Tiffany R Chang1, Natalie L Ullman2, Katelyn Smith2, Dheeraj Gandhi3, Daniel F Hanley2, Wendy C Ziai1
1 Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University, Baltimore, MD, USA
2 Division of Brain Injury Outcomes, Johns Hopkins University, Baltimore, MD, USA
3 Department of Radiology, University of Maryland, Baltimore, MD, USA
Spontaneous intracerebral hemorrhage (sICH) location is often considered singular although hemorrhages do not respect anatomic borders. We hypothesized that number of anatomic subregions involved in sICH decreases with time and is associated with long-term neurologic outcomes.
This was a post hoc exploratory analysis of computed tomography (CT) brain scans collected from three trials evaluating acute therapies for sICH (CLEAR IVH, ICES, MISTIE II). Anatomic subregions involved were recorded for CT images taken at ICH onset, 30 days, and 180 days. Defined subregions included lobar (frontal, parietal, temporal, occipital), basal ganglia (caudate, putamen, globus pallidus), internal capsule, and thalamus (anterolateral, posterolateral, medial, dorsal).
Of 170 patients, primary ICH location was identified as lobar in 42 (24.7%), basal ganglia in 106 (62.4%), and thalamus in 22 (12.4%). Number of anatomic subregions involved on both diagnostic CT and day 30 CT were significantly associated with day 30 poor outcome (mRS 4-6 vs. mRS 0-3) (diagnostic: 3.4±1.5 vs. 2.6±1.2, p=0.03)(day 30: 3.7±1.6 vs. 2.4±1.2, p=0.01). Greater number of regions at day 180 only was associated with poor outcome at day 180 (4.0±1.8 vs. 2.9±1.6; p=0.01). After adjustment for ICH score, number of regions remained significantly associated with poor outcome (day 30: p=0.003; day 180: p=0.05). Number of regions involved increased between diagnosis and day 30/day 180 CT in patients with poor outcomes and decreased in patients with good outcomes (day 30: increase of 0.5±1.4 vs. decrease of 0.2±0.9 regions, p=0.04; day 180: increase of 0.7±1.4 vs. 0.0±1.1 regions, p=0.04).
Number of anatomic subregions involved at days 30 and 180 are significantly associated with neurologic outcome independent of ICH score. Evolution of ICH lesions over time may play a role in recovery. Mechanism of this observed late increase in anatomic distribution represents a topic of further research.
Katelyn K. Smith1, Natalie L. Ullman1, Tiffany Chang2, Paul Vespa3, Neil A. Martin3, Dheeraj Gandhi4, Daniel F. Hanley1, Wendy Ziai2
1 Johns Hopkins Neurology, Division of Brain Injury Outcomes, Baltimore, MD, USA
2 Johns Hopkins Neurology, Neurosurgery and Anesthesiology/Critical Care Medicine, Baltimore, MD, USA
3 UCLA School of Medicine, Neurology and Neurosurgery, Los Angeles, CA, USA
4 University of Maryland, Neurology, Neurosurgery, Diagnostic Radiology & Nuclear Medicine, Baltimore, MD, USA
The long term resolution of spontaneous intercerebral hemorrhage (sICH) on neuroimaging has not been studied. We hypothesized that the volume of residual hypodensity following sICH is associated with original ICH volume and long term neurologic outcomes.
This was a post hoc exploratory analysis of computed tomography (CT) brain scans collected from three trials evaluating acute therapies for sICH (CLEAR IVH, ICES, MISTIE II). A computerized semi-automated volumetric analysis of CT images within 72 hours of ICH onset, at 30 days, and at 180 days was performed on acute ICH volume and the residual hypodensity (RH) in the absence of blood. RH volumes were compared with early ICH volumes and prospectively collected 30 and 180 day modified Rankin scores (mRS).
Of 129 patients with CT at 30 and/or 180 days, median diagnostic/72 hour ICH volumes decreased significantly from 30.6 (iqr33.2)/36.1 (28.7)cc to RH volumes of 7.7(9.9) and 9.0(13.0)cc at 30 and 180 days respectively. Diagnostic ICH volume was highly correlated with RH volume at 30 and 180 days (p5cc increase in RH volume between day 30 and 180.
Residual hypodense regions at 1 and 6 months post sICH are significantly smaller than initial hematoma size and may be associated with long term neurologic outcomes. Increase in RH volume over time may contribute to a poor recovery. The significance of these regions to hematoma formation and regression warrants further investigation.