumed ICH cause. The ‘gold standard’ ICH etiology was determined by a panel of two outside, independent and blinded ICH clinician experts after review of the complete medical record, first without the MRI results, reference standard 1 (RS1), and then with the MRI results, reference standard 2 (RS2). Changes in diagnostic category, diagnostic confidence and management were systematically recorded. The diagnostic yield of MRI was determined for each of the 12 diagnostic categories.

Results: 180 consecutive patients were prospectively enrolled. All patients underwent at least one MRI. No adverse events occurred during MRI acquisition. In 20 patients the MRI was obtained after surgical hematoma evacuation. Mean age was 62±17 years, 47% were female, and 71% had a history of hypertension. Median (IQR) GCS was 14 (10-15). Median and mean ICH volumes were 12 mL (4-35) and 24 (±28) mL. Hematoma location was lobar in 46% and deep in 39% of patients; 43% had associated IVH. Based on RS2, the final ICH diagnosis was hypertension in 44% and cerebral amyloid angiopathy in 13% of patients. MRI led to a change in diagnostic category in 14% of patients using RS1 as the reference, and 18% using RS2. MRI resulted in an improvement in diagnostic confidence in an additional 23% and 26% of patients, respectively. Management was changed in 13% of patients. Within diagnostic categories, the yield of MRI was highest for establishing diagnoses of ICH secondary to cerebral venous thrombosis (56%), ischemic stroke with hemorrhagic transformation (43%), cerebral amyloid angiopathy (35%), neoplasms (33%), and vascular malformations (31%).

Conclusions: The results of this study demonstrate substantial additive clinical benefit of early routine MRI in patients with spontaneous ICH and/or IVH.

Abstract 3051: Blood Pressure Thresholds to Predict the Cause of Intracerebral Hemorrhage

Introduction: Chronic hypertension is a common cause of spontaneous intracerebral hemorrhage (ICH), but not all patients who are hypertensive on hospital presentation have an ICH caused by hypertension (htnICH). We sought to determine blood pressure (BP) thresholds that correlated with a presumed htnICH in a prospective cohort.

Methods: The NIH-funded Diagnostic Utility of MRI in Spontaneous Intracerebral Hemorrhage (DASH) study prospectively enrolled consecutive ICH patients to determine the utility of routine MRI in the diagnosis and management of these patients. Contrast angiography was pursued in a predefined patient subset. At 3 months, ICH cause was determined by the treating stroke physician after review of all clinical information, including MRI in the acute and chronic phase, pathology, and clinic follow-up, as available. Statistical analyses were done using SPSS: χ2; 2 tailed t-tests; and Mann-Whitney U tests were used as appropriate. Receiver operator characteristic (ROC) curves were created and results expressed as area under curve (AUC).

Results: We included 136 patients in this report (age: 63±17yrs; ICH volume: 22±27cc; NIHSS: 9±8; GCS: 13±3). Of these, 70% had a history of hypertension, 40% had an admission SBP> 180mmHg, and 22% an admission SBP >200mmHg. Sixty patients (44%) had htnICH as their final diagnosis. A history of hypertension was associated with htnICH (χ2=11.8, p<0.001), but 48% (46/95) of patients with a history of hypertension did not have a htnICH. Patients with a htnICH had: higher SBP (189 vs 157mmHg, p<0.0001); higher MAP (131 vs 110mmHg, p<0.0001), higher NIHSS (12 vs 6.5, p<0.0001); smaller ICH volumes (16.6 vs 26.0cc, p=0.03); and non-lobar hematomas (χ2=62.3, p180mmHg was 74% specific and 58% sensitive for a subsequent diagnosis of htnICH, a SBP> 200mmHg was 90% specific and 37% sensitive, and a MAP >132mmHg was 90% specific and 45% sensitive. Using ROC analysis, MAP predicted hypertensive etiology with an AUC of 0.75 (p<0.0001, 95% CI: 0.67-0.83). Patients with htnICH and MAP 132mmHg based on age, NIHSS, gender, ICH volume, or ICH location (lobar vs non-lobar). Conversely, patients with non-htnICH and MAP >132mmHg on admission tended to have larger ICH volumes (44 vs 24cc, p=0.07) and higher NIHSS (10 vs 6, p=0.21), but did not differ by location from those with a MAP<132mmHg. Non-lobar location alone was 74% specific and 93% sensitive for htnICH, and a non-lobar ICH or a MAP>132mmHg was 64% specific and 95% sensitive for htnICH.

Conclusions: In our cohort, a history of hypertension predicted htnICH no better than chance. An admission SBP >200mmHg or a MAP >132mmHg predicted htnICH in 90% of these patients, but missed two-thirds of cases. ICH location alone was a sensitive predictor of htnICH, but blood pressure thresholds were more specific.

