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Vohidov F, Andersen JN, Economides KD, Shipitsin MV, Burenkova O, Ackley JC, Vangamudi B, Nguyen HVT, Gallagher NM, Shieh P, Golder MR, Liu J, Dahlberg WK, Ehrlich DJC, Kim J, Kristufek SL, Huh SJ, Neenan AM, Baddour J, Paramasivan S, de Stanchina E, Kc G, Turnquist DJ, Saucier-Sawyer JK, Kopesky PW, Brady SW, Jessel MJ, Reiter LA, Chickering DE, Johnson JA, Blume-Jensen P. Design of BET Inhibitor Bottlebrush Prodrugs with Superior Efficacy and Devoid of Systemic Toxicities. J Am Chem Soc 2021; 143:4714-4724. [PMID: 33739832 DOI: 10.1021/jacs.1c00312] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Prodrugs engineered for preferential activation in diseased versus normal tissues offer immense potential to improve the therapeutic indexes (TIs) of preclinical and clinical-stage active pharmaceutical ingredients that either cannot be developed otherwise or whose efficacy or tolerability it is highly desirable to improve. Such approaches, however, often suffer from trial-and-error design, precluding predictive synthesis and optimization. Here, using bromodomain and extra-terminal (BET) protein inhibitors (BETi)-a class of epigenetic regulators with proven anticancer potential but clinical development hindered in large part by narrow TIs-we introduce a macromolecular prodrug platform that overcomes these challenges. Through tuning of traceless linkers appended to a "bottlebrush prodrug" scaffold, we demonstrate correlation of in vitro prodrug activation kinetics with in vivo tumor pharmacokinetics, enabling the predictive design of novel BETi prodrugs with enhanced antitumor efficacies and devoid of dose-limiting toxicities in a syngeneic triple-negative breast cancer murine model. This work may have immediate clinical implications, introducing a platform for predictive prodrug design and potentially overcoming hurdles in drug development.
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Affiliation(s)
- Farrukh Vohidov
- Department of Chemistry, Massachusetts Institute of Technology, 77 Massachusetts Avenue, Cambridge, Massachusetts 02139, United States
| | - Jannik N Andersen
- XTuit Pharmaceuticals, 35 Gatehouse Drive, Waltham, Massachusetts 02451, United States
| | - Kyriakos D Economides
- XTuit Pharmaceuticals, 35 Gatehouse Drive, Waltham, Massachusetts 02451, United States
| | - Michail V Shipitsin
- XTuit Pharmaceuticals, 35 Gatehouse Drive, Waltham, Massachusetts 02451, United States
| | - Olga Burenkova
- XTuit Pharmaceuticals, 35 Gatehouse Drive, Waltham, Massachusetts 02451, United States
| | - James C Ackley
- XTuit Pharmaceuticals, 35 Gatehouse Drive, Waltham, Massachusetts 02451, United States
| | - Bhavatarini Vangamudi
- XTuit Pharmaceuticals, 35 Gatehouse Drive, Waltham, Massachusetts 02451, United States
| | - Hung V-T Nguyen
- Department of Chemistry, Massachusetts Institute of Technology, 77 Massachusetts Avenue, Cambridge, Massachusetts 02139, United States
| | - Nolan M Gallagher
- Department of Chemistry, Massachusetts Institute of Technology, 77 Massachusetts Avenue, Cambridge, Massachusetts 02139, United States
| | - Peyton Shieh
- Department of Chemistry, Massachusetts Institute of Technology, 77 Massachusetts Avenue, Cambridge, Massachusetts 02139, United States
| | - Matthew R Golder
- Department of Chemistry, Massachusetts Institute of Technology, 77 Massachusetts Avenue, Cambridge, Massachusetts 02139, United States
| | - Jenny Liu
- Department of Chemistry, Massachusetts Institute of Technology, 77 Massachusetts Avenue, Cambridge, Massachusetts 02139, United States.,XTuit Pharmaceuticals, 35 Gatehouse Drive, Waltham, Massachusetts 02451, United States
| | - William K Dahlberg
- XTuit Pharmaceuticals, 35 Gatehouse Drive, Waltham, Massachusetts 02451, United States
| | - Deborah J C Ehrlich
- Department of Chemistry, Massachusetts Institute of Technology, 77 Massachusetts Avenue, Cambridge, Massachusetts 02139, United States
| | - Julie Kim
- Department of Chemistry, Massachusetts Institute of Technology, 77 Massachusetts Avenue, Cambridge, Massachusetts 02139, United States
| | - Samantha L Kristufek
- Department of Chemistry, Massachusetts Institute of Technology, 77 Massachusetts Avenue, Cambridge, Massachusetts 02139, United States
| | - Sung Jin Huh
- XTuit Pharmaceuticals, 35 Gatehouse Drive, Waltham, Massachusetts 02451, United States
| | - Allison M Neenan
- XTuit Pharmaceuticals, 35 Gatehouse Drive, Waltham, Massachusetts 02451, United States
| | - Joelle Baddour
- XTuit Pharmaceuticals, 35 Gatehouse Drive, Waltham, Massachusetts 02451, United States
| | | | - Elisa de Stanchina
- Memorial Sloan Kettering Cancer Center, 417 E 68th St, New York, New York 10065, United States
| | - Gaurab Kc
- XTuit Pharmaceuticals, 35 Gatehouse Drive, Waltham, Massachusetts 02451, United States
| | - David J Turnquist
- XTuit Pharmaceuticals, 35 Gatehouse Drive, Waltham, Massachusetts 02451, United States
| | | | - Paul W Kopesky
- XTuit Pharmaceuticals, 35 Gatehouse Drive, Waltham, Massachusetts 02451, United States
| | - Samantha W Brady
- XTuit Pharmaceuticals, 35 Gatehouse Drive, Waltham, Massachusetts 02451, United States
| | - Michael J Jessel
- XTuit Pharmaceuticals, 35 Gatehouse Drive, Waltham, Massachusetts 02451, United States
| | - Lawrence A Reiter
- XTuit Pharmaceuticals, 35 Gatehouse Drive, Waltham, Massachusetts 02451, United States
| | - Donald E Chickering
- XTuit Pharmaceuticals, 35 Gatehouse Drive, Waltham, Massachusetts 02451, United States
| | - Jeremiah A Johnson
- Department of Chemistry, Massachusetts Institute of Technology, 77 Massachusetts Avenue, Cambridge, Massachusetts 02139, United States
| | - Peter Blume-Jensen
- XTuit Pharmaceuticals, 35 Gatehouse Drive, Waltham, Massachusetts 02451, United States
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Shoamanesh A, Morotti A, Romero JM, Oliveira-Filho J, Schlunk F, Jessel MJ, Ayres AM, Vashkevich A, Schwab K, Afzal MR, Cassarly C, Martin RH, Qureshi AI, Greenberg SM, Rosand J, Goldstein JN. Cerebral Microbleeds and the Effect of Intensive Blood Pressure Reduction on Hematoma Expansion and Functional Outcomes: A Secondary Analysis of the ATACH-2 Randomized Clinical Trial. JAMA Neurol 2019; 75:850-859. [PMID: 29710119 DOI: 10.1001/jamaneurol.2018.0454] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
Importance Response to intensive blood pressure (BP) lowering in acute intracerebral hemorrhage (ICH) might vary with the degree of underlying cerebral small vessel disease. Objectives To characterize cerebral microbleeds (CMBs) in acute ICH and to assess the potential for interaction between underlying small vessel disease (as indicated by CMB number and location) and assignment to acute intensive BP targeting for functional outcomes and hematoma expansion. Design, Setting, and Participants Preplanned subgroup analyses in the Antihypertensive Treatment of Acute Cerebral Hemorrhage 2 (ATACH-2) trial were performed. The ATACH-2 was an open-label international randomized clinical trial that investigated optimal acute BP lowering in 1000 patients with acute ICH. Analyses followed the intent-to-treat paradigm. Participants were enrolled between May 2011 and September 2015 and followed up for 3 months. Eligible participants were aged at least 18 years with ICH volumes less than 60 mL on computed tomography (CT) and a Glasgow Coma Scale score of at least 5 on initial assessment, in whom study drug could be initiated within 4.5 hours of symptom onset. Eight hundred thirty-three participants were excluded, leaving 167 who had an interpretable axial T2*-weighted gradient-recalled echo sequence on magnetic resonance imaging to assess CMBs for inclusion in these subgroup analyses. Main Outcomes and Measures The primary outcome of interest was death or disability (modified Ranking Scale score, 4-6) at 3 months. The secondary outcome of interest was hematoma volume expansion of at least 33% on a CT scan obtained 24 hours after randomization compared with the entry scan. Results A total of 167 patients were included; their mean (SD) age was 61.9 (13.2) years, and 98 (58.7%) were male. Cerebral microbleeds were present in 120 patients. Forty-six of 157 (29.3%) patients had poor outcome (modified Ranking Scale score, ≥4), and hematoma expansion was observed in 29 of 144 (20.1%) patients. Risk of poor outcome was similar for those assigned to intensive vs standard acute BP lowering among patients with CMBs (relative risk, 1.19; 95% CI, 0.61-2.33; P = .61) and those without CMBs (relative risk, 1.42; 95% CI, 0.43-4.70; P = .57), and no significant interaction was observed (interaction coefficient, 0.18; 95% CI, -1.20 to 1.55; P = .80). Risk of hematoma expansion was also similar, and no significant interaction between treatment and CMBs was observed (interaction coefficient, 0.62; 95% CI, -1.08 to 2.31; P = .48). Conclusions and Relevance Cerebral microbleeds are highly prevalent among patients with ICH but do not seem to influence response to acute intensive BP treatment. Trial Registration ClinicalTrials.gov Identifier: NCT01176565.
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Affiliation(s)
- Ashkan Shoamanesh
- Division of Neurology, Department of Medicine, McMaster University, Hamilton, Ontario, Canada.,Population Health Research Institute, McMaster University, Hamilton, Ontario, Canada
| | - Andrea Morotti
- J. Philip Kistler Stroke Research Center, Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston.,Division of Neurocritical Care and Emergency Neurology, Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston.,Stroke Unit, Scientific Institute for Research, Hospitalization and Healthcare (IRCCS) Mondino Foundation, Pavia, Italy
| | - Javier M Romero
- J. Philip Kistler Stroke Research Center, Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston.,Department of Radiology, Massachusetts General Hospital, Harvard Medical School, Boston
| | - Jamary Oliveira-Filho
- J. Philip Kistler Stroke Research Center, Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston
| | - Frieder Schlunk
- J. Philip Kistler Stroke Research Center, Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston
| | - Michael J Jessel
- J. Philip Kistler Stroke Research Center, Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston
| | - Alison M Ayres
- J. Philip Kistler Stroke Research Center, Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston
| | - Anastasia Vashkevich
- J. Philip Kistler Stroke Research Center, Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston
| | - Kristin Schwab
- J. Philip Kistler Stroke Research Center, Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston
| | - Mohammad R Afzal
- Zeenat Qureshi Stroke Research Center, University of Minnesota, Minneapolis
| | - Christy Cassarly
- Department of Public Health Sciences, Medical University of South Carolina, Charleston
| | - Renee H Martin
- Department of Public Health Sciences, Medical University of South Carolina, Charleston
| | - Adnan I Qureshi
- Zeenat Qureshi Stroke Research Center, University of Minnesota, Minneapolis
| | - Steven M Greenberg
- J. Philip Kistler Stroke Research Center, Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston
| | - Jonathan Rosand
- J. Philip Kistler Stroke Research Center, Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston.,Division of Neurocritical Care and Emergency Neurology, Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston
| | - Joshua N Goldstein
- J. Philip Kistler Stroke Research Center, Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston.,Division of Neurocritical Care and Emergency Neurology, Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston.,Department of Emergency Medicine, Massachusetts General Hospital, Harvard Medical School, Boston
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Vohidov F, Andersen JN, Economides KD, Shipitsin MV, Burenkova O, Gallagher NM, Sheih P, Golder M, Liu J, Dahlberg WK, Nguyen HV, Ehrlich DJ, Kim J, Huh SJ, Vangamudi B, Neenan AM, Ackley JC, Baddour J, Paramasivan S, KC G, Turnquist DJ, Saucier-Sawyer JK, Kopesky PW, Brady SW, Jessel MJ, Reiter LA, Chickering DE, Johnson JA, Blume-Jensen P. Abstract LB-062: Development of macromolecular prodrugs of BET-bromodomain inhibitors with superior anti-tumor efficacy that are T-cell sparing and devoid of systemic toxicity. Cancer Res 2018. [DOI: 10.1158/1538-7445.am2018-lb-062] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Abstract
Small molecule BET inhibitors are promising anti-cancer agents, but their clinical development has been limited by hematological and gastrointestinal (GI) toxicity. For the prototype benzodiazepine-derived inhibitor (OTX-015), the dose-limiting toxicities (DLTs) are thrombocytopenia (96%), anemia (91%), and neutropenia (51%) with additional GI events (diarrhea, vomiting and mucositis) reported to limit patient compliance despite evidence of durable/objective tumor responses. Accordingly, based on a review of entries in www.clinicaltrials.gov from January 2017 to January 2018, 11 out of 12 programs are reporting protracted phase I/II development times and reduced patient enrollment targets. To improve the narrow therapeutic index of current BET inhibitors, we here report the development of macromolecular BET inhibitor prodrugs with a favorable bio-distribution and release of active drug in tumor compared to other tissues, including gut and bone marrow.
