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Dowlatshahi D, Deshpande A, Aviv RI, Rodriguez-Luna D, Molina CA, Blas YS, Dzialowski I, Kobayashi A, Boulanger JM, Lum C, Gubitz GJ, Padma V, Roy J, Kase CS, Bhatia R, Hill MD, Demchuk AM. Do Intracerebral Hemorrhage Nonexpanders Actually Expand Into the Ventricular Space? Stroke 2017; 49:201-203. [PMID: 29167385 DOI: 10.1161/strokeaha.117.018716] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2017] [Revised: 09/28/2017] [Accepted: 10/05/2017] [Indexed: 11/16/2022]
Abstract
BACKGROUND AND PURPOSE The computed tomographic angiography spot sign as a predictor of hematoma expansion is limited by its modest sensitivity and positive predictive value. It is possible that hematoma expansion in spot-positive patients is missed because of decompression of intracerebral hemorrhage (ICH) into the ventricular space. We hypothesized that revising hematoma expansion definitions to include intraventricular hemorrhage (IVH) expansion will improve the predictive performance of the spot sign. Our objectives were to determine the proportion of ICH nonexpanders who actually have IVH expansion, determine the proportion of false-positive spot signs that have IVH expansion, and compare the known predictive performance of the spot sign to a revised definition incorporating IVH expansion. METHODS We analyzed patients from the multicenter PREDICT ICH spot sign study. We defined hematoma expansion as ≥6 mL or ≥33% ICH expansion or >2 mL IVH expansion and compared spot sign performance using this revised definition with the conventional 6 mL/33% definition using receiver operating curve analysis. RESULTS Of 311 patients, 213 did not meet the 6-mL/33% expansion definition (nonexpanders). Only 13 of 213 (6.1%) nonexpanders had ≥2 mL IVH expansion. Of the false-positive spot signs, 4 of 40 (10%) had >2 mL ventricular expansion. The area under the curve for spot sign to predict significant ICH expansion was 0.65 (95% confidence interval, 0.58-0.72), which was no different than when IVH expansion was added to the definition (area under the curve, 0.66; 95% confidence interval, 0.58-0.71). CONCLUSIONS Although IVH expansion does indeed occur in a minority of ICH nonexpanders, its inclusion into a revised hematoma expansion definition does not alter the predictive performance of the spot sign.
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Affiliation(s)
- Dar Dowlatshahi
- From the Department of Diagnostic Imaging, Neuroradiology Section, Ottawa Hospital Research Institute (C.L.) and Division of Neurology, Department of Medicine (D.D.), University of Ottawa, Canada; Ottawa Hospital Research Institute, Canada (D.D.); Vinayaka Neuro Multispecialty Centre, Warangal, India (A.D.); Division of Neuroradiology (R.I.A.) and Department of Medical Imaging (R.I.A.), Sunnybrook Health Sciences Centre, University of Toronto, Canada; Department of Neurology, Hospital Universitari Vall d'Hebron, Barcelona, Spain (D.R.-L., C.A.M.); Department of Neurology, Doctor Josep Trueta University Hospital, Institut d'Investigació Biomèdica Girona Foundation, Spain (Y.S.B.); Department of Neurology, Elblandklinikum Meissen Academic Teaching Hospital of the Technische University, Dresden, Germany (I.D.); Second Department of Neurology, Institute of Psychiatry and Neurology, Warsaw, Poland (A.K.); Department of Experimental and Clinical Pharmacology, Warsaw, Poland (A.K.); Department of Medicine, Charles LeMoyne Hospital, University of Sherbrooke, Montreal, Canada (J.-M.B.); Department of Neurology, Dalhousie University, Halifax, Canada (G.G.); Department of Neurology, All India Institute of Medical Sciences, New Delhi (V.P., R.B.); AMRI Neurosciences Centre, Mukundapur, Kolkata, India (J.R.); Department of Neurology, Boston Medical Center, MA (C.S.K.); and Department of Clinical Neurosciences, Calgary Stroke Program, Hotchkiss Brain Institute, University of Calgary, Canada (M.D.H., A.M.D.).
