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  • 1
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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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  • 2
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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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  • 3
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    Perihematomal Edema Is Greater in the Presence of a Spot Sign but Does Not Predict Intracerebral Hematoma Expansion
    Ovid Technologies (Wolters Kluwer Health) ; 2016
    In:  Stroke Vol. 47, No. 2 ( 2016-02), p. 350-355
    Details
    In: Stroke, Ovid Technologies (Wolters Kluwer Health), Vol. 47, No. 2 ( 2016-02), p. 350-355
    Abstract: Perihematomal edema volume may be related to intracerebral hemorrhage (ICH) volume at baseline and, consequently, with hematoma expansion. However, the relationship between perihematomal edema and hematoma expansion has not been well established. We aimed to investigate the relationship among baseline perihematomal edema, the computed tomographic angiography spot sign, hematoma expansion, and clinical outcome in patients with acute ICH. Methods— Predicting Hematoma Growth and Outcome in Intracerebral Hemorrhage Using Contrast Bolus CT (PREDICT) was a prospective observational cohort study of ICH patients presenting within 6 hours from onset. Patients underwent computed tomography and computed tomographic angiography scans at baseline and 24-hour computed tomography scan. A post hoc analysis of absolute perihematomal edema and relative perihematomal edema (absolute perihematomal edema divided by ICH) volumes was performed on baseline computed tomography scans (n=353). Primary outcome was significant hematoma expansion ( 〉 6 mL or 〉 33%). Secondary outcomes were early neurological deterioration, 90-day mortality, and poor outcome. Results— Absolute perihematomal edema volume was higher in spot sign patients (24.5 [11.5–41.8] versus 12.6 [6.9–22] mL; P 〈 0.001), but it was strongly correlated with ICH volume ( ρ =0.905; P 〈 0.001). Patients who experienced significant hematoma expansion had higher absolute perihematomal edema volume (18.4 [10–34.6] versus 11.8 [6.5–22] mL; P 〈 0.001) but similar relative perihematomal edema volume (1.09 [0.89–1.37] versus 1.12 [0.88–1.54] ; P =0.400). Absolute perihematomal edema volume and poorer outcomes were higher by tertiles of ICH volume, and perihematomal edema volume did not independently predict significant hematoma expansion. Conclusions— Perihematomal edema volume is greater at baseline in the presence of a spot sign. However, it is strongly correlated with ICH volume and does not independently predict hematoma expansion.
    Type of Medium: Online Resource
    ISSN: 0039-2499 , 1524-4628
    URL: Article
    DOI: 10.1161/STROKEAHA.115.011295
    RVK:
    XA 10000
    Language: English
    Publisher: Ovid Technologies (Wolters Kluwer Health)
    Publication Date: 2016
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  • 4
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    Prediction of haematoma growth and outcome in patients with intracerebral haemorrhage using the CT-angiography spot sign (PREDICT): a prospective observational study
    Elsevier BV ; 2012
    In:  The Lancet Neurology Vol. 11, No. 4 ( 2012-04), p. 307-314
    Details
    In: The Lancet Neurology, Elsevier BV, Vol. 11, No. 4 ( 2012-04), p. 307-314
    Type of Medium: Online Resource
    ISSN: 1474-4422
    URL: Article
    DOI: 10.1016/S1474-4422(12)70038-8
    Language: English
    Publisher: Elsevier BV
    Publication Date: 2012
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  • 5
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    Abstract TP325: Lack of Early Improvement Predicts Poor Clinical Outcome Following Acute Intracerebral Hemorrhage
    Ovid Technologies (Wolters Kluwer Health) ; 2017
    In:  Stroke Vol. 48, No. suppl_1 ( 2017-02)
    Details
    In: Stroke, Ovid Technologies (Wolters Kluwer Health), Vol. 48, No. suppl_1 ( 2017-02)
