Intraparenchymal Hemorrhage Volume Research Articles

Abstract TP91: Automated Cerebral Hemorrhage Volume Calculation And Stability Detection Using RAPID Software

Introduction: The measurement of intraparenchymal hemorrhage (IPH) volume is important for management, particularly in evaluating expansion on subsequent imaging. However manual volumetric analysis is time-consuming, especially in busy hospital settings. We aimed to use automated RAPID hyperdensity software to accurately measure IPH volume across repeated imaging. Methods: We identified primary IPH cases, without evidence of IVH, SDH, or SAH, from two randomized ICH trials where enrollment was not based on IPH volume. Scans were excluded if (1) there was CT acquisition artifact, (2) measured IPH volume was < 0.4ml, or (3) patient underwent a neurosurgical procedure. Repeat imaging, conducted within 12h, was included in a secondary stability analysis. Manual IPH measurements were conducted by one neuroimaging expert using MIPAV software and compared to the performance of the RAPID hyperdensity module. Results: 149 scans were included with median IPH volume manually measured at 13.3ml (IQR 3.2-27.5) compared to RAPID detection of 18.0ml (IQR 5.1-36.8). The two modalities were highly correlated (Figure 1, r = 0.948, p < 0.001) with a median absolute difference of 3.4ml (IQR 0.2-9.4) and standard error of 0.655. Repeat imaging was available in 65 patients, with a median absolute difference of 0ml (IQR: -2.6-1.5) compared to RAPID detection at 0.1ml (IQR: -2.3-2.7). These absolute differences were also highly correlated (r = 0.878, p < 0.001), with the ability of RAPID to detect a 5ml IPH expansion with a Sensitivity of 98.1% and Specificity 72.7%. Processing time for the software was < 3 minutes. Conclusion: In our pilot data, the RAPID hyperdensity module has high reliability in its ability to quickly automatically detect IPH volume and high sensitivity to detect expansion on subsequent imaging.

Multilesion Segmentations in Patients with Intracerebral Hemorrhage: Reliability of ICH, IVH and PHE Masks.

Background and Purpose: Fully automated methods for segmentation and volume quantification of intraparenchymal hemorrhage (ICH), intraventricular hemorrhage extension (IVH), and perihematomal edema (PHE) are gaining increasing interest. Yet, reliabilities demonstrate considerable variances amongst each other. Our aim was therefore to evaluate both the intra- and interrater reliability of ICH, IVH and PHE on ground-truth segmentation masks. Methods: Patients with primary spontaneous ICH were retrospectively included from a German tertiary stroke center (Charité Berlin; January 2016−June 2020). Baseline and follow-up non-contrast Computed Tomography (NCCT) scans were analyzed for ICH, IVH, and PHE volume quantification by two radiology residents. Raters were blinded to all demographic and outcome data. Inter- and intrarater agreements were determined by calculating the Intraclass Correlation Coefficient (ICC) for a randomly selected set of patients with ICH, IVH, and PHE. Results: 100 out of 670 patients were included in the analysis. Interrater agreements ranged from an ICC of 0.998 for ICH (95% CI [0.993; 0.997]), to an ICC of 0.979 for IVH (95% CI [0.984; 0.993]), and an ICC of 0.886 for PHE (95% CI [0.760; 0.938]), all p-values < 0.001. Intrarater agreements ranged from an ICC of 0.997 for ICH (95% CI [0.996; 0.998]), to an ICC of 0.995 for IVH (95% CI [0.992; 0.996]), and an ICC of 0.980 for PHE (95% CI [0.971; 0.987]), all p-values < 0.001. Conclusion Manual segmentations of ICH, IVH, and PHE demonstrate good-to-excellent inter- and intrarater reliabilities, with the highest agreement for ICH and IVH and lowest for PHE. Therefore, the degree of variances reported in fully automated quantification methods might be related amongst others to variances in ground-truth masks.

Prediction of Intraparenchymal Hemorrhage Progression and Neurologic Outcome in Traumatic Brain Injury Patients Using Radiomics Score and Clinical Parameters.

