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  • 1
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    Abstract WP462: New or Expanding Ventricular Hemorrhage Predicts Poor Outcome After Intracerebral Hemorrhage
    Ovid Technologies (Wolters Kluwer Health) ; 2019
    In:  Stroke Vol. 50, No. Suppl_1 ( 2019-02)
    Details
    In: Stroke, Ovid Technologies (Wolters Kluwer Health), Vol. 50, No. Suppl_1 ( 2019-02)
    Abstract: Introduction: Baseline intraventricular hemorrhage (IVH) is a predictor of poor outcome in acute intracerebral hemorrhage (ICH) patients. However, questions remain as to the exact burden that new IVH development, seen on follow-up imaging, or what degree of interval IVH expansion, impacts long term functioning. Objective: To derive and validate a relationship between IVH change and long term outcome. Methods: Fractional polynomial analysis was used to test linear and non-linear models of 24-hour IVH change and clinical outcome using data from the multicenter PREDICT study. The primary outcome was mRS 4-6 at 90 days. Dichotomous thresholds were derived via assessment of the selected model and diagnostic accuracy measures were calculated. Independent predictors of poor outcome were determined via multivariable logistic regression. The developed model and all derived thresholds were validated in an independent single center cohort. Results: Of the 256 patients from PREDICT, 127 (49.6%) had mRS scores of 4-6 at 90 days. 24-hour IVH change and the primary outcome fit a non-linear relationship, where minimal increases in IVH were associated with a high probability of poor outcome (Figure 1). Mean IVH expansion was 8.6 mL. IVH expansion greater than 1 mL (n=53, Sens 33%, Spec 92%, PPV 79%, NPV 58%, aOR 2.77 [95% CI: 1.12-6.89]) and development of any new IVH (n= 74, Sens 43%, Spec 85%, PPV 74%, NPV 60%, aOR 2.17 [95% CI: 1.02-4.63] ) strongly predicted mRS 4-6 at 90 days. The model and developed thresholds reproduced well in a validation cohort of 170 patients. Conclusion: IVH expansion as minimal as 1 mL, or any new IVH is strongly predictive of poor outcome. This can aid in prognostication, be incorporated into definitions of hematoma expansion for future ICH treatment trials, or even imply that IVH treatment is a therapeutic target that may lead to improved outcomes.
    Type of Medium: Online Resource
    ISSN: 0039-2499 , 1524-4628
    URL: Article
    DOI: 10.1161/str.50.suppl_1.WP462
    RVK:
    XA 10000
    Language: English
    Publisher: Ovid Technologies (Wolters Kluwer Health)
    Publication Date: 2019
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  • 2
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    New and expanding ventricular hemorrhage predicts poor outcome in acute intracerebral hemorrhage
    Ovid Technologies (Wolters Kluwer Health) ; 2019
    In:  Neurology Vol. 93, No. 9 ( 2019-08-27)
    Details
    In: Neurology, Ovid Technologies (Wolters Kluwer Health), Vol. 93, No. 9 ( 2019-08-27)
    Type of Medium: Online Resource
    ISSN: 0028-3878 , 1526-632X
    URL: Article
    DOI: 10.1212/WNL.0000000000008007
    RVK:
    XA 10000
    Language: English
    Publisher: Ovid Technologies (Wolters Kluwer Health)
    Publication Date: 2019
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  • 3
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    Defining the CT Angiography ‘Spot Sign’ in Primary Intracerebral Hemorrhage
    Cambridge University Press (CUP) ; 2009
    In:  Canadian Journal of Neurological Sciences / Journal Canadien des Sciences Neurologiques Vol. 36, No. 4 ( 2009-07), p. 456-461
    Details
    In: Canadian Journal of Neurological Sciences / Journal Canadien des Sciences Neurologiques, Cambridge University Press (CUP), Vol. 36, No. 4 ( 2009-07), p. 456-461