We successfully conjugated two structurally distinct BET inhibitors, including the OTX-015, to Brush polymers using an array of different linker chemistries and evaluated them for in vivo efficacy and toxicity using immunocompetent, orthotopically implanted mouse tumor models. Through rational design of drug conjugation and linker chemistry, we optimized the PK properties and drug release rates offering a ‘depot-like' release of drug in tumor tissue resulting in both improved efficacy and reduction of systemic dose-limiting toxicity. Specifically, these novel formulations were evaluated for myelosuppression and GI toxicity using an array of in vitro, clinical pathology and immunohistopathology techniques. Compared to non-conjugated BET inhibitors, which showed dose-dependent body weight loss, diarrhea, and suppression of white blood cells, the macromolecular BET-BRUSH prodrugs spared the lymphocytes, platelets and neutrophils and showed minimal suppression of the reservoir of myeloid cells in the bone marrow. The improved therapeutic index of the BET-Brush compounds was confirmed through detailed PK/PD/Efficacy studies correlating the concentration of both released and polymer-bound BET inhibitor in tumor and plasma with quantitative tissue biomarker modulation (c-MYC, HEXIM-1 and CD180). Whole organ bio-distribution studies using fluorophore-conjugated BET-Brush confirmed the favorable distribution into tumor over the gut and bone marrow, with BET-Brush showing profound modulation of biomarkers in tumor tissue, but not gut. Notably, the BET-Brush compounds showed suppression of PD-L1 expression in tumors, which in context of preserved T-cells, can make BET-Brush a promising combination with immuno-oncology therapy. Paired with an excellent safety profile of the polymer backbone in rat and non-human primates, these data support the further development of BET-Brush prodrugs as an infrequently dosed treatment for human cancers.
Citation Format: Farrukh Vohidov, Jannik N. Andersen, Kyriakos D. Economides, Michail V. Shipitsin, Olga Burenkova, Nolan M. Gallagher, Peyton Sheih, Matthew Golder, Jenny Liu, William K. Dahlberg, Hung V. Nguyen, Deborah J. Ehrlich, Julie Kim, Sung Jin Huh, Bhavatarini Vangamudi, Allison M. Neenan, James C. Ackley, Joelle Baddour, Sattanathan Paramasivan, Gaurab KC, David J. Turnquist, Jenny K. Saucier-Sawyer, Paul W. Kopesky, Samantha W. Brady, Michael J. Jessel, Lawrence A. Reiter, Donald E. Chickering, Jeremiah A. Johnson, Peter Blume-Jensen. Development of macromolecular prodrugs of BET-bromodomain inhibitors with superior anti-tumor efficacy that are T-cell sparing and devoid of systemic toxicity [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2018; 2018 Apr 14-18; Chicago, IL. Philadelphia (PA): AACR; Cancer Res 2018;78(13 Suppl):Abstract nr LB-062.
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Affiliation(s)
| | | | | | | | | | | | | | | | - Jenny Liu
- 2XTuit Pharmaceuticals, Inc, Waltham, MA
| | | | | | | | | | | | | | | | | | | | | | - Gaurab KC
- 2XTuit Pharmaceuticals, Inc, Waltham, MA
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Xiong L, Boulouis G, Charidimou A, Roongpiboonsopit D, Jessel MJ, Pasi M, Reijmer YD, Fotiadis P, Ayres A, Merrill E, Schwab K, Blacker D, Gurol ME, Greenberg SM, Viswanathan A. Dementia incidence and predictors in cerebral amyloid angiopathy patients without intracerebral hemorrhage. J Cereb Blood Flow Metab 2018; 38:241-249. [PMID: 28318355 PMCID: PMC5951014 DOI: 10.1177/0271678x17700435] [Citation(s) in RCA: 31] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Cerebral amyloid angiopathy (CAA) is a common cause of cognitive impairment in older individuals. This study aimed to investigate predictors of dementia in CAA patients without intracerebral hemorrhage (ICH). A total of 158 non-demented patients from the Stroke Service or the Memory Clinic who met the modified Boston Criteria for probable CAA were included. At baseline, neuroimaging markers, including lobar microbleeds (cerebral microbleeds (CMBs)), white matter hyperintensities (WMH), cortical superficial siderosis (cSS), magnetic resonance imaging (MRI)-visible centrum semiovale perivascular spaces (CSO-PVS), lacunes, and medial temporal atrophy (MTA) were assessed. The overall burden of small vessel disease (SVD) for CAA was calculated by a cumulative score based on CMB number, WMH severity, cSS presence and extent and CSO-PVS severity. The estimated cumulative dementia incidence at 1 year was 14% (95% confidence interval (CI): 5%-23%), and 5 years 73% (95% CI: 55%, 84%). Age (hazard ratio (HR) 1.05 per year, 95% CI: 1.01-1.08, p = 0.007), presence of MCI status (HR 3.40, 95% CI: 1.97-6.92, p < 0.001), MTA (HR 1.71 per point, 95% CI: 1.26-2.32, p = 0.001), and SVD score (HR 1.23 per point, 95% CI: 1.20-1.48, p = 0.030) at baseline were independent predictors for dementia conversion in these patients. Cognitive deterioration of CAA patients appears attributable to cumulative changes, from both vasculopathic and neurodegenerative lesions.
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Affiliation(s)
- Li Xiong
- 1 Department of Neurology, Harvard Medical School, Boston, USA
| | | | | | - Duangnapa Roongpiboonsopit
- 1 Department of Neurology, Harvard Medical School, Boston, USA.,2 Department of Medicine, Naresuan University, Phitsanulok, Thailand
| | | | - Marco Pasi
- 1 Department of Neurology, Harvard Medical School, Boston, USA
| | - Yael D Reijmer
- 1 Department of Neurology, Harvard Medical School, Boston, USA
| | | | - Alison Ayres
- 1 Department of Neurology, Harvard Medical School, Boston, USA
| | - Emily Merrill
- 3 MIND Informatics, Harvard Medical School, Boston, USA
| | - Kristin Schwab
- 1 Department of Neurology, Harvard Medical School, Boston, USA
| | - Deborah Blacker
- 4 Department of Psychiatry, Harvard Medical School, Boston, USA
| | - M Edip Gurol
- 1 Department of Neurology, Harvard Medical School, Boston, USA
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Morotti A, Brouwers HB, Romero JM, Jessel MJ, Vashkevich A, Schwab K, Afzal MR, Cassarly C, Greenberg SM, Martin RH, Qureshi AI, Rosand J, Goldstein JN. Intensive Blood Pressure Reduction and Spot Sign in Intracerebral Hemorrhage: A Secondary Analysis of a Randomized Clinical Trial. JAMA Neurol 2017. [PMID: 28628707 DOI: 10.1001/jamaneurol.2017.1014] [Citation(s) in RCA: 71] [Impact Index Per Article: 10.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
Importance The computed tomographic angiography (CTA) spot sign is associated with intracerebral hemorrhage (ICH) expansion and may mark those patients most likely to benefit from intensive blood pressure (BP) reduction. Objective To investigate whether the spot sign is associated with ICH expansion across a wide range of centers and whether intensive BP reduction decreases hematoma expansion and improves outcome in patients with ICH and a spot sign. Design, Setting, and Participants SCORE-IT (Spot Sign Score in Restricting ICH Growth) is a preplanned prospective observational study nested in the Antihypertensive Treatment of Acute Cerebral Hemorrhage II (ATACH-II) randomized clinical trial. Participants included consecutive patients with primary ICH who underwent a CTA within 8 hours from onset at 59 sites from May 15, 2011, through December 19, 2015. Data were analyzed for the present study from July 1 to August 31, 2016. Main Outcomes and Measures Patients in ATACH-II were randomized to intensive (systolic BP target, <140 mm Hg) vs standard (systolic BP target, <180 mm Hg) BP reduction within 4.5 hours from onset. Expansion of ICH was defined as hematoma growth of greater than 33%, and an unfavorable outcome was defined as a 90-day modified Rankin Scale score of 4 or greater (range, 0-6). The association among BP reduction, ICH expansion, and outcome was investigated with multivariable logistic regression. Results A total of 133 patients (83 men [62.4%] and 50 women [37.6%]; mean [SD] age, 61.9 [13.1] years) were included. Of these, 53 (39.8%) had a spot sign, and 24 of 123 without missing data (19.5%) experienced ICH expansion. The spot sign was associated with expansion with sensitivity of 0.54 (95% CI, 0.34-0.74) and specificity of 0.63 (95% CI, 0.53-0.72). After adjustment for potential confounders, intensive BP treatment was not associated with a significant reduction of ICH expansion (relative risk, 0.83; 95% CI, 0.27-2.51; P = .74) or improved outcome (relative risk of 90-day modified Rankin Scale score ≥4, 1.24; 95% CI, 0.53-2.91; P = .62) in spot sign-positive patients. Conclusions and Relevance The predictive performance of the spot sign for ICH expansion was lower than in prior reports from single-center studies. No evidence suggested that patients with ICH and a spot sign specifically benefit from intensive BP reduction. Trial Registration clinicaltrials.gov Identifier: NCT01176565.
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Affiliation(s)
- Andrea Morotti
- Division of Neurocritical Care and Emergency Neurology, Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston.,J. P. Kistler Stroke Research Center, Massachusetts General Hospital, Harvard Medical School, Boston
| | - H Bart Brouwers
- Department of Neurosurgery, Brain Center Rudolf Magnus University Medical Center, Utrecht, the Netherlands
| | - Javier M Romero
- J. P. Kistler Stroke Research Center, Massachusetts General Hospital, Harvard Medical School, Boston.,Neuroradiology Service, Department of Radiology, Massachusetts General Hospital, Harvard Medical School, Boston
| | - Michael J Jessel
- J. P. Kistler Stroke Research Center, Massachusetts General Hospital, Harvard Medical School, Boston
| | - Anastasia Vashkevich
- J. P. Kistler Stroke Research Center, Massachusetts General Hospital, Harvard Medical School, Boston
| | - Kristin Schwab
- J. P. Kistler Stroke Research Center, Massachusetts General Hospital, Harvard Medical School, Boston
| | | | - Christy Cassarly
- Department of Public Health Sciences, Medical University of South Carolina, Charleston
| | - Steven M Greenberg
- J. P. Kistler Stroke Research Center, Massachusetts General Hospital, Harvard Medical School, Boston
| | - Renee Hebert Martin
- Department of Public Health Sciences, Medical University of South Carolina, Charleston
| | - Adnan I Qureshi
- Zeenat Qureshi Stroke Research Center, University of Minnesota, Minneapolis
| | - Jonathan Rosand
- Division of Neurocritical Care and Emergency Neurology, Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston.,J. P. Kistler Stroke Research Center, Massachusetts General Hospital, Harvard Medical School, Boston
| | - Joshua N Goldstein
- Division of Neurocritical Care and Emergency Neurology, Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston.,J. P. Kistler Stroke Research Center, Massachusetts General Hospital, Harvard Medical School, Boston.,Department of Emergency Medicine, Massachusetts General Hospital, Harvard Medical School, Boston
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6
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Morotti A, Boulouis G, Romero JM, Brouwers HB, Jessel MJ, Vashkevich A, Schwab K, Afzal MR, Cassarly C, Greenberg SM, Martin RH, Qureshi AI, Rosand J, Goldstein JN. Blood pressure reduction and noncontrast CT markers of intracerebral hemorrhage expansion. Neurology 2017; 89:548-554. [PMID: 28701501 DOI: 10.1212/wnl.0000000000004210] [Citation(s) in RCA: 95] [Impact Index Per Article: 13.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2016] [Accepted: 05/15/2017] [Indexed: 12/15/2022] Open
Abstract
OBJECTIVE To validate various noncontrast CT (NCCT) predictors of hematoma expansion in a large international cohort of ICH patients and investigate whether intensive blood pressure (BP) treatment reduces ICH growth and improves outcome in patients with these markers. METHODS We analyzed patients enrolled in the Antihypertensive Treatment of Acute Cerebral Hemorrhage II (ATACH-II) randomized controlled trial. Participants were assigned to intensive (systolic BP <140 mm Hg) vs standard (systolic BP <180 mm Hg) treatment within 4.5 hours from onset. The following NCCT markers were identified: intrahematoma hypodensities, black hole sign, swirl sign, blend sign, heterogeneous hematoma density, and irregular shape. ICH expansion was defined as hematoma growth >33% and unfavorable outcome was defined as modified Rankin Scale score >3 at 90 days. Logistic regression was used to identify predictors of ICH expansion and explore the association between NCCT signs and clinical benefit from intensive BP treatment. RESULTS A total of 989 patients were included (mean age 62 years, 61.9% male), of whom 186/869 experienced hematoma expansion (21.4%) and 361/952 (37.9%) had unfavorable outcome. NCCT markers independently predicted ICH expansion (all p < 0.01) with overall accuracy ranging from 61% to 78% and good interrater reliability (k > 0.6 for all markers). There was no evidence of an interaction between NCCT markers and benefit from intensive BP reduction (all p for interaction >0.10). CONCLUSIONS NCCT signs reliably identify ICH patients at high risk of hematoma growth. However, we found no evidence that patients with these markers specifically benefit from intensive BP reduction. CLINICALTRIALSGOV IDENTIFIER NCT01176565.