| | - Anirudda Deshpande
- From the Department of Diagnostic Imaging, Neuroradiology Section, Ottawa Hospital Research Institute (C.L.) and Division of Neurology, Department of Medicine (D.D.), University of Ottawa, Canada; Ottawa Hospital Research Institute, Canada (D.D.); Vinayaka Neuro Multispecialty Centre, Warangal, India (A.D.); Division of Neuroradiology (R.I.A.) and Department of Medical Imaging (R.I.A.), Sunnybrook Health Sciences Centre, University of Toronto, Canada; Department of Neurology, Hospital Universitari Vall d'Hebron, Barcelona, Spain (D.R.-L., C.A.M.); Department of Neurology, Doctor Josep Trueta University Hospital, Institut d'Investigació Biomèdica Girona Foundation, Spain (Y.S.B.); Department of Neurology, Elblandklinikum Meissen Academic Teaching Hospital of the Technische University, Dresden, Germany (I.D.); Second Department of Neurology, Institute of Psychiatry and Neurology, Warsaw, Poland (A.K.); Department of Experimental and Clinical Pharmacology, Warsaw, Poland (A.K.); Department of Medicine, Charles LeMoyne Hospital, University of Sherbrooke, Montreal, Canada (J.-M.B.); Department of Neurology, Dalhousie University, Halifax, Canada (G.G.); Department of Neurology, All India Institute of Medical Sciences, New Delhi (V.P., R.B.); AMRI Neurosciences Centre, Mukundapur, Kolkata, India (J.R.); Department of Neurology, Boston Medical Center, MA (C.S.K.); and Department of Clinical Neurosciences, Calgary Stroke Program, Hotchkiss Brain Institute, University of Calgary, Canada (M.D.H., A.M.D.)
| | - Richard I Aviv
- From the Department of Diagnostic Imaging, Neuroradiology Section, Ottawa Hospital Research Institute (C.L.) and Division of Neurology, Department of Medicine (D.D.), University of Ottawa, Canada; Ottawa Hospital Research Institute, Canada (D.D.); Vinayaka Neuro Multispecialty Centre, Warangal, India (A.D.); Division of Neuroradiology (R.I.A.) and Department of Medical Imaging (R.I.A.), Sunnybrook Health Sciences Centre, University of Toronto, Canada; Department of Neurology, Hospital Universitari Vall d'Hebron, Barcelona, Spain (D.R.-L., C.A.M.); Department of Neurology, Doctor Josep Trueta University Hospital, Institut d'Investigació Biomèdica Girona Foundation, Spain (Y.S.B.); Department of Neurology, Elblandklinikum Meissen Academic Teaching Hospital of the Technische University, Dresden, Germany (I.D.); Second Department of Neurology, Institute of Psychiatry and Neurology, Warsaw, Poland (A.K.); Department of Experimental and Clinical Pharmacology, Warsaw, Poland (A.K.); Department of Medicine, Charles LeMoyne Hospital, University of Sherbrooke, Montreal, Canada (J.-M.B.); Department of Neurology, Dalhousie University, Halifax, Canada (G.G.); Department of Neurology, All India Institute of Medical Sciences, New Delhi (V.P., R.B.); AMRI Neurosciences Centre, Mukundapur, Kolkata, India (J.R.); Department of Neurology, Boston Medical Center, MA (C.S.K.); and Department of Clinical Neurosciences, Calgary Stroke Program, Hotchkiss Brain Institute, University of Calgary, Canada (M.D.H., A.M.D.)
| | - David Rodriguez-Luna
- From the Department of Diagnostic Imaging, Neuroradiology Section, Ottawa Hospital Research Institute (C.L.) and Division of Neurology, Department of Medicine (D.D.), University of Ottawa, Canada; Ottawa Hospital Research Institute, Canada (D.D.); Vinayaka Neuro Multispecialty Centre, Warangal, India (A.D.); Division of Neuroradiology (R.I.A.) and Department of Medical Imaging (R.I.A.), Sunnybrook Health Sciences Centre, University of Toronto, Canada; Department of Neurology, Hospital Universitari Vall d'Hebron, Barcelona, Spain (D.R.-L., C.A.M.); Department of Neurology, Doctor Josep Trueta University Hospital, Institut d'Investigació Biomèdica Girona Foundation, Spain (Y.S.B.); Department of Neurology, Elblandklinikum Meissen Academic Teaching Hospital of the Technische University, Dresden, Germany (I.D.); Second Department of Neurology, Institute of Psychiatry and Neurology, Warsaw, Poland (A.K.); Department of Experimental and Clinical Pharmacology, Warsaw, Poland (A.K.); Department of Medicine, Charles LeMoyne Hospital, University of Sherbrooke, Montreal, Canada (J.-M.B.); Department of Neurology, Dalhousie University, Halifax, Canada (G.G.); Department of Neurology, All India Institute of Medical Sciences, New Delhi (V.P., R.B.); AMRI Neurosciences Centre, Mukundapur, Kolkata, India (J.R.); Department of Neurology, Boston Medical Center, MA (C.S.K.); and Department of Clinical Neurosciences, Calgary Stroke Program, Hotchkiss Brain Institute, University of Calgary, Canada (M.D.H., A.M.D.)