    Abstract: Background: Early Neurological Worsening (ENW) is common after ICH, and predicts poor outcome. However, there is limited data as to what degree of ENW best relates to outcome. We used two ICH cohorts to refine and validate a definition of ENW that best predicted 90-day outcomes. Methods: We generated receiver operating characteristic (ROC) curves for the association between 24-hour NIHSS change and ICH outcomes using data from the VISTA collaboration. Primary outcome was poor outcome at 90 days (mRS 4-6); secondary outcomes were other mRS cutpoints (mRS 2-6, 3-6, 5-6, 6). We tested the commonly used NIHSS≥4 definition and in addition employed Youden’s J Index to select optimal cutpoints and calculated sensitivity, specificity, and predictive values. Independent predictors of poor outcome were determined via multivariable logistic regression. Definitions were validated in the prospectively collected PREDICT-ICH cohort. Results: Using 552 patients from the VISTA cohort, ROC curves of 24hr NIHSS change had an area under the curve of 0.75. NIHSS change of ≥0 at 24hrs was seen in 46.4%. Youden’s method showed an optimum cutoff at -0.5. Based on this, ENW defined as 〉 0 (Sens 43%, Spec 91%, PPV 83%, aOR 7.13 [CI:4.05-12.55]), ≥0 (Sens 65%, Spec 73%, PPV 70%, aOR 5.05 [CI:3.25-7.85] ), or ≥-1 (Sens 78%, Spec 59%, PPV 65%, aOR 6.04 [CI:3.75-9.71]) all accurately predicted poor outcome. PPV increased with higher NIHSS cutoffs, but at the cost of lower sensitivities. Regression confirmed that all definitions independently predicted outcome at all mRS cutpoints. ENW definitions reproduced well in the validation cohort of 275 patients. Conclusion: All NIHSS cut-offs for ENW predict clinical outcome, regardless of outcome definition. In particular, lack of clinical improvement at 24 hours (i.e. NIHSS is the same or higher) robustly predicted poor outcome, but may not be sufficiently reliable to determine clinical management.
    Type of Medium: Online Resource
    ISSN: 0039-2499 , 1524-4628
    URL: Article
    DOI: 10.1161/str.48.suppl_1.tp325
    RVK:
    XA 10000
    Language: English
    Publisher: Ovid Technologies (Wolters Kluwer Health)
    Publication Date: 2017
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  • 6
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    Validation of the 9-Point and 24-Point Hematoma Expansion Prediction Scores and Derivation of the PREDICT A/B Scores
    Ovid Technologies (Wolters Kluwer Health) ; 2015
    In:  Stroke Vol. 46, No. 11 ( 2015-11), p. 3105-3110
    Details
    In: Stroke, Ovid Technologies (Wolters Kluwer Health), Vol. 46, No. 11 ( 2015-11), p. 3105-3110
    Abstract: Nine- and 24-point prediction scores have recently been published to predict hematoma expansion (HE) in acute intracerebral hemorrhage. We sought to validate these scores and perform an independent analysis of HE predictors. Methods— We retrospectively studied 301 primary or anticoagulation-associated intracerebral hemorrhage patients presenting 〈 6 hours post ictus prospectively enrolled in the Predicting Hematoma Growth and Outcome in Intracerebral Hemorrhage Using Contrast Bolus Computed Tomography (PREDICT) study. Patients underwent baseline computed tomography angiography and 24-hour noncontrast computed tomography follow-up for HE analysis. Discrimination and calibration of the 9- and 24-point scores was assessed. Independent predictors of HE were identified using multivariable regression and incorporated into the PREDICT A/B scores, which were then compared with existing scores. Results— The 9- and 24-point HE scores demonstrated acceptable discrimination for HE 〉 6 mL or 33% and 〉 6 mL, respectively (area under the curve of 0.706 and 0.755, respectively). The 24-point score demonstrated appropriate calibration in the PREDICT cohort (χ 2 statistic, 11.5; P =0.175), whereas the 9-point score demonstrated poor calibration (χ 2 statistic, 34.3; P 〈 0.001). Independent HE predictors included spot sign number, time from onset, warfarin use or international normalized ratio 〉 1.5, Glasgow Coma Scale, and National Institutes of Health Stroke Scale and were included in PREDICT A/B scores. PREDICT A showed improved discrimination compared with both existing scores, whereas performance of PREDICT B varied by definition of expansion. Conclusions— The 9- and 24-point expansion scores demonstrate acceptable discrimination in an independent multicenter cohort; however, calibration was suboptimal for the 9-point score. The PREDICT A score showed improved discrimination for HE prediction but requires independent validation.
