International Journal of Neuroscience, 2014; 124(12): 890–893 Copyright © 2014 Informa Healthcare USA, Inc. ISSN: 0020-7454 print / 1543-5245 online DOI: 10.3109/00207454.2014.887716
RESEARCH ARTICLE
Hematoma expansion in spontaneous intracerebral hemorrhage: predictors and outcome Shadi Yaghi,1 Jamil Dibu,2 Eugene Achi,2 Anand Patel,2 Rohan Samant,3 and Archana Hinduja2 1
Department of Neurology, Stroke division, Columbia University Medical Center, New York, NY, USA; 2 Department of Neurology, University of Arkansas for Medical Sciences, New York, NY, USA; 3 Department of Radiology, University of Arkansas for Medical Sciences, New York, NY, USA Background: Hematoma growth is an independent determinant of outcome in patients with intracerebral hemorrhage (ICH). Predictors of hematoma expansion are poorly defined. Our aim is to determine predictors of hematoma expansion in patients with ICH. Methods: We reviewed our prospective database of patients with ICH between January 2009 and June 2012. Patients were divided into two groups based on the presence or absence of hematoma expansion. Hematoma volume was calculated by thin volumetric cuts using special software. Expansion was defined as 33% increase in hematoma volume over 24 hours. We compared risk factors, laboratory parameters, medications and CT findings between the two groups using Fisher’s exact test. A multivariate regression analysis was performed to identify predictors of expansion. Results: We identified 200 patients with ICH. On univariate analysis, patients with hematoma expansion were more likely to have Warfarin use (37% vs. 11% p = 0.001), low admission GCS (9 ± 4, 11 ± 4, p = 0.003), intraventricular hemorrhage (IVH) (79% vs. 45% p = 0.002) and hydrocephalus (43% vs. 22% p = 0.032). On multivariate regression analysis, prior Warfarin use (OR = 3.6, 95% CI: 1.3,10.3; p = 0.016) and IVH (OR = 5.7, 95% CI: 1.5,20.9; p = 0.009) were significant predictors of hematoma expansion. The ICU length of stay (8 ± 8 vs. 4 ± 6, p = 0.004), intubation rate (82% vs. 32%, p = 0.034), and hospital mortality (68% vs. 20%, p = < 0.001) were significantly higher among patients with hematoma expansion. Conclusion: Patient with prior Warfarin use and IVHs are at risk of hematoma expansion. Aggressive measures to prevent hematoma growth are important in these patients. KEYWORDS: Intracerebral hemorrhage, expansion, outcome
Introduction Intracerebral hemorrhage (ICH) is a devastating condition. It causes 10–15% of strokes [1] with a 30-day mortality of 40% [2, 3], occasionally exceeding 50% [4] with only 30% of patients having a decent functional outcome [5]. Predictors of poor outcome in patients with ICH are advanced age, low admission Glasgow coma scale (GCS), larger hematoma volume, presence of intraventricular hemorrhage (IVH) and early hematoma expansion [5–7]. Among these, the only potentially modifiable predictor is hematoma expansion, which may occur in 16–38%
[8–10] of patients and its prevention may possibly alter the course and outcome of the disease. Several therapeutic measures to prevent hematoma expansion have been studied including aggressive blood pressure control, factor VII and surgery, some of which carry the risk of major adverse events with marginal if any treatment benefits [11–13]. Thus, it is important to tailor such therapies to a subgroup of ICH patients who are more likely to have hematoma expansion. Several retrospective studies with different methodologies identified predictors of hematoma expansion, with conflicting results [14–23]. The aim of our study is to identify clinical, radiological, and laboratory predictors of hematoma expansion in patients with ICH.
