Quantitative imaging for predicting hematoma expansion in intracerebral hemorrhage: A multimodel comparison.

BACKGROUND: Several studies report that radiomics provides additional information for predicting hematoma expansion in intracerebral hemorrhage (ICH). However, the comparison of diagnostic performance of radiomics for predicting revised hematoma expansion (RHE) remains unclear. METHODS: The cohort comprised 312 consecutive patients with ICH. A total of 1106 radiomics features from seven categories were extracted using Python software. Support vector machines achieved the best performance in both the training and validation datasets. Clinical factors models were constructed to predict RHE. Receiver operating characteristic curve analysis was used to assess the abilities of non-contrast computed tomography (NCCT) signs, radiomics features, and combined models to predict RHE. RESULTS: We finally selected the top 21 features for predicting RHE. After univariate analysis, 4 clinical factors and 5 NCCT signs were selected for inclusion in the prediction models. In the training and validation dataset, radiomics features had a higher predictive value for RHE (AUC = 0.83) than a single NCCT sign and expansion-prone hematoma. The combined prediction model including radiomics features, clinical factors, and NCCT signs achieved higher predictive performances for RHE (AUC = 0.88) than other combined models. CONCLUSIONS: NCCT radiomics features have a good degree of discrimination for predicting RHE in ICH patients. Combined prediction models that include quantitative imaging significantly improve the prediction of RHE, which may assist in the risk stratification of ICH patients for anti-expansion treatments.

Corrigendum: New Prediction Models of Functional Outcome in Acute Intracerebral Hemorrhage: The dICH Score and uICH Score.

[This corrects the article DOI: 10.3389/fneur.2021.655800.].

Early Perihematomal Edema Expansion: Definition, Significance, and Association with Outcomes after Intracerebral Hemorrhage.

OBJECTIVE: To investigate the association between early perihematomal edema (PHE) expansion and functional outcome in patients with intracerebral hemorrhage (ICH). METHODS: Patients with ICH who underwent initial computed tomography (CT) scans within 6 hours after the onset of symptoms and follow-up CT scans within 24 ± 12 hours were included. Absolute PHE increase was defined as the absolute increase in PHE volume from baseline to 24 hours. A receiver-operating characteristic (ROC) curve was generated to determine the cutoff value for early PHE expansion, which was operationally defined as an absolute increase in PHE volume of >6 mL. The outcome of interest was 3-month poor outcome defined as modified Rankin scale score of ≥4. A multivariable logistic regression procedure was used to assess the association between early PHE expansion and outcome after ICH. RESULTS: In 233 patients with ICH, 89 (38.2%) patients had poor outcome at 3-month follow-up. Early PHE expansion was observed in 56 of 233 (24.0%) patients. Patients with early PHE expansion were more likely to have poor functional outcome than those without (43.8% vs. 11.8%, p < 0.001). After adjusting for age, admission systolic blood pressure, admission Glasgow Coma Scale score, baseline ICH volume and the presence of intraventricular hemorrhage, and time from onset to CT, early PHE expansion was associated with poor outcome (adjusted odds ratio, 4.25; 95% confidence interval, 1.70-10.60; p = 0.002). CONCLUSIONS: The early PHE expansion was not uncommon in patients with ICH and was correlated with poor outcome following ICH.

New Prediction Models of Functional Outcome in Acute Intracerebral Hemorrhage: The dICH Score and uICH Score.

Objectives: The original intracerebral hemorrhage (oICH) score is the severity score most commonly used in clinical intracerebral hemorrhage (ICH) research but may be influenced by hematoma expansion or intraventricular hemorrhage (IVH) growth in acute ICH. Here, we aimed to develop new clinical scores to improve the prediction of functional outcomes in patients with ICH. Methods: Patients admitted to the First Affiliated Hospital of Chongqing Medical University with primary ICH were prospectively enrolled in this study. Hematoma volume was measured using a semiautomated, computer-assisted technique. The dynamic ICH (dICH) score was developed by incorporating hematoma expansion and IVH growth into the oICH score. The ultra-early ICH (uICH) score was developed by adding the independent non-contrast CT markers to the oICH score. Receiver operating characteristic curve analysis was used to compare performance among the oICH score, dICH score, and uICH score. Results: This study included 76 patients (23.3%) with hematoma expansion and 61 patients (18.7%) with IVH growth. Of 31 patients with two or more non-contrast computed tomography markers, 61.3% died, and 96.8% had poor outcomes at 90 days. After adjustment for potential confounding variables, we found that age, baseline Glasgow Coma Scale score, presence of IVH on initial CT, baseline ICH volume, infratentorial hemorrhage, hematoma expansion, IVH growth, blend sign, black hole sign, and island sign could independently predict poor outcomes in multivariate analysis. In comparison with the oICH score, the dICH score and uICH score exhibited better performance in the prediction of poor functional outcomes. Conclusions: The dICH score and uICH score were useful clinical assessment tools that could be used for risk stratification concerning functional outcomes and provide guidance in clinical decision-making in acute ICH.

