Supratentorial Intracerebral Hemorrhage Patients Research Articles

Neuroendoscopic Surgery Versus Stereotactic Aspiration in the Treatment of Supratentorial Intracerebral Hemorrhage: A Meta-Analysis

Debate persists over the relative merits of Neuroendoscopic Surgery (NS) compared to Stereotactic Aspiration (SA) for treating supratentorial intracerebral hemorrhage (ICH). Consequently, we undertook this meta-analysis to assess the efficacy and safety of NS versus SA. We searched for the all-relevant studies systematically from English databases including PubMed, Embase, Web of Science and the Cochrane Library. Three independent researchers identified and selected these literatures that met the inclusion criteria. Then we evaluated the quality of these studies according to the Cochrane Collaboration's risk of bias tool and the Newcastle-Ottawa Scale. RevMan 5.4 statistical software was used to conduct this meta-analysis. Sixteen studies, including 2722 supratentorial ICH patients, were included in our meta-analysis. The pooled results showed that NS could effectively improve the functional prognosis (P = 0.002), reduce the postoperative mortality (P < 0.00001) and increase the hematoma evacuation rate (P < 0.00001). In addition, SA had more advantages in shortening operation time (P < 0.00001) and reducing intraoperative blood loss (P < 0.0001). However, there was no obvious statistical difference in ICU stays (P = 0.23) between NS and SA. Besides, no sufficient evidence could support a significant difference in hospital stays. In the aspect of complications, NS was discovered to have a positive effect on preventing rebleeding (P = 0.005) and intracranial infection (P = 0.003). However, no significant differences between the two groups in digestive tract ulcer (P = 0.34), epilepsy (P = 0.99), and pneumonia (P = 0.58). In the subgroup analysis, factors including publication time, GCS score, age, and follow-up all significantly influenced the GFO and mortality. Meanwhile, NS behaved more advantageous in improving functional prognosis for patients with hematoma located in the basal ganglia. NS may hold more advantages over SA in the treatment of supratentorial ICH. However, SA is also an effective and suitable alternative for elderly patients, especially those with multiple comorbidities intolerant to extended surgical procedures. Further high-quality studies are warranted to substantiate our findings in the future.

Prediction of functional outcome in supratentorial intracerebral hemorrhage patients treated with stereotactic computed tomographic-guided aspiration and recombinant tissue plasminogen activator (rt-PA)

Background and purposeMinimally invasive surgery for ICH has shown a significantly improved functional outcome for selected ICH patients. This study aimed to evaluate the factors influencing the outcome of supratentorial ICH patients treated with stereotactic computed tomographic (CT) guided recombinant tissue plasminogen activator (rt-PA). MethodsWe retrospectively evaluated data from 80 consecutive supratentorial ICH patients between December 2017 and July 2020, analyzing their 180-day outcomes, and identifying clinical, radiological factors for good prognosis within 180 days. ResultsThe mean age was 55.6 years (SD 11.4). The median preoperative Glasgow Coma Scale (GCS) score was 9 (interquartile range - IQR 6–12). The mean final ICH volume was 26.5 ml (SD 27.5), with ICH volume reduction by an average of 66.7 %. Six months after the procedure, 40 patients (50 %) had favorable outcomes (modified Rankin Scale [mRS]) score 0–3). In multivariate analysis, age (odds ratio [OR] = 0.939, 95 % confidence interval (CI) = 0.894 – 0.986; p = 0.012), the GCS score before operation (OR = 1.525, 95 % CI = 1.008 – 2.309; p = 0.046), the initial midline shift (OR = 0.808, 95 % CI = 0.661 – 0.988; p = 0.038), and the residual volume hematoma (OR = 0.949, 95 % CI = 0.908 – 0.992, p = 0.020) were the significant predictors of a favorable 180-day outcome. Receiver operating characteristic curve analysis confirmed that the best cut-off point for predicting the good functional 180-day outcome was a GCS score of 9 before the procedure [area under the curve: 0.721, 95 % CI = 0.608 – 0.833, p = 0.001]. ConclusionCT-guided thrombolysis and aspiration can be safe and effective in reducing ICH volume. A preoperation GCS score above or equal to 9 and younger age were associated with improved long-term outcomes in patients with supratentorial ICH.

Prognostic significance of serum NLRC4 in patients with acute supratentorial intracerebral hemorrhage: A prospective longitudinal cohort study.