    Abstract: Le spot sign à l’angiographie par tomodensitométrie (angio CT) désigne des foyers intralésionnels de rehaussement associés à une expansion de l’hématome chez les patients qui présentent une hémorragie intracérébrale primaire. Il faudra utiliser une définition radiologique fiable dans le cadre de deux essais cliniques portant sur le facteur VIIa recombinant, dans lesquels les patients seront classifiés selon la présence ou l’absence du spot sign. Nous proposons des critères radiologiques pour le diagnostic du spot sign à l’angio CT et nous décrivons différents aspects morphologiques. Matériel et méthodes : Une cohort prospective composée de 36 patients consécutifs qui ont consulté pour une hémorragie intracérébrale primaire (HIP) ont été inclus dans une etude multicentre effectuée en collaboration dont nous présentons les données. Trois réviseurs ont analysé les études angio CT en double insu. L’analyse de manifestations spécifiques d’HIP et de spot sign a été effectuée, dont la prévalence, le nombre, la taille, la localisation, la morphologie et la densité en unités Hounsfield (UH). Résultats : Au total, 19 foyers rehaussants compatibles avec un spot sign à l’angio CT ont été observés chez douze des trentesix patients (33%). La moyenne de la dimension axiale maximale du spot sign était de 3,7 ± 2,2 mm et la densité moyenne de 216 ± 57,7 UH. Aucune différence significative quant à l’âge ou à la pression sanguine (p = 0,7), la glycémie (p = 0,9), l’INR/PTT (p = 0,3 et 0,4) ou la localisation de l’hématome (p = 0,3) n’a été observée entre les patients présentant ou non le spot sign. Nous proposons une définition de consensus et des critères de classification du spot sign à l’angio CT. Conclusion : Le spot sign est défini comme étant des foyers de rehaussement punctiformes et/ou serpigineux à l’intérieur des marges d’un hématome parenchymateux, sans connexion aux vaisseaux extérieurs. Le spot sign a une dimension maximale de plus de 1,5 mm et une densité UH qui est au moins deux fois celle de l’hématome dans lequel il est situé.
    Type of Medium: Online Resource
    ISSN: 0317-1671 , 2057-0155
    URL: Article
    DOI: 10.1017/S0317167100007782
    RVK:
    XA 10000
    Language: English
    Publisher: Cambridge University Press (CUP)
    Publication Date: 2009
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  • 4
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    Does the Application of X-Ray Contrast Agents Impair the Clinical Effect of Intravenous Recombinant Tissue-Type Plasminogen Activator in Acute Ischemic Stroke Patients?
    Ovid Technologies (Wolters Kluwer Health) ; 2012
    In:  Stroke Vol. 43, No. 6 ( 2012-06), p. 1567-1571
    Details
    In: Stroke, Ovid Technologies (Wolters Kluwer Health), Vol. 43, No. 6 ( 2012-06), p. 1567-1571
    Abstract: Experimental data suggest a negative interaction between x-ray contrast agents and fibrinolytic efficacy of recombinant tissue-type plasminogen activator (rtPA). We hypothesized that the application of a contrast agent before intravenous thrombolysis with rtPA reduces its clinical efficacy in acute ischemic stroke. Methods— We retrospectively studied consecutive ischemic stroke patients receiving contrast agents for computed tomography angiography before intravenous treatment with rtPA. We compared functional outcomes with an historical control group from the Canadian Alteplase for Stroke Effectiveness Study who did not receive contrast agents before thrombolysis with rtPA. Primary end point was favorable functional outcome at 90 days defined as modified Rankin Scale scores 0 to 2. We performed logistic regression analysis and a propensity score matching analysis to estimate the effect size of contrast agent use as a negative predictor of outcome. Results— We identified 111 patients for the computed tomography angiography and 1119 patients for the control group. Proportions of favorable functional outcome were 47.7% (53/111 patients) for the computed tomography angiography group and 49.5% (542/1094 patients) for the control group ( P =0.77). Adjusted probabilities for favorable outcome were 0.48 (95% CI, 0.37–0.58) and 0.51 (95% CI, 0.47–0.54), respectively. Contrast use was associated with reduced odds of favorable outcome (OR, 0.62 ; 95% CI, 0.38–0.99). Propensity score matching suggested a larger effect size (OR, 10.0%; 95% CI, 0.5%–19.3%). Conclusions— Our study did not show a significant negative clinical effect of x-ray contrast agents applied before intravenous thrombolysis with rtPA. However, to confirm a possible small negative interaction between contrast agents and rtPA, additional experimental and prospective clinical studies are needed.