Noncontrast Computed Tomography Markers as Predictors of Revised Hematoma Expansion in Acute Intracerebral Hemorrhage.

Background Noncontrast computed tomography (NCCT) markers are the emerging predictors of hematoma expansion in intracerebral hemorrhage. However, the relationship between NCCT markers and the dynamic change of hematoma in parenchymal tissues and the ventricular system remains unclear. Methods and Results We included 314 consecutive patients with intracerebral hemorrhage admitted to our hospital from July 2011 to May 2017. The intracerebral hemorrhage volumes and intraventricular hemorrhage (IVH) volumes were measured using a semiautomated, computer-assisted technique. Revised hematoma expansion (RHE) was defined by incorporating the original definition of hematoma expansion into IVH growth. Receiver operating characteristic curve analysis was used to compare the performance of the NCCT markers in predicting the IVH growth and RHE. Of 314 patients in our study, 61 (19.4%) had IVH growth and 93 (23.9%) had RHE. After adjustment for potential confounding variables, blend sign, black hole sign, island sign, and expansion-prone hematoma could independently predict IVH growth and RHE in the multivariate logistic regression analysis. Expansion-prone hematoma had a higher predictive performance of RHE than any single marker. The diagnostic accuracy of RHE in predicting poor prognosis was significantly higher than that of hematoma expansion. Conclusions The NCCT markers are independently associated with IVH growth and RHE. Furthermore, the expansion-prone hematoma has a higher predictive accuracy for prediction of RHE and poor outcome than any single NCCT marker. These findings may assist in risk stratification of NCCT signs for predicting active bleeding.

Hydrocephalus Growth: Definition, Prevalence, Association with Poor Outcome in Acute Intracerebral Hemorrhage.

BACKGROUND/OBJECTIVES: To propose a novel definition for hydrocephalus growth and to further describe the association between hydrocephalus growth and poor outcome among patients with intracerebral hemorrhage (ICH). METHODS: We analyzed consecutive patients who presented within 6 h after ICH ictus between July 2011 and June 2017. Follow-up CT scans were performed within 36 h after initial CT scans. The degree of hydrocephalus were evaluated by the hydrocephalus score of Diringer et al. The optimal increase of the hydrocephalus scores between initial and follow-up CT scan was estimated to define hydrocephalus growth. Poor long-term outcome was defined as a modified Rankin Scale of 4-6 at 3 months. Multivariate logistic regression analysis was performed to investigate the hydrocephalus growth for predicting 30-day mortality, 90-day mortality, and poor long-term outcome. RESULTS: A total of 321 patients with ICH were included in the study. Of 64 patients with hydrocephalus growth, 34 (53.1%) patients presented with both concurrent hematoma expansion and intraventricular hemorrhage (IVH) growth. After adjusting for potential confounding factors, hydrocephalus growth independently predicted 30-day mortality, 90-day mortality, and 90-day poor long-term outcome in multivariate logistic regression analysis. Hydrocephalus growth showed higher accuracy for predicting 30-day mortality, 90-day mortality, and poor long-term outcome than IVH growth or hematoma expansion, respectively. CONCLUSIONS: Hydrocephalus growth is defined by strongly predictive of short- or long-term mortality and poor outcome at 90 days, and might be a potential indicator for assisting clinicians for clinical decision-making.

The slice score: A novel scale measuring intraventricular hemorrhage severity and predicting poor outcome following intracerebral hemorrhage.