| | - Carlos A Molina
- From the Department of Diagnostic Imaging, Neuroradiology Section, Ottawa Hospital Research Institute (C.L.) and Division of Neurology, Department of Medicine (D.D.), University of Ottawa, Canada; Ottawa Hospital Research Institute, Canada (D.D.); Vinayaka Neuro Multispecialty Centre, Warangal, India (A.D.); Division of Neuroradiology (R.I.A.) and Department of Medical Imaging (R.I.A.), Sunnybrook Health Sciences Centre, University of Toronto, Canada; Department of Neurology, Hospital Universitari Vall d'Hebron, Barcelona, Spain (D.R.-L., C.A.M.); Department of Neurology, Doctor Josep Trueta University Hospital, Institut d'Investigació Biomèdica Girona Foundation, Spain (Y.S.B.); Department of Neurology, Elblandklinikum Meissen Academic Teaching Hospital of the Technische University, Dresden, Germany (I.D.); Second Department of Neurology, Institute of Psychiatry and Neurology, Warsaw, Poland (A.K.); Department of Experimental and Clinical Pharmacology, Warsaw, Poland (A.K.); Department of Medicine, Charles LeMoyne Hospital, University of Sherbrooke, Montreal, Canada (J.-M.B.); Department of Neurology, Dalhousie University, Halifax, Canada (G.G.); Department of Neurology, All India Institute of Medical Sciences, New Delhi (V.P., R.B.); AMRI Neurosciences Centre, Mukundapur, Kolkata, India (J.R.); Department of Neurology, Boston Medical Center, MA (C.S.K.); and Department of Clinical Neurosciences, Calgary Stroke Program, Hotchkiss Brain Institute, University of Calgary, Canada (M.D.H., A.M.D.)
| | - Yolanda Silva Blas
- From the Department of Diagnostic Imaging, Neuroradiology Section, Ottawa Hospital Research Institute (C.L.) and Division of Neurology, Department of Medicine (D.D.), University of Ottawa, Canada; Ottawa Hospital Research Institute, Canada (D.D.); Vinayaka Neuro Multispecialty Centre, Warangal, India (A.D.); Division of Neuroradiology (R.I.A.) and Department of Medical Imaging (R.I.A.), Sunnybrook Health Sciences Centre, University of Toronto, Canada; Department of Neurology, Hospital Universitari Vall d'Hebron, Barcelona, Spain (D.R.-L., C.A.M.); Department of Neurology, Doctor Josep Trueta University Hospital, Institut d'Investigació Biomèdica Girona Foundation, Spain (Y.S.B.); Department of Neurology, Elblandklinikum Meissen Academic Teaching Hospital of the Technische University, Dresden, Germany (I.D.); Second Department of Neurology, Institute of Psychiatry and Neurology, Warsaw, Poland (A.K.); Department of Experimental and Clinical Pharmacology, Warsaw, Poland (A.K.); Department of Medicine, Charles LeMoyne Hospital, University of Sherbrooke, Montreal, Canada (J.-M.B.); Department of Neurology, Dalhousie University, Halifax, Canada (G.G.); Department of Neurology, All India Institute of Medical Sciences, New Delhi (V.P., R.B.); AMRI Neurosciences Centre, Mukundapur, Kolkata, India (J.R.); Department of Neurology, Boston Medical Center, MA (C.S.K.); and Department of Clinical Neurosciences, Calgary Stroke Program, Hotchkiss Brain Institute, University of Calgary, Canada (M.D.H., A.M.D.)
| | - Imanuel Dzialowski
- From the Department of Diagnostic Imaging, Neuroradiology Section, Ottawa Hospital Research Institute (C.L.) and Division of Neurology, Department of Medicine (D.D.), University of Ottawa, Canada; Ottawa Hospital Research Institute, Canada (D.D.); Vinayaka Neuro Multispecialty Centre, Warangal, India (A.D.); Division of Neuroradiology (R.I.A.) and Department of Medical Imaging (R.I.A.), Sunnybrook Health Sciences Centre, University of Toronto, Canada; Department of Neurology, Hospital Universitari Vall d'Hebron, Barcelona, Spain (D.R.-L., C.A.M.); Department of Neurology, Doctor Josep Trueta University Hospital, Institut d'Investigació Biomèdica Girona Foundation, Spain (Y.S.B.); Department of Neurology, Elblandklinikum Meissen Academic Teaching Hospital of the Technische University, Dresden, Germany (I.D.); Second Department of Neurology, Institute of Psychiatry and Neurology, Warsaw, Poland (A.K.); Department of Experimental and Clinical Pharmacology, Warsaw, Poland (A.K.); Department of Medicine, Charles LeMoyne Hospital, University of Sherbrooke, Montreal, Canada (J.-M.B.); Department of Neurology, Dalhousie University, Halifax, Canada (G.G.); Department of Neurology, All India Institute of Medical Sciences, New Delhi (V.P., R.B.); AMRI Neurosciences Centre, Mukundapur, Kolkata, India (J.R.); Department of Neurology, Boston Medical Center, MA (C.S.K.); and Department of Clinical Neurosciences, Calgary Stroke Program, Hotchkiss Brain Institute, University of Calgary, Canada (M.D.H., A.M.D.)