Abstract 101: Is Intracerebral Hemorrhage-Associated Ischemia a Consequence of Blood Pressure Lowering?

Introduction: The cause of (presumed) ischemic lesions associated with intracerebral hemorrhage (ICH) is poorly understood. We investigated the relationship between BP lowering and the incidence of ipsilateral diffusion weighted imaging (DWI) lesions in a prospective ICH cohort.

Methods: We prospectively enrolled consecutive ICH patients in the NIH-funded DiAgnostic Utility of MRI in Spontaneous Intracerebral Hemorrhage (DASH) study. Two neuroradiologists reviewed the MRIs for evidence of ischemia, defined as: reduced diffusivity ipsilateral to the ICH without evidence of blood products on FLAIR or GRE. Only DWI lesions attributed to tissue compression; vessel compression; or hypoperfusion were included. Patients with post-operative MRIs or insufficient BP data were excluded. Mean arterial blood pressures (MAP) were recorded on admission, and at 6, 12, 18, and 24 hours. Chi-square and t-tests were used as appropriate. Receiver operator characteristic (ROC) curves were created to assess accuracy of predicting DWI lesions.

Results: Of 160 patients, 136 met inclusion criteria (median age: 63 (IQR 50-77); median ICH volume: 10 (IQR 4-33cc); median NIHSS: 6 (IQR 2-16); median GCS: 15 (IQR 10-15); median onset to MRI 40 hrs (IQR 25-75). DWI lesions were observed in 78 (57%) patients. Patients with DWI lesions had higher ICH volumes (32 vs 12cc, p < 0.001); higher admission MAP (125 vs 113mmHg, p=0.006); higher maximal MAP reduction (46 vs 33mmHg, p=0.008); and higher mean %MAP reduction (25 vs 17% p=0.006). DWI lesions were not associated with lowest MAP (80 vs 79mmHg, p=0.97) or mean MAP (90 vs 91, p=0.62). ICH volume and maximum MAP reduction predicted DWI lesions with an area under curve (AUC) of 0.70 (95% CI: 0.61-0.78) and 0.63 (95% CI: 0.53-0.72) respectively. Controlling for ICH volume using logistic regression: for every 10% reduction in MAP the risk of DWI lesions increased substantially (OR 1.28, 95% CI: 1.01-1.62). Similarly, each 10% reduction in mean MAP over the first 24 hours had an increased risk of detecting DWI lesions (OR 1.3, 95% CI: 1.01-1.69). The likelihood of having a DWI lesion was highest in patients with > 30mmHg drop in MAP (OR 2.3, 95% CI: 1.09-4.6). In ICH < 10cc (N=70), DWI lesions were not associated with ICH volume (4.1 vs 4.8cc, p=0.40) but with higher admission MAP (125 vs 112mmHg, p=0.045); maximum MAP reduction (45 vs 31 mmHg, p=0.03); and maximum % MAP reduction (34 vs 25%, p=0.03).

Conclusions: ICH volume and large BP reductions are both associated with the presence of DWI lesions. The likelihood of having a DWI lesion went up by 30% for each 10% drop in MAP from admission, and was 230% higher in patients with > 30 mmHg reduction in MAP. These data suggest that aggressive BP reduction may contribute to ICH associated ischemia, and that percentage-based BP goals may be more appropriate than “one-size fits all” for clinical trial design. Future studies are needed to clarify causation.

Abstract 3148: Self Reported Quality of Life After Intracerebral Hemorrhage: Is a Modified Rankin Scale Score of 4 Worth it?

Background: Intracerebral hemorrhage (ICH) trials often define poor outcome as a modified Rankin Scale Score (mRS) ≥4. While mRS score thresholds are important for demonstrating treatment effect, they do no tell physicians if a treatment outcome is “worth it.” Little self-reported quality of life (QOL) data exists to guide physicians, so opinions during academic discussions and/or family meetings may be driven by personal bias. We sought to describe both self and surrogate reported QOL in ICH survivors in relation to mRS score.

Methods: Consecutive ICH patient were prospectively enrolled in the NIH-funded DiAgnostic Utility of MRI in Spontaneous Intracerebral Hemorrhage (DASH) study. Survivors were followed up at 3 months in clinic and at 12 months by telephone. At each time point, patients or surrogates were asked to rate the patient’s QOL as: excellent, good, fair, or poor. mRS scores were determined by an investigator through a semi-structured interview.

