Predicting Hematoma Expansion Research Articles

Prevalence and the predictive performance of the dynamic CT-angiography spot sign in an observational cohort with intracerebral hemorrhage.

The CT-angiography (CTA) spot sign is a predictor of hematoma expansion (HE). We have previously reported on the use of dynamic CTA (dCTA) to detect spot sign, and to study its formation over the acquisition period. In this study, we report the frequency of dCTA spot sign in acute intracerebral hemorrhage, its sensitivity and specificity to predict HE, and explore the rate of contrast extravasation in relation to hematoma growth.We enrolled consecutive patients presenting with primary intracerebral hemorrhage within 4.5 hours. All patients underwent a dCTA protocol acquired over 60 seconds following contrast injection. We calculated frequency of the dCTA spot sign, predictive performance, and rate of contrast extravasation. We compared extravasation rates to the dichotomous definition of significant HE (defined as 6 mL or 33% growth).In 78 eligible patients, dCTA spot sign frequency was 44.9%. In 61 patients available for expansion analysis, sensitivity and specificity of dCTA spot sign was 65.4% and 62.9%, respectively. Contrast extravasation rate did not significantly predict HE (Odds Ratio 15.6 for each mL/min [95% confidence interval 0.30–820.25], P = .17). Correlation between extravasation rate and HE was low (r = 0.297, P= .11). Patients with significant HE had a higher rate of extravasation as compared to those without (0.12 mL/min vs 0.04 mL/min, P = .03).Dynamic CTA results in a higher frequency of spot sign positivity, but with modest sensitivity and specificity to predict expansion. Extravasation rate is likely related to HE, but a single measurement may be insufficient to predict the magnitude of expansion.

Development and validation of a nomogram for predicting hematoma expansion in intracerebral hemorrhage

Background and objectiveTo develop and validate a clinical nomogram for individualized predicting hematoma expansion (HE) in patients with Intracerebral Hemorrhage (ICH). MethodsA total of 1025 patients with ICH were retrospectively enrolled in the development cohort between 2010 and 2016. We identified and integrated significant factors for HE to build a nomogram. The model was subjected to validation with a separate cohort of 397 patients from the 2017–2019. The predictive accuracy and discriminative ability were measured by concordance index (C-index). The primary outcome was HE, defined as hematoma growth more than 6 mL or 33% increase in the volume. ResultsA total of 1025 patients were included for univariable analysis. HE occurred in 180 patients (17.6%). The time to initial CT (≤6h vs. >6 h; p = 0.001), NIHSS score (0–4 vs. 5–14 vs. ≥15; p = 0.031), CTA spot sign (yes vs. no vs. absent; p = 0.018), hypodensities (p = 0.000), blend sign (p = 0.005), and INR (<1.2 vs. ≥1.2; p = 0.009) were identified and entered into the nomogram. The calibration curves for probability of HE showed optimal agreement between nomogram prediction and actual observation. The C-index was 0.751. The validation cohort consisted of 397 patients and HE occurred in 78 patients (19.6%). The C-index was 0.743. ConclusionsWe developed and validated a nomogram that can individually predict HE for ICH in Chinese populations. This practical prognostic nomogram may help clinicians make decision of clinical practice and design of clinical studies.

Smoking Status Affects the Association Between Hematoma Heterogeneity and Hematoma Expansion

ObjectiveThe purpose of this study was to verify the relationship between hematoma heterogeneity and hematoma expansion and explore any effect modifiers through subgroup analyses.MethodsClinical records of 357 patients with spontaneous cerebral hemorrhage at Shenzhen Second People’s Hospital from March 2016 to October 2018 were included in the study. Hematoma heterogeneity was measured on the first noncontrast computed tomography image according to the Barras scale. Hematoma expansion was defined as an absolute hematoma volume increase of 6 mL, or a 33% increase. We performed univariate and multivariate logistic regression analyses, as well as subgroup analyses, to assess the relationship between the presence of heterogeneity on noncontrast computed tomography and hematoma expansion.ResultsHematoma expansion occurred in 79 (22.13%) of the 357 patients with intracerebral hemorrhage (ICH). Among the patients with ICH, there were 83 smokers, accounting for 23.24%. The average patient age was 56.21 ± 13.75 years, and 74.51% were male. Compared with the absence of heterogeneity, the risk of hematoma expansion increased by 1.06 times (odds ratio, 2.06; 95% confidence interval, 1.10–3.86). Based on the subgroup analysis, smoking status was found to modify the association between heterogeneity and hematoma expansion; the association was stronger in smokers than in nonsmokers (odds ratio, 10.23; 95% confidence interval, 2.15–48.65).ConclusionsHeterogeneity independently predicts hematoma expansion, especially in smoking patients.