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Affiliation(s)
- Andrea Morotti
- From the Department of Neurology, Division of Neurocritical Care and Emergency Neurology (A.M., J.M.R., J.N.G.), Neuroradiology Service, Department of Radiology (J.M.R.), the J.P. Kistler Stroke Research Center (A.M., G.B., J.M.R., M.J.J., A.V., K.S., S.M.G., J.R., J.N.G.), and Department of Emergency Medicine (J.N.G.), Massachusetts General Hospital, Harvard Medical School, Boston; Department of Neuroradiology (G.B.), Université Paris Descartes, INSERM S894, DHU Neurovasc, Centre Hospitalier Sainte-Anne, Paris, France; Department of Neurosurgery (H.B.B.), Brain Center, Rudolf Magnus University Medical Center, Utrecht, the Netherlands; Zeenat Qureshi Stroke Research Center (M.R.A., A.I.Q.), University of Minnesota, Minneapolis; and Department of Public Health Sciences (C.C., R.H.M.), Medical University of South Carolina, Charleston.
| | - Gregoire Boulouis
- From the Department of Neurology, Division of Neurocritical Care and Emergency Neurology (A.M., J.M.R., J.N.G.), Neuroradiology Service, Department of Radiology (J.M.R.), the J.P. Kistler Stroke Research Center (A.M., G.B., J.M.R., M.J.J., A.V., K.S., S.M.G., J.R., J.N.G.), and Department of Emergency Medicine (J.N.G.), Massachusetts General Hospital, Harvard Medical School, Boston; Department of Neuroradiology (G.B.), Université Paris Descartes, INSERM S894, DHU Neurovasc, Centre Hospitalier Sainte-Anne, Paris, France; Department of Neurosurgery (H.B.B.), Brain Center, Rudolf Magnus University Medical Center, Utrecht, the Netherlands; Zeenat Qureshi Stroke Research Center (M.R.A., A.I.Q.), University of Minnesota, Minneapolis; and Department of Public Health Sciences (C.C., R.H.M.), Medical University of South Carolina, Charleston
| | - Javier M Romero
- From the Department of Neurology, Division of Neurocritical Care and Emergency Neurology (A.M., J.M.R., J.N.G.), Neuroradiology Service, Department of Radiology (J.M.R.), the J.P. Kistler Stroke Research Center (A.M., G.B., J.M.R., M.J.J., A.V., K.S., S.M.G., J.R., J.N.G.), and Department of Emergency Medicine (J.N.G.), Massachusetts General Hospital, Harvard Medical School, Boston; Department of Neuroradiology (G.B.), Université Paris Descartes, INSERM S894, DHU Neurovasc, Centre Hospitalier Sainte-Anne, Paris, France; Department of Neurosurgery (H.B.B.), Brain Center, Rudolf Magnus University Medical Center, Utrecht, the Netherlands; Zeenat Qureshi Stroke Research Center (M.R.A., A.I.Q.), University of Minnesota, Minneapolis; and Department of Public Health Sciences (C.C., R.H.M.), Medical University of South Carolina, Charleston
| | - H Bart Brouwers
- From the Department of Neurology, Division of Neurocritical Care and Emergency Neurology (A.M., J.M.R., J.N.G.), Neuroradiology Service, Department of Radiology (J.M.R.), the J.P. Kistler Stroke Research Center (A.M., G.B., J.M.R., M.J.J., A.V., K.S., S.M.G., J.R., J.N.G.), and Department of Emergency Medicine (J.N.G.), Massachusetts General Hospital, Harvard Medical School, Boston; Department of Neuroradiology (G.B.), Université Paris Descartes, INSERM S894, DHU Neurovasc, Centre Hospitalier Sainte-Anne, Paris, France; Department of Neurosurgery (H.B.B.), Brain Center, Rudolf Magnus University Medical Center, Utrecht, the Netherlands; Zeenat Qureshi Stroke Research Center (M.R.A., A.I.Q.), University of Minnesota, Minneapolis; and Department of Public Health Sciences (C.C., R.H.M.), Medical University of South Carolina, Charleston
| | - Michael J Jessel
- From the Department of Neurology, Division of Neurocritical Care and Emergency Neurology (A.M., J.M.R., J.N.G.), Neuroradiology Service, Department of Radiology (J.M.R.), the J.P. Kistler Stroke Research Center (A.M., G.B., J.M.R., M.J.J., A.V., K.S., S.M.G., J.R., J.N.G.), and Department of Emergency Medicine (J.N.G.), Massachusetts General Hospital, Harvard Medical School, Boston; Department of Neuroradiology (G.B.), Université Paris Descartes, INSERM S894, DHU Neurovasc, Centre Hospitalier Sainte-Anne, Paris, France; Department of Neurosurgery (H.B.B.), Brain Center, Rudolf Magnus University Medical Center, Utrecht, the Netherlands; Zeenat Qureshi Stroke Research Center (M.R.A., A.I.Q.), University of Minnesota, Minneapolis; and Department of Public Health Sciences (C.C., R.H.M.), Medical University of South Carolina, Charleston
| | - Anastasia Vashkevich
- From the Department of Neurology, Division of Neurocritical Care and Emergency Neurology (A.M., J.M.R., J.N.G.), Neuroradiology Service, Department of Radiology (J.M.R.), the J.P. Kistler Stroke Research Center (A.M., G.B., J.M.R., M.J.J., A.V., K.S., S.M.G., J.R., J.N.G.), and Department of Emergency Medicine (J.N.G.), Massachusetts General Hospital, Harvard Medical School, Boston; Department of Neuroradiology (G.B.), Université Paris Descartes, INSERM S894, DHU Neurovasc, Centre Hospitalier Sainte-Anne, Paris, France; Department of Neurosurgery (H.B.B.), Brain Center, Rudolf Magnus University Medical Center, Utrecht, the Netherlands; Zeenat Qureshi Stroke Research Center (M.R.A., A.I.Q.), University of Minnesota, Minneapolis; and Department of Public Health Sciences (C.C., R.H.M.), Medical University of South Carolina, Charleston
| | - Kristin Schwab
- From the Department of Neurology, Division of Neurocritical Care and Emergency Neurology (A.M., J.M.R., J.N.G.), Neuroradiology Service, Department of Radiology (J.M.R.), the J.P. Kistler Stroke Research Center (A.M., G.B., J.M.R., M.J.J., A.V., K.S., S.M.G., J.R., J.N.G.), and Department of Emergency Medicine (J.N.G.), Massachusetts General Hospital, Harvard Medical School, Boston; Department of Neuroradiology (G.B.), Université Paris Descartes, INSERM S894, DHU Neurovasc, Centre Hospitalier Sainte-Anne, Paris, France; Department of Neurosurgery (H.B.B.), Brain Center, Rudolf Magnus University Medical Center, Utrecht, the Netherlands; Zeenat Qureshi Stroke Research Center (M.R.A., A.I.Q.), University of Minnesota, Minneapolis; and Department of Public Health Sciences (C.C., R.H.M.), Medical University of South Carolina, Charleston
| | - Mohammad Rauf Afzal
- From the Department of Neurology, Division of Neurocritical Care and Emergency Neurology (A.M., J.M.R., J.N.G.), Neuroradiology Service, Department of Radiology (J.M.R.), the J.P. Kistler Stroke Research Center (A.M., G.B., J.M.R., M.J.J., A.V., K.S., S.M.G., J.R., J.N.G.), and Department of Emergency Medicine (J.N.G.), Massachusetts General Hospital, Harvard Medical School, Boston; Department of Neuroradiology (G.B.), Université Paris Descartes, INSERM S894, DHU Neurovasc, Centre Hospitalier Sainte-Anne, Paris, France; Department of Neurosurgery (H.B.B.), Brain Center, Rudolf Magnus University Medical Center, Utrecht, the Netherlands; Zeenat Qureshi Stroke Research Center (M.R.A., A.I.Q.), University of Minnesota, Minneapolis; and Department of Public Health Sciences (C.C., R.H.M.), Medical University of South Carolina, Charleston
| | - Christy Cassarly
- From the Department of Neurology, Division of Neurocritical Care and Emergency Neurology (A.M., J.M.R., J.N.G.), Neuroradiology Service, Department of Radiology (J.M.R.), the J.P. Kistler Stroke Research Center (A.M., G.B., J.M.R., M.J.J., A.V., K.S., S.M.G., J.R., J.N.G.), and Department of Emergency Medicine (J.N.G.), Massachusetts General Hospital, Harvard Medical School, Boston; Department of Neuroradiology (G.B.), Université Paris Descartes, INSERM S894, DHU Neurovasc, Centre Hospitalier Sainte-Anne, Paris, France; Department of Neurosurgery (H.B.B.), Brain Center, Rudolf Magnus University Medical Center, Utrecht, the Netherlands; Zeenat Qureshi Stroke Research Center (M.R.A., A.I.Q.), University of Minnesota, Minneapolis; and Department of Public Health Sciences (C.C., R.H.M.), Medical University of South Carolina, Charleston
| | - Steven M Greenberg
- From the Department of Neurology, Division of Neurocritical Care and Emergency Neurology (A.M., J.M.R., J.N.G.), Neuroradiology Service, Department of Radiology (J.M.R.), the J.P. Kistler Stroke Research Center (A.M., G.B., J.M.R., M.J.J., A.V., K.S., S.M.G., J.R., J.N.G.), and Department of Emergency Medicine (J.N.G.), Massachusetts General Hospital, Harvard Medical School, Boston; Department of Neuroradiology (G.B.), Université Paris Descartes, INSERM S894, DHU Neurovasc, Centre Hospitalier Sainte-Anne, Paris, France; Department of Neurosurgery (H.B.B.), Brain Center, Rudolf Magnus University Medical Center, Utrecht, the Netherlands; Zeenat Qureshi Stroke Research Center (M.R.A., A.I.Q.), University of Minnesota, Minneapolis; and Department of Public Health Sciences (C.C., R.H.M.), Medical University of South Carolina, Charleston
| | - Reneé Hebert Martin
- From the Department of Neurology, Division of Neurocritical Care and Emergency Neurology (A.M., J.M.R., J.N.G.), Neuroradiology Service, Department of Radiology (J.M.R.), the J.P. Kistler Stroke Research Center (A.M., G.B., J.M.R., M.J.J., A.V., K.S., S.M.G., J.R., J.N.G.), and Department of Emergency Medicine (J.N.G.), Massachusetts General Hospital, Harvard Medical School, Boston; Department of Neuroradiology (G.B.), Université Paris Descartes, INSERM S894, DHU Neurovasc, Centre Hospitalier Sainte-Anne, Paris, France; Department of Neurosurgery (H.B.B.), Brain Center, Rudolf Magnus University Medical Center, Utrecht, the Netherlands; Zeenat Qureshi Stroke Research Center (M.R.A., A.I.Q.), University of Minnesota, Minneapolis; and Department of Public Health Sciences (C.C., R.H.M.), Medical University of South Carolina, Charleston
| | - Adnan I Qureshi
- From the Department of Neurology, Division of Neurocritical Care and Emergency Neurology (A.M., J.M.R., J.N.G.), Neuroradiology Service, Department of Radiology (J.M.R.), the J.P. Kistler Stroke Research Center (A.M., G.B., J.M.R., M.J.J., A.V., K.S., S.M.G., J.R., J.N.G.), and Department of Emergency Medicine (J.N.G.), Massachusetts General Hospital, Harvard Medical School, Boston; Department of Neuroradiology (G.B.), Université Paris Descartes, INSERM S894, DHU Neurovasc, Centre Hospitalier Sainte-Anne, Paris, France; Department of Neurosurgery (H.B.B.), Brain Center, Rudolf Magnus University Medical Center, Utrecht, the Netherlands; Zeenat Qureshi Stroke Research Center (M.R.A., A.I.Q.), University of Minnesota, Minneapolis; and Department of Public Health Sciences (C.C., R.H.M.), Medical University of South Carolina, Charleston
| | - Jonathan Rosand
- From the Department of Neurology, Division of Neurocritical Care and Emergency Neurology (A.M., J.M.R., J.N.G.), Neuroradiology Service, Department of Radiology (J.M.R.), the J.P. Kistler Stroke Research Center (A.M., G.B., J.M.R., M.J.J., A.V., K.S., S.M.G., J.R., J.N.G.), and Department of Emergency Medicine (J.N.G.), Massachusetts General Hospital, Harvard Medical School, Boston; Department of Neuroradiology (G.B.), Université Paris Descartes, INSERM S894, DHU Neurovasc, Centre Hospitalier Sainte-Anne, Paris, France; Department of Neurosurgery (H.B.B.), Brain Center, Rudolf Magnus University Medical Center, Utrecht, the Netherlands; Zeenat Qureshi Stroke Research Center (M.R.A., A.I.Q.), University of Minnesota, Minneapolis; and Department of Public Health Sciences (C.C., R.H.M.), Medical University of South Carolina, Charleston
| | - Joshua N Goldstein
- From the Department of Neurology, Division of Neurocritical Care and Emergency Neurology (A.M., J.M.R., J.N.G.), Neuroradiology Service, Department of Radiology (J.M.R.), the J.P. Kistler Stroke Research Center (A.M., G.B., J.M.R., M.J.J., A.V., K.S., S.M.G., J.R., J.N.G.), and Department of Emergency Medicine (J.N.G.), Massachusetts General Hospital, Harvard Medical School, Boston; Department of Neuroradiology (G.B.), Université Paris Descartes, INSERM S894, DHU Neurovasc, Centre Hospitalier Sainte-Anne, Paris, France; Department of Neurosurgery (H.B.B.), Brain Center, Rudolf Magnus University Medical Center, Utrecht, the Netherlands; Zeenat Qureshi Stroke Research Center (M.R.A., A.I.Q.), University of Minnesota, Minneapolis; and Department of Public Health Sciences (C.C., R.H.M.), Medical University of South Carolina, Charleston
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7
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Boulouis G, Morotti A, Brouwers HB, Charidimou A, Jessel MJ, Auriel E, Pontes-Neto O, Ayres A, Vashkevich A, Schwab KM, Rosand J, Viswanathan A, Gurol ME, Greenberg SM, Goldstein JN. Association Between Hypodensities Detected by Computed Tomography and Hematoma Expansion in Patients With Intracerebral Hemorrhage. JAMA Neurol 2017; 73:961-8. [PMID: 27323314 DOI: 10.1001/jamaneurol.2016.1218] [Citation(s) in RCA: 161] [Impact Index Per Article: 23.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
