Abstract WP228: Imaging Findings Associated With Ultra-Early Neurological Deterioration in EMS-Transported Intracerebral Hemorrhage Patients

Abstract

Background: With the rise of prehospital intervention, intracerebral hemorrhage (ICH) management is increasingly migrating to the field setting. Ultra-early neurologic deterioration (U-END), during prehospital transport and the first minutes after ED arrival, is a novel target for therapy, imaging determinants could provide useful pathophysiologic insights for treatment. Methods: We analyzed all ICH patients enrolled in the NIH Phase 3 Field Administration of Stroke Therapy - Magnesium (FAST-MAG) prehospital trial who had both ED-arrival and 6-48h follow-up brain CT or GRE-MRI. Deterioration was defined as worsening by ≥2 on the Glasgow Coma Scale (GCS), performed serially by paramedics in the field, upon ED arrival, and early in the ED course. Results: Among 213 ICH patients, age was 65.4 (±13.4) and 33.3% were female. Timing from last know well (LKW) to early serial GCS assessments were: field GCS by paramedic, 23 mins (IQR 14-39); ED arrival GCS, 57 mins (IQR 45-75); and early ED course GCS, 89 mins (IQR 65-107). Initial brain imaging was performed 80 min (IQR 66-98) after LKW, using noncontrast CT in 96%. Overall, 38.5% of ICH patients experienced ultra-early neurological deterioration, including 12.7% in prehospital phase only, 12.2% in early ED course only, and 10.3% in both. Initial imaging findings associated with U-END were: larger hematoma volume 28.3 vs 17.6 cc, p<0.001; larger edema volume 15.4 vs 9.8 cc, p=0.001; moderate-severe midline shift 45.5% vs 6.8%, p<0.001; hematoma irregularity, 53.2% vs 33.0%, p=0.002; hematoma heterogeneity, 63.6% vs 40.8%, p=0.001; and basal ganglia location, 64.9% vs 46.3%, p=0.006. In multivariate analysis, U-END in the prehospital phase was associated with hematoma margin irregularity, OR 1.5 (95%CI 1.1-2.2); while U-END during the early ED course was associated with midline shift, OR 7.2 (95%CI 1.9-26.4) and hematoma margin irregularity, OR 2.3 (95%CI 1.1 - 5.1). Conclusions: ICH patients with ultra-early neurological deterioration have larger hematoma and edema volumes on initial brain imaging. Greater hematoma shape irregularity suggests ongoing, multiphasic and multifocal, bleeding is an important, and potentially avertable, contributor to prehospital and early ED course deterioration.