    Type of Medium: Online Resource
    ISSN: 0039-2499 , 1524-4628
    URL: Article
    DOI: 10.1161/STROKEAHA.112.651737
    RVK:
    XA 10000
    Language: English
    Publisher: Ovid Technologies (Wolters Kluwer Health)
    Publication Date: 2012
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  • 5
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    “Clinical-CT Mismatch” and the Response to Systemic Thrombolytic Therapy in Acute Ischemic Stroke
    Ovid Technologies (Wolters Kluwer Health) ; 2005
    In:  Stroke Vol. 36, No. 8 ( 2005-08), p. 1695-1699
    Details
    In: Stroke, Ovid Technologies (Wolters Kluwer Health), Vol. 36, No. 8 ( 2005-08), p. 1695-1699
    Abstract: Background and Purpose— Mismatch between clinical deficits and imaging lesions in acute stroke has been proposed as a method of identifying patients who have hypoperfused but still have viable brain, and may be especially apt to respond to reperfusion therapy. We explored this hypothesis using a combined database including 4 major clinical trials of intravenous (IV) thrombolytic therapy. Methods— To determine what the radiological correlates of a “matched” functional deficit are, we calculated the relationship between the ASPECT score of the 24-hour (follow-up) CT scan and the 24-hour National Institutes of Health Stroke Scale (NIHSS) score on the subsample with ASPECT scores performed at this time (n=820). Based on this empirical relationship, we computed the absolute difference between the observed baseline ASPECT score and the “expected” score (ie, matched) based on baseline NIHSS for all patients (n=2131). We tested whether patients with better than expected baseline ASPECTS were more likely to benefit from IV recombinant tissue plasminogen activation (rtPA). Results— At 24 hours, there was a strong, linear, negative correlation between NIHSS and ASPECTS (r 2 =0.33, P 〈 0.0001); on average, an increase of 10 points on NIHSS corresponded to a decrease of ≈3 points on ASPECTS. At baseline, the average degree of mismatch between the observed and “expected” ASPECTS was 2.1 points (interquartile range, 1.0 to 3.4). However, multiple analyses failed to reveal a consistent relationship between the degree of clinical-CT mismatch at baseline and a patient’s likelihood of benefiting from IV rtPA. Conclusion— Clinical-CT mismatch using ASPECT scoring does not reliably identify patients more or less likely to benefit from IV rtPA.
    Type of Medium: Online Resource
    ISSN: 0039-2499 , 1524-4628
    URL: Article
    DOI: 10.1161/01.STR.0000173397.31469.4b
    RVK:
    XA 10000
    Language: English
    Publisher: Ovid Technologies (Wolters Kluwer Health)
    Publication Date: 2005
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  • 6
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    Extent of Early Ischemic Changes on Computed Tomography (CT) Before Thrombolysis : Prognostic Value of the Alberta Stroke Program Early CT Score in ECASS II
    Ovid Technologies (Wolters Kluwer Health) ; 2006
    In:  Stroke Vol. 37, No. 4 ( 2006-04), p. 973-978
    Details
    In: Stroke, Ovid Technologies (Wolters Kluwer Health), Vol. 37, No. 4 ( 2006-04), p. 973-978
    Abstract: Background and Purpose— The significance of early ischemic changes (EICs) on computed tomography (CT) to triage patients for thrombolysis has been controversial. The Alberta Stroke Program Early CT Score (ASPECTS) semiquantitatively assesses EICs within the middle cerebral artery territory using a10-point grading system. We hypothesized that dichotomized ASPECTS predicts response to intravenous thrombolysis and incidence of secondary hemorrhage within 6 hours of stroke onset. Methods— Data from the European-Australian Acute Stroke Study (ECASS) II study were used in which 800 patients were randomized to recombinant tissue plasminogen activator (rt-PA) or placebo within 6 hours of symptom onset. We retrospectively assessed all baseline CT scans, dichotomized ASPECTS at ≤7 and 〉 7, defined favorable outcome as modified Rankin Scale score 0 to 2 after 90 days, and secondary hemorrhage as parenchymal hematoma 1 (PH1) or PH2. We performed a multivariable logistic regression analysis and assessed for an interaction between rt-PA treatment and baseline ASPECTS score. Results— We scored ASPECTS 〉 7 in 557 and ≤7 in 231 patients. There was no treatment-by-ASPECTS interaction with dichotomized ASPECTS ( P =0.3). This also applied for the 0- to 3-hour and 3- to 6-hour cohorts. However, a treatment-by-ASPECTS effect modification was seen in predicting PH (0.043 for the interaction term), indicating a much higher likelihood of thrombolytic-related parenchymal hemorrhage in those with ASPECTS ≤7. Conclusion— In ECASS II, the effect of rt-PA on functional outcome is not influenced by baseline ASPECTS. Patients with low ASPECTS have a substantially increased risk of thrombolytic-related PH.