IMPORTANCE Hematoma expansion is a potentially modifiable predictor of poor outcome following an acute intracerebral hemorrhage (ICH). The ability to identify patients with ICH who are likeliest to experience hematoma expansion and therefore likeliest to benefit from expansion-targeted treatments remains an unmet need. Hypodensities within an ICH detected by noncontrast computed tomography (NCCT) have been suggested as a predictor of hematoma expansion. OBJECTIVE To determine whether hypodense regions, irrespective of their specific patterns, are associated with hematoma expansion in patients with ICH. DESIGN, SETTING, AND PARTICIPANTS We analyzed a large cohort of 784 patients with ICH (the development cohort; 55.6% female), examined NCCT findings for any hypodensity, and replicated our findings on a different cohort of patients (the replication cohort; 52.7% female). Baseline and follow-up NCCT data from consecutive patients with ICH presenting to a tertiary care hospital between 1994 and 2015 were retrospectively analyzed. Data analyses were performed between December 2015 and January 2016. MAIN OUTCOMES AND MEASURES Hypodensities were analyzed by 2 independent blinded raters. The association between hypodensities and hematoma expansion (>6 cm3 or 33% of baseline volume) was determined by multivariable logistic regression after controlling for other variables associated with hematoma expansion in univariate analyses with P ≤ .10. RESULTS A total of 1029 patients were included in the analysis. In the development and replication cohorts, 222 of 784 patients (28.3%) and 99 of 245 patients (40.4%; 321 of 1029 patients [31.2%]), respectively, had NCCT scans that demonstrated hypodensities at baseline (κ = 0.87 for interrater reliability). In univariate analyses, hypodensities were associated with hematoma expansion (86 of 163 patients with hematoma expansion had hypodensities [52.8%], whereas 136 of 621 patients without hematoma expansion had hypodensities [21.9%]; P < .001). The association between hypodensities and hematoma expansion remained significant (odds ratio, 3.42 [95% CI, 2.21-5.31]; P < .001) in a multivariable model; other independent predictors of hematoma expansion were a CT angiography spot sign, a shorter time to CT, warfarin use, and older age. The independent predictive value of hypodensities was again demonstrated in the replication cohort (odds ratio, 4.37 [95% CI, 2.05-9.62]; P < .001). CONCLUSION AND RELEVANCE Hypodensities within an acute ICH detected on an NCCT scan may predict hematoma expansion, independent of other clinical and imaging predictors. This novel marker may help clarify the mechanism of hematoma expansion and serve as a useful addition to clinical algorithms for determining the risk of and treatment stratification for hematoma expansion.
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Affiliation(s)
- Gregoire Boulouis
- Hemorrhagic Stroke Research Program, Department of Neurology, Massachusetts General Hospital Stroke Research Center, Harvard Medical School, Boston
| | - Andrea Morotti
- Hemorrhagic Stroke Research Program, Department of Neurology, Massachusetts General Hospital Stroke Research Center, Harvard Medical School, Boston
| | - H Bart Brouwers
- Hemorrhagic Stroke Research Program, Department of Neurology, Massachusetts General Hospital Stroke Research Center, Harvard Medical School, Boston2Department of Neurosurgery, Brain Center Rudolf Magnus, University Medical Center Utrecht, Utrecht Universi
| | - Andreas Charidimou
- Hemorrhagic Stroke Research Program, Department of Neurology, Massachusetts General Hospital Stroke Research Center, Harvard Medical School, Boston
| | - Michael J Jessel
- Hemorrhagic Stroke Research Program, Department of Neurology, Massachusetts General Hospital Stroke Research Center, Harvard Medical School, Boston
| | - Eitan Auriel
- Hemorrhagic Stroke Research Program, Department of Neurology, Massachusetts General Hospital Stroke Research Center, Harvard Medical School, Boston
| | - Octávio Pontes-Neto
- Hemorrhagic Stroke Research Program, Department of Neurology, Massachusetts General Hospital Stroke Research Center, Harvard Medical School, Boston
| | - Alison Ayres
- Hemorrhagic Stroke Research Program, Department of Neurology, Massachusetts General Hospital Stroke Research Center, Harvard Medical School, Boston
| | - Anastasia Vashkevich
- Hemorrhagic Stroke Research Program, Department of Neurology, Massachusetts General Hospital Stroke Research Center, Harvard Medical School, Boston
| | - Kristin M Schwab
- Hemorrhagic Stroke Research Program, Department of Neurology, Massachusetts General Hospital Stroke Research Center, Harvard Medical School, Boston
| | - Jonathan Rosand
- Hemorrhagic Stroke Research Program, Department of Neurology, Massachusetts General Hospital Stroke Research Center, Harvard Medical School, Boston3Division of Neurocritical Care and Emergency Neurology, Massachusetts General Hospital, Harvard Medical Sch
| | - Anand Viswanathan
- Hemorrhagic Stroke Research Program, Department of Neurology, Massachusetts General Hospital Stroke Research Center, Harvard Medical School, Boston
| | - Mahmut E Gurol
- Hemorrhagic Stroke Research Program, Department of Neurology, Massachusetts General Hospital Stroke Research Center, Harvard Medical School, Boston
| | - Steven M Greenberg
- Hemorrhagic Stroke Research Program, Department of Neurology, Massachusetts General Hospital Stroke Research Center, Harvard Medical School, Boston
| | - Joshua N Goldstein
- Hemorrhagic Stroke Research Program, Department of Neurology, Massachusetts General Hospital Stroke Research Center, Harvard Medical School, Boston3Division of Neurocritical Care and Emergency Neurology, Massachusetts General Hospital, Harvard Medical Sch
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8
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Boulouis G, van Etten ES, Charidimou A, Auriel E, Morotti A, Pasi M, Haley KE, Brouwers HB, Ayres AM, Vashkevich A, Jessel MJ, Schwab KM, Viswanathan A, Greenberg SM, Rosand J, Goldstein JN, Gurol ME. Association of Key Magnetic Resonance Imaging Markers of Cerebral Small Vessel Disease With Hematoma Volume and Expansion in Patients With Lobar and Deep Intracerebral Hemorrhage. JAMA Neurol 2017; 73:1440-1447. [PMID: 27723863 DOI: 10.1001/jamaneurol.2016.2619] [Citation(s) in RCA: 52] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Importance Hematoma expansion is an important determinant of outcome in spontaneous intracerebral hemorrhage (ICH) due to small vessel disease (SVD), but the association between the severity of the underlying SVD and the extent of bleeding at the acute phase is unknown to date. Objective To investigate the association between key magnetic resonance imaging (MRI) markers of SVD (as per the Standards for Reporting Vascular Changes on Neuroimaging [STRIVE] guidelines) and hematoma volume and expansion in patients with lobar or deep ICH. Design, Setting, and Participants Analysis of data collected from 418 consecutive patients admitted with primary lobar or deep ICH to a single tertiary care medical center between January 1, 2000, and October 1, 2012. Data were analyzed on March 4, 2016. Participants were consecutive patients with computed tomographic images allowing ICH volume calculation and MRI allowing imaging markers of SVD assessment. Main Outcomes and Measures The ICH volumes at baseline and within 48 hours after symptom onset were measured in 418 patients with spontaneous ICH without anticoagulant therapy, and hematoma expansion was calculated. Cerebral microbleeds, cortical superficial siderosis, and white matter hyperintensity volume were assessed on MRI. The associations between these SVD markers and ICH volume, as well as hematoma expansion, were investigated using multivariable models. Results This study analyzed 254 patients with lobar ICH (mean [SD] age, 75 [11] years and 140 [55.1%] female) and 164 patients with deep ICH (mean [SD] age 67 [14] years and 71 [43.3%] female). The presence of cortical superficial siderosis was an independent variable associated with larger ICH volume in the lobar ICH group (odds ratio per quintile increase in final ICH volume, 1.49; 95% CI, 1.14-1.94; P = .004). In multivariable models, the absence of cerebral microbleeds was associated with larger ICH volume for both the lobar and deep ICH groups (odds ratios per quintile increase in final ICH volume, 1.41; 95% CI, 1.11-1.81; P = .006 and 1.43; 95% CI, 1.04-1.99; P = .03; respectively) and with hematoma expansion in the lobar ICH group (odds ratio, 1.70; 95% CI, 1.07-2.92; P = .04). The white matter hyperintensity volumes were not associated with either hematoma volume or expansion. Conclusions and Relevance In patients admitted with primary lobar or deep ICH to a single tertiary care medical center, the presence of cortical superficial siderosis was an independent variable associated with larger lobar ICH volume, and the absence of cerebral microbleeds was associated with larger lobar and deep ICHs. The absence of cerebral microbleeds was independently associated with more frequent hematoma expansion in patients with lobar ICH. We provide an analytical framework for future studies aimed at limiting hematoma expansion.
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Affiliation(s)
- Gregoire Boulouis
- Hemorrhagic Stroke Research Program, Department of Neurology, Massachusetts General Hospital Stroke Research Center, Harvard Medical School, Boston
| | - Ellis S van Etten
- Hemorrhagic Stroke Research Program, Department of Neurology, Massachusetts General Hospital Stroke Research Center, Harvard Medical School, Boston2Department of Neurology, Leiden University Medical Center, Leiden, the Netherlands
| | - Andreas Charidimou
- Hemorrhagic Stroke Research Program, Department of Neurology, Massachusetts General Hospital Stroke Research Center, Harvard Medical School, Boston
| | - Eitan Auriel
- Hemorrhagic Stroke Research Program, Department of Neurology, Massachusetts General Hospital Stroke Research Center, Harvard Medical School, Boston
| | - Andrea Morotti
- Hemorrhagic Stroke Research Program, Department of Neurology, Massachusetts General Hospital Stroke Research Center, Harvard Medical School, Boston
| | - Marco Pasi
- Hemorrhagic Stroke Research Program, Department of Neurology, Massachusetts General Hospital Stroke Research Center, Harvard Medical School, Boston
| | - Kellen E Haley
- Hemorrhagic Stroke Research Program, Department of Neurology, Massachusetts General Hospital Stroke Research Center, Harvard Medical School, Boston
| | - H Bart Brouwers
- Hemorrhagic Stroke Research Program, Department of Neurology, Massachusetts General Hospital Stroke Research Center, Harvard Medical School, Boston3Brain Center Rudolf Magnus, Department of Neurosurgery, University Medical Center Utrecht, Heidelberglaan, Utrecht, the Netherlands
| | - Alison M Ayres
- Hemorrhagic Stroke Research Program, Department of Neurology, Massachusetts General Hospital Stroke Research Center, Harvard Medical School, Boston
| | - Anastasia Vashkevich
- Hemorrhagic Stroke Research Program, Department of Neurology, Massachusetts General Hospital Stroke Research Center, Harvard Medical School, Boston
| | - Michael J Jessel
- Hemorrhagic Stroke Research Program, Department of Neurology, Massachusetts General Hospital Stroke Research Center, Harvard Medical School, Boston
| | - Kristin M Schwab
- Hemorrhagic Stroke Research Program, Department of Neurology, Massachusetts General Hospital Stroke Research Center, Harvard Medical School, Boston
| | - Anand Viswanathan
- Hemorrhagic Stroke Research Program, Department of Neurology, Massachusetts General Hospital Stroke Research Center, Harvard Medical School, Boston
| | - Steven M Greenberg
- Hemorrhagic Stroke Research Program, Department of Neurology, Massachusetts General Hospital Stroke Research Center, Harvard Medical School, Boston
| | - Jonathan Rosand
- Hemorrhagic Stroke Research Program, Department of Neurology, Massachusetts General Hospital Stroke Research Center, Harvard Medical School, Boston
| | - Joshua N Goldstein
- Hemorrhagic Stroke Research Program, Department of Neurology, Massachusetts General Hospital Stroke Research Center, Harvard Medical School, Boston4Division of Neurocritical Care and Emergency Neurology, Massachusetts General Hospital, Harvard Medical School, Boston
| | - M Edip Gurol
- Hemorrhagic Stroke Research Program, Department of Neurology, Massachusetts General Hospital Stroke Research Center, Harvard Medical School, Boston
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Morotti A, Charidimou A, Phuah CL, Jessel MJ, Schwab K, Ayres AM, Romero JM, Viswanathan A, Gurol ME, Greenberg SM, Anderson CD, Rosand J, Goldstein JN. Association Between Serum Calcium Level and Extent of Bleeding in Patients With Intracerebral Hemorrhage. JAMA Neurol 2017; 73:1285-1290. [PMID: 27598746 DOI: 10.1001/jamaneurol.2016.2252] [Citation(s) in RCA: 66] [Impact Index Per Article: 9.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
Importance Calcium is a key cofactor of the coagulation cascade and may play a role in the pathophysiology of intracerebral hemorrhage (ICH). Objective To investigate whether a low serum calcium level is associated with an increase in the extent of bleeding in patients with ICH as measured by baseline hematoma volume and risk of hematoma expansion. Design, Setting, and Participants Prospective cohort study of 2103 consecutive patients with primary ICH ascertained during the period between 1994 and 2015 at an academic medical center. The statistical analysis was performed in January 2016. Main Outcomes and Measures Total calcium level was measured on admission, and hypocalcemia was defined as a serum calcium level of less than 8.4 mg/dL. Baseline and follow-up hematoma volumes, detected by noncontrast computed tomography, were measured using a computer-assisted semiautomatic analysis. Hematoma expansion was defined as an increase of more than 30% or 6 mL from baseline ICH volume. Associations between serum calcium level and baseline hematoma volume and between serum calcium level and ICH expansion were investigated in multivariable linear and logistic regression models, respectively. Results A total of 2123 patients with primary ICH were screened, and 2103 patients met the inclusion criteria (mean [SD] age, 72.7 [12.5] years; 54.3% male patients), of whom 229 (10.9%) had hypocalcemia on admission. Hypocalcemic patients had a higher median baseline hematoma volume than did normocalcemic patients (37 mL [IQR, 15-72 mL] vs 16 mL [IQR, 6-44 mL]; P < .001). Low calcium levels were independently associated with higher baseline ICH volume (β = -0.13, SE = .03, P < .001). A total of 1393 patients underwent follow-up noncontrast computed tomography and were included in the ICH expansion analysis. In this subgroup, a higher serum calcium level was associated with reduced risk of ICH expansion (odds ratio, 0.55 [95% CI, 0.35-0.86]; P = .01), after adjusting for other confounders. Conclusions and Relevance Hypocalcemia correlates with the extent of bleeding in patients with ICH. A low calcium level may be associated with a subtle coagulopathy predisposing to increased bleeding and might therefore be a promising therapeutic target for acute ICH treatment trials.