(1) Background: Radiomics analysis of spontaneous intracerebral hemorrhages on computed tomography (CT) images has been proven effective in predicting hematoma expansion and poor neurologic outcome. In contrast, there is limited evidence on its predictive abilities for traumatic intraparenchymal hemorrhage (IPH). (2) Methods: A retrospective analysis of 107 traumatic IPH patients was conducted. Among them, 45 patients (42.1%) showed hemorrhagic progression of contusion (HPC) and 51 patients (47.7%) had poor neurological outcome. The IPH on the initial CT was manually segmented for radiomics analysis. After feature extraction, selection and repeatability evaluation, several machine learning algorithms were used to derive radiomics scores (R-scores) for the prediction of HPC and poor neurologic outcome. (3) Results: The AUCs for R-scores alone to predict HPC and poor neurologic outcome were 0.76 and 0.81, respectively. Clinical parameters were used to build comparison models. For HPC prediction, variables including age, multiple IPH, subdural hemorrhage, Injury Severity Score (ISS), international normalized ratio (INR) and IPH volume taken together yielded an AUC of 0.74, which was significantly (p = 0.022) increased to 0.83 after incorporation of the R-score in a combined model. For poor neurologic outcome prediction, clinical variables of age, Glasgow Coma Scale, ISS, INR and IPH volume showed high predictability with an AUC of 0.92, and further incorporation of the R-score did not improve the AUC. (4) Conclusion: The results suggest that radiomics analysis of IPH lesions on initial CT images has the potential to predict HPC and poor neurologic outcome in traumatic IPH patients. The clinical and R-score combined model further improves the performance of HPC prediction.

Quantifying Intraparenchymal Hemorrhage after Traumatic Spinal Cord Injury: A Review of Methodology.

Intraparenchymal hemorrhage (IPH) after a traumatic injury has been associated with poor neurological outcomes. Although IPH may result from the initial mechanical trauma, the blood and its breakdown products have potentially deleterious effects. Further, the degree of IPH has been correlated with injury severity and the extent of subsequent recovery. Therefore, accurate evaluation and quantification of IPH following traumatic spinal cord injury (SCI) is important to define treatments' effects on IPH progression and secondary neuronal injury. Imaging modalities, such as magnetic resonance imaging (MRI) and ultrasound (US), have been explored by researchers for the detection and quantification of IPH following SCI. Both quantitative and semiquantitative MRI and US measurements have been applied to objectively assess IPH following SCI, but the optimal methods for doing so are not well established. Studies in animal SCI models (rodent and porcine) have explored US and histological techniques in evaluating SCI and have demonstrated the potential to detect and quantify IPH. Newer techniques using machine learning algorithms (such as convolutional neural networks [CNN]) have also been studied to calculate IPH volume and have yielded promising results. Despite long-standing recognition of the potential pathological significance of IPH within the spinal cord, quantifying IPH with MRI or US is a relatively new area of research. Further studies are warranted to investigate their potential use. Here, we review the different and emerging quantitative MRI, US, and histological approaches used to detect and quantify IPH following SCI.

Intensive Blood Pressure Lowering in Patients with Moderate to Severe Grade Acute Cerebral Hemorrhage: Post Hoc Analysis of Antihypertensive Treatment of Acute Cerebral Hemorrhage (ATACH)-2 Trial

Objective: To study the effect of intensive blood pressure reduction in patients with moderate to severe intracerebral hemorrhage (ICH) within the subjects recruited in Antihypertensive Treatment of Acute Cerebral Hemorrhage 2 trial. Design: Randomized, multicenter, 2 group, open-label clinical trial. Setting: A total of 110 sites in the USA, Japan, China, Taiwan, South Korea, and Germany. Patients: A total of 1,000 patients underwent randomization from May 2011 till September 2015. Interventions: We analyzed the effect of intensive (goal 110–139 mm Hg) over standard (goal 140–179 mm Hg) systolic blood pressure (SBP) reduction using intravenous nicardipine within 4.5 h of symptom onset in moderate to severe grade subjects with ICH in a non-prespecified analysis. Moderate to severe grade was defined by Glasgow Coma Scale score <13 or baseline National Institutes of Health Stroke Scale score ≥10 or baseline intraparenchymal hemorrhage volume ≥30 mL or presence of intraventricular hemorrhage. The primary outcome was death or disability (score 4–6 on the modified Rankin scale) at 3 months after randomization ascertained by a blinded investigator. Measurements and Main Results: Of a total of 682 subjects who met the definition of moderate to severe grade (mean age 61.9 ± 13.1 years, 62.5% men) with a mean baseline SBP of 174.7 ± 24.8 mm Hg, the frequency of hematoma expansion was significantly lower among subjects randomized to intensive SBP reduction than among subjects randomized to standard SBP reduction (20.4 vs. 27.9%, relative risk [RR]: 0.7; 95% confidence interval [CI]: 0.55–0.96). The primary endpoint of death or disability was observed in 52.5% (170/324) of subjects receiving intensive SBP reduction and 48.9% (163/333) of subjects receiving standard SBP reduction (RR: 1.1; 95% CI: 0.9–1.2). Conclusions: Intensive SBP lowering reduced the frequency of hematoma expansion but did not reduce the rate of death or disability in patients with moderate to severe grade ICH.

Deep Versus Lobar Intraparenchymal Hemorrhage: Seizures, Hyperexcitable Patterns, and Clinical Outcomes.