Caspase activation and recruitment domain-containing protein 4 (NLRC4) is implicated in neuroinflammation. The aim of the study was to discern the potential ability of serum NLRC4 in assessment of prognosis after intracerebral hemorrhage (ICH). In this prospective, observational study, serum NLRC4 levels were quantified in 148 acute supratentorial ICH patients and 148 controls. Severity was evaluated using the National Institutes of Health Stroke Scale (NIHSS) and hematoma volume, and poststroke 6-month functional outcome was estimated according to the modified Rankin Scale (mRS). Early neurologic deterioration (END) and 6-month poor outcome (mRS 3-6) were deemed as the two prognostic parameters. Multivariate models were established for investigating associations, and receiver operating characteristic (ROC) curves were configured to indicate predictive capability. Patients had substantially higher serum NLRC4 levels than controls (median, 363.2 pg/ml vs. 74.7 pg/ml). Serum NLRC4 levels had independent correlation with NIHSS scores [β, 0.308; 95% confidence interval (CI), 0.088-0.520], hematoma volume (β, 0.527; 95% CI, 0.385-0.675), serum C-reactive protein levels (β, 0.288; 95% CI, 0.109-0.341) and 6-month mRS scores (β, 0.239; 95% CI, 0.100-0.474). Serum NLRC4 levels above 363.2 pg/ml were independently predictive of END (odds ratio, 3.148; 95% CI, 1.278-7.752) and 6-month poor outcome (odds ratio, 2.468; 95% CI, 1.036-5.878). Serum NLRC4 levels significantly distinguished END risk [area under ROC curve (AUC), 0.765; 95% CI, 0.685-0.846] and 6-month poor outcome (AUC, 0.795; 95% CI, 0.721-0.870). In terms of predictive ability for 6-month poor outcome, serum NLRC4 levels combined with NIHSS scores and hematoma volume was superior to NIHSS scores combined with hematoma volume, NIHSS scores and hematoma volume (AUC, 0.913 vs. 0.870, 0.864 and 0.835; all P < 0.05). Nomograms were built to reflect prognosis and END risk of combination models, where serum NLRC4, NIHSS scores and hematoma volume were enforced. Calibration curves confirmed stability of combination models. Markedly raised serum NLRC4 levels following ICH, in close relation to illness severity, are independently associated with poor prognosis. Such results are indicative of the notion that determination of serum NLRC4 may aid in severity assessment and prediction of functional outcome of ICH patients.

Abstract WP125: Relationships Of Hemoglobin With Ischemic Lesions After Intracerebral Hemorrhage

Introduction: Hemoglobin concentrations and diffusion weighted imaging (DWI) lesions are separately known to be associated with poor intracerebral hemorrhage (ICH) outcomes. Though hemoglobin concentrations are related to both hypoxia and thrombosis at their extremes, it is unknown whether hemoglobin concentrations relate to DWI lesions after ICH. Methods: Spontaneous, supratentorial ICH patients with available baseline hemoglobin and hospitalized MRI data enrolled into a multicenter cohort study between 2010-2016 were analyzed. Baseline hemoglobin was assessed as both a continuous variable (g/dL) and categorical variable (&lt;11, 11 to &lt;13, 13 to &lt;15, &gt;/=15 g/dL). Primary analyses assessed relationships of baseline hemoglobin with MRI DWI lesions. Secondary analyses assessed independent relationships of hemoglobin and DWI lesions with poor 3-month outcomes (modified Rankin Scale [mRS] 4-6). Separate multivariable regression models assessed these relationships after adjusting for relevant covariates. Results: Of 917 ICH patients analyzed, the mean baseline hemoglobin was 13.8 g/dL (+/-1.9), 60% were deep ICH, and DWI lesions were identified in 27% of the cohort. In our primary analyses, increased hemoglobin, defined as a continuous variable, was associated with DWI lesions (adjusted OR 1.21, 95% CI: 1.07-1.37) after adjusting for sex, race, ICH severity, time to MRI, and blood pressure treatment change. In secondary analyses, DWI lesions were associated with poor 3-month outcomes (adjusted OR 1.83, 95% CI: 1.24-2.69) adjusting for similar covariates. We identified associations of low hemoglobin categories, when referenced to hemoglobin 13 to &lt;15 g/dL, with poor outcomes (&lt;11 g/dL: adjusted OR 1.99, 95% CI: 1.05-3.79; 11 to &lt;13 g/dL: adjusted OR 1.62, 95% CI: 1.04-2.52). Effect estimates of high hemoglobin (&gt;/=15 g/dL) with poor outcomes were smaller and imprecise (adjusted OR 1.39, 95% CI: 0.89-2.17). Conclusions: We identified novel relationships between higher baseline hemoglobin concentrations and DWI lesions in ICH patients. Further studies are required to clarify the role of hemoglobin concentrations on both cerebral small vessel disease pathophysiology and ICH outcomes.

Increased serum pannexin-1 concentrations reflect illness severity and predict a poor prognosis after acute supratentorial intracerebral hemorrhage: A prospective longitudinal cohort study