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Affiliation(s)
- Andrea Morotti
- Neurology Unit, Department of Clinical and Experimental Sciences, University of Brescia, Brescia, Italy2Division of Neurocritical Care and Emergency Neurology, Department of Neurology, Massachusetts General Hospital, Boston3J. Philip Kistler Stroke Research Center, Massachusetts General Hospital, Boston
| | - Andreas Charidimou
- J. Philip Kistler Stroke Research Center, Massachusetts General Hospital, Boston
| | - Chia-Ling Phuah
- Division of Neurocritical Care and Emergency Neurology, Department of Neurology, Massachusetts General Hospital, Boston3J. Philip Kistler Stroke Research Center, Massachusetts General Hospital, Boston
| | - Michael J Jessel
- J. Philip Kistler Stroke Research Center, Massachusetts General Hospital, Boston
| | - Kristin Schwab
- J. Philip Kistler Stroke Research Center, Massachusetts General Hospital, Boston
| | - Alison M Ayres
- J. Philip Kistler Stroke Research Center, Massachusetts General Hospital, Boston
| | - Javier M Romero
- Neuroradiology Service, Department of Radiology, Massachusetts General Hospital, Boston
| | - Anand Viswanathan
- J. Philip Kistler Stroke Research Center, Massachusetts General Hospital, Boston
| | - M Edip Gurol
- J. Philip Kistler Stroke Research Center, Massachusetts General Hospital, Boston
| | - Steven M Greenberg
- J. Philip Kistler Stroke Research Center, Massachusetts General Hospital, Boston
| | - Christopher D Anderson
- Division of Neurocritical Care and Emergency Neurology, Department of Neurology, Massachusetts General Hospital, Boston3J. Philip Kistler Stroke Research Center, Massachusetts General Hospital, Boston
| | - Jonathan Rosand
- Division of Neurocritical Care and Emergency Neurology, Department of Neurology, Massachusetts General Hospital, Boston3J. Philip Kistler Stroke Research Center, Massachusetts General Hospital, Boston
| | - Joshua N Goldstein
- Division of Neurocritical Care and Emergency Neurology, Department of Neurology, Massachusetts General Hospital, Boston3J. Philip Kistler Stroke Research Center, Massachusetts General Hospital, Boston5Department of Emergency Medicine, Massachusetts General Hospital, Boston
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10
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Boulouis G, Charidimou A, Jessel MJ, Xiong L, Roongpiboonsopit D, Fotiadis P, Pasi M, Ayres A, Merrill ME, Schwab KM, Rosand J, Gurol ME, Greenberg SM, Viswanathan A. Abstract TMP95: Small Vessel Disease Burden and Clinical Symptoms in Cerebral Amyloid Angiopathy Patients Presenting Without Symptomatic Hemorrhage. Stroke 2017. [DOI: 10.1161/str.48.suppl_1.tmp95] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Introduction:
Cerebral amyloid angiopathy (CAA) is a common age-related small vessel disease (SVD). Patients without ICH typically present with transient focal neurological episodes (TFNEs) or cognitive symptoms. We sought to determine if SVD lesion burden differed between CAA patients first presenting with TFNEs versus cognitive symptoms.
Methods:
A total of 647 patients presenting either to a stroke department (n=205) or an outpatient memory clinic (n=442), were screened for eligibility. Patients meeting modified Boston criteria for probable CAA were included and markers of SVD were quantified including cerebral microbleeds (CMBs), perivascular spaces, cortical superficial siderosis (cSS), and white matter hyperintensities (WMH). Patients were classified according to presentation symptoms (TFNEs vs cognitive). Total CAA-SVD burden was assessed using a validated summary score. Individual neuroimaging markers and total SVD burden were compared between groups using univariable and multivariable models.
Results:
There were 261 probable CAA patients included. After adjustment for confounders, patients first seen for TFNEs (n=97) demonstrated a higher prevalence of cSS (p<.0001), higher WMH volumes (p=0.03) and a trend towards higher CMBs counts (p=.09). The total SVD summary score was higher in patients seen for TFNEs (adjusted OR per additional score point=1.46, 95%CI [1.16 - 1.84], p=0.013).
Conclusion:
We present a large cohort of probable CAA patients without ICH and show that those first evaluated for TFNEs bear a higher burden of structural MRI SVD related damage compared to those first seen for cognitive symptoms. This study sheds light on CAA disease phenotypes, adds to the understanding of CAA clinical expression, and sets the basis for future works investigating CAA prognosis amongst phenotypes.
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Affiliation(s)
| | | | | | - Li Xiong
- Neurology Dept, Massachusetts General Hosp, Boston, MA
| | | | | | - Marco Pasi
- Neurology Dept, Massachusetts General Hosp, Boston, MA
| | - Alison Ayres
- Neurology Dept, Massachusetts General Hosp, Boston, MA
| | | | | | | | - M. Edip Gurol
- Neurology Dept, Massachusetts General Hosp, Boston, MA
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Morotti A, Brouwers BH, Romero JM, Jessel MJ, Vashkevich A, Schwab K, Afzal R, Cassarly C, Greenberg SM, Hebert Martin R, Qureshi AI, Rosand J, Goldstein JN. Abstract 215: Does the CT Angiography Spot Sign Identify Intracerebral Hemorrhage Patients More Likely to Benefit From Intensive Blood Pressure Reduction? Stroke 2017. [DOI: 10.1161/str.48.suppl_1.215] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background and Purpose:
the computed tomography angiography (CTA) spot sign is a strong predictor of intracerebral hemorrhage (ICH) expansion, and may mark those most likely to benefit from intensive blood pressure (BP) reduction. The Spot Sign score in restricting ICH growth (SCORE-IT) study analyzed whether intensive BP reduction improved outcome in Spot Sign positive patients enrolled in the Antihypertensive Treatment of Acute Cerebral Hemorrhage II (ATACH-2) clinical trial.
Methods:
In ATACH-2, patients with ICH were randomly assigned to intensive (systolic BP target: 110-139 mmHg) versus standard (systolic BP target: 140-179 mmHg) BP treatment within 4.5 h from stroke onset. This analysis included patients with a CTA performed within 8 hours from onset. The association between intensive BP lowering, ICH expansion and functional outcome was investigated with a multivariable logistic regression model.
Results:
133 subjects met the inclusion criteria, of whom 53 (39.9%) had a spot sign and 24/123 (19.5%) experienced ICH expansion. A total of 56/123 patients had a 90 day modified Rankin scale (mRS) >3 (45.5%). Among Spot positive patients, 74.1% of those in the intensive BP lowering group had poor outcome, compared with 50.0% of those in the standard group (p=0.31). After adjustment for potential confounders, intensive BP lowering was not associated with a significant reduction of ICH expansion (odds ratio [OR] 0.83, 95% confidence interval [CI] 0.27 - 2.51, p = 0.74) or improved functional outcome (OR for mRS>3 1.24, 95% CI 0.53 - 2.91, p = 0.62) in spot sign positive ICH patients.
Conclusions:
We found no evidence that ICH patients with a spot sign specifically benefit from intensive BP reduction.
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Affiliation(s)
- Andrea Morotti
- Neurology, Massachusetts General Hosp, Harvard Med Sch, Boston, MA
| | - Bart H Brouwers
- Dept of Neurosurgery, Brain Cntr Rudolf Magnus Univ Med Cntr, Utrecht, Netherlands
| | - Javier M Romero
- Neurology, Massachusetts General Hosp, Harvard Med Sch, Boston, MA
| | - Michael J Jessel
- Neurology, Massachusetts General Hosp, Harvard Med Sch, Boston, MA
| | | | - Kristin Schwab
- Neurology, Massachusetts General Hosp, Harvard Med Sch, Boston, MA
| | | | - Christy Cassarly
- Dept of Public Health Sciences, Med Univ of South Carolina, Charleston, SC
| | | | | | - Adnan I Qureshi
- Zeenat Qureshi Stroke Rsch Cntr, Univ of Minnesota, Minneapolis, MN
| | - Jonathan Rosand
- Neurology, Massachusetts General Hosp, Harvard Med Sch, Boston, MA
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12
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Morotti A, Marini S, Jessel MJ, Schwab K, Ayres AM, Kourkoulis C, Gurol EM, Viswanathan A, Greenberg SM, Anderson CD, Goldstein JN, Rosand J. Abstract TP326: Lymphopenia, Infectious Complications and Outcome in Spontaneous Intracerebral Hemorrhage. Stroke 2017. [DOI: 10.1161/str.48.suppl_1.tp326] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background and Purpose:
lymphopenia is increasingly recognized as a consequence of acute illness and may predispose to infections. We investigated whether admission lymphopenia (AL) is associated with increased risk of infectious complications and poor outcome in patients with spontaneous intracerebral hemorrhage (ICH).
Methods:
we analyzed a prospectively collected cohort of ICH patients ascertained between 1994 and 2015. Subjects were included if they had a lymphocyte count obtained within 24 h from onset and AL was defined as lymphocyte count<1000/uL. Infectious complications were assessed through retrospective chart review and the association between AL, infectious complications and mortality was investigated with a multivariable Cox regression and logistic regression respectively.
Results:
2014 patients met the inclusion criteria (median age 75, males 54.0%) of whom 548 (27.2%) had AL and 605 (30.0%) experienced an infectious complication. Overall case fatality at 90 days was 36.9%. Patients with AL were more severely affected, as highlighted by larger hematoma volume, higher frequency of intraventricular hemorrhage and lower Glasgow Coma Scale score (all p<0.001). AL was independently associated with increased risk of pneumonia (Hazard Ratio [HR] 1.65, 95% confidence interval [CI] 1.32-2.05, p<0.001) and multiple infections (HR 1.75, 95% CI 1.22-2.51, p=0.002). The association with urinary tract infection, sepsis or other infections was not significant. AL was also an independent predictor of 90-day mortality (odds ratio 1.55, 95% CI 1.18-2.04, p=0.002) after adjusting for confounders.
Conclusions:
AL is common in ICH and associated with increased risk of infectious complications and poor outcome. Further studies will be needed to determine whether prophylactic antibiotics in ICH patients with AL can improve outcome.
