Vignan Yogendrakumar1, Tim Ramsay2, Dean Fergusson2, Andrew M Demchuk2, Richard I Aviv2, David Rodriguez-Luna2, Carlos A Molina2, Yolanda Silva2, Imanuel Dzialowski2, Adam Kobayashi2, Jean-Martin Boulanger2, Cheemun Lum2, Gord Gubitz2, Padma Srivastava2, Jayanta Roy2, Carlos S Kase2, Rohit Bhatia2, Michael D Hill2, Andrew D Warren2, Christopher D Anderson2, Mahmut E Gurol2, Steve M Greenberg2, Anand Viswanathan2, Jonathan Rosand2, Joshua N Goldstein2, Dar Dowlatshahi2. 1. From the Ottawa Stroke Program (V.Y., D.D.), Department of Medicine (Neurology), Department of Radiology (C.L.), Ottawa Methods Center (T.R., D.F.), and Ottawa Hospital Research Institute (T.R., D.F., D.D.), University of Ottawa, Ontario; Calgary Stroke Program (A.M.D., M.D.H.), Department of Clinical Neurosciences, Department of Radiology, Hotchkiss Brain Institute, University of Calgary, Alberta; Division of Neuroradiology and Department of Medical Imaging (R.I.A.), Sunnybrook Health Sciences Centre, University of Toronto, Ontario, Canada; Department of Neurology (D.R.-L., C.A.M.), Hospital Universitari Vall d'Hebron, Barcelona; Department of Neurology (Y.S.), Dr. Josep Trueta University Hospital, Institut d'Investigació Biomèdica Girona Foundation, Spain; Department of Neurology (I.D.), Elblandklinikum Meissen Academic Teaching Hospital of Technische University, Dresden, Germany; Interventional Stroke and Cerebrovascular Treatment Center and 2nd Department of Neurology (A.K.), Institute of Psychiatry and Neurology, and Department of Experimental and Clinical Pharmacology, Warsaw, Poland; Department of Medicine (J.-M.B.), Charles LeMoyne Hospital, University of Sherbrooke, Longueuil, Quebec; Department of Neurology (G.G.), Dalhousie University, Halifax, Nova Scotia, Canada; Department of Neurology (P.S., R.B.), All India Institute of Medical Sciences, New Delhi; Apollo Gleneagles Hospitals (J.R.), Kolkata, India; Department of Neurology (C.S.K.), Boston Medical Center; and Department of Neurology (A.D.W., C.D.A., M.E.G., S.M.G., A.V., J.R.), Henry and Allison McCance Center for Brain Health (J.R.), and Department of Emergency Medicine (J.N.G.), Massachusetts General Hospital, Boston. vyogendrakumar@toh.on.ca. 2. From the Ottawa Stroke Program (V.Y., D.D.), Department of Medicine (Neurology), Department of Radiology (C.L.), Ottawa Methods Center (T.R., D.F.), and Ottawa Hospital Research Institute (T.R., D.F., D.D.), University of Ottawa, Ontario; Calgary Stroke Program (A.M.D., M.D.H.), Department of Clinical Neurosciences, Department of Radiology, Hotchkiss Brain Institute, University of Calgary, Alberta; Division of Neuroradiology and Department of Medical Imaging (R.I.A.), Sunnybrook Health Sciences Centre, University of Toronto, Ontario, Canada; Department of Neurology (D.R.-L., C.A.M.), Hospital Universitari Vall d'Hebron, Barcelona; Department of Neurology (Y.S.), Dr. Josep Trueta University Hospital, Institut d'Investigació Biomèdica Girona Foundation, Spain; Department of Neurology (I.D.), Elblandklinikum Meissen Academic Teaching Hospital of Technische University, Dresden, Germany; Interventional Stroke and Cerebrovascular Treatment Center and 2nd Department of Neurology (A.K.), Institute of Psychiatry and Neurology, and Department of Experimental and Clinical Pharmacology, Warsaw, Poland; Department of Medicine (J.-M.B.), Charles LeMoyne Hospital, University of Sherbrooke, Longueuil, Quebec; Department of Neurology (G.G.), Dalhousie University, Halifax, Nova Scotia, Canada; Department of Neurology (P.S., R.B.), All India Institute of Medical Sciences, New Delhi; Apollo Gleneagles Hospitals (J.R.), Kolkata, India; Department of Neurology (C.S.K.), Boston Medical Center; and Department of Neurology (A.D.W., C.D.A., M.E.G., S.M.G., A.V., J.R.), Henry and Allison McCance Center for Brain Health (J.R.), and Department of Emergency Medicine (J.N.G.), Massachusetts General Hospital, Boston.