BackgroundPannexin-1 is a nonselective, large pore and voltage gated channel protein, whose activation may aggravate acute brain injury. We ascertained the clinical significance of serum pannexin-1 as a prognostic biomarker of acute intracerebral hemorrhage (ICH). MethodsIn this prospective, observational study of 124 acute supratentorial ICH patients and 124 healthy controls, serum pannexin-1 concentrations were determined. Admission National Institutes of Health Stroke Scale (NIHSS) score and hematoma volume were used for assessment of hemorrhagic severity, post-stroke 6-month modified Rankin scale (mRS) score was registered to reflect clinical outcome and early neurologic deterioration (END) and 6-month poor outcome (mRS score of 3–6) were regarded as the 2 prognostic parameters. Their associations with serum pannexin-1 concentrations were investigated using multivariate analysis. The predictive performance was evaluated in terms of area under receiver operating characteristic curve (AUC). ResultsIn comparison to controls, significantly increased serum pannexin-1 concentrations after ICH (median, 6.8 vs. 2.7 mg/ml) were independently correlative with NIHSS score (β, 0.193; 95% CI: 0.086–0.300), hematoma volume (β, 0.641; 95% CI: 0.423–0.859) and mRS score (β, 0.199; 95% CI: 0.065–0.174), were independently predictive of END (OR, 1.176; 95% CI: 1.081–1.280) and poor outcome (odds ratio, 1.218; 95% CI: 1.059–1.400), as well as were efficiently discriminative of END (AUC, 0.764; 95% CI: 0.663–0.864) and poor 6-month outcome (AUC, 0.790; 95% CI: 0.711–0.870). Serum pannexin-1 combined with NIHSS score and hematoma volume (AUC, 0.908; 95% CI: 0.857–0.960) displayed significantly higher predictive ability for poor 6-month outcome than NIHSS score and hematoma volume alone (both P < 0.05). ConclusionRising serum pannexin-1 concentrations following ICH, in strong correlation with hemorrhagic severity, independently distinguish the risk of END and 90-day poor outcome. Assumably, serum pannexin-1 may represent a valuable prognostic biomarker of ICH.

Elevated serum nuclear factor erythroid 2-related factor 2 levels contribute to a poor prognosis after acute supratentorial intracerebral hemorrhage: A prospective cohort study.

Nuclear factor erythroid 2-related factor 2 (Nrf2) is a key transcriptional factor for antioxidant response element-regulated genes. The purpose of this study was to assess the prognostic role of serum Nrf2 in intracerebral hemorrhage (ICH). In this prospective observational study, serum Nrf2 levels of 115 acute supratentorial ICH patients and 115 controls were gaged. Early neurologic deterioration (END) was defined as an increase of four or greater points in National Institutes of Health Stroke Scale (NIHSS) score or death at post-stroke 24 h. A poor outcome was referred to as the post-stroke 90-day modified Rankin scale (mRS) score of 3-6. END and a poor outcome were considered as the two prognostic parameters. As compared to controls, serum Nrf2 levels of patients were substantially elevated (P < 0.001), with its levels increasing during the 6-h period immediately, peaking in 12-18 h, plateauing at 18-24 h, and decreasing gradually thereafter (P < 0.05). Serum Nrf2 levels of patients were independently correlated with NIHSS score (t = 3.033; P = 0.003) and hematoma volume (t = 3.210; P = 0.002), independently predicted END (odds ratio 1.125; 95% confidence interval 1.027-1.232; P = 0.011) and poor outcome (odds ratio 1.217; 95% confidence interval 1.067-1.387; P = 0.013), as well as efficiently distinguished END (area under curve 0.771; 95% confidence interval 0.666-0.877; P < 0.001) and poor outcome (area under curve 0.803; 95% confidence interval 0.725-0.882; P < 0.001). Its predictive ability was equivalent to those of NIHSS score and hematoma volume (both P > 0.05), and it also significantly improved their predictive abilities under receiver operating characteristic (ROC) curve (all P < 0.05). Elevated serum Nrf2 levels are closely correlated with severity, END, and 90-day poor outcome following ICH. Hence, Nrf2 may play an important role in acute brain injury after ICH, and serum Nrf2 may have the potential to serve as a prognostic biomarker of ICH.

Comparison of endoscopic and open surgery in life-threatening large spontaneous supratentorial intracerebral hemorrhage: A propensity-matched analysis.

Conventionally, open surgery (OS), including standard craniotomy (SC) and decompressive craniectomy (DC) with hematoma evacuation, is adopted to treat life-threatening large spontaneous supratentorial intracerebral hemorrhage (ICH). Recently, endoscopic surgery (ES), a minimally invasive surgical treatment, has gained increased popularity. However, the safety and efficacy of ES for life-threatening large ICH is uncertain. The aim of this study was to evaluate the effectiveness and safety of ES for life-threatening large ICH and compare it with traditional OS. We retrospectively analyzed the clinical and imaging data of consecutive supratentorial ICH patients with preoperative Glasgow Coma Scale (GCS) score ⩽ 8, who underwent ES or OS between May 2015 and October 2021. To minimize bias in case selection, propensity score matching was performed (ratio 1:2, caliper o.2). The primary outcome was a prognosis-based dichotomized (favorable or unfavorable) outcome of the 5-point Glasgow Outcome Scale (GOS) at 6 months. Favorable outcome was defined as a GOS score of 4 to 5 at 6 months. Sensitivity analysis was also performed to ensure the robustness of the findings. Of 695 patients who underwent surgical treatment for spontaneous ICH, 191 patients were identified to be eligible, with 58 patients in the ES group and 133 patients in the OS group. Propensity score matching improved covariate balance and generated a comparable cohort (53 ES and 106 OS) for all analyses. The ES group had a higher incidence of the primary outcome of favorable outcome at 6 months (ES 20/53 (37.7%) vs. OS 22/106 (20.8%); propensity score-matched relative risk (RR) (95% CI) = 1.74 (1.13-2.68); p = 0.013). Sensitivity analysis showed the result was stable. ES is a safe treatment for life-threatening large spontaneous supratentorial ICH patients and may achieve better outcomes than OS.