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Affiliation(s)
- Andrea Morotti
- Neurology, Massachusetts General Hosp, Harvard Med Sch, Boston, MA
| | - Sandro Marini
- Neurology, Massachusetts General Hosp, Harvard Med Sch, Boston, MA
| | - Michael J Jessel
- Neurology, Massachusetts General Hosp, Harvard Med Sch, Boston, MA
| | - Kristin Schwab
- Neurology, Massachusetts General Hosp, Harvard Med Sch, Boston, MA
| | - Alison M Ayres
- Neurology, Massachusetts General Hosp, Harvard Med Sch, Boston, MA
| | | | - Edip M Gurol
- Neurology, Massachusetts General Hosp, Harvard Med Sch, Boston, MA
| | | | | | | | | | - Jonathan Rosand
- Neurology, Massachusetts General Hosp, Harvard Med Sch, Boston, MA
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13
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Boulouis G, Charidimou A, Jessel MJ, Xiong L, Roongpiboonsopit D, Fotiadis P, Pasi M, Ayres A, Merrill ME, Schwab KM, Rosand J, Gurol ME, Greenberg SM, Viswanathan A. Small vessel disease burden in cerebral amyloid angiopathy without symptomatic hemorrhage. Neurology 2017; 88:878-884. [PMID: 28130469 DOI: 10.1212/wnl.0000000000003655] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2016] [Accepted: 10/12/2016] [Indexed: 01/02/2023] Open
Abstract
OBJECTIVE Cerebral amyloid angiopathy (CAA) is a common age-related small vessel disease (SVD). Patients without intracerebral hemorrhage (ICH) typically present with transient focal neurologic episodes (TFNEs) or cognitive symptoms. We sought to determine if SVD lesion burden differed between patients with CAA first presenting with TFNEs vs cognitive symptoms. METHODS A total of 647 patients presenting either to a stroke department (n = 205) or an outpatient memory clinic (n = 442) were screened for eligibility. Patients meeting modified Boston criteria for probable CAA were included and markers of SVD were quantified, including cerebral microbleeds (CMBs), perivascular spaces, cortical superficial siderosis (cSS), and white matter hyperintensities (WMHs). Patients were classified according to presentation symptoms (TFNEs vs cognitive). Total CAA-SVD burden was assessed using a validated summary score. Individual neuroimaging markers and total SVD burden were compared between groups using univariable and multivariable models. RESULTS There were 261 patients with probable CAA included. After adjustment for confounders, patients first seen for TFNEs (n = 97) demonstrated a higher prevalence of cSS (p < 0.0001), higher WMH volumes (p = 0.03), and a trend toward higher CMB counts (p = 0.09). The total SVD summary score was higher in patients seen for TFNEs (adjusted odds ratio per additional score point 1.46, 95% confidence interval 1.16-1.84, p = 0.013). CONCLUSIONS Patients with probable CAA without ICH first evaluated for TFNEs bear a higher burden of structural MRI SVD-related damage compared to those first seen for cognitive symptoms. This study sheds light on neuroimaging profile differences across clinical phenotypes of patients with CAA without ICH.
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Affiliation(s)
- Gregoire Boulouis
- From the Hemorrhagic Stroke Research Program, Department of Neurology, Massachusetts General Hospital Stroke Research Center (G.B., A.C., M.J.J., L.X., D.R., P.F., M.P., A.A., K.M.S., J.R., M.E.G., S.M.G., A.V.), MIND Informatics, Massachusetts General Hospital Biomedical Informatics Core (M.E.M., J.R.), and Division of Neurocritical Care and Emergency Neurology, Massachusetts General Hospital (J.R.), Harvard Medical School, Boston, MA; Neuroradiology Department (G.B.), Université Paris Descartes, INSERM S894, Centre Hospitalier Sainte-Anne, Paris, France; and Faculty of Medicine (D.R.), Naresuan University, Phitsanulok, Thailand.
| | - Andreas Charidimou
- From the Hemorrhagic Stroke Research Program, Department of Neurology, Massachusetts General Hospital Stroke Research Center (G.B., A.C., M.J.J., L.X., D.R., P.F., M.P., A.A., K.M.S., J.R., M.E.G., S.M.G., A.V.), MIND Informatics, Massachusetts General Hospital Biomedical Informatics Core (M.E.M., J.R.), and Division of Neurocritical Care and Emergency Neurology, Massachusetts General Hospital (J.R.), Harvard Medical School, Boston, MA; Neuroradiology Department (G.B.), Université Paris Descartes, INSERM S894, Centre Hospitalier Sainte-Anne, Paris, France; and Faculty of Medicine (D.R.), Naresuan University, Phitsanulok, Thailand
| | - Michael J Jessel
- From the Hemorrhagic Stroke Research Program, Department of Neurology, Massachusetts General Hospital Stroke Research Center (G.B., A.C., M.J.J., L.X., D.R., P.F., M.P., A.A., K.M.S., J.R., M.E.G., S.M.G., A.V.), MIND Informatics, Massachusetts General Hospital Biomedical Informatics Core (M.E.M., J.R.), and Division of Neurocritical Care and Emergency Neurology, Massachusetts General Hospital (J.R.), Harvard Medical School, Boston, MA; Neuroradiology Department (G.B.), Université Paris Descartes, INSERM S894, Centre Hospitalier Sainte-Anne, Paris, France; and Faculty of Medicine (D.R.), Naresuan University, Phitsanulok, Thailand
| | - Li Xiong
- From the Hemorrhagic Stroke Research Program, Department of Neurology, Massachusetts General Hospital Stroke Research Center (G.B., A.C., M.J.J., L.X., D.R., P.F., M.P., A.A., K.M.S., J.R., M.E.G., S.M.G., A.V.), MIND Informatics, Massachusetts General Hospital Biomedical Informatics Core (M.E.M., J.R.), and Division of Neurocritical Care and Emergency Neurology, Massachusetts General Hospital (J.R.), Harvard Medical School, Boston, MA; Neuroradiology Department (G.B.), Université Paris Descartes, INSERM S894, Centre Hospitalier Sainte-Anne, Paris, France; and Faculty of Medicine (D.R.), Naresuan University, Phitsanulok, Thailand
| | - Duangnapa Roongpiboonsopit
- From the Hemorrhagic Stroke Research Program, Department of Neurology, Massachusetts General Hospital Stroke Research Center (G.B., A.C., M.J.J., L.X., D.R., P.F., M.P., A.A., K.M.S., J.R., M.E.G., S.M.G., A.V.), MIND Informatics, Massachusetts General Hospital Biomedical Informatics Core (M.E.M., J.R.), and Division of Neurocritical Care and Emergency Neurology, Massachusetts General Hospital (J.R.), Harvard Medical School, Boston, MA; Neuroradiology Department (G.B.), Université Paris Descartes, INSERM S894, Centre Hospitalier Sainte-Anne, Paris, France; and Faculty of Medicine (D.R.), Naresuan University, Phitsanulok, Thailand
| | - Panagiotis Fotiadis
- From the Hemorrhagic Stroke Research Program, Department of Neurology, Massachusetts General Hospital Stroke Research Center (G.B., A.C., M.J.J., L.X., D.R., P.F., M.P., A.A., K.M.S., J.R., M.E.G., S.M.G., A.V.), MIND Informatics, Massachusetts General Hospital Biomedical Informatics Core (M.E.M., J.R.), and Division of Neurocritical Care and Emergency Neurology, Massachusetts General Hospital (J.R.), Harvard Medical School, Boston, MA; Neuroradiology Department (G.B.), Université Paris Descartes, INSERM S894, Centre Hospitalier Sainte-Anne, Paris, France; and Faculty of Medicine (D.R.), Naresuan University, Phitsanulok, Thailand
| | - Marco Pasi
- From the Hemorrhagic Stroke Research Program, Department of Neurology, Massachusetts General Hospital Stroke Research Center (G.B., A.C., M.J.J., L.X., D.R., P.F., M.P., A.A., K.M.S., J.R., M.E.G., S.M.G., A.V.), MIND Informatics, Massachusetts General Hospital Biomedical Informatics Core (M.E.M., J.R.), and Division of Neurocritical Care and Emergency Neurology, Massachusetts General Hospital (J.R.), Harvard Medical School, Boston, MA; Neuroradiology Department (G.B.), Université Paris Descartes, INSERM S894, Centre Hospitalier Sainte-Anne, Paris, France; and Faculty of Medicine (D.R.), Naresuan University, Phitsanulok, Thailand
| | - Alison Ayres
- From the Hemorrhagic Stroke Research Program, Department of Neurology, Massachusetts General Hospital Stroke Research Center (G.B., A.C., M.J.J., L.X., D.R., P.F., M.P., A.A., K.M.S., J.R., M.E.G., S.M.G., A.V.), MIND Informatics, Massachusetts General Hospital Biomedical Informatics Core (M.E.M., J.R.), and Division of Neurocritical Care and Emergency Neurology, Massachusetts General Hospital (J.R.), Harvard Medical School, Boston, MA; Neuroradiology Department (G.B.), Université Paris Descartes, INSERM S894, Centre Hospitalier Sainte-Anne, Paris, France; and Faculty of Medicine (D.R.), Naresuan University, Phitsanulok, Thailand
| | - M Emily Merrill
- From the Hemorrhagic Stroke Research Program, Department of Neurology, Massachusetts General Hospital Stroke Research Center (G.B., A.C., M.J.J., L.X., D.R., P.F., M.P., A.A., K.M.S., J.R., M.E.G., S.M.G., A.V.), MIND Informatics, Massachusetts General Hospital Biomedical Informatics Core (M.E.M., J.R.), and Division of Neurocritical Care and Emergency Neurology, Massachusetts General Hospital (J.R.), Harvard Medical School, Boston, MA; Neuroradiology Department (G.B.), Université Paris Descartes, INSERM S894, Centre Hospitalier Sainte-Anne, Paris, France; and Faculty of Medicine (D.R.), Naresuan University, Phitsanulok, Thailand
| | - Kristin M Schwab
- From the Hemorrhagic Stroke Research Program, Department of Neurology, Massachusetts General Hospital Stroke Research Center (G.B., A.C., M.J.J., L.X., D.R., P.F., M.P., A.A., K.M.S., J.R., M.E.G., S.M.G., A.V.), MIND Informatics, Massachusetts General Hospital Biomedical Informatics Core (M.E.M., J.R.), and Division of Neurocritical Care and Emergency Neurology, Massachusetts General Hospital (J.R.), Harvard Medical School, Boston, MA; Neuroradiology Department (G.B.), Université Paris Descartes, INSERM S894, Centre Hospitalier Sainte-Anne, Paris, France; and Faculty of Medicine (D.R.), Naresuan University, Phitsanulok, Thailand
| | - Jonathan Rosand
- From the Hemorrhagic Stroke Research Program, Department of Neurology, Massachusetts General Hospital Stroke Research Center (G.B., A.C., M.J.J., L.X., D.R., P.F., M.P., A.A., K.M.S., J.R., M.E.G., S.M.G., A.V.), MIND Informatics, Massachusetts General Hospital Biomedical Informatics Core (M.E.M., J.R.), and Division of Neurocritical Care and Emergency Neurology, Massachusetts General Hospital (J.R.), Harvard Medical School, Boston, MA; Neuroradiology Department (G.B.), Université Paris Descartes, INSERM S894, Centre Hospitalier Sainte-Anne, Paris, France; and Faculty of Medicine (D.R.), Naresuan University, Phitsanulok, Thailand
| | - M Edip Gurol
- From the Hemorrhagic Stroke Research Program, Department of Neurology, Massachusetts General Hospital Stroke Research Center (G.B., A.C., M.J.J., L.X., D.R., P.F., M.P., A.A., K.M.S., J.R., M.E.G., S.M.G., A.V.), MIND Informatics, Massachusetts General Hospital Biomedical Informatics Core (M.E.M., J.R.), and Division of Neurocritical Care and Emergency Neurology, Massachusetts General Hospital (J.R.), Harvard Medical School, Boston, MA; Neuroradiology Department (G.B.), Université Paris Descartes, INSERM S894, Centre Hospitalier Sainte-Anne, Paris, France; and Faculty of Medicine (D.R.), Naresuan University, Phitsanulok, Thailand
| | - Steven M Greenberg
- From the Hemorrhagic Stroke Research Program, Department of Neurology, Massachusetts General Hospital Stroke Research Center (G.B., A.C., M.J.J., L.X., D.R., P.F., M.P., A.A., K.M.S., J.R., M.E.G., S.M.G., A.V.), MIND Informatics, Massachusetts General Hospital Biomedical Informatics Core (M.E.M., J.R.), and Division of Neurocritical Care and Emergency Neurology, Massachusetts General Hospital (J.R.), Harvard Medical School, Boston, MA; Neuroradiology Department (G.B.), Université Paris Descartes, INSERM S894, Centre Hospitalier Sainte-Anne, Paris, France; and Faculty of Medicine (D.R.), Naresuan University, Phitsanulok, Thailand
| | - Anand Viswanathan
- From the Hemorrhagic Stroke Research Program, Department of Neurology, Massachusetts General Hospital Stroke Research Center (G.B., A.C., M.J.J., L.X., D.R., P.F., M.P., A.A., K.M.S., J.R., M.E.G., S.M.G., A.V.), MIND Informatics, Massachusetts General Hospital Biomedical Informatics Core (M.E.M., J.R.), and Division of Neurocritical Care and Emergency Neurology, Massachusetts General Hospital (J.R.), Harvard Medical School, Boston, MA; Neuroradiology Department (G.B.), Université Paris Descartes, INSERM S894, Centre Hospitalier Sainte-Anne, Paris, France; and Faculty of Medicine (D.R.), Naresuan University, Phitsanulok, Thailand
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14
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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] [What about the content of this article? (0)] [Affiliation(s)] [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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15
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Boulouis G, Morotti A, Brouwers HB, Charidimou A, Jessel MJ, Auriel E, Pontes-Neto O, Ayres A, Vashkevich A, Schwab KM, Rosand J, Viswanathan A, Gurol ME, Greenberg SM, Goldstein JN. Noncontrast Computed Tomography Hypodensities Predict Poor Outcome in Intracerebral Hemorrhage Patients. Stroke 2016; 47:2511-6. [PMID: 27601380 DOI: 10.1161/strokeaha.116.014425] [Citation(s) in RCA: 61] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2016] [Accepted: 08/02/2016] [Indexed: 11/16/2022]
Abstract
BACKGROUND AND PURPOSE Noncontrast computed tomographic (CT) hypodensities have been shown to be associated with hematoma expansion in intracerebral hemorrhage (ICH), but their impact on functional outcome is yet to be determined. We evaluated whether baseline noncontrast CT hypodensities are associated with poor clinical outcome. METHODS We performed a retrospective review of a prospectively collected cohort of consecutive patients with primary ICH presenting to a single academic medical center between 1994 and 2016. The presence of CT hypodensities was assessed by 2 independent raters on the baseline CT. Unfavorable outcome was defined as a modified Rankin score >3 at 90 days. The associations between CT hypodensities and unfavorable outcome were investigated using uni- and multivariable logistic regression models. RESULTS During the study period, 1342 patients presented with ICH and 800 met restrictive inclusion criteria (baseline CT available for review, and 90-day outcome available). Three hundred and four (38%) patients showed hypodensities on CT, and 520 (65%) patients experienced unfavorable outcome. In univariate analysis, patients with unfavorable outcome were more likely to demonstrate hypodensities (48% versus 20%; P<0.0001). After adjustment for age, admission Glasgow coma scale, warfarin use, intraventricular hemorrhage, baseline ICH volume, and location, CT hypodensities were found to be independently associated with an increase in the odds of unfavorable outcome (odds ratio 1.70, 95% confidence interval [1.10-2.65]; P=0.018). CONCLUSIONS The presence of noncontract CT hypodensities at baseline independently predicts poor outcome and comes as a useful and widely available addition to our ability to predict ICH patients' clinical evolution.
