Intraventricular Extension of Supratentorial Intracerebral Hemorrhage: The Modified Graeb Scale Improves Outcome Prediction in Lund Stroke Register.

BACKGROUND/AIMS: The modified Graeb Scale (mGS) is a semi-quantitative method to assess the extension of intraventricular hemorrhage (IVH) in patients with intracerebral hemorrhage (ICH). The mGS has been shown to prognosticate outcome after ICH in cohorts derived from convenience samples. We evaluated the external validity of mGS in supratentorial ICH-patients from an unselected cohort. METHODS: ICH-patients were included prospectively and consecutively in Lund Stroke Register. Follow-up survival status was obtained from the National Census Office; functional outcome was obtained from the Swedish Stroke Register or medical records. Using multivariate analyses, we examined if mGS was related to 30-day survival or poor functional outcome (modified Rankin Scale ≥4) at 90 days. RESULTS: Of 198 supratentorial ICH-patients, 86 (43%) had IVH (median mGS 12, range 1-28). In multivariate regression analyses, the mGS independently predicted 30-day mortality (per point; OR 1.16; 95% CI 1.06-1.27; p = 0.002) and poor functional outcome (OR 1.11; 95% CI 1.02-1.20; p = 0.011) after ICH. In receiver-operator characteristic analysis, the addition of mGS tended to be associated with a higher prognostic accuracy for survival (area under curve 0.886 vs. not including mGS 0.812; p = 0.053). CONCLUSIONS: The mGS improves outcome prediction after supratentorial ICH beyond other previously established factors in an unselected population.

No exacerbation of perihematomal edema with intraventricular tissue plasminogen activator in patients with spontaneous intraventricular hemorrhage.

INTRODUCTION: In severe spontaneous intraventricular hemorrhage (IVH), intraventricular (IVR) administration of tissue plasminogen activator (rtPA) clears blood from the ventricles more rapidly than with external ventricular drainage (EVD) alone. However, experimental studies suggest tPA may be neurotoxic in compromised brain tissue and may exacerbate perihematomal edema. METHODS: We used computerized volumetrics to assess change in intracerebral hemorrhage (ICH), IVH, ventricular, and perihematomal edema (PHE) volumes at 2-4 (T1) and 5-9 (T2) days following diagnostic CT scans (T0) of 24 patients (12 tPA-treated; 12 controls) with IVH requiring EVD. Controls from a hospital registry were matched by IVH and ICH volume to tPA-treated patients who came from a multicenter trial involving 52 patients with IVH. RESULTS: There were no significant differences between matched pairs in admission ICH and IVH volumes. IVR tPA resulted in more rapid clearance of IVH as determined by T2-T0 decrease in median IVH volume (tPA: -18.7 cc, iqr 14.9; control:-6.9 cc, iqr 6.4; P = 0.002). Median ratios of PHE to ICH volume were not significantly different in control versus tPA-treated patients at T1 and T2 [control:tPA = 0.55:0.56 (T1); P = 0.84 and 0.81:0.71 (T2); P = 1.00]. Total ventricular volume was significantly larger in the control group at T2 (mean: 57.57 ± 10.32 vs. tPA: 24.80 ± 2.67 cc; P = 0.01). Bacterial ventriculitis was more frequent in the control group (5 vs. 1 episodes; P = 0.06) as was shunt dependence (4 vs. 0 cases; P = 0.03). CONCLUSIONS: For case matched large IVH with small ICH volume, IVR tPA enhances lysis of intraventricular blood clots and has no significant impact on PHE.

Minimally invasive surgery plus recombinant tissue-type plasminogen activator for intracerebral hemorrhage evacuation decreases perihematomal edema.

BACKGROUND AND PURPOSE: Perihematomal edema (PHE) can worsen outcomes after intracerebral hemorrhage (ICH). Reports suggest that blood degradation products lead to PHE. We hypothesized that hematoma evacuation will reduce PHE volume and that treatment with recombinant tissue-type plasminogen activator (rt-PA) will not exacerbate it. METHODS: Minimally invasive surgery and rt-PA in ICH evacuation (MISTIE) phase II tested safety and efficacy of hematoma evacuation after ICH. We conducted a semiautomated, computerized volumetric analysis on computed tomography to assess impact of hematoma removal on PHE and effects of rt-PA on PHE. Volumetric analyses were performed on baseline stability and end of treatment scans. RESULTS: Seventy-nine surgical and 39 medical patients from minimally invasive surgery and rt-PA in ICH evacuation phase II (MISTIE II) were analyzed. Mean hematoma volume at end of treatment was 19.6±14.5 cm(3) for the surgical cohort and 40.7±13.9 cm(3) for the medical cohort (P<0.001). Edema volume at end of treatment was lower for the surgical cohort: 27.7±13.3 cm(3) than medical cohort: 41.7±14.6 cm(3) (P<0.001). Graded effect of clot removal on PHE was observed when patients with >65%, 20% to 65%, and <20% ICH removed were analyzed (P<0.001). Positive correlation between PHE reduction and percent of ICH removed was identified (ρ=0.658; P<0.001). In the surgical cohort, 69 patients underwent surgical aspiration and rt-PA, whereas 10 underwent surgical aspiration only. Both cohorts achieved similar clot reduction: surgical aspiration and rt-PA, 18.9±14.5 cm(3); and surgical aspiration only, 24.5±14.0 cm(3) (P=0.26). Edema at end of treatment in surgical aspiration and rt-PA was 28.1±13.8 cm(3) and 24.4±8.6 cm(3) in surgical aspiration only (P=0.41). CONCLUSIONS: Hematoma evacuation is associated with significant reduction in PHE. Furthermore, PHE does not seem to be exacerbated by rt-PA, making such neurotoxic effects unlikely when the drug is delivered to intracranial clot.