    Type of Medium: Online Resource
    ISSN: 0039-2499 , 1524-4628
    URL: Article
    DOI: 10.1161/01.STR.0000206215.62441.56
    RVK:
    XA 10000
    Language: English
    Publisher: Ovid Technologies (Wolters Kluwer Health)
    Publication Date: 2006
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  • 7
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    Asymptomatic Hemorrhage After Thrombolysis May Not Be Benign : Prognosis by Hemorrhage Type in the Canadian Alteplase for Stroke Effectiveness Study Registry
    Ovid Technologies (Wolters Kluwer Health) ; 2007
    In:  Stroke Vol. 38, No. 1 ( 2007-01), p. 75-79
    Details
    In: Stroke, Ovid Technologies (Wolters Kluwer Health), Vol. 38, No. 1 ( 2007-01), p. 75-79
    Abstract: Background and Purpose— There is ongoing controversy about the impact of hemorrhagic transformation after thrombolysis on long-term functional outcome. We sought to study the relation between the type of hemorrhagic transformation on CT scans and functional outcome. Methods— Data were obtained from the Canadian Alteplase for Stroke Effectiveness Study. This study was established as a registry to prospectively collect data for acute stroke patients receiving intravenous alteplase within 3 hours from stroke onset between February 1999 and June 2001. Follow-up was completed at 90 days, and good functional outcome was defined as a modified Rankin Scale score of 0 or 1. Copies of head CT scans obtained at 24 to 48 hours after starting treatment were read in consensus by a central reading panel consisting of 1 neuroradiologist and 1 stroke neurologist. According to European Cooperative Acute Stroke Study criteria, hemorrhagic transformation was classified as none, hemorrhagic infarction (HI-1 and HI-2), or parenchymal hematoma (PH-1 and PH-2). We compared outcome across groups and performed a multivariable analysis including previously determined important predictors of good outcome in acute ischemic stroke. Results— From 1135 patients enrolled at 60 centers across Canada, 954 follow-up CT scans were assessable. We observed some hemorrhagic transformation in 259 of 954 (27.1%) patients (110 HI-1, 57 HI-2, 48 PH-1, and 44 PH-2). Proportions of patients with good outcome were 41% with no hemorrhagic transformation, 30% with HI-1, 17% with HI-2, 15% with PH-1, and 7% with PH-2 ( P 〈 0.0001, χ 2 test). After adjustment for age, baseline serum glucose, baseline Alberta Stroke Program Early CT score, and baseline National Institutes of Health Stroke Scale score, HI-1 was not a predictor of outcome. However, HI-2 (odds ratio=0.38, 95% CI=0.17 to 0.83), PH-1 (odds ratio=0.32, 95% CI=0.12 to 0.80), and PH-2 (odds ratio=0.14, 95% CI=0.04 to 0.48) were all negative predictors of outcome. Conclusions— The likelihood of a poor outcome after thrombolysis was proportional to the extent of hemorrhage on CT scans. HI grades of hemorrhagic transformation may not be benign.