To compare electrographic seizures, hyperexcitable patterns, and clinical outcomes in lobar and deep intraparenchymal hemorrhage. Additionally, to characterize electrographic seizure and hyperexcitable pattern predictors in each group and determine seizure risk with thalamic involvement. Retrospective cohort study. Tertiary academic medical center. Consecutive adult patients with nontraumatic intraparenchymal hemorrhage undergoing continuous electroencephalography at our center between January 2013 and December 2016. Not applicable. Based on head CT closest to the initial continuous electroencephalography session, we classified intraparenchymal hemorrhage as isolated deep (no insular, subarachnoid, subdural extension) or lobar. Hyperexcitable patterns included the following: periodic discharges, spike-wave complexes, any rhythmic delta other than generalized. We used Fisher exact test for categorical and Mann-Whitney U test for continuous variables. Multivariable regression identified predictors of electrographic seizures, hyperexcitable patterns, and poor outcomes (score of 1-2 on Glasgow Outcome Scale) in lobar intraparenchymal hemorrhage. The cohort comprised of 128 patients, 88 lobar, and 40 deep intraparenchymal hemorrhage. Electrographic seizures occurred in 17% of lobar and 5% of deep intraparenchymal hemorrhage (p = 0.09). Hyperexcitable patterns were more frequent in the lobar group (44.3% vs 17.5%; p = 0.005). In multivariable analyses in the lobar group, lateralized rhythmic delta activity predicted electrographic seizures (odds ratio, 6.24; CI, 1.49-26.08; p = 0.012); insular involvement predicted hyperexcitable patterns (odds ratio, 4.88; CI, 1.36-17.57; p = 0.015); coma, temporal lobe involvement, intraparenchymal hemorrhage volume, and electrographic seizures predicted poor outcome. Thalamic involvement did not affect electrographic seizures or hyperexcitable patterns in either group. Electrographic seizures are frequent in lobar intraparenchymal hemorrhage, occurring in one in six monitored patients, as opposed to only 5% in isolated deep intraparenchymal hemorrhage not extending to cortex/insula, subarachnoid, or subdural spaces. Patients with lobar intraparenchymal hemorrhage and lateralized rhythmic delta activity were six times as likely to have electrographic seizures, which were associated with 5.47 higher odds of a poor outcome. Coma, temporal lobe involvement, hematoma volume, and electrographic seizures predicted poor outcome in lobar intraparenchymal hemorrhage.

Reliability of ABC/2 Method in Measuring of Infarct Volume in Magnetic Resonance Diffusion-Weighted Image.

Aims:Manual planimetry is the current method defining infarct volume on magnetic resonance (MR) diffusion-weighted image. ABC/2 method is an ellipsoid geometric formula with advantage estimation of intraparenchymal hemorrhage volume. Our study aimed to find the reliability and reproducibility of ABC/2 method compared to manual planimetric segmentation method.Settings and Design:This was a cross-sectional analytical study with retrospective and prospective data collection.Subjects and Methods:A total of 109 patients with acute ischemic stroke and underwent MR images at Ramathibodi Hospital were retrospectively reviewed. Relationship between manual planimetric segmentation and ABC/2 methods (nonadjusted ABC/2 method and adjusted ABC*/2 method) was determined using Wilcoxon signed-rank test, linear regression analysis, and Bland–Altman plot. Subgroup analysis by location, onset, shape, and size of infarct volume was performed. Interobserver reliability was established using intraclass correlation coefficient and Bland–Altman plot.Statistical Analysis Used:Wilcoxon signed-rank test, linear regression analysis, and Bland–Altman plot were used for statistical analysis.Results:Infarct volume measured with nonadjusted ABC/2 method (23.56, 48.81, 4.25, 0.11, 318.94) (mean, standard deviation, median, minimum, maximum) and adjusted ABC*/2 method (13.37, 28.3, 2.08, 0.06, 170.10) was smaller than manual planimetric method (28.50, 58.64, 5.56, 0.27, 335.49) (P < 0.001). Linear regression's slope confirmed underestimation of volume infarct. In round-to-ellipsoid shape and white matter group, the differences found between nonadjusted ABC/2 and manual planimetric methods are not statistically significant.Conclusions:ABC/2 method is a simple, rapid, and reproducible method with an excellent positive correlation of both adjusted and nonadjusted ABC/2 methods to manual planimetric segmentation method but tendency to underestimated infarct volume. High interobserver reliability and good agreement between two observers have been established. The utilization of nonadjusted ABC/2 method should be used with caution due to its tendency to underestimate the infarct volume.

Tight Control of Systolic Blood Pressure in Spontaneous Intraparenchymal Brain Hemorrhage.