Received 6 October 2013; revised 20 January 2014; accepted 23 January 2014. Disclosures: The Authors of this article have no financial disclosure Correspondence: Shadi Yaghi, MD, Department of Neurology, Stroke division, Columbia University Medical Center, 710 W. 168th Street, New York, NY 10032, USA. Tel: (212) 305–8389. Fax: (212) 305–3741. E-mail: [email protected]
890
Methods IRB approval was obtained to review our prospective database of patients with ICH between January 2009
Hematoma expansion in intracerebral hemorrhage
and June 2012. Only patients who had initial CT (computed tomography) within 12 hours of symptom onset and a follow up imaging within 24 hours of the initial imaging were included. For patients transferred from another facility, only patients with initial imaging within 12 hours of symptoms onset were included. This image taken at the outside facility was used as baseline to determine the hematoma volume. Hematoma volume was calculated by a staff neuroradiologist from thin volumetric cuts using Philips Brilliant Workspace software on admission CT scan. Expansion was defined as at least 33% increase in hematoma volume over 24 hours. According to our protocol, all patients were admitted to the neurological intensive care unit for at least 24 hours followed up by a CT scan at 24 hours or earlier (if the patient demonstrated neurological decline) to look for hematoma expansion. All patients either underwent a CT angiogram, digital subtraction angiogram or magnetic resonance imaging of the intracranial vasculature to evaluate the etiology. Patients with ICH secondary to arteriovenous malformations, trauma, tumor, aneurysm, infarction, cerebral venous thrombosis, moyamoya disease, infective endocarditis and patients who underwent surgical evacuation were excluded. During this period, Vitamin K and fresh frozen plasma were used for reversal of coagulopathy from Warfarin. Patients were divided into two groups based on the presence or absence of hematoma expansion. We compared the baseline demographics (mean age and gender), risk factors (hypertension, diabetes, hyperlipidemia, coronary artery disease, smoking, alcohol use, cocaine use, mean systolic blood pressure, mean diastolic blood pressure, intubation and GCS), medications (Warfarin, aspirin, clopidogrel and statin), laboratory parameters (troponin elevation and mean blood sugar), CT findings (hematoma location, mean hematoma volume, IVH and hydrocephalus) and outcome (mean length of intensive care unit stay and in-hospital mortality) between the two groups using Fisher’s exact test for categorical variables and t-test for continuous variables. A multivariate regression analysis was performed to identify predictors of hematoma expansion. Statistical significant was defined as p ≤ 0.05.
Results We identified 200 patients with ICH, of which 28 patients (14%) had hematoma expansion. All patients on Warfarin had an international normalized ratio ≥1.7, (INR = 1.7–7) on presentation. On univariate analysis, patients with hematoma expansion were more likely to be on Warfarin (37% vs. 11% p = 0.001), with low admission GCS (9 ± 4 vs. 11 ± 4, p = 0.003), IVH (79% vs. 45% p = 0.002) and hydrocephalus (43% vs. C
2014 Informa Healthcare USA, Inc.
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22% p = 0.032). All the other factors were not statistically significant (Table 1). On multivariate regression analysis (Table 2), prior Warfarin use (OR = 3.6, 95% CI: 1.3,10.3; p = 0.016) and IVH (OR = 5.7, 95% CI: 1.5,20.9; p = 0.009) were the only significant predictors of hematoma expansion (Table 2). In addition, the intensive care unit (ICU) length of stay (8 ± 8 vs. 4 ± 6, p = 0.004), intubation rate (82% vs. 32%, p = 0.034), and hospital mortality (68% vs. 20%, p =
RESEARCH ARTICLE
Hematoma expansion in spontaneous intracerebral hemorrhage: predictors and outcome Shadi Yaghi,1 Jamil Dibu,2 Eugene Achi,2 Anand Patel,2 Rohan Samant,3 and Archana Hinduja2 1
Department of Neurology, Stroke division, Columbia University Medical Center, New York, NY, USA; 2 Department of Neurology, University of Arkansas for Medical Sciences, New York, NY, USA; 3 Department of Radiology, University of Arkansas for Medical Sciences, New York, NY, USA Background: Hematoma growth is an independent determinant of outcome in patients with intracerebral hemorrhage (ICH). Predictors of hematoma expansion are poorly defined. Our aim is to determine predictors of hematoma expansion in patients with ICH. Methods: We reviewed our prospective database of patients with ICH between January 2009 and June 2012. Patients were divided into two groups based on the presence or absence of hematoma expansion. Hematoma volume was calculated by thin volumetric cuts using special software. Expansion was defined as 33% increase in hematoma volume over 24 hours. We compared risk factors, laboratory parameters, medications and CT findings between the two groups using Fisher’s exact test. A multivariate regression analysis was performed to identify predictors of expansion. Results: We identified 200 patients with ICH. On univariate analysis, patients with hematoma expansion were more likely to have Warfarin use (37% vs. 11% p = 0.001), low admission GCS (9 ± 4, 11 ± 4, p = 0.003), intraventricular hemorrhage (IVH) (79% vs. 45% p = 0.002) and hydrocephalus (43% vs. 22% p = 0.032). On multivariate regression analysis, prior Warfarin use (OR = 3.6, 95% CI: 1.3,10.3; p = 0.016) and IVH (OR = 5.7, 95% CI: 1.5,20.9; p = 0.009) were significant predictors of hematoma expansion. The ICU length of stay (8 ± 8 vs. 4 ± 6, p = 0.004), intubation rate (82% vs. 32%, p = 0.034), and hospital mortality (68% vs. 20%, p = < 0.001) were significantly higher among patients with hematoma expansion. Conclusion: Patient with prior Warfarin use and IVHs are at risk of hematoma expansion. Aggressive measures to prevent hematoma growth are important in these patients. KEYWORDS: Intracerebral hemorrhage, expansion, outcome
Introduction Intracerebral hemorrhage (ICH) is a devastating condition. It causes 10–15% of strokes [1] with a 30-day mortality of 40% [2, 3], occasionally exceeding 50% [4] with only 30% of patients having a decent functional outcome [5]. Predictors of poor outcome in patients with ICH are advanced age, low admission Glasgow coma scale (GCS), larger hematoma volume, presence of intraventricular hemorrhage (IVH) and early hematoma expansion [5–7]. Among these, the only potentially modifiable predictor is hematoma expansion, which may occur in 16–38%
[8–10] of patients and its prevention may possibly alter the course and outcome of the disease. Several therapeutic measures to prevent hematoma expansion have been studied including aggressive blood pressure control, factor VII and surgery, some of which carry the risk of major adverse events with marginal if any treatment benefits [11–13]. Thus, it is important to tailor such therapies to a subgroup of ICH patients who are more likely to have hematoma expansion. Several retrospective studies with different methodologies identified predictors of hematoma expansion, with conflicting results [14–23]. The aim of our study is to identify clinical, radiological, and laboratory predictors of hematoma expansion in patients with ICH.