| | - Adam Kobayashi
- From the Department of Diagnostic Imaging, Neuroradiology Section, Ottawa Hospital Research Institute (C.L.) and Division of Neurology, Department of Medicine (D.D.), University of Ottawa, Canada; Ottawa Hospital Research Institute, Canada (D.D.); Vinayaka Neuro Multispecialty Centre, Warangal, India (A.D.); Division of Neuroradiology (R.I.A.) and Department of Medical Imaging (R.I.A.), Sunnybrook Health Sciences Centre, University of Toronto, Canada; Department of Neurology, Hospital Universitari Vall d'Hebron, Barcelona, Spain (D.R.-L., C.A.M.); Department of Neurology, Doctor Josep Trueta University Hospital, Institut d'Investigació Biomèdica Girona Foundation, Spain (Y.S.B.); Department of Neurology, Elblandklinikum Meissen Academic Teaching Hospital of the Technische University, Dresden, Germany (I.D.); Second Department of Neurology, Institute of Psychiatry and Neurology, Warsaw, Poland (A.K.); Department of Experimental and Clinical Pharmacology, Warsaw, Poland (A.K.); Department of Medicine, Charles LeMoyne Hospital, University of Sherbrooke, Montreal, Canada (J.-M.B.); Department of Neurology, Dalhousie University, Halifax, Canada (G.G.); Department of Neurology, All India Institute of Medical Sciences, New Delhi (V.P., R.B.); AMRI Neurosciences Centre, Mukundapur, Kolkata, India (J.R.); Department of Neurology, Boston Medical Center, MA (C.S.K.); and Department of Clinical Neurosciences, Calgary Stroke Program, Hotchkiss Brain Institute, University of Calgary, Canada (M.D.H., A.M.D.)
| | - Jean-Martin Boulanger
- From the Department of Diagnostic Imaging, Neuroradiology Section, Ottawa Hospital Research Institute (C.L.) and Division of Neurology, Department of Medicine (D.D.), University of Ottawa, Canada; Ottawa Hospital Research Institute, Canada (D.D.); Vinayaka Neuro Multispecialty Centre, Warangal, India (A.D.); Division of Neuroradiology (R.I.A.) and Department of Medical Imaging (R.I.A.), Sunnybrook Health Sciences Centre, University of Toronto, Canada; Department of Neurology, Hospital Universitari Vall d'Hebron, Barcelona, Spain (D.R.-L., C.A.M.); Department of Neurology, Doctor Josep Trueta University Hospital, Institut d'Investigació Biomèdica Girona Foundation, Spain (Y.S.B.); Department of Neurology, Elblandklinikum Meissen Academic Teaching Hospital of the Technische University, Dresden, Germany (I.D.); Second Department of Neurology, Institute of Psychiatry and Neurology, Warsaw, Poland (A.K.); Department of Experimental and Clinical Pharmacology, Warsaw, Poland (A.K.); Department of Medicine, Charles LeMoyne Hospital, University of Sherbrooke, Montreal, Canada (J.-M.B.); Department of Neurology, Dalhousie University, Halifax, Canada (G.G.); Department of Neurology, All India Institute of Medical Sciences, New Delhi (V.P., R.B.); AMRI Neurosciences Centre, Mukundapur, Kolkata, India (J.R.); Department of Neurology, Boston Medical Center, MA (C.S.K.); and Department of Clinical Neurosciences, Calgary Stroke Program, Hotchkiss Brain Institute, University of Calgary, Canada (M.D.H., A.M.D.)
| | - Cheemun Lum
- From the Department of Diagnostic Imaging, Neuroradiology Section, Ottawa Hospital Research Institute (C.L.) and Division of Neurology, Department of Medicine (D.D.), University of Ottawa, Canada; Ottawa Hospital Research Institute, Canada (D.D.); Vinayaka Neuro Multispecialty Centre, Warangal, India (A.D.); Division of Neuroradiology (R.I.A.) and Department of Medical Imaging (R.I.A.), Sunnybrook Health Sciences Centre, University of Toronto, Canada; Department of Neurology, Hospital Universitari Vall d'Hebron, Barcelona, Spain (D.R.-L., C.A.M.); Department of Neurology, Doctor Josep Trueta University Hospital, Institut d'Investigació Biomèdica Girona Foundation, Spain (Y.S.B.); Department of Neurology, Elblandklinikum Meissen Academic Teaching Hospital of the Technische University, Dresden, Germany (I.D.); Second Department of Neurology, Institute of Psychiatry and Neurology, Warsaw, Poland (A.K.); Department of Experimental and Clinical Pharmacology, Warsaw, Poland (A.K.); Department of Medicine, Charles LeMoyne Hospital, University of Sherbrooke, Montreal, Canada (J.-M.B.); Department of Neurology, Dalhousie University, Halifax, Canada (G.G.); Department of Neurology, All India Institute of Medical Sciences, New Delhi (V.P., R.B.); AMRI Neurosciences Centre, Mukundapur, Kolkata, India (J.R.); Department of Neurology, Boston Medical Center, MA (C.S.K.); and Department of Clinical Neurosciences, Calgary Stroke Program, Hotchkiss Brain Institute, University of Calgary, Canada (M.D.H., A.M.D.)
