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BACKGROUND: Spontaneous intracerebral hemorrhage (ICH) in the cerebellum has a poor short-term prognosis, whereas data on the long-term case fatality and recurrent vascular events are sparse. Herewith, we aimed to assess the long-term case fatality and recurrence rate of vascular events after a first cerebellar ICH. METHODS: In this international cohort study, we included patients from 10 hospitals (the United States and Europe from 1997 to 2017) aged ≥18 years with a first spontaneous cerebellar ICH who were discharged alive. Data on long-term case fatality and recurrence of vascular events (recurrent ICH [supratentoria or infratentorial], ischemic stroke, myocardial infarction, or major vascular surgery) were collected for survival analysis and absolute event rate calculation. RESULTS: We included 405 patients with cerebellar ICH (mean age [SD], 72 [13] years, 49% female). The median survival time was 67 months (interquartile range, 23-100 months), with a cumulative survival rate of 34% at 10-year follow-up (median follow-up time per center ranged: 15-80 months). In the 347 patients with data on vascular events 92 events occurred in 78 patients, after initial cerebellar ICH: 31 (8.9%) patients had a recurrent ICH (absolute event rate, 1.8 per 100 patient-years [95% CI, 1.2-2.6]), 39 (11%) had an ischemic stroke (absolute event rate, 2.3 [95% CI, 1.6-3.2]), 13 (3.7%) had a myocardial infarction (absolute event rate, 0.8 [95% CI, 0.4-1.3]), and 5 (1.4%) underwent major vascular surgery (absolute event rate, 0.3 [95% CI, 0.1-0.7]). The median time to a first vascular event during follow-up was 27 months (interquartile range, 8.7-50 months), with a cumulative hazard of 47% at 10 years. CONCLUSIONS: The long-term prognosis of patients who survive a first spontaneous cerebellar ICH is poor and comparable to that of patients who survive a first supratentorial ICH. Further identification of patients at high risk of vascular events following the initial cerebellar ICH is needed. Including patients with cerebellar ICH in randomized controlled trials on secondary prevention of patients with ICH is warranted.
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In this paper, the random packing fraction of hard disks in a plane is analyzed, following a geometric probabilistic approach. First, the random close packing (RCP) of equally sized disks is modelled. Subsequently, following the same methodology, a simple, statistical geometric model is proposed for the random loose packing (RLP) of monodisperse disks. This very basic derivation of RLP leads to a packing value (≈0.66) that is in very good agreement with values that have been obtained previously for 2D disk packings. The present geometrical model also enables a closed-form expression for the contact (coordination) number as a function of the packing density at different states of compaction. These predictions are thoroughly compared with empirical and simulation results, among others the Rényi parking model, yielding good agreement.
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INTRODUCTION: MR-tractography is increasingly used in neurosurgical practice to evaluate the anatomical relationships between glioma and nearby subcortical tracts. In some patients, the subcortical tracts seem displaced by the glioma, while in other patients, the subcortical tracts seem infiltrated without displacement. At this point, it is unknown whether these different patterns are related to tumor type. The aim of this exploratory study was to investigate whether tumor type is related to the spatial tractography pattern of the frontal aslant tract (FAT) in low-grade gliomas (LGGs). METHODS: In 64 IDH-mutated LGG patients, the FAT was generated using a pipeline for automatic tractography. In 41 patients, the glioma adjoined the FAT, and four blinded reviewers independently assessed the following two dichotomous categories (yes/no): (i) glioma displaces the tract, and (ii) glioma infiltrates the tract. RESULTS: Fisher's exact tests demonstrated strong and significant positive associations between displacement and astrocytomas (p = .002, φ = .497) and infiltration and oligodendrogliomas (p = .004, φ = .484). The interobserver agreement was good for both categories: (i) κ = 0.76 and (ii) κ = 0.71. CONCLUSION: High sensitivity but low specificity for displacement in astrocytomas demonstrates that in the case of an astrocytoma, the tract is most likely displaced, but that displacement in itself is not necessarily predictive for astrocytomas, as oligodendrogliomas may both infiltrate and displace a tract. Overall, these results demonstrate that oligodendrogliomas tend to infiltrate the nearby subcortical tract, whereas astrocytomas only tend to displace it.