Efficacy of the Combined Swirl Sign with Blend Sign for Predicting Hematoma Expansion in Spontaneous Intracerebral Hemorrhage in Elderly Patients

Efficacy of the Combined Swirl Sign with Blend Sign for Predicting Hematoma Expansion in Spontaneous Intracerebral Hemorrhage in Elderly Patients

Surgical strategy for patients with supratentorial spontaneous intracerebral hemorrhage: minimally invasive surgery and conventional surgery.

ObjectiveThe role of surgery in spontaneous intracerebral hemorrhage (sICH) is still controversial. We aimed to investigate the effectiveness of minimally invasive surgery (MIS) compared to conventional surgery (CS) for supratentorial sICH.MethodsThe medical data of 70 patients with surgically treated supratentorial sICH were retrospectively reviewed. MIS was performed in 35 patients, and CS was performed in 35 patients. The surgical technique was selected based on the neurological status and radiological findings, such as hematoma volume, neurological status and spot signs on computed tomographic angiography. Treatment outcomes, prognostic factors and the usefulness of the spot sign were analyzed.ResultsClinical states in both groups were statistically similar, preoperatively, and in 1 and 3 months after surgery. Both groups showed significant progressive improvement till 3 months after surgery. Better preoperative neurological status, more hematoma removal and intensive care unit (ICU) stay ≤7 days were the significant prognostic factors for favorable 3-month clinical outcomes (odds ratio [OR] 0.31, 95% confidence interval [CI] 0.10–0.96, p=0.04; OR 1.04, 95% CI 1.01–1.08, p=0.02; OR 26.31, 95% CI 2.46–280.95, p=0.01, respectively). Initial hematoma volume and MIS were significant prognostic factors for a short ICU stay (≤7 days; OR 0.95; 95% CI 0.91–0.99; p=0.01; OR 3.91, 95% CI 1.03–14.82, p=0.045, respectively). No patients in the MIS group experienced hematoma expansion before surgery or postoperative rebleeding.ConclusionsMIS was not inferior to CS in terms of clinical outcomes. The spot sign seems to be an effective radiological marker for predicting hematoma expansion and determining the surgical technique.

Black Hole Sign on Noncontrast Computed Tomography in Predicting Hematoma Expansion in Patients with Intracerebral Hemorrhage: A Meta-analysis.

Black hole sign represents a novel imaging marker for predicting hematoma expansion (HE) in patients with intracerebral hemorrhage (ICH). Several previous studies have reported the accuracy of black hole sign in predicting HE, but the accuracy was variable. We performed a meta-analysis to systematically assess the accuracy of black hole sign in predicting HE in patients with ICH. A systematic search was performed to identify relevant English and Chinese articles (from inception to January 2019). All studies on the accuracy of black hole sign in predicting HE in patients with ICH were included. Pooled sensitivity, specificity, and positive and negative likelihood ratios were calculated. Pooling was conducted using the bivariate generalized linear mixed model. Forest plots and a summary receiver operator characteristic plot were generated. We used I² to test heterogeneity and investigated the source of heterogeneity by meta-regression. Publication bias was assessed by Deeks' funnel plot asymmetry test. A total of 6 studies with 1876 patients were included in this meta-analysis. The pooled sensitivity, specificity, and positive and negative likelihood ratios of black hole sign for predicting HE were 0.30, 0.93, 4.00 and 0.75, respectively. The area under the curve (AUC) was 0.83. The studies had substantial heterogeneity (I²=89.00%, 95% CI 78.00-100.00). Low risk of publication bias was detected. Black hole sign is a useful imaging marker with high specificity in predicting hematoma expansion in patients with intracerebral hemorrhage.