    Type of Medium: Online Resource
    ISSN: 0039-2499 , 1524-4628
    URL: Article
    DOI: 10.1161/01.STR.0000251644.76546.62
    RVK:
    XA 10000
    Language: English
    Publisher: Ovid Technologies (Wolters Kluwer Health)
    Publication Date: 2007
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  • 8
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    Abstract 93: Do Intracerebral Hemorrhage “Non-Expanders” Actually Expand into the Ventricular Space?
    Ovid Technologies (Wolters Kluwer Health) ; 2015
    In:  Stroke Vol. 46, No. suppl_1 ( 2015-02)
    Details
    In: Stroke, Ovid Technologies (Wolters Kluwer Health), Vol. 46, No. suppl_1 ( 2015-02)
    Abstract: Background: The CT-angiography spot sign as a predictor of hematoma expansion (HE) is limited by its modest sensitivity and PPV. Spot sign studies restrict HE definitions to the parenchymal component of ICH and do not consistently evaluate intraventricular hemorrhage (IVH) expansion. Decompression of ICH into the ventricular space can lead to underestimation of HE and overestimation of false-positive spot signs. We hypothesized that a proportion of ICH “non-expanders” expand into the ventricular space and including IVH expansion in HE definitions will improve the predictive performance of the spot sign. Our objectives were: 1) determine the proportion of ICH “non-expanders” who have IVH expansion, 2) determine the proportion of “false-positive” spot signs that have IVH expansion, 3) compare the known predictive performance of the spot sign to its performance when using an HE definition incorporating IVH expansion, and 4) explore the predictors of IVH expansion. Methods: We analyzed patients from the multicenter PREDICT ICH spot sign study. We defined HE as ≥6mL or ≥33% ICH expansion or 〉 2ml IVH expansion, and compared the performance of this new definition with the conventional 6mL/33% parenchymal definition using ROC analysis. We used regression analysis to determine the predictors of IVH expansion. Results: Of 315 patients with complete imaging, 215 did not meet the 6mL/33% expansion definition ("non-expanders"). Only 14/215 (6.5%) of “non-expanders” had ≥2mL IVH expansion. Of the “false positive” spot signs, 4/39 (10.3%) had 〉 2mL ventricular expansion. The AUC for spot sign to predict significant ICH expansion was 0.65 [95% CI 0.58-0.72], which was no different then when IVH expansion was added to the HE definition: AUC 0.64 [95% CI 0.58-0.71] . Predictors for IVH expansion included IVH at baseline (aOR 2.5, p=0.013), elevated INR (aOR 2.5, p=0.011), and spot sign (aOR 5.9, p 〈 0.001). Conclusions: IVH expansion occurs in a small minority of “non-expanders”, and only 10% of “false positive” post signs actually expended in the ventricular space. Furthermore, revising HE definitions to include IVH expansion did not alter the predictive performance of the spot sign.
    Type of Medium: Online Resource
    ISSN: 0039-2499 , 1524-4628
    URL: Article
    DOI: 10.1161/str.46.suppl_1.93
    RVK:
    XA 10000
    Language: English
    Publisher: Ovid Technologies (Wolters Kluwer Health)
    Publication Date: 2015
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  • 9
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    Tissue Window in Stroke Thrombolysis Study (TWIST): A Safety Study
    Cambridge University Press (CUP) ; 2013
    In:  Canadian Journal of Neurological Sciences / Journal Canadien des Sciences Neurologiques Vol. 40, No. 1 ( 2013-01), p. 17-20
    Details
    In: Canadian Journal of Neurological Sciences / Journal Canadien des Sciences Neurologiques, Cambridge University Press (CUP), Vol. 40, No. 1 ( 2013-01), p. 17-20
    Abstract: Stroke thrombolysis is limited by the “last-seen well” principle, which defines stroke onset time. A significant minority of stroke patients (~15%) awake with their symptoms and are by definition ineligible for thrombolysis because they were “last-seen well” at the time they went to bed implying an interval that is most often greater than three hours. Methods: A single-centre prospective, safety study was designed to thrombolyse 20 subjects with stroke-on-awakening. Patients were eligible for inclusion if they were last seen well less than 12 hours previously, specifically including those who awoke from sleep with their stroke deficits. They had a baseline computed tomogram (CT) scan with an ASPECTS score greater than 5, no evidence of well-evolved infarction and a CT angiogram / Trans-cranial Doppler ultrasound study demonstrating an intracranial arterial occlusion. Patients fulfilled all other standard criteria for stroke thrombolysis. The primary outcome was safety defined by symptomatic ICH or death. Results: Among 89 screened patients, 20 were treated with thrombolysis. Two patients (10%) died due to massive carotid territory stroke and two patients (10%) died of stroke complications. Two patients (10%) showed asymptomatic intracerebral hemorrhage (ICH) (petechial hemorrhage) and none symptomatic ICH. Reasons for exclusion were: (a) ASPECTS ≤ 5 (29); (b) well-evolved infarcts on CT (19); (c) historical mRS 〉 2 (17); (d) no demonstrable arterial occlusion or were too mild to warrant treatment (10). Conclusions: Patients who awake with their deficits can be safely treated with thrombolysis based upon a tissue window defined by NCCT and CTA/TCD.