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Astrocitoma , Neoplasias Encefálicas , Glioma , Oligodendroglioma , Humanos , Oligodendroglioma/diagnóstico por imagem , Oligodendroglioma/patologia , Neoplasias Encefálicas/patologia , Glioma/patologia , Astrocitoma/diagnóstico por imagem , Astrocitoma/patologiaRESUMO
Background and Purpose: The computed tomography angiography spot sign is associated with hematoma expansion, case fatality, and poor functional outcome in spontaneous supratentorial intracerebral hemorrhage (ICH). However, no data are available on the spot sign in spontaneous cerebellar ICH. Methods: We investigated consecutive patients with spontaneous cerebellar ICH at 3 academic hospitals between 2002 and 2017. We determined patient characteristics, hematoma expansion (>33% or 6 mL), rate of expansion, discharge and 90-day case fatality, and functional outcome. Poor functional outcome was defined as a modified Rankin Scale score of 4 to 6. Associations were tested using univariable and multivariable logistic regression. Results: Three hundred fifty-eight patients presented with cerebellar ICH, of whom 181 (51%) underwent a computed tomography angiography. Of these 181 patients, 121 (67%) were treated conservatively of which 15 (12%) had a spot sign. Patients with a spot sign treated conservatively presented with larger hematoma volumes (median [interquartile range]: 26 [741] versus 6 [213], P=0.001) and higher speed of expansion (median [interquartile range]: 15 [243] mL/h versus 1 [50] mL/h, P=0.034). In multivariable analysis, presence of the spot sign was independently associated with death at 90 days (odds ratio, 7.6 [95% CI, 1.688], P=0.037). With respect to surgically treated patients (n=60, [33%]), 14 (23%) patients who underwent hematoma evacuation had a spot sign. In these 60 patients, patients with a spot sign were older (73.5 [9.2] versus 66.6 [15.4], P=0.047) and more likely to be female (71% versus 37%, P=0.033). In a multivariable analysis, the spot sign was independently associated with death at 90 days (odds ratio, 2.1 [95% CI, 1.14.3], P=0.033). Conclusions: In patients with spontaneous cerebellar ICH treated conservatively, the spot sign is associated with speed of hematoma expansion, case fatality, and poor functional outcome. In surgically treated patients, the spot sign is associated with 90-day case fatality.
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Doenças Cerebelares/fisiopatologia , Hemorragia Cerebral/fisiopatologia , Angiografia por Tomografia Computadorizada , Hematoma/fisiopatologia , Idoso , Idoso de 80 Anos ou mais , Doenças Cerebelares/diagnóstico , Angiografia Cerebral/métodos , Hemorragia Cerebral/diagnóstico por imagem , Angiografia por Tomografia Computadorizada/métodos , Feminino , Hematoma/diagnóstico por imagem , Humanos , Modelos Logísticos , Masculino , Pessoa de Meia-Idade , Prognóstico , Tomografia Computadorizada por Raios X/métodosRESUMO
BACKGROUND: In patients with spontaneous cerebellar intracerebral hemorrhage (ICH) guidelines advocate evacuation when the hematoma diameter is > 3 cm. We studied outcome in patients with cerebellar ICH > 3 cm who did not undergo immediate hematoma evacuation. METHODS: We included consecutive patients with cerebellar ICH > 3 cm at two academic hospitals between 2008 and 2017. Patients who died < 24 h (h) were excluded because of probable confounding by indication. We determined patient characteristics, hematoma volumes, EVD placement, secondary hematoma evacuation, in-hospital and 3-month case-fatality, and functional outcome. RESULTS: Of 130 patients with cerebellar ICH, 98 (77%) had a hematoma > 3 cm of whom 22 (23%) died < 24 h and 28 (29%) underwent hematoma evacuation < 24 h. Thus, 48 patients were initially treated conservatively (mean age 70 ± 13, 24 (50%) female). Of these 48 patients, 7 (15%) underwent secondary hematoma evacuation > 24 h, of whom 1 (14%) had received an EVD < 24 h. Five others also received an EVD < 24 h without subsequent hematoma evacuation. Of the 41 patients without secondary hematoma evacuation, 11 (28%) died and 20 (51%) had a favorable outcome (mRS of 0-3) at 3 months. The 7 patients who underwent secondary hematoma evacuation had a decrease in GCS score of at least two points prior to surgery; two (29%) had deceased at 3 months; and 5 (71%) had a good functional outcome (mRS 0-3). CONCLUSIONS: While cerebellar ICH > 3 cm is often considered an indication for immediate hematoma evacuation, there may be a subgroup of patients in whom surgery can be safely deferred. Further data are needed to assess the optimal timing and indications of surgical treatment in these patients.
