Abstract 35: Stabilizing Bleeding Prior To Acute Therapies For Spontaneous Intracerebral Hemorrhage

Abstract

Objective: Criteria for stabilizing intracranial bleeding (intracerebral (ICH), intraventricular (IVH) and external ventricular drain-related) in patients screened for acute therapies for spontaneous ICH involving surgery and/or thrombolytic therapy have not been established. We investigated the incidence, time course and factors associated with hematoma growth in the pre-randomization (PR) phase of 3 clinical trials with protocolized serial imaging. Methods: Serial CT assessments were performed prospectively on pre-randomization (PR) scans of 141 patients enrolled in the MISTIE II (N=117) and ICES (N=24) trials and the first 300 patients enrolled in the CLEAR III IVH trial to determine the end of ICH and IVH expansion and the occurrence of catheter tract hemorrhage (CTH). We determined ICH, IVH and CTH volumes from diagnosis up to 1st dose of study drug (CLEAR IVH) or 48 hours (MISTIE/ICES) using computerized volumetrics. Results: Of 117 patients enrolled in MISTIE/ICES, median [iqr] ICH volume was 38.44 [26.39] cc. PR hematoma expansion > 5cc/>33% was detected in 62 (44%)/38 (27%). Median time to hematoma stability was 14.63/19.82 hours respectively with final events at 40.65/42.60 hrs. Of 300 patients enrolled in CLEAR III, median ICH volume was 7.42[10.08] cc. Initial hematoma expansion >5cc occurred in 33 (11.0%); hematomas were stable at 46.80 hrs after diagnostic CT, the final event detected at 71.87 hrs. Median IVH volume was 26.0[27.20] cc. Initial IVH expansion > 5cc occurred in 82 (27.4%) with stability at 41.27 hrs after diagnostic CT; the final event was detected at 50.50 hrs. CTH was detected in 66 (22.1%). CTH >5cc occurred in 3 (1%). CTHs were stable at median 37.20 hrs after EVD placement, the last CTH detected at 125.50 hrs post-EVD. Only antiplatelet therapy was significantly associated with CTH. In all trials, independent predictors of ICH or IVH expansion >5cc were age, partial thromboplastin time, NIHSS and time from symptom onset to CT. Conclusions: CTHs rarely expand in the initial stabilization period, but may be detected after 24 hours from EVD placement. IVH expansion is significantly more common than ICH expansion in patients with severe IVH. Most bleeding events appear to stabilize within 48 hours after diagnostic CT scan.