BackgroundTight blood pressure control is critical in neurosurgical patients. Systolic blood pressure (SBP) must be low enough to avoid injury and minimize intraparenchymal hemorrhage (IPH) but high enough to maintain cerebral perfusion. American Heart Association (AHA) guidelines recommend SBP <140 in intracerebral hemorrhage. This paper sought to elucidate the effect of early control of SBP on IPH expansion.Methods134 patients with spontaneous IPH between 2011 and 2015 were analyzed utilizing chart review. Initial versus follow-up bleed size, presentation and discharge condition, discharge disposition, and blood pressure control adequacy were analyzed using the generalized linear model.ResultsAltered mental status was the most common presenting complaint (78%). Presenting GCS failed to demonstrate a significant main effect. Age, initial IPH volume, presenting SBP, and one-hour SBP significantly affected IPH percent expansion (p=0.002, =0.002, <0.0005, and =0.026). Several two-way interactions affected IPH percent change implying synergistic effects of the predictor variables.ConclusionPatients aged 60-70 years had the largest percent IPH expansion followed by patients aged 20-30 years. Initial IPH volume of 65.23-78.26 ml showed the largest expansion. Initial IPH volume of 52.18-65.22 ml demonstrated the least percentage of IPH expansion. One-hour control of SBP to binned groups of 111-121 mmHg or 121-132 mmHg portends relative minima in bleed expansion corresponding with AHA recommendations for IPH patients. This study suggests that this degree of early and aggressive control of SBP is achievable, safe, and may minimize IPH expansion. Future studies are needed to elucidate the role of co-morbidities and to confirm these findings in broader populations.

Abstract WP68: Interpretable Deep Learning-based Characterization of Intracranial Hemorrhage on Head CT

Background: Machine learning algorithms have proven accurate in the detection of intracranial hemorrhage (ICH) on head CT. Most reported algorithms, however, are limited to binary detection and global lesion volume estimation. We developed a pipeline to additionally perform subtype classification for clinical risk stratification, while also providing visual displays to improve interpretability of algorithm output (“black box problem”) and enable clinical systems integration. Methods: We developed a convolutional neural network (CNN) for ICH detection and subtype classification. The algorithm was trained on 2,209 head CT exams (hemorrhage-negative controls and the 5 major ICH subtypes) and outputs class-activation heatmaps to aid interpretability. We quantify intraparenchymal hemorrhage (IPH) volume using a modified U-Net CNN trained on a cohort of 110 manually-segmented hematomas to precisely delineate lesion boundaries. Algorithm output was stored as DICOM segmentation objects which can be overlaid on native images within our existing viewer applications, enabling the user to dynamically adjust characteristics such as color and transparency. Results: Diagnostic performance for ICH detection was high with ROC area-under-curve of 0.98. Fig 1A shows a heatmap highlighting different ICH foci. IPH subtype classification performance is summarized in Fig 1B with area-under-curve of 0.95. Fig 1C shows IPH segmentation and volume estimation overlays with automatically generated text for the medical record. Dice similarity coefficient for segmentation was 0.87. Conclusion: We describe a machine-learning approach for ICH detection, subtype classification, and IPH-specific volume estimation. Utilizing easily interpretable heatmaps, dynamically-adjustable overlays, and automated result text generation, our pipeline is capable of providing accurate information optimized for clinical integration.

Abstract 128: Intensive Blood Pressure Lowering in Patients with Moderate to Severe Grade Acute Cerebral Hemorrhage: Post Hoc Subgroup Analysis of Antihypertensive Treatment of Acute Cerebral Hemorrhage (ATACH)-2 Trial

Background: The intent to treat analysis of ATACH-2 trial did not demonstrate any difference in rates of death or disability with intensive systolic blood pressure (SBP) reduction compared with standard SBP reduction in patients with intracerebral hemorrhage (ICH). The benefit may have been obscured due to relatively high proportion of good grade patients (ceiling effect) in both treatment groups. Methods: We evaluated the effect of intensive (goal 110-139 mmHg) over standard (goal 140-179 mmHg) SBP reduction using intravenous nicardipine within 4.5 hours of symptom onset in a subgroup of moderate to severe grade subjects with ICH. Moderate to severe grade was defined by Glasgow coma scale score &lt;13 or baseline National Institutes of Health Stroke Scale score ≥10 or baseline intraparenchymal hemorrhage volume ≥30cm 3 or presence of intraventricular hemorrhage. The primary outcome was death or disability (score 4-6 on modified Rankin scale) at 3-months post-randomization ascertained by a blinded investigator. Results: A total of 682 subjects (336 in intensive and 346 in standard groups) met the definition of moderate to severe grade. The primary endpoint of death or disability was observed in 52.5% of subjects receiving intensive treatment and 48.9% subjects receiving standard treatment (relative risk: 1.07; 95% confidence interval: 0.86 to 1.33). Serious adverse events were significantly higher (relative risk: 1.38; 95% confidence interval: 1.04 to 1.84), among patients randomized to intensive treatment (32.7% and 23.7% for intensive and standard treatment groups, respectively). Conclusions: Similar to the conclusion from the overall ATACH-2 Trial sample, the rate of death or disability in the moderate to severe ICH subjects was similar, but significantly higher rate of serious adverse events were observed in subjects randomized to intensive SBP reduction.