Absolute hypodensity sign by noncontrast computed tomography as a reliable predictor for early hematoma expansion

ObjectiveEarly hematoma expansion in intracerebral hemorrhage (ICH) patients is strongly associated with poor outcome and potentially preventable if high-risk patients are timely identified. We aimed to investigate whether a novel sign detected by noncontrast computed tomography (NCCT) named absolute hypodensity sign (AHS) was an appropriate candidate for hematoma expansion prediction. Materials and MethodsSpontaneous ICH patients all underwent baseline NCCT scan within 6 h after ICH onset and the follow-up NCCT scan within 24 h after initial CT scan. AHS was defined as a hypoattenuating area with a distinct margin within the hematoma, the minimal density of which should be ≤30 Hounsfeld units. We used univariate and multivariate logistic regression analyses for determining the association between hematoma expansion and the presence of AHS. We also compared the diagnostic efficacy with blend sign and black hole sign. ResultsA total of 348 ICH patients were included, 87 of which were found hematoma expansion. AHS was positive in 76 patients (21.8%) (κ = 0.88 for interrater reliability) and 63.2% of the patients with hematoma expansion were observed AHS. The multivariate logistic regression analysis demonstrated AHS was an independent predictor for hematoma expansion (odds ratio: 33.454, 95% confidence interval: 13.628–82.126, P < 0.001). The sensitivity, specificity, positive predictive value, negative predictive value and accuracy of AHS for hematoma expansion prediction were 63.2%, 92.0%, 72.4%, 88.2%, 84.8%, respectively, which were higher than blend sign and black hole sign except the specificity of black hole sign. ConclusionOur findings indicate AHS is a reliable predictor for early hematoma expansion due to its feasibility and convenience for clinical practice.

The predictive accuracy of satellite sign for hematoma expansion in intracerebral hemorrhage: A meta-analysis

Background and purposeSatellite sign is a novel neuroimaging marker for predicting hematoma expansion (HE), which is closely related to unfavorable prognosis in patients with spontaneous intracerebral hemorrhage (ICH). However, the predictive value of satellite sign varied according to previous studies. Thus, we conduct this meta-analysis to systematically review the application value of satellite sign in related studies. MethodsWe searched the literature in PubMed, Embase, and Web of Science from inception to April 10, 2020. Effect values, including sensitivity, specificity, and positive and negative likelihood ratio were pooled to assess the diagnostic value of satellite sign for HE in patients with ICH. ResultsThe meta-analysis included five studies with a total of 1493 patients. Results showed that the pooled diagnostic sensitivity and specificity were 0.50 (95 % CI, 0.31−0.70) and 0.71 (95 % CI, 0.56−0.83), respectively. In addition, the pooled positive and negative likelihood ratios were 1.7 (95 % CI, 1.5–2.1) and 0.70 (95 % CI, 0.54−0.89), respectively. No significant publication bias was found. ConclusionSatellite sign exhibited moderate sensitivity and specificity for predicting HE in patients with ICH. Further studies are needed to explore its value in clinical application.

Distribution and predictive performance of the temporal phase of dynamic spot sign appearance in acute intracerebral hemorrhage.