Defining Minor Intracerebral Hemorrhage

Background and Purpose: The minor stroke concept has not been analyzed in intracerebral hemorrhage (ICH) patients. Our purpose was to determine the optimal cut point on the NIH Stroke Scale (NIHSS) for defining a minor ICH (mICH) in patients with primary ICH. Methods: An ICH was considered minor if associated with a favorable 3-month outcome (modified Rankin Scale score ≤2). For supratentorial ICH, the discovery cohort consisted of 478 patients prospectively admitted at University Hospital del Mar. Association between NIHSS at admission and 3-month outcome was evaluated with area under the curve-receiver operating characteristics (AUC-ROC) and Youden’s index to identify the optimal NIHSS cutoff point to define mICH. External validation was performed in a cohort of 242 supratentorial ICH patients from University Hospital Sant Pau. For infratentorial location, patients from both hospitals (n = 85) were analyzed together. Results: The best ­NIHSS cutoff point defining supratentorial-mICH was 6 (AUC-ROC = 0.815 [0.774–0.857] in the discovery cohort and AUC-ROC = 0.819 [0.756–0.882] in the external validation cohort). For infratentorial ICH, the best cutoff point was 4 (AUC-ROC = 0.771 [0.664–0.877]). Using these cutoff points, 40.5% of all primary ICH cases were mICH. Of these, 70.2% were living independently at 3-month follow-up (72% for supratentorial ICH and 56.1% for infratentorial ICH) and 6.5% had died (5.3% for supratentorial ICH, and 14.6% for infratentorial ICH). For patients identified as non-mICH, good 3-month outcome was observed in 11.3% of cases; mortality was 51%. Conclusions: The definition of mICH using the NIHSS cutoff point of 6 for supratentorial ICH and 4 for infratentorial ICH is useful to identify good outcome in ICH patients.

Can brain natriuretic peptide, S100b, and interleukin-6 prognosticate the neurological consequences in Egyptian patients presented with supratentorial intracerebral hemorrhage?

Background: Biomarkers in supratentorial intracerebral hemorrhage (SICH) enhance the prognosis of the disease. This study aimed to assess the prognosticative grade of S100 calcium-binding protein B (S100B), interleukin-6 (IL-6), and the pro-brain natriuretic peptide (pro-BNP) in SICH outcome prediction.Methods: Blood samples of 50 SICH patients were analyzed for the biomarkers. The patients were classified into two groups with and without intraventricular hemorrhage (IVH). The following scales including Glasgow Coma Score (GCS), the Barthel index (BI), intracerebral hemorrhage (ICH) score, ICH volume, National Institutes of Health Stroke Scale (NIHSS), Modified Rankin Score (mRS), and length of stay were used to evaluate the severity.Results: The severity scores (NIHSS, GCS, BI, mRI) were significantly higher in SICH patients with IVH versus SICH patients without IVH (P = 0.002, 0.008, 0.001, and 0.03, respectively). Serum levels for a pro-BNP and S100b are significantly higher in SICH patients with IVH versus SICH patients without IVH (P = 0.02 and 0.027, respectively). Multivariate correlations between demographic (age), biomarkers panel (IL-6, S100b, and proBNP), and clinical and severity scores (ICH score, ICH volume, length of hospital stay [LOS], BI, mRS, GCS, and NIHSSS) in all studied patients showed a highly significant correlation between ICH score and pro-BNP (P = 0.04). There was a highly significant correlation between LOS and IL-6 (P = 0.003).Conclusion: Pro-BNP, IL-6, and S100b are greatly associated with the presence of IVH that, in turn, correlated well with poor clinical outcome measures.

Association of Brain Iron Overload With Brain Edema and Brain Atrophy After Intracerebral Hemorrhage.

Objective: This study evaluated iron overload after intracerebral hemorrhage (ICH) using ESWAN sequences.Methods: This single-center prospective observational cohort study enrolled supratentorial ICH patients. MRI was obtained with a 3.0-T scanner at day 1, day 14, day 30, and follow-up (300 days or later). R2* mapping was generated based on the ESWAN. R2* value of the ipsilateral side represented iron deposition, and the R2* value of the contralateral side served as control. R2* value was adjusted by volume and used to assess total iron overload. Brain edema was measured on T2 FLAIR-weighted images. Brain atrophy was calculated as the contralateral hemisphere volume minus the injured hemisphere volume.Results: Twnety-seven patients with a spontaneous supratentorial ICH were included in this analysis. The ipsilateral R2* value was 40.27 ± 11.62, 41.92 ± 13.56, and 60.89 ± 14.09 at days 1, 14, and 30, respectively. The R2* value was significantly higher in the ICH side than the contralateral side (p < 0.01). Increased R2* value was seen on day 30 compared to day 14 (p < 0.01). The R2* value showed logistic decay with the distance to the hematoma margin (p < 0.01). Brain edema at day 14 and brain atrophy at follow-up correlated with R2* value adjusted by volume at day 14 (p < 0.01).Conclusions: After ICH, the iron deposition in the perihematomal region was progressively increased during the first month. R2* value adjusted by volume predicted acute brain edema and chronic brain atrophy.