Abstract
OBJECTIVE: To describe the relationship between intraventricular hemorrhage (IVH) expansion and long-term outcome and to use this relationship to select and validate clinically relevant thresholds of IVH expansion in 2 separate intracerebral hemorrhage (ICH) populations. METHODS: We used fractional polynomial analysis to test linear and nonlinear models of 24-hour IVH volume change and clinical outcome with data from the Predicting Hematoma Growth and Outcome in Intracerebral Hemorrhage Using Contrast Bolus CT (PREDICT)-ICH study. The primary outcome was poor clinical outcome (modified Rankin Scale [mRS] score 4-6) at 90 days. We derived dichotomous thresholds from the selected model and calculated diagnostic accuracy measures. We validated all thresholds in an independent single-center ICH cohort (Massachusetts General Hospital). RESULTS: Of the 256 patients from PREDICT, 127 (49.6%) had an mRS score of 4 to 6. Twenty-four-hour IVH volume change and poor outcome fit a nonlinear relationship, in which minimal increases in IVH were associated with a high probability of an mRS score of 4 to 6. IVH expansion ≥1 mL (n = 53, sensitivity 33%, specificity 92%, adjusted odds ratio [aOR] 2.68, 95% confidence interval [CI] 1.11-6.46) and development of any new IVH (n = 74, sensitivity 43%, specificity 85%, aOR 2.53, 95% CI 1.22-5.26) strongly predicted poor outcome at 90 days. The dichotomous thresholds reproduced well in a validation cohort of 169 patients. CONCLUSION: IVH expansion as small as 1 mL or any new IVH is strongly predictive of poor outcome. These findings may assist clinicians with bedside prognostication and could be incorporated into definitions of hematoma expansion to inform future ICH treatment trials.
OBJECTIVE: To describe the relationship between intraventricular hemorrhage (IVH) expansion and long-term outcome and to use this relationship to select and validate clinically relevant thresholds of IVH expansion in 2 separate intracerebral hemorrhage (ICH) populations. METHODS: We used fractional polynomial analysis to test linear and nonlinear models of 24-hour IVH volume change and clinical outcome with data from the Predicting Hematoma Growth and Outcome in Intracerebral Hemorrhage Using Contrast Bolus CT (PREDICT)-ICH study. The primary outcome was poor clinical outcome (modified Rankin Scale [mRS] score 4-6) at 90 days. We derived dichotomous thresholds from the selected model and calculated diagnostic accuracy measures. We validated all thresholds in an independent single-center ICH cohort (Massachusetts General Hospital). RESULTS: Of the 256 patients from PREDICT, 127 (49.6%) had an mRS score of 4 to 6. Twenty-four-hour IVH volume change and poor outcome fit a nonlinear relationship, in which minimal increases in IVH were associated with a high probability of an mRS score of 4 to 6. IVH expansion ≥1 mL (n = 53, sensitivity 33%, specificity 92%, adjusted odds ratio [aOR] 2.68, 95% confidence interval [CI] 1.11-6.46) and development of any new IVH (n = 74, sensitivity 43%, specificity 85%, aOR 2.53, 95% CI 1.22-5.26) strongly predicted poor outcome at 90 days. The dichotomous thresholds reproduced well in a validation cohort of 169 patients. CONCLUSION: IVH expansion as small as 1 mL or any new IVH is strongly predictive of poor outcome. These findings may assist clinicians with bedside prognostication and could be incorporated into definitions of hematoma expansion to inform future ICH treatment trials.
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