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Doenças Cerebelares , Hematoma , Doenças Cerebelares/complicações , Doenças Cerebelares/cirurgia , Cerebelo , Hemorragia Cerebral/complicações , Hemorragia Cerebral/cirurgia , Feminino , Hematoma/etiologia , Hematoma/cirurgia , Humanos , Resultado do TratamentoRESUMO
BACKGROUND AND OBJECTIVE: The aim of this study was to evaluate the impact of radiographic cerebral small vessel disease (CSVD) on the severity of acute intracerebral hemorrhage (ICH) as measured by: ICH volume, hematoma expansion, and extension of intraventricular hemorrhage (IVH). METHODS: CSVD was determined on baseline computed tomography (CT) scans of patients from the Ethnic and Racial Variations of Intracerebral Hemorrhage study through the extent of leukoaraiosis and cerebral atrophy using visual rating scales. The associations of leukoaraiosis and atrophy with ICH volume, hematoma expansion, IVH presence, and severity of IVH were tested using multivariable regression models. Secondary analyses were stratified by hemorrhage location. Bonferroni correction was applied to correct for multiple testing. RESULTS: A total of 2579 patients (mean age 61.7 years, 59% male) met inclusion criteria. Median ICH volume was 10.5 (Interquartile range [IQR] 4.0-25.3) mL. IVH was detected in 971 patients (38%). Neither leukoaraiosis nor atrophy was associated with hematoma expansion. Increasing grades of leukoaraiosis were associated with increased risk of IVH in a dose-dependent manner, while cerebral atrophy was inversely associated with IVH (both P for trend < 0.001). Increasing grades of global atrophy were dose-dependently associated with lower ICH volumes (ß (95% Confidence Interval [CI]) - 0.30[- 0.46, - 0.14], - 0.33[- 0.49, - 0.17], - 0.40[- 0.60, - 0.20], and - 0.54[- 0.76, - 0.32], for grades 1, 2, 3 and 4 compared to 0; all P < 0.001). The associations of leukoaraiosis with ICH volume were consistent with those of atrophy, albeit not meeting statistical significance. CONCLUSIONS: Leukoaraiosis and cerebral atrophy appear to have opposing associations with ICH severity. Cerebral atrophy correlates with smaller ICH volume and decreased risk and severity of IVH, while leukoaraiosis is associated with increased risk of IVH. Whether these observations reflect overlapping or divergent underlying mechanisms requires further study.
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Hemorragia Cerebral/diagnóstico por imagem , Hemorragia Cerebral Intraventricular/diagnóstico por imagem , Doenças de Pequenos Vasos Cerebrais/diagnóstico por imagem , Hematoma/diagnóstico por imagem , Leucoaraiose/diagnóstico por imagem , Idoso , Atrofia , Hemorragia Cerebral/epidemiologia , Hemorragia Cerebral Intraventricular/epidemiologia , Doenças de Pequenos Vasos Cerebrais/epidemiologia , Comorbidade , Progressão da Doença , Feminino , Hematoma/epidemiologia , Humanos , Leucoaraiose/epidemiologia , Masculino , Pessoa de Meia-Idade , Índice de Gravidade de DoençaRESUMO
This paper focuses on the functionalization of heterogeneous and highly contaminated waste material, namely bottom ashes (BA) with a particle size ≤ 125 µm that cannot be recycled with conventional treatments. The main goal of this study is to modify this waste into a valuable material that can be used in various applications, especially in the building sector. The complex mineralogical nature of this material was investigated with quantitative XRD, which confirms the presence of crystalline and amorphous phases such as silicates, carbonates, metallic oxides and amorphous glass. A hydrophobic modification was performed by using a fluorosilane grafting agent that utilizes the reactive surface sites of these minerals to form silanol bonds. Results showed that the 2.5% (m/m) of silane made the BA hydrophobic. Moreover, a thorough characterization showed that fluorosilane was well-grafted at the surface of the BA, with more than 60% of the fluorosilane chemisorbed on the surface. Additionally, the hydrophobic modification led to a significant decrease of the leaching of the contaminants (Cr, Cu, Mo and Sb) from the BA particles. Following this methodology, fine fraction of BA could be eventually used as a building material, preventing the landfill of this toxic waste.