OBJECTIVES: To quantify extent of intraventricular hemorrhage (IVH) following intracerebral hemorrhage (ICH) with a novel, simple IVH severity score, and to explore and compare its performance in predicting worse outcomes. PATIENTS AND METHODS: A new scoring system for IVH severity was proposed and termed Slice score. The Slice score features non-septum pellucidum section, internal capsule section, third ventricle occipital horn section, three standardized scans for scoring the lateral ventricles. 652 scans from 326 subjects were retrospectively analyzed. The correlations between measured IVH volume and Slice score, original Graeb, LeRoux, and IVH score (IVHS) were compared. The association between these scores and clinical outcomes were evaluated using logistic regression. We then identified clinical thresholds of Slice score by balancing the probability of prediction and accuracy. Primary outcome was defined as 90-day poor outcome (modified Rankin Scale score ≥ 4) and secondary outcome was 90-day mortality. RESULTS: Of 326 ICH patients, 122 (37.4%) had poor outcome and 59 (18.1%) died at 3 months. The Slice score showed the highest correlation with measured IVH volume (R = 0.73, R2 = 0.54, p < 0.001). The observed area under the curve were similar among the Slice, original Graeb, LeRoux score, and IVH score for poor outcome (0.633, 0.633, 0.632, 0.634, respectively), and for mortality (0.660, 0.660, 0.660, 0.656, respectively). All IVH scales were independently associated with 90-day poor outcome and mortality with close odds ratio in adjusted models (all odds ratio > 1.07, all p < 0.05). Multivariable Analyses of categorized Slice score revealed optimal thresholds of 6 and 12 for primary and secondary outcomes (odds ratio 4.20, 95% confidence interval 1.82-10.02, p = 0.001; odds ratio 5.41, 95% confidence interval 1.66-17.43, p = 0.005, respectively). CONCLUSIONS: The Slice score correlated highly with the IVH volume, was a reliable volumetric scale for measuring IVH severity, and could be an easy-to-use tool for predicting 90-day poor outcome and mortality in ICH.

Combination of ultra-early hematoma growth and blend sign for predicting hematoma expansion and functional outcome.

OBJECTIVE: Ultra-early hematoma growth (uHG) in acute intracerebral hemorrhage (ICH) has been well established and can improve spot sign in the prediction of hematoma expansion (HE) and poor outcome. This study aimed to investigate whether uHG can improve blend sign as a promising combining marker to stratify HE and poor outcome. PATIENTS AND METHODS: A consecutive cohort study in patients with primary ICH conducted in the First Affiliated Hospital of Chongqing Medical University. Demographic characteristics, medical history, clinical features and radiological characteristics were recorded. Univariate analysis and multivariate logistic regression analyses were used to identify independently risk factors of HE and poor outcome. ß coefficient was calculated for combining markers using the logistic regression. Receiver operating characteristic (ROC) curves were fitted to calculate predictive values for each variable and combining markers to stratify HE and poor outcome. RESULTS: Among 257 ICH patients in the study, there were 85 (33.1 %) patients with HE. Blend sign and uHG were independently associated with HE and poor outcome (P < 0.05). Age, admission GCS score, presence of IVH at baseline CT were also independently associated with poor outcome (P < 0.05). Combining marker including uHG and blend sign had the best AUC (0.846, 0.80-0.90), sensitivity (87.1 %), NPV (91.0 %), and -LR (0.2) than single variable to stratify HE. Combining marker including uHG, blend sign and risk clinical factors had the best AUC (0.800, 0.75-0.85), sensitivity (75.6 %), NPV (73.2 %), -LR (0.33) than single variable and the ICH score to stratify poor outcome. ICH score had the highest PPV (80.3 %) and + LR (3.68) to stratify poor outcome than other variables. CONCLUSION: The combination of both uHG and blend sign could be a simple and useful tool for better stratification of HE and poor outcome.

Benign Intracerebral Hemorrhage: A Population at Low Risk for Hematoma Growth and Poor Outcome.