    Type of Medium: Online Resource
    ISSN: 0317-1671 , 2057-0155
    URL: Article
    DOI: 10.1017/S0317167100012890
    RVK:
    XA 10000
    Language: English
    Publisher: Cambridge University Press (CUP)
    Publication Date: 2013
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  • 10
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    Extent of Hypoattenuation on CT Angiography Source Images in Basilar Artery Occlusion : Prognostic Value in the Basilar Artery International Cooperation Study
    Ovid Technologies (Wolters Kluwer Health) ; 2011
    In:  Stroke Vol. 42, No. 12 ( 2011-12), p. 3454-3459
    Details
    In: Stroke, Ovid Technologies (Wolters Kluwer Health), Vol. 42, No. 12 ( 2011-12), p. 3454-3459
    Abstract: The posterior circulation Acute Stroke Prognosis Early CT Score (pc-ASPECTS) quantifies the extent of early ischemic changes in the posterior circulation with a 10-point grading system. We hypothesized that pc-ASPECTS applied to CT angiography source images predicts functional outcome of patients in the Basilar Artery International Cooperation Study (BASICS). Methods— BASICS was a prospective, observational registry of consecutive patients with acute symptomatic basilar artery occlusion. Functional outcome was assessed at 1 month. We applied pc-ASPECTS to CT angiography source images of patients with CT angiography for confirmation of basilar artery occlusion. We calculated unadjusted and adjusted risk ratios (RRs) of pc-ASPECTS dichotomized at ≥8 versus 〈 8. Primary outcome measure was favorable outcome (modified Rankin Scale scores 0–3). Secondary outcome measures were mortality and functional independence (modified Rankin Scale scores 0–2). Results— Of 158 patients included, 78 patients had a CT angiography source images pc-ASPECTS ≥8. Patients with a pc-ASPECTS ≥8 more often had a favorable outcome than patients with a pc-ASPECTS 〈 8 (crude RR, 1.7; 95% CI, 0.98–3.0). After adjustment for age, baseline National Institutes of Health Stroke Scale score, and thrombolysis, pc-ASPECTS ≥8 was not related to favorable outcome (RR, 1.3; 95% CI, 0.8–2.2), but it was related to reduced mortality (RR, 0.7; 95% CI, 0.5–0.98) and functional independence (RR, 2.0; 95% CI, 1.1–3.8). In post hoc analysis, pc-ASPECTS dichotomized at ≥6 versus 〈 6 predicted a favorable outcome (adjusted RR, 3.1; 95% CI, 1.2–7.5). Conclusions— pc-ASPECTS on CT angiography source images independently predicted death and functional independence at 1 month in the CT angiography subgroup of patients in the BASICS registry.
    Type of Medium: Online Resource
    ISSN: 0039-2499 , 1524-4628
    URL: Article
    DOI: 10.1161/STROKEAHA.111.622175
    RVK:
    XA 10000
    Language: English
    Publisher: Ovid Technologies (Wolters Kluwer Health)
    Publication Date: 2011
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