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Affiliation(s)
- Gregoire Boulouis
- From the Hemorrhagic Stroke Research Program, Department of Neurology, Massachusetts General Hospital Stroke Research Center, Harvard Medical School, Boston (G.B., A.M., H.B.B., A.C., M.J.J., E.A., O.P.-N., A.A., A. Vashkevich, K.M.S., J.R., A. Viswanathan, M.E.G., S.M.G., J.N.G.); Department of Neurosurgery, Brain Center Rudolf Magnus, University Medical Center Utrecht, Utrecht University, The Netherlands (H.B.B.); Stroke Service, Department of Neuroscience and Behavioral Sciences, Ribeirao Pre- to School of Medicine, University of Sao Paulo (O.P.-N.); Division of Neurocritical Care and Emergency Neurology, Massachusetts General Hospital, Harvard Medical School, Boston (J.R., J.N.G.); Department of Emergency Medicine, Massachusetts General Hospital, Boston (J.N.G.).
| | - Andrea Morotti
- From the Hemorrhagic Stroke Research Program, Department of Neurology, Massachusetts General Hospital Stroke Research Center, Harvard Medical School, Boston (G.B., A.M., H.B.B., A.C., M.J.J., E.A., O.P.-N., A.A., A. Vashkevich, K.M.S., J.R., A. Viswanathan, M.E.G., S.M.G., J.N.G.); Department of Neurosurgery, Brain Center Rudolf Magnus, University Medical Center Utrecht, Utrecht University, The Netherlands (H.B.B.); Stroke Service, Department of Neuroscience and Behavioral Sciences, Ribeirao Pre- to School of Medicine, University of Sao Paulo (O.P.-N.); Division of Neurocritical Care and Emergency Neurology, Massachusetts General Hospital, Harvard Medical School, Boston (J.R., J.N.G.); Department of Emergency Medicine, Massachusetts General Hospital, Boston (J.N.G.)
| | - H Bart Brouwers
- From the Hemorrhagic Stroke Research Program, Department of Neurology, Massachusetts General Hospital Stroke Research Center, Harvard Medical School, Boston (G.B., A.M., H.B.B., A.C., M.J.J., E.A., O.P.-N., A.A., A. Vashkevich, K.M.S., J.R., A. Viswanathan, M.E.G., S.M.G., J.N.G.); Department of Neurosurgery, Brain Center Rudolf Magnus, University Medical Center Utrecht, Utrecht University, The Netherlands (H.B.B.); Stroke Service, Department of Neuroscience and Behavioral Sciences, Ribeirao Pre- to School of Medicine, University of Sao Paulo (O.P.-N.); Division of Neurocritical Care and Emergency Neurology, Massachusetts General Hospital, Harvard Medical School, Boston (J.R., J.N.G.); Department of Emergency Medicine, Massachusetts General Hospital, Boston (J.N.G.)
| | - Andreas Charidimou
- From the Hemorrhagic Stroke Research Program, Department of Neurology, Massachusetts General Hospital Stroke Research Center, Harvard Medical School, Boston (G.B., A.M., H.B.B., A.C., M.J.J., E.A., O.P.-N., A.A., A. Vashkevich, K.M.S., J.R., A. Viswanathan, M.E.G., S.M.G., J.N.G.); Department of Neurosurgery, Brain Center Rudolf Magnus, University Medical Center Utrecht, Utrecht University, The Netherlands (H.B.B.); Stroke Service, Department of Neuroscience and Behavioral Sciences, Ribeirao Pre- to School of Medicine, University of Sao Paulo (O.P.-N.); Division of Neurocritical Care and Emergency Neurology, Massachusetts General Hospital, Harvard Medical School, Boston (J.R., J.N.G.); Department of Emergency Medicine, Massachusetts General Hospital, Boston (J.N.G.)
| | - Michael J Jessel
- From the Hemorrhagic Stroke Research Program, Department of Neurology, Massachusetts General Hospital Stroke Research Center, Harvard Medical School, Boston (G.B., A.M., H.B.B., A.C., M.J.J., E.A., O.P.-N., A.A., A. Vashkevich, K.M.S., J.R., A. Viswanathan, M.E.G., S.M.G., J.N.G.); Department of Neurosurgery, Brain Center Rudolf Magnus, University Medical Center Utrecht, Utrecht University, The Netherlands (H.B.B.); Stroke Service, Department of Neuroscience and Behavioral Sciences, Ribeirao Pre- to School of Medicine, University of Sao Paulo (O.P.-N.); Division of Neurocritical Care and Emergency Neurology, Massachusetts General Hospital, Harvard Medical School, Boston (J.R., J.N.G.); Department of Emergency Medicine, Massachusetts General Hospital, Boston (J.N.G.)
| | - Eitan Auriel
- From the Hemorrhagic Stroke Research Program, Department of Neurology, Massachusetts General Hospital Stroke Research Center, Harvard Medical School, Boston (G.B., A.M., H.B.B., A.C., M.J.J., E.A., O.P.-N., A.A., A. Vashkevich, K.M.S., J.R., A. Viswanathan, M.E.G., S.M.G., J.N.G.); Department of Neurosurgery, Brain Center Rudolf Magnus, University Medical Center Utrecht, Utrecht University, The Netherlands (H.B.B.); Stroke Service, Department of Neuroscience and Behavioral Sciences, Ribeirao Pre- to School of Medicine, University of Sao Paulo (O.P.-N.); Division of Neurocritical Care and Emergency Neurology, Massachusetts General Hospital, Harvard Medical School, Boston (J.R., J.N.G.); Department of Emergency Medicine, Massachusetts General Hospital, Boston (J.N.G.)
| | - Octavio Pontes-Neto
- From the Hemorrhagic Stroke Research Program, Department of Neurology, Massachusetts General Hospital Stroke Research Center, Harvard Medical School, Boston (G.B., A.M., H.B.B., A.C., M.J.J., E.A., O.P.-N., A.A., A. Vashkevich, K.M.S., J.R., A. Viswanathan, M.E.G., S.M.G., J.N.G.); Department of Neurosurgery, Brain Center Rudolf Magnus, University Medical Center Utrecht, Utrecht University, The Netherlands (H.B.B.); Stroke Service, Department of Neuroscience and Behavioral Sciences, Ribeirao Pre- to School of Medicine, University of Sao Paulo (O.P.-N.); Division of Neurocritical Care and Emergency Neurology, Massachusetts General Hospital, Harvard Medical School, Boston (J.R., J.N.G.); Department of Emergency Medicine, Massachusetts General Hospital, Boston (J.N.G.)
| | - Alison Ayres
- From the Hemorrhagic Stroke Research Program, Department of Neurology, Massachusetts General Hospital Stroke Research Center, Harvard Medical School, Boston (G.B., A.M., H.B.B., A.C., M.J.J., E.A., O.P.-N., A.A., A. Vashkevich, K.M.S., J.R., A. Viswanathan, M.E.G., S.M.G., J.N.G.); Department of Neurosurgery, Brain Center Rudolf Magnus, University Medical Center Utrecht, Utrecht University, The Netherlands (H.B.B.); Stroke Service, Department of Neuroscience and Behavioral Sciences, Ribeirao Pre- to School of Medicine, University of Sao Paulo (O.P.-N.); Division of Neurocritical Care and Emergency Neurology, Massachusetts General Hospital, Harvard Medical School, Boston (J.R., J.N.G.); Department of Emergency Medicine, Massachusetts General Hospital, Boston (J.N.G.)
| | - Anastasia Vashkevich
- From the Hemorrhagic Stroke Research Program, Department of Neurology, Massachusetts General Hospital Stroke Research Center, Harvard Medical School, Boston (G.B., A.M., H.B.B., A.C., M.J.J., E.A., O.P.-N., A.A., A. Vashkevich, K.M.S., J.R., A. Viswanathan, M.E.G., S.M.G., J.N.G.); Department of Neurosurgery, Brain Center Rudolf Magnus, University Medical Center Utrecht, Utrecht University, The Netherlands (H.B.B.); Stroke Service, Department of Neuroscience and Behavioral Sciences, Ribeirao Pre- to School of Medicine, University of Sao Paulo (O.P.-N.); Division of Neurocritical Care and Emergency Neurology, Massachusetts General Hospital, Harvard Medical School, Boston (J.R., J.N.G.); Department of Emergency Medicine, Massachusetts General Hospital, Boston (J.N.G.)
| | - Kristin M Schwab
- From the Hemorrhagic Stroke Research Program, Department of Neurology, Massachusetts General Hospital Stroke Research Center, Harvard Medical School, Boston (G.B., A.M., H.B.B., A.C., M.J.J., E.A., O.P.-N., A.A., A. Vashkevich, K.M.S., J.R., A. Viswanathan, M.E.G., S.M.G., J.N.G.); Department of Neurosurgery, Brain Center Rudolf Magnus, University Medical Center Utrecht, Utrecht University, The Netherlands (H.B.B.); Stroke Service, Department of Neuroscience and Behavioral Sciences, Ribeirao Pre- to School of Medicine, University of Sao Paulo (O.P.-N.); Division of Neurocritical Care and Emergency Neurology, Massachusetts General Hospital, Harvard Medical School, Boston (J.R., J.N.G.); Department of Emergency Medicine, Massachusetts General Hospital, Boston (J.N.G.)
| | - Jonathan Rosand
- From the Hemorrhagic Stroke Research Program, Department of Neurology, Massachusetts General Hospital Stroke Research Center, Harvard Medical School, Boston (G.B., A.M., H.B.B., A.C., M.J.J., E.A., O.P.-N., A.A., A. Vashkevich, K.M.S., J.R., A. Viswanathan, M.E.G., S.M.G., J.N.G.); Department of Neurosurgery, Brain Center Rudolf Magnus, University Medical Center Utrecht, Utrecht University, The Netherlands (H.B.B.); Stroke Service, Department of Neuroscience and Behavioral Sciences, Ribeirao Pre- to School of Medicine, University of Sao Paulo (O.P.-N.); Division of Neurocritical Care and Emergency Neurology, Massachusetts General Hospital, Harvard Medical School, Boston (J.R., J.N.G.); Department of Emergency Medicine, Massachusetts General Hospital, Boston (J.N.G.)
| | - Anand Viswanathan
- From the Hemorrhagic Stroke Research Program, Department of Neurology, Massachusetts General Hospital Stroke Research Center, Harvard Medical School, Boston (G.B., A.M., H.B.B., A.C., M.J.J., E.A., O.P.-N., A.A., A. Vashkevich, K.M.S., J.R., A. Viswanathan, M.E.G., S.M.G., J.N.G.); Department of Neurosurgery, Brain Center Rudolf Magnus, University Medical Center Utrecht, Utrecht University, The Netherlands (H.B.B.); Stroke Service, Department of Neuroscience and Behavioral Sciences, Ribeirao Pre- to School of Medicine, University of Sao Paulo (O.P.-N.); Division of Neurocritical Care and Emergency Neurology, Massachusetts General Hospital, Harvard Medical School, Boston (J.R., J.N.G.); Department of Emergency Medicine, Massachusetts General Hospital, Boston (J.N.G.)