Results: Self reported QOL was available in 95 patients with 143 QOL ratings, and surrogate reported QOL in 66 patients with 84 QOL ratings. Of self-reporters with a mRS of 4, 29% reported at least a good QOL, and 93% rated at least a fair QOL ( Figure 1). Of self-reporters with a mRS of 3, 58% reported at least a good QOL, and 97% rated at least a fair QOL. Patients with a mRS of 4 were less likely to report a poor QOL than surrogate raters (χ 2 =3.9, p=0.05, Figure 2). In all patients, both self-reported and surrogate reported QOL were only loosely associated with mRS (R 2 =0.25 and R 2 =0.12, respectively). Forty-eight patients had self-reported QOL at 3 and 12 months. In these patients mRS improved in 16 (33%) patients without an associated improvement in QOL. Seven patients (15%) reported an improvement in QOL, but only 3 had an improvement in their mRS between 3 and 12 months. In 3 (6%) patients, the mRS worsened while QOL remained unchanged. No change in mRS was seen in 8 (17%) patients who reported worse QOL at 12 than at 3 months.

Conclusions: Self reported QOL is only loosely correlated with mRS for the individual patient. Patient surrogates are more prone to rate QOL of patients with a mRS of 4 as poor than patients themselves. These data are clinically relevant as mRS alone may not capture the satisfaction of the individual patient with their outcome.

A comparison of cooling techniques to treat cardiac arrest patients with hypothermia

Introduction. We sought to compare the performance of endovascular cooling to conventional surface cooling after cardiac arrest. Methods. Patients in coma following cardiopulmonary resuscitation were cooled with an endovascular cooling catheter or with ice bags and cold-water-circulating cooling blankets to a target temperature of 32.0-34.0°C for 24 hours. Performance of cooling techniques was compared by (1) number of hourly recordings in target temperature range, (2) time elapsed from the written order to initiate cooling and target temperature, and (3) adverse events during the first week. Results. Median time in target temperature range was 19 hours (interquartile range (IQR), 16-20) in the endovascular group versus. 10 hours (IQR, 7-15) in the surface group (P = .001). Median time to target temperature was 4 (IQR, 2.8-6.2) and 4.5 (IQR, 3-6.5) hours, respectively (P = .67). Adverse events were similar. Conclusion. Endovascular cooling maintains target temperatures better than conventional surface cooling.

Favorable outcome from a locked-in state despite extensive pontine infarction by MRI

INTRODUCTION

Outcome prediction of patients who are in a locked-in state is challenging. Extensive pontine infarction on diffusion weighted imaging MRI (DWI) has been proposed as a poor prognosticator. We report on three patients with a locked-in state with unexpected favorable recoveries despite DWI evidence of widespread pontine ischemia.

METHODS

Report of three cases.

RESULTS

Three young patients (32-, 30-, and 16-years-old) presented with a locked-in state caused by pontine infarction. The first patient did not receive any acute stroke therapies, the second patient underwent endovascular therapy 20 h after symptom onset resulting in partial recanalization of the basilar artery, and the third patient progressed to a locked-in state despite having received intravenous tissue plasminogen activator. The DWI of all three patients demonstrated acute and widespread pontine infarction involving more than two-thirds of the pons. Two patients regained full independence in their activities of daily living. The third patient remained wheelchair bound, but lives with her family, eats independently, uses a typewriter and wrote a book.

CONCLUSION

Patients who are in a locked-in state may have substantial functional recovery despite DWI evidence of extensive pontine infarction.

Natural history of perihematomal edema after intracerebral hemorrhage measured by serial magnetic resonance imaging

BACKGROUND AND PURPOSE

knowledge on the natural history and clinical impact of perihematomal edema (PHE) associated with intracerebral hemorrhage is limited. We aimed to define the time course, predictors, and clinical significance of PHE measured by serial magnetic resonance imaging.

METHODS

patients with primary supratentorial intracerebral hemorrhage ≥ 5 cm(3) underwent serial MRIs at prespecified intervals during the first month. Hematoma (H(v)) and PHE (E(v)) volumes were measured on fluid-attenuated inversion recovery images. Relative PHE was defined as E(v)/H(v). Neurologic assessments were performed at admission and with each MRI. Barthel Index, modified Rankin scale, and extended Glasgow Outcome scale scores were assigned at 3 months.

RESULTS

twenty-seven patients with 88 MRIs were prospectively included. Median H(v) and E(v) on the first MRI were 39 and 46 cm(3), respectively. Median peak absolute E(v) was 88 cm(3). Larger hematomas produced a larger absolute E(v) (r(2)=0.6) and a smaller relative PHE (r(2)=0.7). Edema volume growth was fastest in the first 2 days but continued until 12 ± 3 days. In multivariate analysis, a higher admission hematocrit was associated with a greater delay in peak PHE (P=0.06). Higher admission partial thromboplastin time was associated with higher peak rPHE (P=0.02). Edema volume growth was correlated with a decline in neurologic status at 48 hours (81 vs 43 cm(3), P=0.03) but not with 3-month functional outcome.