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Cinza de Carvão , Incineração , Carbonatos , Materiais de Construção , Resíduos SólidosRESUMO
Background and Purpose- In this study, we aim to investigate the association of computed tomography-based markers of cerebral small vessel disease with functional outcome and recovery after intracerebral hemorrhage. Methods- Computed tomographic scans of patients in the ERICH study (Ethnic and Racial Variations of Intracerebral Hemorrhage) were evaluated for the extent of leukoaraiosis and cerebral atrophy using visual rating scales. Poor functional outcome was defined as a modified Rankin Scale (mRS) of ≥3. Multivariable logistic and linear regression models were used to explore the associations of cerebral small vessel disease imaging markers with poor functional outcome at discharge and, as a measure of recovery, change in mRS from discharge to 90 days poststroke. Results- After excluding in-hospital deaths, data from 2344 patients, 583 (24.9%) with good functional outcome (mRS of 0-2) at discharge and 1761 (75.1%) with poor functional outcome (mRS of 3-5) at discharge, were included. Increasing extent of leukoaraiosis (P for trend, 0.01) and only severe (grade 4) global atrophy (odds ratio, 2.02; 95% CI, 1.22-3.39, P=0.007) were independently associated with poor functional outcome at discharge. Mean (SD) mRS change from discharge to 90-day follow-up was 0.57 (1.18). Increasing extent of leukoaraiosis (P for trend, 0.002) and severe global atrophy (ß [SE], -0.23 [0.115]; P=0.045) were independently associated with less improvement in mRS from discharge to 90 days poststroke. Conclusions- In intracerebral hemorrhage survivors, the extent of cerebral small vessel disease at the time of intracerebral hemorrhage is associated with poor functional outcome at hospital discharge and impaired functional recovery from discharge to 90 days poststroke.
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Hemorragia Cerebral/complicações , Hemorragia Cerebral/patologia , Doenças de Pequenos Vasos Cerebrais/complicações , Adulto , Idoso , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Recuperação de Função Fisiológica , Estudos Retrospectivos , Acidente Vascular Cerebral/complicações , Acidente Vascular Cerebral/patologiaRESUMO
The challenge of sustainable use of MSWI residues such as fly ash is particularly acute. One of the possible uses of these residues in making secondary building materials. However, MSWI fly ash is highly contaminated with toxic elements such as Pb, Zn, Cd, Cu, etc. Its treatment to reduce the environmental impact is required before reuse or disposal. Here, the efficiency of a new three-step combined treatment with two complexing agents (ethylenediaminetetraacetate and gluconate) to increase the toxic-element elution from fly ash in contrast to conventional water-only treatments is shown. The compositions of raw and differently treated (reagent-combined and water-only treatments) MSWI fly ash were compared by macro- and microelemental, mineralogical, and microstructure analysis, in addition to the standard leaching test. The relevancy for such comprehensive analysis of MSWI fly ash prior and after treatments to minimize the environmental risks is shown. For Cd, Cu, and Zn, the combined treatment is proved to be 10-1000-fold more efficient than the water-only one. It was shown that the same WFA, which seems non-hazardous according to the leaching test after being washed with water, proves to be extremely hazardous when more properties are taken into account. Thus, it is relevant not only to study the leaching of WFA components and the factors affecting it, but also to pay detailed attention to amounts of elements remaining in the material after treatments.
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Metais Pesados , Eliminação de Resíduos , Carbono , Cinza de Carvão , Incineração , Material Particulado , Resíduos SólidosRESUMO
Coil migration following cerebral aneurysm treatment has been described and may result in stroke, recurrent aneurysm, or local mass effect. Cerebral coil embolization is also applied in arteriovenous malformations and arteriovenous fistulas, but these pathologies are relatively rare and coil migration is not as well described. Furthermore, these cases are more commonly treated with combinations of multiple modalities to achieve cure. Embolization, surgery, and radiation each have risks and benefits and combinations may have synergistic risks and benefits not seen in monotherapy. We report a case of extravascular and extra-corporeal coil migration after embolization and craniectomy to treat a patient with hemorrhage from an arteriovenous fistula.
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Embolização Terapêutica/efeitos adversos , Aneurisma Intracraniano/terapia , Falha de Prótese , Prótese Vascular/efeitos adversos , Humanos , Masculino , Pessoa de Meia-Idade , Couro Cabeludo/patologiaRESUMO
Despite numerous studies concerning the application of by-products in the construction field, municipal solid waste incineration (MSWI) residues are not widely used as secondary building materials. In some European countries, washing treatment to the full bottom ash (BA) fraction (0-32 mm) is applied, isolating more contaminated particles, smaller than 0.063 mm. Therefore, a MWSI sludge is produced, having a high moisture content, and thus a limited presence of soluble species. In order to enhance its performance as building material, here, dry mechanical activation is applied on MSWI sludge. Thereafter, a reactivity comparison between reference BA and untreated and treated MSWI sludge is provided, evaluating their behaviour in the presence of cement and their pozzolanic activity. Moreover, the mechanical performances, as 25% substitution of Portland cement (PC) are assessed, based on the EN 450. Mechanical activation enhances MSWI sludge physically due to the improved particle morphology and packing. Chemically, the hydration degree of PC is enhanced by the MSWI sludge by ≈25%. The milling treatment proved to be beneficial to the residues performances in the presence of PC, providing 32% higher strength than untreated sample. Environmentally, the compliance with the unshaped material legislation is successfully verified, according to the Soil Quality Decree.