| | - Mahmut E Gurol
- From the Hemorrhagic Stroke Research Program, Department of Neurology, Massachusetts General Hospital Stroke Research Center, Harvard Medical School, Boston (G.B., A.M., H.B.B., A.C., M.J.J., E.A., O.P.-N., A.A., A. Vashkevich, K.M.S., J.R., A. Viswanathan, M.E.G., S.M.G., J.N.G.); Department of Neurosurgery, Brain Center Rudolf Magnus, University Medical Center Utrecht, Utrecht University, The Netherlands (H.B.B.); Stroke Service, Department of Neuroscience and Behavioral Sciences, Ribeirao Pre- to School of Medicine, University of Sao Paulo (O.P.-N.); Division of Neurocritical Care and Emergency Neurology, Massachusetts General Hospital, Harvard Medical School, Boston (J.R., J.N.G.); Department of Emergency Medicine, Massachusetts General Hospital, Boston (J.N.G.)
| | - Steven M Greenberg
- From the Hemorrhagic Stroke Research Program, Department of Neurology, Massachusetts General Hospital Stroke Research Center, Harvard Medical School, Boston (G.B., A.M., H.B.B., A.C., M.J.J., E.A., O.P.-N., A.A., A. Vashkevich, K.M.S., J.R., A. Viswanathan, M.E.G., S.M.G., J.N.G.); Department of Neurosurgery, Brain Center Rudolf Magnus, University Medical Center Utrecht, Utrecht University, The Netherlands (H.B.B.); Stroke Service, Department of Neuroscience and Behavioral Sciences, Ribeirao Pre- to School of Medicine, University of Sao Paulo (O.P.-N.); Division of Neurocritical Care and Emergency Neurology, Massachusetts General Hospital, Harvard Medical School, Boston (J.R., J.N.G.); Department of Emergency Medicine, Massachusetts General Hospital, Boston (J.N.G.)
| | - Joshua N Goldstein
- From the Hemorrhagic Stroke Research Program, Department of Neurology, Massachusetts General Hospital Stroke Research Center, Harvard Medical School, Boston (G.B., A.M., H.B.B., A.C., M.J.J., E.A., O.P.-N., A.A., A. Vashkevich, K.M.S., J.R., A. Viswanathan, M.E.G., S.M.G., J.N.G.); Department of Neurosurgery, Brain Center Rudolf Magnus, University Medical Center Utrecht, Utrecht University, The Netherlands (H.B.B.); Stroke Service, Department of Neuroscience and Behavioral Sciences, Ribeirao Pre- to School of Medicine, University of Sao Paulo (O.P.-N.); Division of Neurocritical Care and Emergency Neurology, Massachusetts General Hospital, Harvard Medical School, Boston (J.R., J.N.G.); Department of Emergency Medicine, Massachusetts General Hospital, Boston (J.N.G.)
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16
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Morotti A, Phuah CL, Anderson CD, Jessel MJ, Schwab K, Ayres AM, Pezzini A, Padovani A, Gurol ME, Viswanathan A, Greenberg SM, Goldstein JN, Rosand J. Leukocyte Count and Intracerebral Hemorrhage Expansion. Stroke 2016; 47:1473-8. [PMID: 27103016 DOI: 10.1161/strokeaha.116.013176] [Citation(s) in RCA: 79] [Impact Index Per Article: 9.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2016] [Accepted: 03/22/2016] [Indexed: 12/30/2022]
Abstract
BACKGROUND AND PURPOSE Acute leukocytosis is a well-established response to intracerebral hemorrhage (ICH). Leukocytes, because of their interaction with platelets and coagulation factors, may in turn play a role in hemostasis. We investigated whether admission leukocytosis was associated with reduced bleeding after acute ICH. METHODS Consecutive patients with primary ICH were prospectively collected from 1994 to 2015 and retrospectively analyzed. We included subjects with a follow-up computed tomographic scan available and automated complete white blood cell count performed within 48 hours from onset. Baseline and follow-up hematoma volumes were calculated with semiautomated software, and hematoma expansion was defined as volume increase >30% or 6 mL. The association between white blood cell count and ICH expansion was investigated with multivariate logistic regression. RESULTS A total of 1302 subjects met eligibility criteria (median age, 75 years; 55.8% men), of whom 207 (15.9%) experienced hematoma expansion. Higher leukocyte count on admission was associated with reduced risk of hematoma expansion (odds ratio for 1000 cells increase, 0.91; 95% confidence interval, 0.86-0.96; P=0.001). The risk of hematoma expansion was inversely associated with neutrophil count (odds ratio, 0.90; 95% confidence interval, 0.85-0.96; P=0.001) and directly associated with monocyte count (odds ratio, 2.71; 95% confidence interval, 1.08-6.83; P=0.034). There was no association between lymphocyte count and ICH expansion (odds ratio, 0.96; 95% confidence interval, 0.79-1.17; P=0.718). CONCLUSIONS Higher admission white blood cell count is associated with lower risk of hematoma expansion. This highlights a potential role of the inflammatory response in modulating the coagulation cascade after acute ICH.
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Affiliation(s)
- Andrea Morotti
- From the Neurology Unit, Department of Clinical and Experimental Sciences, University of Brescia, Brescia, Italy (A.M., A. Pezzini, A. Padovani); Division of Neurocritical Care and Emergency Neurology, Department of Neurology (A.M., C.-L.P., C.D.A., M.J.J., J.N.G., J.R.), Hemorrhagic Stroke Research Center (A.M., C.-L.P., C.D.A., M.J.J., K.S., A.A., M.E.G., A.V., S.M.G., J.N.G., J.R.), and Department of Emergency Medicine (J.N.G.), Massachusetts General Hospital, Boston.
| | - Chia-Ling Phuah
- From the Neurology Unit, Department of Clinical and Experimental Sciences, University of Brescia, Brescia, Italy (A.M., A. Pezzini, A. Padovani); Division of Neurocritical Care and Emergency Neurology, Department of Neurology (A.M., C.-L.P., C.D.A., M.J.J., J.N.G., J.R.), Hemorrhagic Stroke Research Center (A.M., C.-L.P., C.D.A., M.J.J., K.S., A.A., M.E.G., A.V., S.M.G., J.N.G., J.R.), and Department of Emergency Medicine (J.N.G.), Massachusetts General Hospital, Boston
| | - Christopher D Anderson
- From the Neurology Unit, Department of Clinical and Experimental Sciences, University of Brescia, Brescia, Italy (A.M., A. Pezzini, A. Padovani); Division of Neurocritical Care and Emergency Neurology, Department of Neurology (A.M., C.-L.P., C.D.A., M.J.J., J.N.G., J.R.), Hemorrhagic Stroke Research Center (A.M., C.-L.P., C.D.A., M.J.J., K.S., A.A., M.E.G., A.V., S.M.G., J.N.G., J.R.), and Department of Emergency Medicine (J.N.G.), Massachusetts General Hospital, Boston
| | - Michael J Jessel
- From the Neurology Unit, Department of Clinical and Experimental Sciences, University of Brescia, Brescia, Italy (A.M., A. Pezzini, A. Padovani); Division of Neurocritical Care and Emergency Neurology, Department of Neurology (A.M., C.-L.P., C.D.A., M.J.J., J.N.G., J.R.), Hemorrhagic Stroke Research Center (A.M., C.-L.P., C.D.A., M.J.J., K.S., A.A., M.E.G., A.V., S.M.G., J.N.G., J.R.), and Department of Emergency Medicine (J.N.G.), Massachusetts General Hospital, Boston
| | - Kristin Schwab
- From the Neurology Unit, Department of Clinical and Experimental Sciences, University of Brescia, Brescia, Italy (A.M., A. Pezzini, A. Padovani); Division of Neurocritical Care and Emergency Neurology, Department of Neurology (A.M., C.-L.P., C.D.A., M.J.J., J.N.G., J.R.), Hemorrhagic Stroke Research Center (A.M., C.-L.P., C.D.A., M.J.J., K.S., A.A., M.E.G., A.V., S.M.G., J.N.G., J.R.), and Department of Emergency Medicine (J.N.G.), Massachusetts General Hospital, Boston
| | - Alison M Ayres
- From the Neurology Unit, Department of Clinical and Experimental Sciences, University of Brescia, Brescia, Italy (A.M., A. Pezzini, A. Padovani); Division of Neurocritical Care and Emergency Neurology, Department of Neurology (A.M., C.-L.P., C.D.A., M.J.J., J.N.G., J.R.), Hemorrhagic Stroke Research Center (A.M., C.-L.P., C.D.A., M.J.J., K.S., A.A., M.E.G., A.V., S.M.G., J.N.G., J.R.), and Department of Emergency Medicine (J.N.G.), Massachusetts General Hospital, Boston
| | - Alessandro Pezzini
- From the Neurology Unit, Department of Clinical and Experimental Sciences, University of Brescia, Brescia, Italy (A.M., A. Pezzini, A. Padovani); Division of Neurocritical Care and Emergency Neurology, Department of Neurology (A.M., C.-L.P., C.D.A., M.J.J., J.N.G., J.R.), Hemorrhagic Stroke Research Center (A.M., C.-L.P., C.D.A., M.J.J., K.S., A.A., M.E.G., A.V., S.M.G., J.N.G., J.R.), and Department of Emergency Medicine (J.N.G.), Massachusetts General Hospital, Boston
| | - Alessandro Padovani
- From the Neurology Unit, Department of Clinical and Experimental Sciences, University of Brescia, Brescia, Italy (A.M., A. Pezzini, A. Padovani); Division of Neurocritical Care and Emergency Neurology, Department of Neurology (A.M., C.-L.P., C.D.A., M.J.J., J.N.G., J.R.), Hemorrhagic Stroke Research Center (A.M., C.-L.P., C.D.A., M.J.J., K.S., A.A., M.E.G., A.V., S.M.G., J.N.G., J.R.), and Department of Emergency Medicine (J.N.G.), Massachusetts General Hospital, Boston
| | - M Edip Gurol
- From the Neurology Unit, Department of Clinical and Experimental Sciences, University of Brescia, Brescia, Italy (A.M., A. Pezzini, A. Padovani); Division of Neurocritical Care and Emergency Neurology, Department of Neurology (A.M., C.-L.P., C.D.A., M.J.J., J.N.G., J.R.), Hemorrhagic Stroke Research Center (A.M., C.-L.P., C.D.A., M.J.J., K.S., A.A., M.E.G., A.V., S.M.G., J.N.G., J.R.), and Department of Emergency Medicine (J.N.G.), Massachusetts General Hospital, Boston
| | - Anand Viswanathan
- From the Neurology Unit, Department of Clinical and Experimental Sciences, University of Brescia, Brescia, Italy (A.M., A. Pezzini, A. Padovani); Division of Neurocritical Care and Emergency Neurology, Department of Neurology (A.M., C.-L.P., C.D.A., M.J.J., J.N.G., J.R.), Hemorrhagic Stroke Research Center (A.M., C.-L.P., C.D.A., M.J.J., K.S., A.A., M.E.G., A.V., S.M.G., J.N.G., J.R.), and Department of Emergency Medicine (J.N.G.), Massachusetts General Hospital, Boston
| | - Steven M Greenberg
- From the Neurology Unit, Department of Clinical and Experimental Sciences, University of Brescia, Brescia, Italy (A.M., A. Pezzini, A. Padovani); Division of Neurocritical Care and Emergency Neurology, Department of Neurology (A.M., C.-L.P., C.D.A., M.J.J., J.N.G., J.R.), Hemorrhagic Stroke Research Center (A.M., C.-L.P., C.D.A., M.J.J., K.S., A.A., M.E.G., A.V., S.M.G., J.N.G., J.R.), and Department of Emergency Medicine (J.N.G.), Massachusetts General Hospital, Boston
| | - Joshua N Goldstein
- From the Neurology Unit, Department of Clinical and Experimental Sciences, University of Brescia, Brescia, Italy (A.M., A. Pezzini, A. Padovani); Division of Neurocritical Care and Emergency Neurology, Department of Neurology (A.M., C.-L.P., C.D.A., M.J.J., J.N.G., J.R.), Hemorrhagic Stroke Research Center (A.M., C.-L.P., C.D.A., M.J.J., K.S., A.A., M.E.G., A.V., S.M.G., J.N.G., J.R.), and Department of Emergency Medicine (J.N.G.), Massachusetts General Hospital, Boston
| | - Jonathan Rosand
- From the Neurology Unit, Department of Clinical and Experimental Sciences, University of Brescia, Brescia, Italy (A.M., A. Pezzini, A. Padovani); Division of Neurocritical Care and Emergency Neurology, Department of Neurology (A.M., C.-L.P., C.D.A., M.J.J., J.N.G., J.R.), Hemorrhagic Stroke Research Center (A.M., C.-L.P., C.D.A., M.J.J., K.S., A.A., M.E.G., A.V., S.M.G., J.N.G., J.R.), and Department of Emergency Medicine (J.N.G.), Massachusetts General Hospital, Boston
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