| | - Gordon J Gubitz
- From the Department of Diagnostic Imaging, Neuroradiology Section, Ottawa Hospital Research Institute (C.L.) and Division of Neurology, Department of Medicine (D.D.), University of Ottawa, Canada; Ottawa Hospital Research Institute, Canada (D.D.); Vinayaka Neuro Multispecialty Centre, Warangal, India (A.D.); Division of Neuroradiology (R.I.A.) and Department of Medical Imaging (R.I.A.), Sunnybrook Health Sciences Centre, University of Toronto, Canada; Department of Neurology, Hospital Universitari Vall d'Hebron, Barcelona, Spain (D.R.-L., C.A.M.); Department of Neurology, Doctor Josep Trueta University Hospital, Institut d'Investigació Biomèdica Girona Foundation, Spain (Y.S.B.); Department of Neurology, Elblandklinikum Meissen Academic Teaching Hospital of the Technische University, Dresden, Germany (I.D.); Second Department of Neurology, Institute of Psychiatry and Neurology, Warsaw, Poland (A.K.); Department of Experimental and Clinical Pharmacology, Warsaw, Poland (A.K.); Department of Medicine, Charles LeMoyne Hospital, University of Sherbrooke, Montreal, Canada (J.-M.B.); Department of Neurology, Dalhousie University, Halifax, Canada (G.G.); Department of Neurology, All India Institute of Medical Sciences, New Delhi (V.P., R.B.); AMRI Neurosciences Centre, Mukundapur, Kolkata, India (J.R.); Department of Neurology, Boston Medical Center, MA (C.S.K.); and Department of Clinical Neurosciences, Calgary Stroke Program, Hotchkiss Brain Institute, University of Calgary, Canada (M.D.H., A.M.D.)
| | - Vasantha Padma
- From the Department of Diagnostic Imaging, Neuroradiology Section, Ottawa Hospital Research Institute (C.L.) and Division of Neurology, Department of Medicine (D.D.), University of Ottawa, Canada; Ottawa Hospital Research Institute, Canada (D.D.); Vinayaka Neuro Multispecialty Centre, Warangal, India (A.D.); Division of Neuroradiology (R.I.A.) and Department of Medical Imaging (R.I.A.), Sunnybrook Health Sciences Centre, University of Toronto, Canada; Department of Neurology, Hospital Universitari Vall d'Hebron, Barcelona, Spain (D.R.-L., C.A.M.); Department of Neurology, Doctor Josep Trueta University Hospital, Institut d'Investigació Biomèdica Girona Foundation, Spain (Y.S.B.); Department of Neurology, Elblandklinikum Meissen Academic Teaching Hospital of the Technische University, Dresden, Germany (I.D.); Second Department of Neurology, Institute of Psychiatry and Neurology, Warsaw, Poland (A.K.); Department of Experimental and Clinical Pharmacology, Warsaw, Poland (A.K.); Department of Medicine, Charles LeMoyne Hospital, University of Sherbrooke, Montreal, Canada (J.-M.B.); Department of Neurology, Dalhousie University, Halifax, Canada (G.G.); Department of Neurology, All India Institute of Medical Sciences, New Delhi (V.P., R.B.); AMRI Neurosciences Centre, Mukundapur, Kolkata, India (J.R.); Department of Neurology, Boston Medical Center, MA (C.S.K.); and Department of Clinical Neurosciences, Calgary Stroke Program, Hotchkiss Brain Institute, University of Calgary, Canada (M.D.H., A.M.D.)
| | - Jayanta Roy
- From the Department of Diagnostic Imaging, Neuroradiology Section, Ottawa Hospital Research Institute (C.L.) and Division of Neurology, Department of Medicine (D.D.), University of Ottawa, Canada; Ottawa Hospital Research Institute, Canada (D.D.); Vinayaka Neuro Multispecialty Centre, Warangal, India (A.D.); Division of Neuroradiology (R.I.A.) and Department of Medical Imaging (R.I.A.), Sunnybrook Health Sciences Centre, University of Toronto, Canada; Department of Neurology, Hospital Universitari Vall d'Hebron, Barcelona, Spain (D.R.-L., C.A.M.); Department of Neurology, Doctor Josep Trueta University Hospital, Institut d'Investigació Biomèdica Girona Foundation, Spain (Y.S.B.); Department of Neurology, Elblandklinikum Meissen Academic Teaching Hospital of the Technische University, Dresden, Germany (I.D.); Second Department of Neurology, Institute of Psychiatry and Neurology, Warsaw, Poland (A.K.); Department of Experimental and Clinical Pharmacology, Warsaw, Poland (A.K.); Department of Medicine, Charles LeMoyne Hospital, University of Sherbrooke, Montreal, Canada (J.-M.B.); Department of Neurology, Dalhousie University, Halifax, Canada (G.G.); Department of Neurology, All India Institute of Medical Sciences, New Delhi (V.P., R.B.); AMRI Neurosciences Centre, Mukundapur, Kolkata, India (J.R.); Department of Neurology, Boston Medical Center, MA (C.S.K.); and Department of Clinical Neurosciences, Calgary Stroke Program, Hotchkiss Brain Institute, University of Calgary, Canada (M.D.H., A.M.D.)