Received 6 October 2013; revised 20 January 2014; accepted 23 January 2014. Disclosures: The Authors of this article have no financial disclosure Correspondence: Shadi Yaghi, MD, Department of Neurology, Stroke division, Columbia University Medical Center, 710 W. 168th Street, New York, NY 10032, USA. Tel: (212) 305–8389. Fax: (212) 305–3741. E-mail: [email protected]
890
Methods IRB approval was obtained to review our prospective database of patients with ICH between January 2009
Hematoma expansion in intracerebral hemorrhage
and June 2012. Only patients who had initial CT (computed tomography) within 12 hours of symptom onset and a follow up imaging within 24 hours of the initial imaging were included. For patients transferred from another facility, only patients with initial imaging within 12 hours of symptoms onset were included. This image taken at the outside facility was used as baseline to determine the hematoma volume. Hematoma volume was calculated by a staff neuroradiologist from thin volumetric cuts using Philips Brilliant Workspace software on admission CT scan. Expansion was defined as at least 33% increase in hematoma volume over 24 hours. According to our protocol, all patients were admitted to the neurological intensive care unit for at least 24 hours followed up by a CT scan at 24 hours or earlier (if the patient demonstrated neurological decline) to look for hematoma expansion. All patients either underwent a CT angiogram, digital subtraction angiogram or magnetic resonance imaging of the intracranial vasculature to evaluate the etiology. Patients with ICH secondary to arteriovenous malformations, trauma, tumor, aneurysm, infarction, cerebral venous thrombosis, moyamoya disease, infective endocarditis and patients who underwent surgical evacuation were excluded. During this period, Vitamin K and fresh frozen plasma were used for reversal of coagulopathy from Warfarin. Patients were divided into two groups based on the presence or absence of hematoma expansion. We compared the baseline demographics (mean age and gender), risk factors (hypertension, diabetes, hyperlipidemia, coronary artery disease, smoking, alcohol use, cocaine use, mean systolic blood pressure, mean diastolic blood pressure, intubation and GCS), medications (Warfarin, aspirin, clopidogrel and statin), laboratory parameters (troponin elevation and mean blood sugar), CT findings (hematoma location, mean hematoma volume, IVH and hydrocephalus) and outcome (mean length of intensive care unit stay and in-hospital mortality) between the two groups using Fisher’s exact test for categorical variables and t-test for continuous variables. A multivariate regression analysis was performed to identify predictors of hematoma expansion. Statistical significant was defined as p ≤ 0.05.
Results We identified 200 patients with ICH, of which 28 patients (14%) had hematoma expansion. All patients on Warfarin had an international normalized ratio ≥1.7, (INR = 1.7–7) on presentation. On univariate analysis, patients with hematoma expansion were more likely to be on Warfarin (37% vs. 11% p = 0.001), with low admission GCS (9 ± 4 vs. 11 ± 4, p = 0.003), IVH (79% vs. 45% p = 0.002) and hydrocephalus (43% vs. C
2014 Informa Healthcare USA, Inc.
891
22% p = 0.032). All the other factors were not statistically significant (Table 1). On multivariate regression analysis (Table 2), prior Warfarin use (OR = 3.6, 95% CI: 1.3,10.3; p = 0.016) and IVH (OR = 5.7, 95% CI: 1.5,20.9; p = 0.009) were the only significant predictors of hematoma expansion (Table 2). In addition, the intensive care unit (ICU) length of stay (8 ± 8 vs. 4 ± 6, p = 0.004), intubation rate (82% vs. 32%, p = 0.034), and hospital mortality (68% vs. 20%, p =