Thresholds for Volume and Expansion in Intraparenchymal Hemorrhage: Predictors of Neurologic Deterioration and Mortality.

Spontaneous intraparenchymal hemorrhage (IPH) is a common neurosurgical emergency, with hemorrhage size and expansion associated with poor clinical outcomes. In this study, radiologic risk factors and specific IPH volume thresholds were calculated to identify heightened risk of neurologic deterioration and mortality. A consecutive review of all patients with nontraumatic IPH transferred to a tertiary academic neurosurgery service was performed over 2 years. IPH volume, hemorrhage location, presence of intraventricular hemorrhage, hydrocephalus, anticoagulant use, and neurologic status were reviewed. A maximum Youden index was calculated to determine thresholds of initial IPH volume and expansion most predictive of deterioration and mortality. A total of 202 transfers were studied. Both initial IPH volume at the outside hospital and IPH expansion were correlated with neurologic deterioration and death. The most predictive threshold for mortality was 32 mL of initial IPH volume (area under the curve 0.758, P<0.001, confidence interval 1.012-1.035) and 1 mL of expansion. The threshold for neurologic deterioration was 18 mL of initial volume (area under the curve 0.690, P=0.004, confidence interval 1.004-1.025) and 1 mL of expansion. Both intraventricular hemorrhage and hydrocephalus were independently associated with elevated risk for deterioration and mortality, while anticoagulant use was associated with neurologic deterioration. Volume and growth of IPH are significant predictors of neurologic deterioration and death. An initial volume over 32 mL is associated with increased mortality risk, whereas risk of neurologic deterioration appears to peak at a smaller volume of 18 mL. Any measurable IPH expansion suggests elevated risk of deterioration and mortality.

Abstract 3688: Factors Associated with Individual Variations in Systolic Blood Pressure Responsive to Intravenous Antihypertensive Medication. Results from the Antihypertensive Treatment of Acute Cerebral Hemorrhage (ATACH) Study

Introduction: There is considerable variation in blood pressure response to intravenous antihypertensive medication within patients with intracerebral hemorrhage (ICH). Objective: To study the variation in systolic blood pressure (SBP) responsiveness to IV nicardipine infusion and effect of various baseline factors on such responsiveness. We also studied the effect of SBP responsiveness on hematoma expansion, perihematomal edema, and three month outcome among subjects with ICH. Material and Methods: A post-hoc analysis of a multicenter prospective study recruiting subjects with ICH and elevated systolic blood pressure (SBP)≥170 mm Hg who presented within 6 hours of symptom onset was performed. Baseline SBP was calculated using the average of maximum and minimum SBP recorded prior to initiation of treatment. The SBP responsiveness was defined by the ratio between maximum change in SBP (difference between initial SBP and minimum SBP within the first hour) and maximum dose of nicardipine used in the first hour. This value was dichotomized at the median of 8.0, and we defined those with higher values to be responders and lower to be non-responders. We evaluated the effect of SBP reduction (relative to initial SBP) on: (1) hematoma expansion, defined as an increase in the volume of intraparenchymal hemorrhage of &gt;33% measured on the 24-hour computed tomographic (CT) scan compared with the baseline CT scan; (2) relative edema expansion, defined as increase of &gt;40% in edema volume to hematoma volume ratio between baseline and 24-hour CT scan; and (3) poor outcome defined by modified Rankin scale (mRS) of 4-6 at 3 months following treatment. Results: A total of 56 subjects were treated with IV nicardipine (aged 62 ±15 years; 57% men). The initial mean serum glucose was higher, although not statistically significant, among the 29 responders compared with 27 poor responders (148±72 versus 125±41). There were no clinically meaningful differences in the patient’s age, initial hematoma volume, initial Glasgow Coma Scale score, serum creatinine, or previous use of antihypertensive medication between responders and poor responders. The mean maximum dose of IV nicardipine used was 6.9 (±4.2) mg/hr and mean maximum reduction of SBP of 55.4 (±32.0) mm Hg within the first hour. The risk of poor outcome (mRS 4-6) in the responder was 10% less relative to the non-responders (relative risk [RR]=0.90, 95% confidence interval [CI]: 0.48, 1.69; n=50). The RRs were 0.81 (95% CI: 0.34, 1.93; n=54) for hematoma expansion &gt;33%; and 0.89 (95% CI: 0.52, 1.53; n=51) for relative edema expansion &gt;40%. Conclusions: There is considerable variation in blood pressure responsiveness to intravenous antihypertensive medication with potential prognostic implications. The variation in responsiveness does not appear to be influenced by other patient related factors that are known to influence functional outcome from ICH.