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Materiais de Construção , Incineração , Resíduos Sólidos , Cinza de Carvão , Europa (Continente) , Eliminação de Resíduos , EsgotosRESUMO
Intracerebral hemorrhage (ICH) is the stroke subtype with the worst prognosis and has no established acute treatment. ICH is classified as lobar or nonlobar based on the location of ruptured blood vessels within the brain. These different locations also signal different underlying vascular pathologies. Heritability estimates indicate a substantial genetic contribution to risk of ICH in both locations. We report a genome-wide association study of this condition that meta-analyzed data from six studies that enrolled individuals of European ancestry. Case subjects were ascertained by neurologists blinded to genotype data and classified as lobar or nonlobar based on brain computed tomography. ICH-free control subjects were sampled from ambulatory clinics or random digit dialing. Replication of signals identified in the discovery cohort with p < 1 × 10(-6) was pursued in an independent multiethnic sample utilizing both direct and genome-wide genotyping. The discovery phase included a case cohort of 1,545 individuals (664 lobar and 881 nonlobar cases) and a control cohort of 1,481 individuals and identified two susceptibility loci: for lobar ICH, chromosomal region 12q21.1 (rs11179580, odds ratio [OR] = 1.56, p = 7.0 × 10(-8)); and for nonlobar ICH, chromosomal region 1q22 (rs2984613, OR = 1.44, p = 1.6 × 10(-8)). The replication included a case cohort of 1,681 individuals (484 lobar and 1,194 nonlobar cases) and a control cohort of 2,261 individuals and corroborated the association for 1q22 (p = 6.5 × 10(-4); meta-analysis p = 2.2 × 10(-10)) but not for 12q21.1 (p = 0.55; meta-analysis p = 2.6 × 10(-5)). These results demonstrate biological heterogeneity across ICH subtypes and highlight the importance of ascertaining ICH cases accordingly.
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Hemorragia Cerebral/genética , Cromossomos Humanos Par 1 , Predisposição Genética para Doença , Estudo de Associação Genômica Ampla , Estudos de Casos e Controles , Humanos , Locos de Características QuantitativasRESUMO
OBJECTIVE: To investigate the presence of inflammation and resolution pathways in osteoarthritis (OA). DESIGN: Tissues were obtained from knee OA patients and control rheumatoid arthritis (RA) patients. Cells in synovial fluid (SF) were visualized by flow cytometry. Cytokines and chemokines were measured by multiplex assay. Lipid mediators (LMs) were determined by targeted lipidomics using liquid-chromatography mass spectrometry. RESULTS: SF of OA patients contained less cells, especially neutrophils, less cytokines and comparable levels of chemokines compared to RA controls. Thirty-seven lipids were detected in the soluble fraction of SF, including polyunsaturated fatty acids (PUFAs) and their pro-inflammatory and pro-resolving lipoxygenase (LOX) and cyclooxygenase (COX) pathway markers in both OA and RA patients. Among these, pro-inflammatory LM such as prostaglandin E2 (PGE2) and thromboxane B2, as well as precursors and pathway markers of resolution such as 17-HDHA and 18-HEPE were detected. Interestingly, the pro-resolving lipid RvD2 could also be detected, but only in the insoluble fraction (cells and undigested matrix). Ratios of metabolites to their precursors indicated a lower activity of 5-LOX and 15-LOX in OA compared to RA, with no apparent differences in COX-derived products. Interestingly, synovial tissue and SF cells could produce 5-LOX and 15-LOX metabolites, indicating these cells as possible source of LM. CONCLUSIONS: By using a state-of-the-art technique, we show for the first time that resolution pathways are present in OA patients. A better understanding of these pathways could guide us to more effective therapeutic approaches to inhibit inflammation and further structural damage in OA and RA.