    Type of Medium: Online Resource
    ISSN: 0039-2499 , 1524-4628
    URL: Article
    DOI: 10.1161/STROKEAHA.115.009893
    RVK:
    XA 10000
    Language: English
    Publisher: Ovid Technologies (Wolters Kluwer Health)
    Publication Date: 2015
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  • 7
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    Abstract 115: Venous Phase Acquisition Is the Best Bolus Timing to Increase Spot Sign Detection in ICH, But Frequency and Extent of Hematoma Expansion Are Greater in Spot Signs Detected in the Arterial Phase of CTA
    Ovid Technologies (Wolters Kluwer Health) ; 2013
    In:  Stroke Vol. 44, No. suppl_1 ( 2013-02)
    Details
    In: Stroke, Ovid Technologies (Wolters Kluwer Health), Vol. 44, No. suppl_1 ( 2013-02)
    Abstract: Background: Although the PREDICT study validated the spot sign for predicting significant hematoma expansion (HE) in acute intracerebral hemorrhage (ICH), the sensitivity was 51% and PPV 61%. Recent studies suggest that second pass imaging can increase the yield of contrast extravasation. The present analysis aimed to determine the frequency of spot sign depending on the phase of image acquisition, and whether an early phase spot sign has greater HE compared to later phases. Methods: The PREDICT study was a multicentric, prospective, observational cohort study of ICH patients presented 〈 6 hours. A blinded neurologist measured the Hounsfield units of an arterial and venous structure at three levels on CTA source images. The nearest structure to ICH was chosen to classify each study into the phase of acquisition. CTA were classified in 10 phases from early triggering to steady state, including arterial peak (5), arterial-venous equilibrium (6), and venous peak (7). Significant HE was defined as ICH enlargement 〉 33% or 〉 6mL at 24 hours. Results: Overall (n=378), 77.5% of CTA were acquired in arterial phases. The spot sign occurred in 29.6%, and there was a trend to more frequent detection in the venous phases (37.6% vs. 27.3%, p=0.066) and in later image acquisition phases (p=0.141; Fig). HE analysis was limited to 318 patients: 26.7% presented spot sign and 32.4% experienced significant HE. In spot-sign positive group, there was a trend that HE occurred more frequently in earlier image acquisition phases (p=0.193, Fig). Similarly, median total hematoma enlargement (ICH+IVH) was greater in earlier phases (p=0.041; Fig). Conclusions: This analysis highlights improved spot sign detection with later image acquisition in venous phase of CTA. However spot signs identified in the arterial phase are associated with more frequent hematoma expansion and greater extent. A two phase CTA is optimal in ICH patients and should include image acquisition in the arterial and venous phases.