Dynamic CT angiography (dCTA) contrast extravasation, known as the "dynamic spot sign", can predict hematoma expansion (HE) in intracerebral hemorrhage (ICH). Recent reports suggest the phase of spot sign appearance is related to the magnitude of HE. We used dCTA to explore the association between the phase of spot sign appearance and HE, clinical outcome, and contrast extravasation rates. We assessed consecutive patients who presented with primary ICH within 4.5 hours from symptom onset who underwent a standardized dCTA protocol and were spot sign positive. The independent variable was the phase of spot sign appearance. The primary outcome was significant HE (either 6 mL or 33% growth). Secondary outcomes included total absolute HE, mortality, and discharge mRS. Mann-Whitney U, Fisher's exact test, and logistic regression were used, as appropriate. Of the 35 patients with spot signs, 27/35 (77%) appeared in the arterial phase and 8/35 (23%) appeared in the venous phase. Thirty patients had follow-up CT scans. Significant HE was seen in 14/23 (60.87%) and 3/7 (42.86%) of arterial and venous cohorts, respectively (p = 0.67). The sensitivity and specificity in predicting significant HE were 82% and 31% for the arterial phase and 18% and 69% for the venous phase, respectively. There was a non-significant trend towards greater total HE, in-hospital mortality, and discharge mRS of 4-6 in the arterial spot sign cohort. Arterial spot signs demonstrated a higher median contrast extravasation rate (0.137 mL/min) compared to venous spot signs (0.109 mL/min). Our exploratory analyses suggest that spot sign appearance in the arterial phase may be more likely associated with HE and poorer prognosis in ICH. This may be related to higher extravasation rates of arterial phase spot signs. However, further studies with larger sample sizes are warranted to confirm the findings.

Do Imaging Markers of Cerebral Small Vessel Disease Predict Hematoma Volume and Outcome in Acute Intracerebral Hemorrhage?

Background and Purpose:Cerebral small vessel disease (CSVD) markers have not been widely studied in relation to hematoma volume and growth in hypertensive intracerebral hemorrhage (ICH). The objectives to assess the relationship of white matter hyperintense lesions (WMHL), microbleeds (MBs), and cortical siderosis (CSS) with hematoma volume, hematoma expansion (HE), and 3 months outcome in patients with hypertensive ICH.Methods:All consecutive acute hypertensive supratentorial ICH presenting to the emergency were prospectively recruited. Baseline and 24 hours computed tomography (CT) to assess hematoma volume and magnetic resonance imaging (MRI) for CSVD markers were performed in all subjects. WMHL (graded using Fazekas's scale), MBs, and CSS were assessed and compared with baseline variables and outcomes. All the images were assessed by an experienced stroke neurologist/neuroradiologist.Results:One hundred and fifty-seven patients were screened and 60 were included. Mean age was 54.08 ± 11.57 years and 47 (78%) were males. Of 60, 19 (28.1%) had HE, 31 (51.6%) had major bleed (>30 ml), and 28 (47.46%) had poor 3 month outcome (mRS 4-6). On univariate analysis, high grade WMHL was associated with greater HE [odds ratio (OR): 2.65, confidence interval (CI) 1.48–4.72, P = 0.001), greater proportion with volume >30 ml (OR: 7.16, CI: 1.09–47.13, P = 0.001) and poor outcome (OR: 2.1, CI: 0.05–3.27, P = 0.001). MBs were associated with poor outcome (P = 0.029) but not with HE/volume. CSS was related to HE (P = 0.031), a large volume bleed (P = 0.023), and poor outcome (P = 0.021). On multivariate model, only WMHL independently predicted HE (P = 0.034), greater proportion with bleed volume >30 ml (P = 0.041), and poor outcome (P = 0.042).Conclusions:WMHL in MRI serves as a predictor of hematoma expansion, a large volume bleed, and poor outcome in hypertensive ICH and may be incorporated into existing prediction models.

The extravasation of contrast as a predictor of cerebral hemorrhagic contusion expansion, poor neurological outcome and mortality after traumatic brain injury: A systematic review and meta-analysis.

BackgroundThe active extravasation of contrast on CT angiography (CTA) in primary intracerebral hemorrhages (ICH) is recognized as a predictive factor for ICH expansion, unfavorable outcomes and mortality. However, few studies have been conducted on the setting of traumatic brain injury (TBI).PurposeTo perform a literature systematic review and meta-analysis of the association of contrast extravasation on cerebral hemorrhagic contusion expansion, neurological outcomes and mortality.Data sourcesThe PubMed, Cochrane Library, Medline, Scielo, VHL and IBECS databases up to September 21, 2019, were searched for eligible studies.Study selectionA total of 505 individual titles and abstracts were identified and screened. A total of 36 were selected for full text analysis, out of which 4 fulfilled all inclusion and exclusion criteria.Data analysisAll 4 studies yielded point estimates suggestive of higher risk for hematoma expansion with contrast extravasation and the summary RR was 5.75 (95%CI 2.74–10.47, p<0.001). Contrast extravasation was also associated with worse neurological outcomes (RR 3.25, 95%CI 2.24–4.73, p<0.001) and higher mortality (RR 2.77, 95%CI 1.03–7.47, p = 0.04).Data synthesisThis study is a Systematic Review and Meta-Analysis revealed the extravasation of contrast is a useful imaging sign to predict hematoma expansion, worse neurological outcomes and higher mortality.LimitationsOnly four articles were selected.ConclusionsThe extravasation of contrast in the setting of TBI is a useful imaging sign to predict hematoma expansion, worse neurological outcomes and higher mortality.