CONCLUSIONS

PHE volume measured by MRI increases most rapidly in the first 2 days after symptom onset and peaks toward the end of the second week. The timing and magnitude of PHE volume are associated with hematologic factors. Its clinical significance deserves further study.

MRI profile of the perihematomal region in acute intracerebral hemorrhage

BACKGROUND AND PURPOSE

The pathophysiology of the presumed perihematomal edema immediately surrounding an acute intracerebral hemorrhage is poorly understood, and its composition may influence clinical outcome. Method-Twenty-three patients from the Diagnostic Accuracy of MRI in Spontaneous intracerebral Hemorrhage (DASH) study were prospectively enrolled and studied with MRI. Perfusion-weighted imaging, diffusion-weighted imaging, and fluid-attenuated inversion recovery sequences were coregistered. TMax (the time when the residue function reaches its maximum) and apparent diffusion coefficient values in the presumed perihematomal edema regions of interest were compared with contralateral mirror and remote ipsilateral hemispheric regions of interest.

RESULTS

Compared with mirror and ipsilateral hemispheric regions of interest, TMax (the time when the residue function reaches its maximum) and apparent diffusion coefficient were consistently increased in the presumed perihematomal edema. Two thirds of the patients also exhibited patchy regions of restricted diffusion in the presumed perihematomal edema.

CONCLUSIONS

The MRI profile of the presumed perihematomal edema in acute intracerebral hemorrhage exhibits delayed perfusion and increased diffusivity mixed with areas of reduced diffusion.

Utility of early MRI in the diagnosis and management of acute spontaneous intracerebral hemorrhage

BACKGROUND

The optimal diagnostic evaluation for spontaneous intracerebral hemorrhage (ICH) remains controversial. In this retrospective study, we assessed the utility of early magnetic resonance imaging (MRI) in ICH diagnosis and management.

METHODS

Eighty-nine (72%) of 123 patients with spontaneous ICH underwent a brain CT and MRI within 30 days of ICH onset. Seventy patients with a mean age of 62 ± 15 years were included. A stroke neurologist and a general neurologist, each blinded to the final diagnosis, independently reviewed the admission data and the initial head CT and then assigned a presumed ICH cause under 1 of 9 categories. ICH cause was potentially modified after subsequent MRI review. The final 'gold standard' ICH etiology was determined after review of the complete medical record by an independent investigator. Change in diagnostic category and confidence and the potential impact on patient management were systematically recorded.

RESULTS

Mean time to MRI was 3 ± 5 days. Final ICH diagnosis was hypertension or cerebral amyloid angiopathy (CAA) in 50% of patients. After MRI review the stroke neurologist changed diagnostic category in 14%, diagnostic confidence in an additional 23% and management in 20%, and the general neurologist did so in 19, 21 and 21% of patients, respectively. MRI yield was highest in ICH secondary to ischemic stroke, CAA, vascular malformations and neoplasms, and did not differ by age, history of hypertension, hematoma location or the presence of intraventricular hemorrhage.

CONCLUSIONS

The results of this study suggest potential additive clinical benefit of early MRI in patients with spontaneous ICH.

Outcome prediction in mechanically ventilated neurologic patients by junior neurointensivists

OBJECTIVE

Physician prediction of outcome in critically ill neurologic patients impacts treatment decisions and goals of care. In this observational study, we prospectively compared predictions by neurointensivists to patient outcomes at 6 months.

METHODS

Consecutive neurologic patients requiring mechanical ventilation for 72 hours or more were enrolled. The attending neurointensivist was asked to predict 6-month 1) functional outcome (modified Rankin scale [mRS]), 2) quality of life (QOL), and 3) whether supportive care should be withdrawn. Six-month functional outcome was determined by telephone interviews and dichotomized to good (mRS 0-3) and poor outcome (mRS 4-6).

RESULTS

Of 187 eligible patients, 144 were enrolled. Neurointensivists correctly predicted 6-month functional outcome in 80% (95% confidence interval [CI], 72%-86%) of patients. Accuracy for a predicted good outcome was 63% (95% CI, 50%-74%) and for poor outcome 94% (95% CI, 85%-98%). Excluding patients who had life support withdrawn, accuracy for good outcome was 73% (95% CI, 60%-84%) and for poor outcome 87% (95% CI, 74%-94%). Accuracy for exact agreement between neurointensivists' mRS predictions and actual 6-month mRS was only 43% (95% CI, 35%-52%). Predicted accuracy for QOL was 58% (95% CI, 39%-74%) for good/excellent and 67% (95% CI, 46%-83%) for poor/fair. Of 27 patients for whom withdrawal of care was recommended, 1 patient survived in a vegetative state.

CONCLUSIONS

Prediction of long-term functional outcomes in critically ill neurologic patients is challenging. Our neurointensivists were more accurate in predicting poor outcome than good outcome in patients requiring mechanical ventilation >or=72 hours.