    Type of Medium: Online Resource
    ISSN: 0039-2499 , 1524-4628
    URL: Article
    DOI: 10.1161/str.44.suppl_1.A115
    RVK:
    XA 10000
    Language: English
    Publisher: Ovid Technologies (Wolters Kluwer Health)
    Publication Date: 2013
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  • 8
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    Intracerebral Hematoma Morphologic Appearance on Noncontrast Computed Tomography Predicts Significant Hematoma Expansion
    Ovid Technologies (Wolters Kluwer Health) ; 2015
    In:  Stroke Vol. 46, No. 11 ( 2015-11), p. 3111-3116
    Details
    In: Stroke, Ovid Technologies (Wolters Kluwer Health), Vol. 46, No. 11 ( 2015-11), p. 3111-3116
    Abstract: Hematoma expansion in intracerebral hemorrhage is associated with higher morbidity and mortality. The computed tomography (CT) angiographic spot sign is highly predictive of expansion, but other morphological features of intracerebral hemorrhage such as fluid levels, density heterogeneity, and margin irregularity may also predict expansion, particularly in centres where CT angiography is not readily available. Methods— Baseline noncontrast CT scans from patients enrolled in the Predicting Hematoma Growth and Outcome in Intracerebral Hemorrhage Using Contrast Bolus CT (PREDICT) study were assessed for the presence of fluid levels and degree of density heterogeneity and margin irregularity using previously validated scales. Presence and grade of these metrics were correlated with the presence of hematoma expansion as defined by the PREDICT study on 24-hour follow-up scan. Results— Three hundred eleven patients were included in the analysis. The presence of fluid levels and increasing heterogeneity and irregularity were associated with 24-hour hematoma expansion ( P =0.021, 0.003 and 0.049, respectively) as well as increases in absolute hematoma size. Fluid levels had the highest positive predictive value (50%; 28%–71%), whereas margin irregularity had the highest negative predictive value (78%; 71%–85). Noncontrast metrics had comparable predictive values as spot sign for expansion when controlled for vitamin K, antiplatelet use, and baseline National Institutes of Health Stroke Scale, although in a combined area under the receiver-operating characteristic curve model, spot sign remained the most predictive. Conclusions— Fluid levels, density heterogeneity, and margin irregularity on noncontrast CT are associated with hematoma expansion at 24 hours. These markers may assist in prediction of outcomes in scenarios where CT angiography is not readily available and may be of future help in refining the predictive value of the CT angiography spot sign.
    Type of Medium: Online Resource
    ISSN: 0039-2499 , 1524-4628
    URL: Article
    DOI: 10.1161/STROKEAHA.115.010566
    RVK:
    XA 10000
    Language: English
    Publisher: Ovid Technologies (Wolters Kluwer Health)
    Publication Date: 2015
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  • 9
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    Abstract 3046: Co-registration and 3D Comparison Reveal a Variable Trajectory of Intracerebral Hemorrhage Expansion in Relation to Spot Sign Location: Analysis from the PREDICT Study
    Ovid Technologies (Wolters Kluwer Health) ; 2012
    In:  Stroke Vol. 43, No. suppl_1 ( 2012-02)
    Details
    In: Stroke, Ovid Technologies (Wolters Kluwer Health), Vol. 43, No. suppl_1 ( 2012-02)
    Abstract: Background: Intracerebral hemorrhage (ICH) expansion can have devastating effects for patients. The spot sign, a form of contrast extravasation, has been shown to predict hemorrhage expansion. However, the relationship between the location of the spot sign within the ICH and the direction of hemorrhage expansion has not been defined. We hypothesized that the spot sign can predict the trajectory of ICH expansion. Methods: Data from PREDICT, a prospective, observational cohort study coordinated at the University of Calgary, were used to conduct this case series. Non-contrast computed tomography (CT) and CT-angiography data were obtained for each subject. We used segmentation software to outline ICH volume on baseline and follow-up CTs. We then co-registered the scans and volumes in the same space to allow for three-dimensional voxel-to-voxel comparison along the x-, y-, and z-axes. This comparison yielded three points in three-dimensional space: the spot sign center of mass, the baseline ICH center of mass, and the follow-up ICH center of mass. Distances and angles between these points were used to classify four groups of ICH expansion: 1) perpendicular to the spot sign and baseline ICH center of mass; 2) away from the spot sign; 3) toward the spot sign; and, 4) circumferential. Results: Eighty-two PREDICT study subjects exhibited spot signs. Forty were multiple spot signs and 42 were single spot signs eligible for this analysis. Seven subjects were excluded because of surgery or incomplete imaging. Sixteen subjects were not co-registered because of head motion or insufficient image quality. Nineteen single spot subjects were successfully co-registered. The radius of these 19 hemorrhages was 1.6±0.4 cm (assuming a sphere). The spot sign was located 1.4±0.6 times the length of the radius away from the baseline ICH center of mass. We classified nine co-registered subjects into the four groups because they showed significant hemorrhage expansion defined as ≥6 mL or ≥33% from baseline to follow-up. Four subjects exhibited hemorrhage expansion away from the spot sign, three exhibited circumferential hemorrhage expansion, and two exhibited hemorrhage expansion toward the spot sign. No hemorrhages expanded perpendicular to the spot sign. Conclusion: The spot sign is generally located in the periphery of the ICH. Hemorrhages do not consistently expand in one specific trajectory from the spot sign. This study suggests that the spot sign location may not be useful to predict the direction of hemorrhage expansion.