A Nomogram Model of Radiomics and Satellite Sign Number as Imaging Predictor for Intracranial Hematoma Expansion.

BackgroundWe aimed to construct and validate a nomogram model based on the combination of radiomic features and satellite sign number for predicting intracerebral hematoma expansion.MethodsA total of 129 patients from two institutions were enrolled in this study. The preprocessed initial CT images were used for radiomic feature extraction. The ANOVA-Kruskal–Wallis test and least absolute shrinkage and selection operator regression were applied to identify candidate radiomic features and construct the Radscore. A nomogram model was developed by integrating the Radscore with a satellite sign number. The discrimination performance of the proposed model was evaluated by receiver operating characteristic (ROC) analysis, and the predictive accuracy was assessed via a calibration curve. Decision curve analysis (DCA) and Kaplan–Meier (KM) survival analysis were performed to evaluate the clinical value of the model.ResultsFour optimal features were ultimately selected and contributed to the Radscore construction. A positive correlation was observed between the satellite sign number and Radscore (Pearson’s r: 0.451). The nomogram model showed the best performance with high area under the curves in both training cohort (0.881, sensitivity: 0.973; specificity: 0.787) and external validation cohort (0.857, sensitivity: 0.950; specificity: 0.766). The calibration curve, DCA, and KM analysis indicated the high accuracy and clinical usefulness of the nomogram model for hematoma expansion prediction.ConclusionA nomogram model of integrated radiomic signature and satellite sign number based on noncontrast CT images could serve as a reliable and convenient measurement of hematoma expansion prediction.

Can a Non-Contrast CT Scan of Brain Predict Hematoma Expansion in Acute Intracerebral Hemorrhage?

A 52-year-old male presented with acute intracerebral hemorrhage. The non-contrast CT scan of brain was suggestive of the “CT blend sign” which predicts early hematoma expansion and poor prognosis. Despite appropriate management, hematoma growth was seen in repeat CT scan of brain. Other signs which predict hematoma growth are swirl sign, black hole sign, and fluid levels on non-contrast CT scan and spot sign on contrast-enhanced CT scan.

A Review of the Applications of Dual-Energy CT in Acute Neuroimaging.

Dual-energy computed tomography (CT) is a promising tool with increasing availability and multiple emerging and established clinical applications in neuroradiology. With its ability to allow characterization of materials based on their differential attenuation when imaged at two different energy levels, dual-energy CT can help identify the composition of brain, neck, and spinal components. Virtual monoenergetic imaging allows a range of simulated single energy-level reconstructions to be created with postprocessing. Low-energy reconstructions can aid identification of edema, ischemia, and subtle lesions due to increased soft tissue contrast as well as increasing contrast-to-noise ratios on angiographic imaging. Higher energy reconstructions can reduce image artifact from dental amalgam, aneurysm clips and coils, spinal hardware, dense contrast, and dense bones. Differentiating iodine from hemorrhage may help guide management of patients after thrombectomy and aid diagnosis of enhancing tumors within parenchymal hemorrhages. Iodine quantification may predict hematoma expansion in aneurysmal bleeds and outcomes in traumatic brain injury. Calcium and bone subtraction can be used to distinguish hemorrhage from brain parenchymal mineralization as well as improving visualization of extra-axial lesions and vessels adjacent to dense plaque or skull. This article reviews the basics of dual-energy CT and highlights many of its clinical applications in the evaluation of acute neurological presentations.