| | - Carlos S Kase
- From the Department of Diagnostic Imaging, Neuroradiology Section, Ottawa Hospital Research Institute (C.L.) and Division of Neurology, Department of Medicine (D.D.), University of Ottawa, Canada; Ottawa Hospital Research Institute, Canada (D.D.); Vinayaka Neuro Multispecialty Centre, Warangal, India (A.D.); Division of Neuroradiology (R.I.A.) and Department of Medical Imaging (R.I.A.), Sunnybrook Health Sciences Centre, University of Toronto, Canada; Department of Neurology, Hospital Universitari Vall d'Hebron, Barcelona, Spain (D.R.-L., C.A.M.); Department of Neurology, Doctor Josep Trueta University Hospital, Institut d'Investigació Biomèdica Girona Foundation, Spain (Y.S.B.); Department of Neurology, Elblandklinikum Meissen Academic Teaching Hospital of the Technische University, Dresden, Germany (I.D.); Second Department of Neurology, Institute of Psychiatry and Neurology, Warsaw, Poland (A.K.); Department of Experimental and Clinical Pharmacology, Warsaw, Poland (A.K.); Department of Medicine, Charles LeMoyne Hospital, University of Sherbrooke, Montreal, Canada (J.-M.B.); Department of Neurology, Dalhousie University, Halifax, Canada (G.G.); Department of Neurology, All India Institute of Medical Sciences, New Delhi (V.P., R.B.); AMRI Neurosciences Centre, Mukundapur, Kolkata, India (J.R.); Department of Neurology, Boston Medical Center, MA (C.S.K.); and Department of Clinical Neurosciences, Calgary Stroke Program, Hotchkiss Brain Institute, University of Calgary, Canada (M.D.H., A.M.D.)
| | - Rohit Bhatia
- From the Department of Diagnostic Imaging, Neuroradiology Section, Ottawa Hospital Research Institute (C.L.) and Division of Neurology, Department of Medicine (D.D.), University of Ottawa, Canada; Ottawa Hospital Research Institute, Canada (D.D.); Vinayaka Neuro Multispecialty Centre, Warangal, India (A.D.); Division of Neuroradiology (R.I.A.) and Department of Medical Imaging (R.I.A.), Sunnybrook Health Sciences Centre, University of Toronto, Canada; Department of Neurology, Hospital Universitari Vall d'Hebron, Barcelona, Spain (D.R.-L., C.A.M.); Department of Neurology, Doctor Josep Trueta University Hospital, Institut d'Investigació Biomèdica Girona Foundation, Spain (Y.S.B.); Department of Neurology, Elblandklinikum Meissen Academic Teaching Hospital of the Technische University, Dresden, Germany (I.D.); Second Department of Neurology, Institute of Psychiatry and Neurology, Warsaw, Poland (A.K.); Department of Experimental and Clinical Pharmacology, Warsaw, Poland (A.K.); Department of Medicine, Charles LeMoyne Hospital, University of Sherbrooke, Montreal, Canada (J.-M.B.); Department of Neurology, Dalhousie University, Halifax, Canada (G.G.); Department of Neurology, All India Institute of Medical Sciences, New Delhi (V.P., R.B.); AMRI Neurosciences Centre, Mukundapur, Kolkata, India (J.R.); Department of Neurology, Boston Medical Center, MA (C.S.K.); and Department of Clinical Neurosciences, Calgary Stroke Program, Hotchkiss Brain Institute, University of Calgary, Canada (M.D.H., A.M.D.)