Quantitative Corticospinal Tract Assessment in Acute Intracerebral Hemorrhage

Intracerebral hemorrhage (ICH) prognostication during the acute phase is often subjective among physicians and often affects treatment decisions. The present study explores objective imaging parameters using quantitative corticospinal tract (CST) fiber reconstruction during the acute phase of ICH and correlates these parameters with functional outcome and patient recovery. We prospectively enrolled nonsurgical spontaneous supratentorial ICH patients and obtained an MRI scan on day 5 ± 1. Q-space diffeomorphic reconstruction was performed using DSI Studio, and quantitative anisotropy (QA) was calculated. The CST was reconstructed based on QA. The dichotomized modified Rankin Scale score on day 90 (favorable outcome = 0–2) and Barthel Index (favorable recovery = 100 on day 90 or improvement between discharge and day 90 > 60%) were assessed. Thirty-three patients, median age 72 years (interquartile range (IQR) 64–83), 21 female (64%), 21 (64%) with lobar hemorrhage, median ICH volume on admission 15.0 (IQR 7.0–27.4) mL, were included. Sixteen patients (48%) had a favorable outcome and 24 (73%) had a favorable recovery. The mean number of ipsilesional reconstructed CST fiber pathways was higher in patients with favorable outcomes (153 (standard deviation (SD) 103) vs. 60 (SD 39), p = 0.003) and predicted outcome after adjustment (Exp(B) = 1.016 (95% CI = 1.002–1.030)). QA in the ipsilesional posterior limb of the internal capsule showed a trend towards an association with favorable outcome (Exp(B) = 1.194 (95% CI = 0.991–1.439 (adjusted))). The total (ipsilesional + contralesional) number of reconstructed fiber pathways was associated with favorable recovery (Exp(B) = 1.025 (95% CI = 1.003–1.047 (adjusted))). Quantitative tractography parameters assessed in the acute phase of ICH may represent a promising predictor of long-term outcome and recovery. This might facilitate prognostic evaluation and organization of rehabilitation.

Hematoma enlargement characteristics in deep versus lobar intracerebral hemorrhage.

ObjectiveHematoma enlargement (HE) is associated with clinical outcomes after supratentorial intracerebral hemorrhage (ICH). This study evaluates whether HE characteristics and association with functional outcome differ in deep versus lobar ICH.MethodsPooled analysis of individual patient data between January 2006 and December 2015 from a German‐wide cohort study (RETRACE, I + II) investigating ICH related to oral anticoagulants (OAC) at 22 participating centers, and from one single‐center registry (UKER‐ICH) investigating non‐OAC‐ICH patients. Altogether, 1954 supratentorial ICH patients were eligible for outcome analyses, which were separately conducted or controlled for OAC, that is, vitamin‐K‐antagonists (VKA, n = 1186) and non‐vitamin‐K‐antagonist‐oral‐anticoagulants (NOAC, n = 107). Confounding was addressed using propensity score matching, cox regression modeling and multivariate modeling. Main outcomes were occurrence, extent, and timing of HE (>33%/>6 mL) and its association with 3‐month functional outcome.ResultsOccurrence of HE was not different after deep versus lobar ICH in patients with non‐OAC‐ICH (39/356 [11.0%] vs. 36/305 [11.8%], P = 0.73), VKA‐ICH (249/681 [36.6%] vs. 183/505 [36.2%], P = 0.91), and NOAC‐ICH (21/69 [30.4%] vs. 12/38 [31.6%], P = 0.90). HE extent did not differ after non‐OAC‐ICH (deep:+59% [40–122] vs. lobar:+74% [37–124], P = 0.65), but both patients with VKA‐ICH and NOAC‐ICH showed greater HE extent after deep ICH [VKA‐ICH, deep: +94% [54–199] vs. lobar: +56% [35–116], P < 0.001; NOAC‐ICH, deep: +74% [56–123] vs. lobar: +40% [21–49], P = 0.001). Deep compared to lobar ICH patients had higher HE hazard during first 13.5 h after onset (Hazard ratio [HR]: 1.85 [1.03–3.31], P = 0.04), followed by lower hazard (13.5–26.5 h, HR: 0.46 [0.23–0.89], P = 0.02), and equal hazard thereafter (HR: 0.96 [0.56–1.65], P = 0.89). Odds ratio for unfavorable outcome was higher after HE in deep (4.31 [2.71–6.86], P < 0.001) versus lobar ICH (2.82 [1.71–4.66], P < 0.001), and only significant after small‐medium (1st volume‐quarter, deep: 3.09 [1.52–6.29], P < 0.01; lobar: 3.86 [1.35–11.04], P = 0.01) as opposed to large‐sized ICH (4th volume‐quarter, deep: 1.09 [0.13–9.20], P = 0.94; lobar: 2.24 [0.72–7.04], P = 0.17).InterpretationHE occurrence does not differ among deep and lobar ICH. However, compared to lobar ICH, HE after deep ICH is of greater extent in OAC‐ICH, occurs earlier and may be of greater clinical relevance. Overall, clinical significance is more apparent after small–medium compared to large‐sized bleedings.