Background To define benign intracerebral hemorrhage ( ICH ) and to investigate the association between benign ICH , hematoma expansion, and functional outcome. Methods and Results We analyzed a prospectively collected cohort of patients with ICH, who presented within 6 hours of symptom onset between July 2011 and February 2017 to a tertiary teaching hospital. Follow-up computed tomographic scanning was performed within 36 hours after initial computed tomographic scanning. Benign ICH was operationally defined as homogeneous and regularly shaped small ICH . The presence of benign ICH was judged by 2 independent reviewers (Q.L., W.Y.) on the basis of the admission computed tomographic scan. Functional independence was defined as a modified Rankin Scale score of 0 to 2 at 3 months. The associations between benign ICH , hematoma expansion, and functional outcome were assessed by using multivariable logistic regression analyses. A total of 288 patients with ICH were included. Benign ICH was found in 48 patients (16.7%). None of the patients with benign ICH had early hematoma expansion. The sensitivity, specificity, positive predictive value, negative predictive value, and accuracy of benign ICH for predicting functional independence at 3 months were 30.7%, 96.6%, 90.0%, 60.0%, and 0.637, respectively. Conclusions Patients with benign ICH are at low risk of hematoma expansion and poor outcome. These patients may be safe for less intensive monitoring and are unlikely to benefit from therapies aimed at preventing ICH expansion.

Comparison of Satellite Sign and Island Sign in Predicting Hematoma Growth and Poor Outcome in Patients with Primary Intracerebral Hemorrhage.

OBJECTIVE: Satellite sign (SS) and island sign (IS) are novel noncontrast computed tomography (CT) predictors of hematoma growth. The aim of this study was to compare diagnostic performance of IS and SS in predicting hematoma growth and functional outcome in patients with intracerebral hemorrhage (ICH). METHODS: The study included patients with ICH who underwent baseline CT scan within 6 hours of symptom onset and follow-up CT scan within 36 hours after initial CT between July 2012 and April 2017. Sensitivity, specificity, positive predictive value, and negative predictive value of IS and SS in predicting hematoma growth and functional outcome were assessed. Accuracy of the 2 signs in predicting hematoma growth and functional outcome was analyzed using receiver operating characteristic analysis. Association between the presence of IS and SS and ICH growth was assessed using multivariate logistic regression. RESULTS: Of 307 patients with ICH, IS was observed in 46 patients (15.0%), and SS was observed in 151 patients (49.2%). Rates of hematoma growth were 40.4% in SS+ patients, 91.3% in IS+ patients, 18.4% in SS-IS- patients, 21.1% in SS+IS- patients, 100% in SS-IS+ patients, and 90.5% in SS+IS+ patients. After adjusting for potential confounders, IS remained an independent predictor for hematoma growth and poor functional outcome. The area under the curve of IS was significantly larger than the area under the curve of SS in predicting hematoma growth (P = 0.001). CONCLUSIONS: IS seems to be an optimal shape irregularity imaging marker for predicting hematoma growth and functional outcome in patients with ICH.

Expansion-Prone Hematoma: Defining a Population at High Risk of Hematoma Growth and Poor Outcome.

BACKGROUND: Noncontrast computed tomography (CT) markers are increasingly used for predicting hematoma expansion. The aim of our study was to investigate the predictive value of expansion-prone hematoma in predicting hematoma expansion and outcome in patients with intracerebral hemorrhage (ICH). METHODS: Between July 2011 and January 2017, ICH patients who underwent baseline CT scan within 6 h of symptoms onset and follow-up CT scan were recruited into the study. Expansion-prone hematoma was defined as the presence of one or more of the following imaging markers: blend sign, black hole sign, or island sign. The diagnostic performance of blend sign, black hole sign, island sign, and expansion-prone hematoma in predicting hematoma expansion was assessed. Predictors of hematoma growth and poor outcome were analyzed using multivariable logistical regression analysis. RESULTS: A total of 282 patients were included in our final analysis. Of 88 patients with early hematoma growth, 69 (78.4%) had expansion-prone hematoma. Expansion-prone hematoma had a higher sensitivity and accuracy for predicting hematoma expansion and poor outcome when compared with any single imaging marker. After adjustment for potential confounders, expansion-prone hematoma independently predicted hematoma expansion (OR 28.33; 95% CI 12.95-61.98) and poor outcome (OR 5.67; 95% CI 2.82-11.40) in multivariable logistic model. CONCLUSION: Expansion-prone hematoma seems to be a better predictor than any single noncontrast CT marker for predicting hematoma expansion and poor outcome. Considering the high risk of hematoma expansion in these patients, expansion-prone hematoma may be a potential therapeutic target for anti-expansion treatment in future clinical studies.