| | - Michael D Hill
- From the Department of Diagnostic Imaging, Neuroradiology Section, Ottawa Hospital Research Institute (C.L.) and Division of Neurology, Department of Medicine (D.D.), University of Ottawa, Canada; Ottawa Hospital Research Institute, Canada (D.D.); Vinayaka Neuro Multispecialty Centre, Warangal, India (A.D.); Division of Neuroradiology (R.I.A.) and Department of Medical Imaging (R.I.A.), Sunnybrook Health Sciences Centre, University of Toronto, Canada; Department of Neurology, Hospital Universitari Vall d'Hebron, Barcelona, Spain (D.R.-L., C.A.M.); Department of Neurology, Doctor Josep Trueta University Hospital, Institut d'Investigació Biomèdica Girona Foundation, Spain (Y.S.B.); Department of Neurology, Elblandklinikum Meissen Academic Teaching Hospital of the Technische University, Dresden, Germany (I.D.); Second Department of Neurology, Institute of Psychiatry and Neurology, Warsaw, Poland (A.K.); Department of Experimental and Clinical Pharmacology, Warsaw, Poland (A.K.); Department of Medicine, Charles LeMoyne Hospital, University of Sherbrooke, Montreal, Canada (J.-M.B.); Department of Neurology, Dalhousie University, Halifax, Canada (G.G.); Department of Neurology, All India Institute of Medical Sciences, New Delhi (V.P., R.B.); AMRI Neurosciences Centre, Mukundapur, Kolkata, India (J.R.); Department of Neurology, Boston Medical Center, MA (C.S.K.); and Department of Clinical Neurosciences, Calgary Stroke Program, Hotchkiss Brain Institute, University of Calgary, Canada (M.D.H., A.M.D.)
| | - Andrew M Demchuk
- From the Department of Diagnostic Imaging, Neuroradiology Section, Ottawa Hospital Research Institute (C.L.) and Division of Neurology, Department of Medicine (D.D.), University of Ottawa, Canada; Ottawa Hospital Research Institute, Canada (D.D.); Vinayaka Neuro Multispecialty Centre, Warangal, India (A.D.); Division of Neuroradiology (R.I.A.) and Department of Medical Imaging (R.I.A.), Sunnybrook Health Sciences Centre, University of Toronto, Canada; Department of Neurology, Hospital Universitari Vall d'Hebron, Barcelona, Spain (D.R.-L., C.A.M.); Department of Neurology, Doctor Josep Trueta University Hospital, Institut d'Investigació Biomèdica Girona Foundation, Spain (Y.S.B.); Department of Neurology, Elblandklinikum Meissen Academic Teaching Hospital of the Technische University, Dresden, Germany (I.D.); Second Department of Neurology, Institute of Psychiatry and Neurology, Warsaw, Poland (A.K.); Department of Experimental and Clinical Pharmacology, Warsaw, Poland (A.K.); Department of Medicine, Charles LeMoyne Hospital, University of Sherbrooke, Montreal, Canada (J.-M.B.); Department of Neurology, Dalhousie University, Halifax, Canada (G.G.); Department of Neurology, All India Institute of Medical Sciences, New Delhi (V.P., R.B.); AMRI Neurosciences Centre, Mukundapur, Kolkata, India (J.R.); Department of Neurology, Boston Medical Center, MA (C.S.K.); and Department of Clinical Neurosciences, Calgary Stroke Program, Hotchkiss Brain Institute, University of Calgary, Canada (M.D.H., A.M.D.)
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Hanley DF, Lane K, McBee N, Ziai W, Tuhrim S, Lees KR, Dawson J, Gandhi D, Ullman N, Mould WA, Mayo SW, Mendelow AD, Gregson B, Butcher K, Vespa P, Wright DW, Kase CS, Carhuapoma JR, Keyl PM, Diener-West M, Muschelli J, Betz JF, Thompson CB, Sugar EA, Yenokyan G, Janis S, John S, Harnof S, Lopez GA, Aldrich EF, Harrigan MR, Ansari S, Jallo J, Caron JL, LeDoux D, Adeoye O, Zuccarello M, Adams HP, Rosenblum M, Thompson RE, Awad IA. Thrombolytic removal of intraventricular haemorrhage in treatment of severe stroke: results of the randomised, multicentre, multiregion, placebo-controlled CLEAR III trial. Lancet 2017; 389:603-611. [PMID: 28081952 PMCID: PMC6108339 DOI: 10.1016/s0140-6736(16)32410-2] [Citation(s) in RCA: 268] [Impact Index Per Article: 38.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/01/2016] [Revised: 09/26/2016] [Accepted: 09/27/2016] [Indexed: 02/04/2023]
Abstract
BACKGROUND Intraventricular haemorrhage is a subtype of intracerebral haemorrhage, with 50% mortality and serious disability for survivors. We aimed to test whether attempting to remove intraventricular haemorrhage with alteplase versus saline irrigation improved functional outcome. METHODS In this randomised, double-blinded, placebo-controlled, multiregional trial (CLEAR III), participants with a routinely placed extraventricular drain, in the intensive care unit with stable, non-traumatic intracerebral haemorrhage volume less than 30 mL, intraventricular haemorrhage obstructing the 3rd or 4th ventricles, and no underlying pathology were adaptively randomly assigned (1:1), via a web-based system to receive up to 12 doses, 8 h apart of 1 mg of alteplase or 0·9% saline via the extraventricular drain. The treating physician, clinical research staff, and participants were masked to treatment assignment. CT scans were obtained every 24 h throughout dosing. The primary efficacy outcome was good functional outcome, defined as a modified Rankin Scale score (mRS) of 3 or less at 180 days per central adjudication by blinded evaluators. This study is registered with ClinicalTrials.gov, NCT00784134. FINDINGS Between Sept 18, 2009, and Jan 13, 2015, 500 patients were randomised: 249 to the alteplase group and 251 to the saline group. 