Fully Automated Segmentation Algorithm for Perihematomal Edema Volumetry After Spontaneous Intracerebral Hemorrhage.

Background and Purpose- Perihematomal edema (PHE) is a promising surrogate marker of secondary brain injury in patients with spontaneous intracerebral hemorrhage, but it can be challenging to accurately and rapidly quantify. The aims of this study are to derive and internally validate a fully automated segmentation algorithm for volumetric analysis of PHE. Methods- Inpatient computed tomography scans of 400 consecutive adults with spontaneous, supratentorial intracerebral hemorrhage enrolled in the Intracerebral Hemorrhage Outcomes Project (2009-2018) were separated into training (n=360) and test (n=40) datasets. A fully automated segmentation algorithm was derived from manual segmentations in the training dataset using convolutional neural networks, and its performance was compared with that of manual and semiautomated segmentation methods in the test dataset. Results- The mean volumetric dice similarity coefficients for the fully automated segmentation algorithm were 0.838±0.294 and 0.843±0.293 with manual and semiautomated segmentation methods as reference standards, respectively. PHE volumes derived from the fully automated versus manual (r=0.959; P<0.0001), fully automated versus semiautomated (r=0.960; P<0.0001), and semiautomated versus manual (r=0.961; P<0.0001) segmentation methods had strong between-group correlations. The fully automated segmentation algorithm (mean 18.0±1.8 seconds/scan) quantified PHE volumes at a significantly faster rate than both of the manual (mean 316.4±168.8 seconds/scan; P<0.0001) and semiautomated (mean 480.5±295.3 seconds/scan; P<0.0001) segmentation methods. Conclusions- The fully automated segmentation algorithm accurately quantified PHE volumes from computed tomography scans of supratentorial intracerebral hemorrhage patients with high fidelity and greater efficiency compared with manual and semiautomated segmentation methods. External validation of fully automated segmentation for assessment of PHE is warranted.

Abstract WMP104: Fully Automated Segmentation Algorithm for Volumetric Analysis of Perihematomal Edema After Spontaneous Intracerebral Hemorrhage

Background: Perihematomal edema (PHE) is a promising marker of secondary injury in patients with spontaneous intracerebral hemorrhage (ICH). It can be challenging to accurately and rapidly quantify. The aims of this study are to derive and internally validate a fully automated segmentation algorithm for volumetric PHE analysis. Methods: Inpatient CT scans of 400 consecutive adults with spontaneous supratentorial ICH enrolled in the Intracerebral Hemorrhage Outcomes Project (2009-2018) were separated into training (n=360) and test (n=40) datasets. A fully automated algorithm was derived from manual segmentations in the training dataset using convolutional neural networks and its performance was compared to manual and semi-automated segmentation methods in the test dataset. Results: The mean volumetric Dice similarity coefficients for the fully automated algorithm were 0.838±0.294 and 0.843±0.293 with manual and semi-automated segmentations as reference standards, respectively. PHE volumes derived from fully automated vs. manual (R 2 =0.959;p&lt;0.001), fully automated vs. semi-automated (R 2 =0.960;p&lt;0.001) and semi-automated vs. manual (R 2 =0.961; p&lt;0.001) methods had strong between group correlations. The fully automated algorithm (mean 18.0±1.8 seconds/scan) quantified PHE volumes at a significantly faster rate than manual (mean 316.4±168.8 seconds/scan; p&lt;0.001) and semi-automated (mean 480.5±295.3 seconds/scan; p&lt;0.001) methods. Conclusions: The fully automated algorithm accurately quantified PHE from CT scans of supratentorial ICH patients with high fidelity and greater efficiency compared with manual and semi-automated segmentation methods.

Abstract 78: Fully Automated Segmentation Algorithm for Hematoma Volumetric Analysis in Spontaneous Intracerebral Hemorrhage

Background and Purpose: Hematoma volume measurements influence prognosis and treatment decisions in patients with spontaneous intracerebral hemorrhage (ICH). The aims of this study are to derive and validate a fully automated segmentation algorithm for ICH volumetric analysis using deep learning methods. Methods: Inpatient computed tomography scans of 300 consecutive adults (age ≥18 years) with spontaneous, supratentorial ICH who were enrolled in the Intracerebral Hemorrhage Outcomes Project (2009-2018) were separated into training (n=260) and test (n=40) datasets. A fully automated segmentation algorithm was derived using convolutional neural networks (CNN), and it was trained on manual segmentations from the training dataset. The algorithm’s performance was assessed against manual and semi-automated segmentation methods in the test dataset. Results: The mean volumetric Dice similarity coefficients for the fully automated segmentation algorithm when tested against manual and semi-automated segmentation methods were 0.894±0.264 and 0.905±0.254, respectively. ICH volumes derived from fully automated vs. manual (R 2 =0.981;p&lt;0.0001), fully automated vs. semi-automated (R 2 =0.978;p&lt;0.0001), and semi-automated vs. manual (R 2 =0.990;p&lt;0001) segmentation methods had strong between-group correlations. The fully automated segmentation algorithm (mean 12.0±2.7 seconds/scan) was significantly faster than both of the manual (mean 201.5±92.2 seconds/scan; p&lt;0.001) and semi-automated (mean 288.58±160.3 seconds/scan; p&lt;0.001) segmentation methods. Conclusions: The fully automated segmentation algorithm quantified hematoma volumes from CT scans of supratentorial ICH patients with similar accuracy and substantially greater efficiency compared with manual and semi-automated segmentation methods.