Blood-fluid level on computed tomography head: a sign of warfarin-associated intraparenchymal hemorrhage

“Blood/fluid level” represents interface between the plasma and sedimented blood and is defined radiologically as presence of area of low computed tomography (CT) attenuation above and high CT attenuation below a discrete line of separation in an area of intraparenchymal hemorrhage. It is a rare finding seen in association with large clot volume of intraparenchymal hemorrhage. We present a case of warfarin-related intraparenchymal hemorrhage presenting with a classic sign of “blood/fluid level” on CT head with small clot volume.

Are routine repeat imaging and intensive care unit admission necessary in mild traumatic brain injury?

More than 1.5 million Americans suffer a traumatic brain injury (TBI) each year. Seventy-five percent of these patients have a mild TBI, with Glasgow Coma Scale (GCS) Score 13-15. At the authors' institution, the usual practice has been to admit those patients with an associated intracranial hemorrhage (ICH) to an ICU and to obtain repeat head CT scans 12-24 hours after admission. The purpose of this study was to determine if there exists a subpopulation of mild TBI patients with an abnormal head CT scan that requires neither repeat brain imaging nor admission to an ICU. This group of patients was further classified based on initial clinical factors and imaging characteristics. A retrospective review of all patients admitted to a Level I trauma center from January 2007 through December 2008 was performed using the hospital Trauma Registry Database, medical records, and imaging data. The inclusion criteria were as follows: 1) an admission GCS score ≥ 13; 2) an isolated head injury with no other injury requiring ICU admission; 3) an initial head CT scan positive for ICH; and 4) an initial management plan that was nonoperative. Collected data included age, etiology, initial GCS score, time of injury, duration of ICU stay, duration of hospital stay, and anticoagulation status. Primary outcomes measured were the occurrence of neurological or medical decline and the need for neurosurgical intervention. Imaging data were analyzed and classified based on the predominant blood distribution found on admission imaging. Data were further categorized based on the Marshall CT classification, Rotterdam score, and volume of intraparenchymal hemorrhage (IPH). Progression was defined as an increase in the Marshall classification, an increase in the Rotterdam score, or a 30% increase in IPH volume. Three hundred twenty-one of 1101 reviewed cases met inclusion criteria for the study. Only 4 patients (1%) suffered a neurological decline and 4 (1%) required nonemergent neurosurgical intervention. There was a medical decline in 18 of the patients (6%) as a result of a combination of events such as respiratory distress, myocardial infarction, and sepsis. Both patient age and the transfusion of blood products were significant predictors of medical decline. Overall patient mortality was 1%. Based on imaging data, the rate of injury progression was 6%. The only type of ICH found to have a significant rate of progression (53%) was a subfrontal/temporal intraparenchymal contusion. Other variables found to be significant predictors of progression on head CT scans were the use of anticoagulation, an age over 65 years, and a volume of ICH > 10 ml. Most patients with mild TBI have a good outcome without the necessity of neurosurgical intervention. Mild TBI patients with a convexity SAH, small convexity contusion, small IPH (≤ 10 ml), and/or small subdural hematoma do not require admission to an ICU or repeat imaging in the absence of a neurological decline.

Evaluation of Intraventricular Hemorrhage in Pediatric Intracerebral Hemorrhage

Previous studies of pediatric intracerebral hemorrhage have investigated isolated intraparenchymal hemorrhage. The authors investigated whether detailed assessment of intraventricular hemorrhage enhanced outcome prediction after intracerebral hemorrhage. They prospectively enrolled 46 children, full-term to 17 years, median age 2.7 years, with spontaneous intraparenchymal hemorrhage and/or intraventricular hemorrhage. Outcome was assessed with the King's Outcome Scale for Childhood Head Injury. Twenty-six (57%) had intraparenchymal hemorrhage, 10 (22%) had pure intraventricular hemorrhage, and 10 (22%) had both. There were 2 deaths, both with intraparenchymal hemorrhage and intraventricular hemorrhage volume ≥4% of total brain volume. Presence of intraventricular hemorrhage was not associated with poor outcome, but hydrocephalus showed a trend (P = .09) toward poor outcome. In receiver operating characteristic curve analysis, combined intraparenchymal hemorrhage and intraventricular hemorrhage volume also showed a trend toward better outcome prediction than intraparenchymal hemorrhage volume alone. Although not an independent outcome predictor, future studies should assess intraventricular hemorrhage qualitatively and quantitatively.