180-day follow-up data were available for analysis from 246 of 249 participants in the alteplase group and 245 of 251 participants in the placebo group. The primary efficacy outcome was similar in each group (good outcome in alteplase group 48% vs saline 45%; risk ratio [RR] 1·06 [95% CI 0·88-1·28; p=0·554]). A difference of 3·5% (RR 1·08 [95% CI 0·90-1·29], p=0·420) was found after adjustment for intraventricular haemorrhage size and thalamic intracerebral haemorrhage. At 180 days, the treatment group had lower case fatality (46 [18%] vs saline 73 [29%], hazard ratio 0·60 [95% CI 0·41-0·86], p=0·006), but a greater proportion with mRS 5 (42 [17%] vs 21 [9%]; RR 1·99 [95% CI 1·22-3·26], p=0·007). Ventriculitis (17 [7%] alteplase vs 31 [12%] saline; RR 0·55 [95% CI 0·31-0·97], p=0·048) and serious adverse events (114 [46%] alteplase vs 151 [60%] saline; RR 0·76 [95% CI 0·64-0·90], p=0·002) were less frequent with alteplase treatment. Symptomatic bleeding (six [2%] in the alteplase group vs five [2%] in the saline group; RR 1·21 [95% CI 0·37-3·91], p=0·771) was similar. INTERPRETATION In patients with intraventricular haemorrhage and a routine extraventricular drain, irrigation with alteplase did not substantially improve functional outcomes at the mRS 3 cutoff compared with irrigation with saline. Protocol-based use of alteplase with extraventricular drain seems safe. Future investigation is needed to determine whether a greater frequency of complete intraventricular haemorrhage removal via alteplase produces gains in functional status. FUNDING National Institute of Neurological Disorders and Stroke.
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Affiliation(s)
- Daniel F Hanley
- Johns Hopkins University, School of Medicine, Brain Injury Outcomes Division, Baltimore, MD, USA.
| | - Karen Lane
- Johns Hopkins University, School of Medicine, Brain Injury Outcomes Division, Baltimore, MD, USA
| | - Nichol McBee
- Johns Hopkins University, School of Medicine, Brain Injury Outcomes Division, Baltimore, MD, USA
| | - Wendy Ziai
- Johns Hopkins University, School of Medicine, Brain Injury Outcomes Division, Baltimore, MD, USA
| | - Stanley Tuhrim
- Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | | | | | | | - Natalie Ullman
- Johns Hopkins University, School of Medicine, Brain Injury Outcomes Division, Baltimore, MD, USA
| | - W Andrew Mould
- Johns Hopkins University, School of Medicine, Brain Injury Outcomes Division, Baltimore, MD, USA
| | | | | | | | | | - Paul Vespa
- University of California, Los Angeles, CA, USA
| | | | | | - J Ricardo Carhuapoma
- Johns Hopkins University, School of Medicine, Brain Injury Outcomes Division, Baltimore, MD, USA
| | - Penelope M Keyl
- Johns Hopkins University, School of Medicine, Brain Injury Outcomes Division, Baltimore, MD, USA
| | - Marie Diener-West
- Johns Hopkins University Bloomberg School of Public Health, Department of Biostatistics, Baltimore, MD, USA
| | - John Muschelli
- Johns Hopkins University Bloomberg School of Public Health, Department of Biostatistics, Baltimore, MD, USA
| | - Joshua F Betz
- Johns Hopkins University Bloomberg School of Public Health, Department of Biostatistics, Baltimore, MD, USA
| | - Carol B Thompson
- Johns Hopkins University Bloomberg School of Public Health, Department of Biostatistics, Baltimore, MD, USA
| | - Elizabeth A Sugar
- Johns Hopkins University Bloomberg School of Public Health, Department of Biostatistics, Baltimore, MD, USA
| | - Gayane Yenokyan
- Johns Hopkins University Bloomberg School of Public Health, Department of Biostatistics, Baltimore, MD, USA
| | - Scott Janis
- National Institutes of Health, National institute of Neurological Disorders and Stroke, Bethesda, MD, USA
| | | | - Sagi Harnof
- Chaim Sheba Medical Center, Ramat Gan, Israel
| | | | | | | | | | - Jack Jallo
- Thomas Jefferson University Hospital, Philadelphia, PA, USA
| | | | - David LeDoux
- North Shore Long Island Jewish Medical Center, Manhasset, NY, USA
| | | | | | | | - Michael Rosenblum
- Johns Hopkins University Bloomberg School of Public Health, Department of Biostatistics, Baltimore, MD, USA
| | - Richard E Thompson
- Johns Hopkins University Bloomberg School of Public Health, Department of Biostatistics, Baltimore, MD, USA
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