The Modified Graeb Score: an enhanced tool for intraventricular hemorrhage measurement and prediction of functional outcome.

BACKGROUND AND PURPOSE: Simple and rapid measures of intraventricular hemorrhage (IVH) volume are lacking. We developed and validated a modification of the original Graeb scale to facilitate rapid assessment of IVH over time. METHODS: We explored the relationship between the modified Graeb scale (mGS), original Graeb scale, measured IVH volume, and outcome using data from the Clot Lysis: Evaluating Accelerated Resolution of Hemorrhage with rtPA B (CLEAR B) study. We also explored its reliability. We then evaluated the relationship between mGS and outcome in a large sample of participants with IVH using data contained within the Virtual International Stroke Trials Archive (VISTA). We defined outcome using the modified Rankin scale (>3 signifying poor outcome). RESULTS: The CLEAR B study included 360 scans from 36 subjects. The mGS score and IVH volume were highly correlated (R = 0.80, P<0.0001, R(2) 0.65). Baseline mGS was predictive of poor outcome (area under receiving operating characteristic curve 0.74, 95% confidence interval, 0.57-0.91), whereas the original Graeb scale was not. The VISTA study included 399 participants. Each unit increase in the mGS led to a 12% increase in the odds of a poor outcome (odds ratio, 1.12; 95% confidence interval, 1.05-1.19). Measures of reliability (intra- and inter- reader) were good in both studies. CONCLUSIONS: The mGS, a semiquantitative scale for IVH volume measurement, is a reliable measure with prognostic validity suitable for rapid use in clinical practice and in research.

Comparison of 3-segmentation techniques for intraventricular and intracerebral hemorrhages in unenhanced computed tomography scans.

OBJECTIVES: The Clot Lysis Evaluating Accelerated Resolution of Intraventricular Hemorrhage Trial phase III is a multicenter, randomized clinical trial in the management and treatment of subjects with small intracerebral hemorrhage and large intraventricular hemorrhage. Accurate localization, segmentation, and quantification of hemorrhage are necessary for decision making and treatment. Our studies are aimed at developing algorithms for accurate and automatic hemorrhage segmentation for this trial. METHODS: Two hundred one computed tomography scans of 41 patients with 2.5- to 10-mm slice thickness from 10 hospitals were used. Techniques based on thresholding, clustering, and graph theory modified using textural energy-based normalization were used along with preprocessing (filtering, skull stripping) and postprocessing (artifact removal). The segmented results of each method are compared with the ground truths. RESULTS: The median sensitivity, specificity, and dice statistical index (DSI) are 86.19%, 99.94%, and 0.8655 for modified thresholding; 83.23%, 99.93%, and 0.8410 for modified fuzzy C-means; and 87.28%, 99.81%, and 0.7917 for modified normalized cut method, respectively. The preprocessing and postprocessing enhanced the DSI by 10% and 3%, respectively. Usage of textural energy along with the Hounsfield value in the modified methods increased the DSI by about 8% to 10%. The methods reduced the time needed for processing from 20 to 30 minutes to 2 to 3 minutes per case. CONCLUSIONS: The modified thresholding provided the highest accuracy, least computation time, and implementation complexity compared with other 2 methods. The method reduces the time to localize and segment the hemorrhagic regions and also provides quantitative information that is critical to precise therapeutic decision making.

An evaluation of diabetes-related measures of control after 6 months of clinical pharmacy specialist intervention.

PURPOSE: To evaluate the effectiveness of a pharmacist management regarding the percentages of patients meeting American Diabetes Association (ADA) treatment goals for diabetes and specific Veterans Health Administration (VA) performance measures individually and in combination after 6 months of intervention. METHODS: We retrospectively evaluated the electronic medical record of all new patients seen between October 1, 2007 and March 31, 2009, with an A1c >7%. Primary objectives included the percentages of patients meeting ADA treatment goals individually and in combination after 6 months in addition to the percentage meeting the 3 VA performance goals individually and in combination. RESULTS: One-hundred and ninety-seven patients met inclusion criteria. There were 6% of patients who met all ADA goals and 79% who met all VA performance measure goals at study end. Individual goal analyses revealed 43% of patients at a goal A1c of <7%, 55% of patients were at low-density lipoprotein (LDL) goal, 45% of patients at systolic blood pressure (SBP) goal, and 51% of patients at diastolic blood pressure (DBP) goal. Evaluation for VA performance measures showed that 91% patients at goal for A1c, 55% at LDL goal, 70% at systolic BP goal, and 87% met diastolic BP goal. CONCLUSIONS: Six months of pharmacist intervention resulted in improvement in patients achieving ADA and VA performance measure goals individually and in combination.