    Type of Medium: Online Resource
    ISSN: 0039-2499 , 1524-4628
    URL: Article
    DOI: 10.1161/str.43.suppl_1.A3046
    RVK:
    XA 10000
    Language: English
    Publisher: Ovid Technologies (Wolters Kluwer Health)
    Publication Date: 2012
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  • 10
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    Venous Phase of Computed Tomography Angiography Increases Spot Sign Detection, but Intracerebral Hemorrhage Expansion Is Greater in Spot Signs Detected in Arterial Phase
    Ovid Technologies (Wolters Kluwer Health) ; 2014
    In:  Stroke Vol. 45, No. 3 ( 2014-03), p. 734-739
    Details
    In: Stroke, Ovid Technologies (Wolters Kluwer Health), Vol. 45, No. 3 ( 2014-03), p. 734-739
    Abstract: Variability in computed tomography angiography (CTA) acquisitions may be one explanation for the modest accuracy of the spot sign for predicting intracerebral hemorrhage expansion detected in the multicenter Predicting Hematoma Growth and Outcome in Intracerebral Hemorrhage Using Contrast Bolus CT (PREDICT) study. This study aimed to determine the frequency of the spot sign in intracerebral hemorrhage and its relationship with hematoma expansion depending on the phase of image acquisition. Methods— PREDICT study was a prospective observational cohort study of patients with intracerebral hemorrhage presenting within 6 hours from onset. A post hoc analysis of the Hounsfield units of an artery and venous structure were measured on CTA source images of the entire PREDICT cohort in a core laboratory. Each CTA study was classified into arterial or venous phase and into 1 of 5 specific image acquisition phases. Significant hematoma expansion and total hematoma enlargement were recorded at 24 hours. Results— Overall (n=371), 77.9% of CTA were acquired in arterial phase. The spot sign, present in 29.9% of patients, was more frequently seen in venous phase as compared with arterial phase (39% versus 27.3%; P =0.041) and the later the phase of image acquisition ( P =0.095). Significant hematoma expansion ( P =0.253) and higher total hematoma enlargement ( P =0.019) were observed more frequently among spot sign–positive patients with earlier phases of image acquisition. Conclusions— Later image acquisition of CTA improves the frequency of spot sign detection. However, spot signs identified in earlier phases may be associated with greater absolute enlargement. A multiphase CTA including arterial and venous acquisitions could be optimal in patients with intracerebral hemorrhage.
    Type of Medium: Online Resource
    ISSN: 0039-2499 , 1524-4628
    URL: Article
    DOI: 10.1161/STROKEAHA.113.003007
    RVK:
    XA 10000
    Language: English
    Publisher: Ovid Technologies (Wolters Kluwer Health)
    Publication Date: 2014
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