Nomogram Model for Predicting Hematoma Expansion in Spontaneous Intracerebral Hemorrhage: Multicenter Retrospective Study

To establish a new nomogram model and provide a new theoretical basis for the diagnosis and treatment of spontaneous intracerebral hemorrhage. The clinical data and noncontrast computed tomography images of patients with spontaneous intracerebral hemorrhage in 3 tertiary medical centers were collected continuously. Univariate and binary logistic regression analysis were performed to screen out the independent predictors that were significantly associated with hematoma expansion. The nomogram model was drawn by R programming language. According to the related risk factors of nomogram, decision curve analysis and clinical impact curve were established. The numbers of the 3 cooperative units were 554, 582, and 202, respectively. Island sign, blend sign, swirl sign, intraventricular hemorrhage, history of diabetes, time to baseline computed tomography scan, and baseline hematoma volume were independent predictors of hematoma expansion. Baseline hematoma volume >20 mL (odds ratio, 4.088; 95% confidence interval, 2.802-5.964; P < 0.0001) was the most dangerous factor for predicting hematoma expansion, followed by the time to baseline computed tomography scan ≤1 hour (odds ratio, 4.188; 95% confidence interval, 2.598-6.750; P < 0.0001). Decision curve analysis showed that the net benefit of patients was the highest when nomogram score existed. When the threshold probability was >40%, the prediction probability of hematoma expansion was close to the actual probability. This nomogram model could accurately predict hematoma expansion of spontaneous intracerebral hemorrhage, which provided a theoretical basis for clinicians to intervene in the early stage.

Abstract 7: Cerebral Small Vessel Disease Burden and Association With Post-Surgical Rebleeding and Long-Term Outcome in Intracerebral Hemorrhage Patients From the Mistie III Trial

Objectives: To examine the effect of cerebral small vessel disease (CSVD) markers and CSVD burden on hematoma expansion and long-term functional outcomes in large spontaneous intracerebral hemorrhage (ICH) &gt;30 mL. Method: Retrospective analysis of 288 patients from the MISTIE III trial with qualified MRI sequences. MISTIE III evaluated minimally invasive surgery plus alteplase (vs medical management). We identified 6 CSVD markers including lacunes, cerebral microbleeds (CMB), enlarged perivascular space (EPVS), white matter hyperintensities (WMH), cortical superficial siderosis (cSS), and acute DWI positive lesions. First 5 components were reviewed on day 1 MRI and DWI lesions on day 7. The primary outcome was death or major disability at one year (modified Rankin score 4-6). Secondary outcome was post-surgical rebleeding, defined as symptomatic or asymptomatic hemorrhage expansion within 72 hours post last dose of alteplase. Result: Unfavorable outcome occurred in 65.9% at one year. Post-surgical ICH expansion occurred in 34 (22.9%) of 148 surgical patients. Mean time from symptom onset to first MRI was 0.94 (IQR 0.2-6.3) days. Most individual CSVD markers were more common in patients with unfavorable vs. favorable outcome: CMB≧5 (26.1% vs 15.0%, p=0.03), DWI lesions (65.8%vs 49.6%, p=0.006), cSS (16.8% vs 7.1%, p=0.02) severe WMH (67.7% vs 29.9%, p&lt;0.001) severe EPVS in basal ganglia (19.3% vs 10.2%, p=0.047), and lacunes (11.2% vs 6.3%, p=0.21), In the multivariable adjusted model, cumulative CSVD score (one point for each component: CMB≥5, severe EPVS in basal ganglia, lacunes, severe WMH and cSS) was independently associated with unfavorable outcome (OR 0.56, 95%CI 0.41-0.76, p&lt;0.001; AUC 0.855). We did not find a relationship between either independent CSVD markers or CSVD score with post-surgical ICH expansion. Cumulative CSVD score in multivariable analysis adjusted for predictors of hematoma expansion had OR 0.77 (95% CI 0.50-1.19, p=0.77; AUC 0.659). Conclusion: In large volume ICH patients with long-term follow-up, heavy burden of CSVD at ICH onset remains an independent predictor of unfavorable outcome, and particularly severe white matter hyperintensities. CSVD markers did not show association with post-surgical ICH expansion.

