Abstract 3173: Imaging Findings at the Earliest Stages of Intracerebral Hemorrhage

Abstract

Background: Imaging findings in intracerebral hemorrhage (ICH) patients at ultra-early time points have not been well characterized. Objective: To describe imaging findings in consecutive ICH patients being transported by ambulance within 2 hours from symptom onset. Methods: We analyzed consecutive ICH patients enrolled in the multicenter, NIH Field Administration of Stroke Therapy (FAST-MAG) clinical trial. First brain imaging studies obtained in the ED were independently reviewed by 2 neurologists for ICH location, volume, presence of intraventricular hemorrhage (IVH), heterogeneity (defined as >20 point difference in Hounsfield units), irregular borders, multilobulation, and substantial edema (defined as >0.5cm). Leukoaraiosis was graded using the Fazekas scale for periventricular and deep white matter changes (0-3 for each). Results: Among 127 patients (enrolled en route to 23 hospitals), mean age was 66 (SD 14), 34% were women, 35% had Hispanic ethnicity, 83% were white, and 84% had a history of HTN. At time of first field evaluation by paramedics [mean 31 (SD 23) minutes after last known well time (LKWT)], the initial BP was 177/95 (SD 34/22) and median (IQR) Glasgow Coma Scale of 15 (15-15). First brain imaging studies were obtained a mean of 100 (SD 35, range 54-255) minutes after LKWT, and were CT in 90% and MRI in 10%. Location of ICH was most often in the lentiform nucleus (42%) followed by thalamus (40%), and cortex (4%), with one case each of caudate, pons, and cerebellar deep nuclei. The mean volume of initial hematoma was 19.6 (SD 23) ml. IVH was present in 45 (35%), significant edema in 13 (10%), and midline shift in 24 (19%). Hemorrhage density was heterogeneous in 34 (27%), multilobulated in 55 (43%) and with irregular borders in 77 (60%). Leukoaraiosis (LA) was common, with moderate to severe LA (Fazekas grades 2, 3) present in the periventricular region in 58% and deep regions centrum semiovale in 35%. Conclusions: Among ICH patients presenting within the first 2h, deep hemorrhages predominate over superficial and intraventricular extension is already present in one-third, but ICH volume is moderate and substantial edema present in only one-tenth. These findings suggest substantial opportunities for intervention to avert hemorrhage and edema growth ultra-early after ICH onset.