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Lipídeos/análise , Osteoartrite do Joelho/metabolismo , Líquido Sinovial/química , Estudos de Casos e Controles , Células Cultivadas , Quimiocinas/metabolismo , Citocinas/metabolismo , Humanos , Metabolismo dos Lipídeos/fisiologia , Líquido Sinovial/citologiaRESUMO
OBJECTIVE: In observational epidemiologic studies, higher plasma high-density lipoprotein cholesterol (HDL-C) has been associated with increased risk of intracerebral hemorrhage (ICH). DNA sequence variants that decrease cholesteryl ester transfer protein (CETP) gene activity increase plasma HDL-C; as such, medicines that inhibit CETP and raise HDL-C are in clinical development. Here, we test the hypothesis that CETP DNA sequence variants associated with higher HDL-C also increase risk for ICH. METHODS: We performed 2 candidate-gene analyses of CETP. First, we tested individual CETP variants in a discovery cohort of 1,149 ICH cases and 1,238 controls from 3 studies, followed by replication in 1,625 cases and 1,845 controls from 5 studies. Second, we constructed a genetic risk score comprised of 7 independent variants at the CETP locus and tested this score for association with HDL-C as well as ICH risk. RESULTS: Twelve variants within CETP demonstrated nominal association with ICH, with the strongest association at the rs173539 locus (odds ratio [OR] = 1.25, standard error [SE] = 0.06, p = 6.0 × 10-4 ) with no heterogeneity across studies (I2 = 0%). This association was replicated in patients of European ancestry (p = 0.03). A genetic score of CETP variants found to increase HDL-C by â¼2.85mg/dl in the Global Lipids Genetics Consortium was strongly associated with ICH risk (OR = 1.86, SE = 0.13, p = 1.39 × 10-6 ). INTERPRETATION: Genetic variants in CETP associated with increased HDL-C raise the risk of ICH. Given ongoing therapeutic development in CETP inhibition and other HDL-raising strategies, further exploration of potential adverse cerebrovascular outcomes may be warranted. Ann Neurol 2016;80:730-740.
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Hemorragia Cerebral/genética , Proteínas de Transferência de Ésteres de Colesterol/genética , Predisposição Genética para Doença/genética , Adulto , Idoso , HDL-Colesterol/sangue , HDL-Colesterol/genética , Feminino , Genótipo , Humanos , Masculino , Pessoa de Meia-Idade , Polimorfismo de Nucleotídeo ÚnicoRESUMO
The particle growth of silica below the isoelectric point plays a key role in oil well cements, production of silica gels and production of nanosilica by dissolving silicates. In this article, we study the particle growth of silica below the isoelectric point using olivine, a silicate mineral, and sodium silicate solutions as silica sources in acid, where the particle size, soluble silica concentration, specific surface area and gelling time were measured. The size of the primary particles detected by laser light scattering is 3 nm in the experiments with sodium silicate solutions. These particles grow then by aggregation forming linear chains which in time will start to branch. The particle growth follows a quadratic polynomial function and particles as large as 100 and 500 nm are detected in the final stages of experiments using sodium silica solutions and olivine, respectively. Based on these findings, a comprehensive model describing the silica particle development below the isoelectric point is proposed. This model gives fundamental information about the growth mechanism and the properties of silica (e.g., particle size of the primary particles, size of the aggregates) at the different growth stages.
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BACKGROUND AND PURPOSE: Noncontrast computed tomographic (CT) hypodensities have been shown to be associated with hematoma expansion in intracerebral hemorrhage (ICH), but their impact on functional outcome is yet to be determined. We evaluated whether baseline noncontrast CT hypodensities are associated with poor clinical outcome. METHODS: We performed a retrospective review of a prospectively collected cohort of consecutive patients with primary ICH presenting to a single academic medical center between 1994 and 2016. The presence of CT hypodensities was assessed by 2 independent raters on the baseline CT. Unfavorable outcome was defined as a modified Rankin score >3 at 90 days. The associations between CT hypodensities and unfavorable outcome were investigated using uni- and multivariable logistic regression models. RESULTS: During the study period, 1342 patients presented with ICH and 800 met restrictive inclusion criteria (baseline CT available for review, and 90-day outcome available). Three hundred and four (38%) patients showed hypodensities on CT, and 520 (65%) patients experienced unfavorable outcome. In univariate analysis, patients with unfavorable outcome were more likely to demonstrate hypodensities (48% versus 20%; P<0.0001). After adjustment for age, admission Glasgow coma scale, warfarin use, intraventricular hemorrhage, baseline ICH volume, and location, CT hypodensities were found to be independently associated with an increase in the odds of unfavorable outcome (odds ratio 1.70, 95% confidence interval [1.10-2.65]; P=0.018). CONCLUSIONS: The presence of noncontract CT hypodensities at baseline independently predicts poor outcome and comes as a useful and widely available addition to our ability to predict ICH patients' clinical evolution.