Correlation of Glasgow outcome scale (GOS) and Haematoma Volume during Surgical and Conservative Management of Spontaneous Supratentorial Intracerebral Hemorrhage Patients

Background: Haematoma volume is an important issue for the management of spontaneous supratentorial intracerebral hemorrhage patients.&#x0D; Objective: The purpose of the present study was to correlate the Glasgow outcome scale (GOS) and haematoma volume during surgical and conservative management of spontaneous supratentorial intracerebral hemorrhage patients.&#x0D; Methodology: This randomized control trial which was conducted in the Department of Neurosurgery at Dhaka Medical College and Hospital from January 2010 to October 2011 for a period of one year and ten months. All hypertensive patients with spontaneous supratentorial intracerebral hemorrhage who were admitted within 48 hours of stroke in Neurosurgery Department during the study period were considered as a study population. Patients underwent surgery was considered as group I and patients those who did not give the consent for operation were treated conservatively was considered as group II. Surgery and conservative groups were matched in age, GCS, GOS, hematoma location and volume of hematoma.&#x0D; Result: A total of 31 patients were enrolled in this study of which 14 patients underwent surgical evacuation and 17 cases were selected for conservative therapy. Significant negative correlation was found between GCS on admission with hematoma volume in surgery group (r=-0.631; P=0.016) and conservative group (r=- 0.854; p=0.001). A negative but not significant correlation (r=-0.426; P=0.129) between GOS with hematoma volume in group I, where negative significant correlation (r=-0.503; P=0.039) in conservative group II.&#x0D; Conclusion: In conclusion Glasgow outcome scale (GOS) is positively correlated with the haematoma volume during surgical and conservative management of spontaneous supratentorial intracerebral hemorrhage patients&#x0D; Journal of Science Foundation 2019;17(1):9-14

Fully Automated Segmentation Algorithm for Hematoma Volumetric Analysis in Spontaneous Intracerebral Hemorrhage.

Background and Purpose- Hematoma volume measurements influence prognosis and treatment decisions in patients with spontaneous intracerebral hemorrhage (ICH). The aims of this study are to derive and validate a fully automated segmentation algorithm for ICH volumetric analysis using deep learning methods. Methods- In-patient computed tomography scans of 300 consecutive adults (age ≥18 years) with spontaneous, supratentorial ICH who were enrolled in the ICHOP (Intracerebral Hemorrhage Outcomes Project; 2009-2018) were separated into training (n=260) and test (n=40) datasets. A fully automated segmentation algorithm was derived using convolutional neural networks, and it was trained on manual segmentations from the training dataset. The algorithm's performance was assessed against manual and semiautomated segmentation methods in the test dataset. Results- The mean volumetric Dice similarity coefficients for the fully automated segmentation algorithm when tested against manual and semiautomated segmentation methods were 0.894±0.264 and 0.905±0.254, respectively. ICH volumes derived from fully automated versus manual (R2=0.981; P<0.0001), fully automated versus semiautomated (R2=0.978; P<0.0001), and semiautomated versus manual (R2=0.990; P<0001) segmentation methods had strong between-group correlations. The fully automated segmentation algorithm (mean 12.0±2.7 s/scan) was significantly faster than both of the manual (mean 201.5±92.2 s/scan; P<0.001) and semiautomated (mean 288.58±160.3 s/scan; P<0.001) segmentation methods. Conclusions- The fully automated segmentation algorithm quantified hematoma volumes from computed tomography scans of supratentorial ICH patients with similar accuracy and substantially greater efficiency compared with manual and semiautomated segmentation methods. External validation of the fully automated segmentation algorithm is warranted.

Feasibility of improving cerebral autoregulation in acute intracerebral hemorrhage (BREATHE-ICH) study: Results from an experimental interventional study.