Abstract TP338: The Dynamic CT Angiography Spot Sign: Prevalence, Predictive Value, and Rate of Contrast Extravasation

Introduction: Hematoma expansion is a predictor of poor clinical outcome in intracerebral hemorrhage (ICH). The CT angiography (CTA) spot sign is a validated predictor of hematoma expansion, but its predictive performance is modest. This is in part because traditional “static” CTA can miss delayed spot signs, depending on the timing of image acquisition. Dynamic CTA (dCTA) can detect delayed spot sign formation and allows calculation of contrast extravasation rate. However, the predictive performance of a delayed “dynamic spot” and the relationship between rate of extravasation and hematoma expansion are not known. Our primary objective was to calculate the prevalence and predictive performance of the dynamic spot sign with dCTA. Our secondary objective was to determine whether the rate of contrast extravasation predicts significant hematoma expansion. Methods: We prospectively enrolled 79 patients who presented with primary ICH and underwent dCTA within 6 hours from onset. Primary outcomes were the prevalence of dCTA spot sign and its predictive performance for significant hematoma expansion (increase in hematoma by 6mL or 33% from baseline). For the secondary objective, we calculated the rate of contrast extravasation as the slope of the time curve from the first appearance of contrast at a spot sign to the maximal volume of contrast in 19 acquisitions over 60 seconds. We assessed the relationship between rate of extravasation and hematoma expansion using Mann-Whitney U test and logistic regression. Results: The prevalence of the dCTA spot sign was 45.6% (95% CI, 34.5-56.6%). Significant HE was seen in 58.1% (18/31) of spot-positive patients versus 29.0% (9/31) of spot-negative patients (P=0.04). The sensitivity and specificity of the dCTA spot sign in predicting significant HE was 67% and 63%, respectively. Median rate of extravasation was 0.0022 mL/min in patients with hematoma expansion vs 0.0013 mL/min in those without (p=0.05). Conclusion: Dynamic CTA had a higher spot sign prevalence than conventional CTA. While the sensitivity in predicting expansion was higher with dCTA, the specificity was lower, possibly due to a lower risk of expansion with delayed spot signs. The rate of extravasation was roughly double in patients with hematoma expansion.

Abstract WP415: Cigarette Smoking as Risk Factor for Hematoma Expansion in Primary Intracerebral Hemorrhage: Analysis From a Randomized Clinical Trial

Background: Cigarette smoking is a well-known risk factor for ischemic and hemorrhagic stroke. We evaluated the impact of smoking status on hematoma expansion and clinical outcome in patients with primary intracerebral hemorrhage (ICH). Methods: This is a post hoc exploratory analysis of Antihypertensive Treatment at Acute Cerebral Hemorrhage(ATACH)-2 trial. Patients with ICH were randomized into intensive blood pressure lowering(SBP: &lt;139 mmHg) versus Baseline characteristics were compared based on smoking status. Analysis of outcome measures was adjusted for covariates included in the ATACH-2 primary analysis or those associated with smoking status. Results: Of total of 914 patients in the trial with known smoking status, 439 (48%) patients were ever-smokers (264 current smokers and 175 former smokers). Current and former smokers were younger and more likely to be male. There was no difference in the baseline Glasgow Coma Scale(GCS) score and initial hematoma size based on smoking status. Ever-smokers had higher rate of thalamic hemorrhage (42% vs 34%) and intraventricular hemorrhage (29% vs 23%); this rate was highest among former smokers (49% and 35%, respectively). Ever-smokers had higher rate of hematoma expansion in 24 hour [adjusted RR (95% CI): 1.46; (1.05 -2.03)] compared to non-smokers after adjusting for confounding factors. There was no significant difference in the rate of death and disability at 90 days between the two groups [adjusted RR; (95% CI): 1.18; (0.93 -1.50)]. Conclusions: Our analysis demonstrates cigarette smoking as an independent predictor for hematoma expansion. There was no significant difference in death and disability based on smoking status.