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Encéfalo/diagnóstico por imagem , Hemorragia Cerebral/diagnóstico por imagem , Idoso , Idoso de 80 Anos ou mais , Angiografia Cerebral , Feminino , Humanos , Processamento de Imagem Assistida por Computador , Masculino , Pessoa de Meia-Idade , Valor Preditivo dos Testes , Prognóstico , Estudos Retrospectivos , Tomografia Computadorizada por Raios XRESUMO
BACKGROUND AND PURPOSE: Hematoma expansion after acute intracerebral hemorrhage is common and is associated with early deterioration and poor clinical outcome. The computed tomographic angiography (CTA) spot sign is a promising predictor of expansion; however, frequency and predictive values are variable across studies, possibly because of differences in onset-to-CTA time. We performed a patient-level meta-analysis to define the relationship between onset-to-CTA time and frequency and predictive ability of the spot sign. METHODS: We completed a systematic review for studies of CTA spot sign and hematoma expansion. We subsequently pooled patient-level data on the frequency and predictive values for significant hematoma expansion according to 5 predefined categorized onset-to-CTA times. We calculated spot-sign frequency both as raw and frequency-adjusted rates. RESULTS: Among 2051 studies identified, 12 met our inclusion criteria. Baseline hematoma volume, spot-sign status, and time-to-CTA were available for 1176 patients, and 1039 patients had follow-up computed tomographies for hematoma expansion analysis. The overall spot sign frequency was 26%, decreasing from 39% within 2 hours of onset to 13% beyond 8 hours (P<0.001). There was a significant decrease in hematoma expansion in spot-positive patients as onset-to-CTA time increased (P=0.004), with positive predictive values decreasing from 53% to 33%. CONCLUSIONS: The frequency of the CTA spot sign is inversely related to intracerebral hemorrhage onset-to-CTA time. Furthermore, the positive predictive value of the spot sign for significant hematoma expansion decreases as time-to-CTA increases. Our results offer more precise risk stratification for patients with acute intracerebral hemorrhage and will help refine clinical prediction rules for intracerebral hemorrhage expansion.
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Angiografia Cerebral/tendências , Hemorragia Cerebral/diagnóstico por imagem , Progressão da Doença , Hematoma/diagnóstico por imagem , Tomografia Computadorizada por Raios X/tendências , Angiografia Cerebral/métodos , Hemorragia Cerebral/epidemiologia , Hematoma/epidemiologia , Humanos , Valor Preditivo dos Testes , Fatores de Tempo , Tomografia Computadorizada por Raios X/métodosRESUMO
BACKGROUND AND PURPOSE: In patients with intracerebral hemorrhage (ICH), it is not clear if hypernatremia is merely a marker of disease severity or if elevated sodium levels are harmful. We hypothesized that hypernatremia at hospital discharge in primary ICH patients would be associated with increased mortality following discharge. METHODS: We performed a two-center observational study of critically ill ICH patients in Boston. We studied 5100 patients, age ≥18 years, who were diagnosed with ICH (ICD-9 code 431), received medical or surgical critical care between 1997 and 2011 and survived hospitalization. The exposure of interest was serum sodium within 24 h of hospital discharge, categorized as Na ≤ 145 mmol/L and Na > 145 mmol/L. The primary outcome was 30-day post-discharge mortality. Odds ratios were estimated by logistic regression models adjusted for age, race, gender, Deyo-Charlson Index, patient type (medical versus surgical) and sepsis. RESULTS: In ICH patients who received critical care and survived hospitalization, the serum sodium at discharge was a predictor of post-discharge mortality. Patients with a discharge Na > 145 mmol/L have an OR for mortality in the 30 days following hospital discharge of 1.82 (95 %CI 1.38-2.38; P < 0.001) and an adjusted OR of 1.87 (95 %CI 1.40-2.48; P < 0.001) both relative to patients with a discharge Na ≤ 145 mmol/L. The adjusted model showed good discrimination AUC 0.77 (95 %CI 0.74-0.79) and calibration (Hosmer-Lemeshow χ (2) P = 0.68). CONCLUSIONS: In critically ill ICH patients who survive hospitalization, hypernatremia at the time of discharge is a robust predictor of post-discharge mortality.
