Abstract 3816: Frequency and Predictors of Hemorrhage Expansion in Ultra-Early Intracerebral Hemorrhage Patients

Abstract

Background: Studies of intracerebral hemorrhage (ICH) have reported varying rates of hemorrhage expansion after initial imaging and have analyzed clinical predictors of ICH expansion obtained in the Emergency Department (ED). None have evaluated prehospital predictors and few have looked at ultra-early time points. Objective: To delineate the frequency and prehospital predictors of hemorrhage expansion among ultra-early ICH patients. Methods: We analyzed consecutive ICH patients enrolled in the Field Administration of Stroke Therapy - Magnesium (FAST-MAG) study (a multicenter, phase 3, NIH-funded, randomized, placebo-controlled trial of field-initiated magnesium sulfate v placebo in likely stroke patients within 2 hours of symptom onset) who had both ED and follow-up brain imaging study. Paramedic evaluation included stroke deficit severity assessed by the Los Angeles Motor Scale (LAMS), and level of consciousness on the Glasgow Coma Scale (GCS). Imaging studies were independently analyzed by 2 neurologists for ICH volume using the ABC/2 method. Hemorrhage expansion was considered present if volume increased by >33% and/or 12.5 ml, a definition associated with a 23% rate of hemorrhage expansion in the INTERACT trial. Results: Among 105 ICH patients meeting entry criteria, mean age was 67 (SD 14) years, 28% women, 36% Hispanic ethnicity and 83% white race. Paramedic assessment occurred at median 25 (IQR 17, 40) minutes after last known well time (LKWT), at which time patients had mean SBP/DBP of 178/95 (SD 35/23), median LAMS of 4 (IQR 4,5) and GCS of 15 (IQR 15,15). First brain imaging occurred a median of 93 (IQR 77, 115) minutes after LKWT, and follow-up scans occurred 21 (IQR 5, 42) hours after initial imaging. Initial brain imaging was CT in 91% and MRI in 9%, and follow-up was CT in 91% and MRI in 9%. Mean initial hematoma volume was 17.3 (SD 17) ml, follow-up volume 28.7 (SD 36) ml, with an absolute increase of 11.4 (SD 27) ml. Expansion according to the predefined criteria occurred in 37 (35%) cases. Hematoma expansion was associated with earlier paramedic evaluation (24 min v 36 minutes, P=0.01), presence of IVH on initial CT (OR 2.8, 95% CI 1.2, 6.5), and first ED BP (184/99 v 171/88 p=0.028 for SBP and p=0.010 for DBP). Prehospital BP trended higher (185/101 v 174/92, p=0.134 for SBP, p=0.094 for DBP) but this was not significant. Hematoma expansion was not associated with initial volume, time between scans, age, gender, race, vascular risk factors, or prehospital LAMS, GCS or blood pressure. Conclusions: Among ICH patients with ultra-early initial brain imaging, hematoma expansion is common, occurring in one-third of individuals, more frequenty than later imaged cohorts. Clinical and imaging markers of initial expansive tendency - earlier field presentation, higher BP in the ED and presence of intraventricular hemorrhage - predicted subsequent further hematoma expansion.