Cerebral autoregulation is impaired in a multitude of neurological conditions. Increasingly, clinical studies are correlating the nature of this impairment with prognostic markers. In acute intracerebral hemorrhage, impairment of cerebral autoregulation has been associated with worsening clinical outcomes including poorer Glasgow Coma Score and larger hematoma volume. Hypocapnia has been shown to improve cerebral autoregulation despite concerns over hypoperfusion and consequent ischemic risks, and it is therefore hypothesized that hypocapnia (via hyperventilation) in acute intracerebral hemorrhage may improve cerebral autoregulation and consequently clinical outcome. To assess the feasibility and acceptability of the first cerebral autoregulation-targeted intervention in acute intracerebral hemorrhage utilizing a simple bed-side hyperventilatory maneuver. Twelve patients with acute intracerebral hemorrhage within 48 h of onset were enrolled. The experimental setup measured cerebral blood flow velocity (transcranial Doppler), blood pressure (Finometer), and end-tidal CO2 (EtCO2, capnography) at baseline, and in response to hypocapnia (-5 mmHg below baseline) achieved via a 90-s hyperventilatory maneuver. Cerebral autoregulation was evaluated with transfer function analysis and autoregulatory index calculations. We observed tolerance to the protocol in a cohort of mild (National Institutes of Health Scale 4) supratentorial intracerebral hemorrhage patients with small volume hematomas without intraventricular extension. Importantly, a significant difference was noted between ipsilateral autoregulatory index at baseline 4.8 (1.7) and autoregulatory index during hypocapnic intervention 7.0 (0.8) (p = 0.0004), reflecting improved cerebral autoregulation, though a dose-dependent effect of EtCO2 on autoregulatory index was not observed. In this small study, there was no observed effect on 14-day death and disability in recruited participants. This is the first report of improvement in cerebral autoregulation in acute intracerebral hemorrhage using a non-invasive interventional maneuver, through induction of hypocapnia via hyperventilation.ClinicalTrials.gov Identifier: NCT03324321URL: https://clinicaltrials.gov/ct2/show/NCT03324321.

Abstract TP432: Dilated Optic Nerve Sheath Diameter by Trans-Orbital Ultrasound Predicts Mortality Among Patients With Acute Intracerebral Hemorrhage

Introduction: Supratentorial Intracerebral hemorrhage (ICH) main prognostic factors on admission are age, Glasgow coma scale (GCS), ICH volume and ventricular hemorrhage. Subsequent ICH expansion and associated elevated intracranial pressure (ICP) have also been linked to poorer outcomes. Dilatation of optic nerve sheath diameter (ONSD) by trans-orbital ultrasound examination is an increasingly recognized marker of elevated ICP. We sought to evaluate whether increased ONSD at hospital admission could be associated with mortality among patients with supratentorial ICH. Methods: Prospective cohort of consecutive acute supratentorial ICH patients admitted to a tertiary stroke center. Exclusion criteria: 1) last well seen &gt; 24 hours; 2) immediate surgical intervention indicated by neurosurgery team; 3) Secondary ICH (anticoagulants and antiplatelets were allowed); 4) previous optic nerve pathology precluding accurate ONSD measurements. Ultrasound assessment and CT performed within the first hour after admission. Primary outcome was 90-days mortality. Multivariate logistic regression, ROC curve and c-statistics was used to identify independent predictors of mortality. Results: Between July 2014 and July 2017, 57 patients were evaluated. Among those, 13 were excluded and 44 were recruited into the trial. Their mean age was 62.3± 13.1 years and 32 (72.7%) were male. On univariate analysis, ICH volume on admission CT scan, ICH ipsilateral ONSD measurement on admission TCCD, diabetes and current smoking were predictors of mortality. After multivariate analysis, ipsilateral ONSD (OR:6.24;95CI%1.18-33.1;p=0.031) was an independent predictor of mortality, even after adjustment for ICH volume, age, GCS and intraventricular hemorrhage. The ONSD had an area under the curve (AUC) of 0.71 (p=0.021) for mortality at 3 months. Conclusion: ONSD is a non-invasively, bedside, low cost technique that could be used to estimate increased ICP in patients with acute supratentorial ICH. Among these patients, increased ONSD is an independent predictor of mortality at 3 months.

Impact of Supratentorial Cerebral Hemorrhage on the Complexity of Heart Rate Variability in Acute Stroke

Acute stroke commonly affects cardiac autonomic responses resulting in reduced heart rate variability (HRV). Multiscale entropy (MSE) is a novel non-linear method to quantify the complexity of HRV. This study investigated the influence of intracerebral hemorrhage (ICH) locations and intraventricular hemorrhage (IVH) on the complexity of HRV. We recruited 93 supratentorial ICH patients (male 59%, mean age 61 years), and the locations of ICH included basal ganglia (n = 40), thalamus (n = 35), and lobar (n = 18) group. Continuous one-hour electrocardiography signals were obtained from patients after admission, and the complexity index was defined as the area under the MSE curve. The complexity index was lower in lobar ICH (21.6 ± 7.9) than basal ganglia (27.9 ± 6.4) and thalamus (28.5 ± 7.2) groups. The complexity index was inversely correlated with initial stroke severity (r = −0.26), size of hematoma (r = −0.35) and ICH score (r = −0.26), especially among patients with intraventricular hemorrhage (r = −0.60, −0.60, and −0.41 respectively). A higher complexity can predict a good functional outcome (adjusted odds ratio 1.09, 95% confidence intervals 1.00–1.19) at post-stroke 3 months. In summary, more severe stroke and larger hematoma volume resulted in lower complexity of HRV. Lobar hemorrhage and IVH had great impacts on the cardiac autonomic function.