Assuntos
Hemorragia Cerebral/sangue , Hemorragia Cerebral/mortalidade , Hipernatremia/sangue , Avaliação de Resultados em Cuidados de Saúde , Idoso , Idoso de 80 Anos ou mais , Hemorragia Cerebral/terapia , Cuidados Críticos , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Alta do PacienteRESUMO
BACKGROUND AND PURPOSE: The computed tomography angiography (CTA) spot sign is a validated predictor of hematoma expansion and poor outcome in supratentorial intracerebral hemorrhage (ICH), but patients with brainstem ICH have typically been excluded from the analyses. We investigated the frequency of spot sign and its relationship with hematoma expansion and outcome in patients with primary pontine hemorrhage (PPH). METHODS: We performed a retrospective analysis of PPH cases obtained from a prospectively collected cohort of consecutive ICH patients who underwent CTA. CTA first-pass readings for spot sign presence were analyzed by two trained readers. Baseline and follow-up hematoma volumes on non-contrast CT scans were assessed by semi-automated computer-assisted volumetric analysis. Sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), positive and negative likelihood ratio, and accuracy of spot sign for prediction of in-hospital mortality were calculated. RESULTS: 49 subjects met the inclusion criteria of whom 11 (22.4 %) showed a spot sign. In-hospital mortality was higher in spot sign-positive versus spot sign-negative subjects (90.9 vs 47.4 %, p = 0.020). Spot sign showed excellent specificity (95 %) and PPV (91 %) in predicting in-hospital mortality. Absolute hematoma growth, defined as parenchymal and intraventricular hematoma expansion of any amount, was significantly higher in spot sign-positive versus spot sign-negative subjects (13.72 ± 20.93 vs 3.76 ± 8.55 mL, p = 0.045). CONCLUSIONS: As with supratentorial ICH, the CTA spot sign is a common finding and is associated with higher risk of hematoma expansion and mortality in PPH. This marker may assist clinicians in prognostic stratification.
Assuntos
Angiografia por Tomografia Computadorizada/normas , Hematoma/diagnóstico por imagem , Hematoma/patologia , Mortalidade Hospitalar , Hemorragias Intracranianas/diagnóstico por imagem , Hemorragias Intracranianas/patologia , Ponte/diagnóstico por imagem , Ponte/patologia , Idoso , Estudos de Coortes , Angiografia por Tomografia Computadorizada/métodos , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Valor Preditivo dos Testes , Sensibilidade e EspecificidadeRESUMO
BACKGROUND AND PURPOSE: In primary intracerebral hemorrhage, the presence of contrast extravasation after computed tomographic angiography (CTA), termed the spot sign, predicts hematoma expansion and mortality. Because the biological underpinnings of the spot sign are not fully understood, we investigated whether the rate of contrast extravasation, which may reflect the rate of bleeding, predicts expansion and mortality beyond the simple presence of the spot sign. METHODS: Consecutive intracerebral hemorrhage patients with first-pass CTA followed by a 90-second delayed postcontrast CT (delayed CTA) were included. CTAs were reviewed for spot sign presence by 2 blinded readers. Spot sign volumes on first-pass and delayed CTA and intracerebral hemorrhage volumes were measured using semiautomated software. Extravasation rates were calculated and tested for association with hematoma expansion and mortality using uni- and multivariable logistic regressions. RESULTS: One hundred and sixty-two patients were included, 48 (30%) of whom had ≥1 spot sign. Median spot sign volume was 0.04 mL on first-pass CTA and 0.4 mL on delayed CTA. Median extravasation rate was 0.23 mL/min overall and 0.30 mL/min among expanders versus 0.07 mL/min in nonexpanders. Extravasation rates were also significantly higher in patients who died in hospital: 0.27 mL/min versus 0.04 mL/min. In multivariable analysis, the extravasation rate was independently associated with in-hospital mortality (odds ratio, 1.09 [95% confidence interval, 1.04-1.18], P=0.004), 90-day mortality (odds ratio, 1.15 [95% confidence interval, 1.08-1.27]; P=0.0004), and hematoma expansion (odds ratio, 1.03 [95% confidence interval, 1.01-1.08]; P=0.047). CONCLUSIONS: Contrast extravasation rate, or spot sign growth, further refines the ability to predict hematoma expansion and mortality. Our results support the hypothesis that the spot sign directly measures active bleeding in acute intracerebral hemorrhage.