Prognostic Value of Intraventricular Bleeding in Spontaneous Intraparenchymal Cerebral Hemorrhage of Small Volume

The literature is controversial on whether intraventricular bleeding has a negative impact on the prognosis of spontaneous intracerebral hemorrhage. Nevertheless, an association between intraventricular bleeding and spontaneous intracerebral hemorrhage volumes has been consistently reported. To evaluate the prognostic value of intraventricular bleeding in deep intraparenchymal hypertensive spontaneous hemorrhage with a bleeding volume <30 cm(3). Of the 320 patients initially evaluated, 33 met the inclusion criteria and were enrolled in this prospective study. The volume of intraparenchymal hemorrhage was calculated by brain computed tomography (CT) image analysis, and the volume of intraventricular bleeding was calculated by the LeRoux scale. Clinical data, including neurological complications, were collected daily during hospitalization. Neurological outcome was evaluated 30 days after the event by using the Glasgow outcome scale. Patients were assigned to 1 of 3 groups according to intraventricular bleeding: Control, no intraventricular bleeding; LR 1, intraventricular bleeding with LeRoux scale scores of 1 to 8; or LR 2, intraventricular bleeding with LeRoux scale scores >8. There were no significant differences among groups concerning age, mean blood pressure, and time from onset to brain CT scan. Patients with greater intraventricular bleeding presented lower initial Glasgow coma scale scores, increased ventricular index and width of temporal horns, increased number of clinical and neurological complications, and longer hospitalization. Furthermore, their relative risk for unfavorable clinical outcome was 1.9 (95% confidence interval 1.25-2.49). Intraventricular bleeding with a LeRoux scale score >8 appears to have a negative effect on deep spontaneous intraparenchymal cerebral hemorrhage of small volume.

Effect of Systolic Blood Pressure Reduction on Hematoma Expansion, Perihematomal Edema, and 3-Month Outcome Among Patients With Intracerebral Hemorrhage

Evidence indicates that systolic blood pressure (SBP) reduction may reduce hematoma expansion in patients with intracerebral hemorrhage (ICH) who are initially seen with acute hypertensive response. To explore the relationship between different variables of SBP reduction and hematoma expansion, perihematomal edema, and 3-month outcome among patients with ICH. Post hoc analysis of a traditional phase 1 dose-escalation multicenter prospective study. Emergency departments and intensive care units. Patients having ICH with an elevated SBP of at least 170 mm Hg who were seen within 6 hours of symptom onset. Systolic blood pressure reduction using intravenous nicardipine hydrochloride targeting 3 tiers of sequentially escalating SBP reduction goals (170-199, 140-169, or 110-139 mm Hg). We evaluated the effect of SBP reduction (relative to initial SBP) on the following: hematoma expansion (defined as an increased intraparenchymal hemorrhage volume >33% on 24-hour vs baseline computed tomographic [CT] images), higher perihematomal edema ratio (defined as a >40% increased ratio of edema volume to hematoma volume on 24-hour vs baseline CT images), and poor 3-month outcome (defined as a modified Rankin scale score of 4-6). Sixty patients (mean [SD] age, 62.0 [15.1] years; 34 men) were recruited (18, 20, and 22 patients in each of the 3 SBP reduction goal tiers). The median area under the curve (AUC) (calculated as the area between the hourly SBP measurements over 24 hours and the baseline SBP) was 1360 (minimum, 3643; maximum, 45) U. Comparing patients having less vs more aggressive SBP reduction based on 24-hour AUC analysis, frequencies were 32% vs 17% for hematoma expansion, 61% vs 40% for higher perihematomal edema ratio, and 46% vs 38% for poor 3-month outcome (P > .05 for all). The median SBP reductions were 54 mm Hg at 6 hours and 62 mm Hg at 6 hours from treatment initiation. Comparing patients having equal to or less vs more than the median SBP reduction at 2 hours, frequencies were 21% vs 31% for hematoma expansion, 42% vs 57% for higher perihematomal edema ratio, and 35% vs 48% for poor 3-month outcome (P > .05 for all). We found no significant relationship between SBP reduction and any of the outcomes measured herein; however, the Antihypertensive Treatment of Acute Cerebral Hemorrhage study was primarily a safety study and was not powered for such end points. The consistent favorable direction of these associations supports further studies with an adequately powered randomized controlled design to evaluate the efficacy of aggressive pharmacologic SBP reduction.