Abstract 76: Non-Contrast CT Markers and Pre- and Post-Surgical Hematoma Expansion in the MISTIE III Trial Surgical Cohort

Introduction: A range of findings on non-contrast CT (NCCT) have been found to predict hematoma expansion after spontaneous ICH, but it is unclear whether these findings predict peri-procedural bleeding. We explored whether any specific NCCT marker(s) predict pre- or post-surgical hematoma expansion events. Methods: NCCTs were reviewed for presence of black hole sign, blend sign, swirl sign, and island sign in the surgical cohort from the MISTIE-III trial which evaluated minimally invasive surgery plus alteplase in ICH &gt;30 mL. Hematoma expansion was defined as any expansion ≥6 mL or 33% ICH volume increase during pre-surgical period (Model 1) from diagnostic CT (DiagCT) to 24 hours post DiagCT and from stability CT (StabCT) to 24 hours post last dose of alteplase (Model 2). Blend sign was removed from analysis due to small sample size. Multivariable logistic regression analysis was performed to identify independent predictors of pre-op and post-op hematoma expansion. Results: Of 250 surgical subjects, 5 were excluded due to poor image quality. Expansion events occurred in 82 of 234 (35.0%) subjects in the pre-op interval and in 15 of 226 (7%) in the post-op interval. None of the markers were significant for pre-op expansion, but ICH volume and time from ictus to DiagCT were statistically significant predictors. Swirl sign, ICH volume, and posterior trajectory compared to lateral trajectory were independent predictors of post-op expansion events. Expansion volume pre-op and post-op were weakly associated with presence of swirl sign; Spearmans rho=0.3 p=0.065 and rho=0.60 p=0.047, respectively. Conclusion: This is the first analysis of impact of NCCT markers on re-bleeding post minimally invasive surgery from a large clinical trial. Despite an absence of association between NCCT markers and hematoma expansion in the pre-surgical period perhaps reflecting inclusion criteria for hemorrhage stability, swirl sign was associated with post-surgical rebleeding.

Abstract TP332: Multi-Institutional Validation of the NAG Scale for Predicting Hematoma Expansion in Acute Intracerebral Hemorrhage Patients

Background and Purpose: Early hematoma expansion (HE) is seen in about 30% of intracerebral hemorrhage (ICH) patients, but detecting those patients with high risk of HE is challenging. The NAG scale was previously published as the simple predictive scale for HE in acute ICH patients. Multi-institutional validation for utility of the scale was the aim of this study. Methods: We retrospectively reviewed consecutive primary ICH patients, who were admitted between September 2016 and December 2018 to Jikei University Hospital or Kashiwa Hospital, Japan. NAG scale is consist of 3 factors based on examination on admission; NIHSS ≥10, Anticoagulant agents use, Glucose ≥133 mg/dl, with 1 point assigned for each parameter. Patients received an initial non-contrast computed tomography (CT) scan within 24 hours from symptom onset, and underwent follow-up CT scans at 6 hours, 24 hours, and 7 days after admission. The HE was defined as an increment in hemorrhage volume &gt;33% or an absolute increase &gt;6 mL on follow-up CT scans. Poor prognosis was defined as modified Rankin Scale 4-6 at discharge. We performed logistic regression analysis and receiver operating characteristic curves to determine discrimination ability of the score. Results: A total of 142 patients (96 men; median age 64 years; median NIHSS 11) were included in our study, and HE was observed in 38 patients (27%). Higher NAG sores were related to HE (P&lt;0.001), poor prognosis (P&lt;0.001), and in-hospital death (P&lt;0.001). The C statistic was 0.72 (95% confidence interval [CI], 0.63-0.82) for HE, 0.67 (95% CI, 0.58-0.76) for poor prognosis, and 0.85 (95% CI, 0.74-0.95) for in-hospital death. Multivariate logistic regression analysis with known risk factors showed the NAG scale was the independent factor for HE (Odds ratio, 2.95; 95% CI, 1.57-5.52; P = 0.001). Conclusion: Multi-institutional validation of the NAG scale showed good discrimination.