Hemorrhagic Complications Of External Ventricular Drainage

Despite the widespread use of external ventricular drainage (EVD), the frequency of associated hemorrhagic complications remains unclear. This retrospective study examined the frequency of hemorrhagic complications of EVD and attempted to discern associated risk factors. Treatment records from 160 patients admitted during a 2.5-year period who required EVD placement were reviewed. Indications for placement of EVD included acute complications of cerebrovascular disease (n = 94), traumatic brain injury (n = 36), primary hydrocephalus (n = 16), and tumor (n = 14). Patients received either a 3.0 or 2.5-mm outer diameter ventricular catheter (n = 82 and 78, respectively). Postinsertion computed tomographic scans were obtained within 24 hours on all patients and were analyzed for any new hemorrhage related to the ventricular catheter. Patient age, sex, catheter type, and dimensions of hemorrhage were also analyzed. The incidence of EVD-related hemorrhage was 33 +/- 0.04%. However, the incidence of detectable change in the clinical neurological examination was 2.5%. A significant proportion of EVD-related hemorrhages were small (<4 cm), punctate, intraparenchymal hematomas. Patients with cerebrovascular disease exhibited an increased incidence (39%) of hemorrhage. The mean volume of intraparenchymal hemorrhage was larger in patients who received the 2.5-mm ventricular catheter, as well as those admitted for cerebrovascular disease. Hemorrhagic complications of EVD placement are more common than previously suspected. Admitting diagnosis seems to have an effect on the development of an associated hemorrhage and its size. Catheter gauge has an effect on hematoma volume. Most of the hemorrhages seen on postinsertion computed tomographic scans do not cause detectable changes in the clinical examination.

Treatment of acute hypertension in patients with intracerebral hemorrhage using American Heart Association guidelines*

To determine the feasibility and safety of treatment of acute hypertension in patients with intracerebral hemorrhage within 24 hrs of symptom onset. Elevated blood pressure, observed in up to 56% of patients with intracerebral hemorrhage, may predispose to hematoma expansion; on the other hand, reduction of blood pressure may reduce hematoma expansion and subsequent death and disability. Single-center prospective registry supplemented by retrospective chart review. University-affiliated medical center with dedicated stroke service. All patients admitted to the stroke service with spontaneous intracerebral hemorrhage and acute hypertension within 24 hrs of symptom onset. Patients were treated with intravenous nicardipine within 24 hrs of symptom onset to reduce and maintain mean arterial pressure of <130 mm Hg. The mean arterial pressure goal was consistent with the American Heart Association guidelines. The primary outcome was the tolerability of the treatment as assessed by achieving and maintaining the mean arterial pressure goals for 24 hrs after initiation of intravenous nicardipine infusion. Other end points ascertained were: neurologic deterioration defined by a decline in Glasgow Coma Scale from pretreatment assessment by >or=2 points or increase in National Institutes of Health Stroke Scale score by >or=2 points and hemorrhage growth defined as an increase in the volume of intraparenchymal hemorrhage of >33% as measured by image analysis on the 24-hr computed tomographic scan compared with the baseline computed tomographic scan. Rates of favorable outcome and death were ascertained at 1 month. Of the total 46 patients admitted with intracerebral hemorrhage in our service, 29 patients were treated. Mean age of the treated patients was 58 +/- 13 yrs; ten were women. Initial National Institutes of Health Stroke Scale ranged from 1 to 38. The primary outcome of tolerability was achieved in 25 of the 29 patients (86%). Neurologic deterioration was observed in 4 of 29 patients. Hematoma enlargement was observed in five patients. Favorable outcome (defined as modified Rankin scale of <or=2) and death at 1-month was observed in 11 (38%) and 9 (31%) of the 29 patients, respectively. We observed a high rate of tolerability among patients with intracerebral hemorrhage who were treated with intravenous nicardipine using mean arterial pressure goals defined by American Heart Association guidelines within 24 hrs of symptom onset.

Differential concentration-dependent effects of prolonged norepinephrine infusion on intraparenchymal hemorrhage and cortical contusion in brain-injured rats.

Under clinical conditions catecholamines are infused to elevate cerebral perfusion pressure and improve impaired posttraumatic cerebral microcirculation. This, however, is associated with the risk of additional hemorrhage in the acute phase following traumatic brain injury. In the present study we investigated the dose-dependent effects of prolonged norepinephrine infusion on arterial blood pressure, blood glucose, and structural damage in brain-injured rats. At 4 h following induction of a focal cortical contusion (CCI), 40 rats were randomized to receive low (0.15), medium (0.3), or high dose (1 microg/kg/min) norepinephrine. Control rats were given equal volume of NaCl. Norepinephrine and NaCl were infused intravenously via Alzet osmotic pumps for 44 h. Mean arterial blood pressure (MABP), blood gases and blood glucose were determined before, at 4, 24, 48 h after CCI in repeatedly anesthetized rats (n = 28). Systolic arterial blood pressure (SABP) was measured using the tail cuff method in awake, restrained rats (n = 12). Cortical contusion and intraparenchymal hemorrhage volume were quantified at 48 h in all rats. MABP determined in anesthetized rats was only marginally increased. SABP was significantly elevated during infusion of medium and high dose norepinephrine in awake rats, exceeding 140 mm Hg. Medium and high dose norepinephrine significantly increased cortical hemorrhage by 157% and 142%, without increasing the cortical contusion volume. Low dose norepinephrine significantly reduced the cortical contusion by 44%. Norepinephrine aggravates the underlying brain damage during the acute posttraumatic phase. Future studies are needed to determine the least deleterious norepinephrine concentration.