Density and Shape as CT Predictors of Intracerebral Hemorrhage Growth

Abstract

Background and Purpose-Intracerebral hemorrhage (ICH) growth predicts mortality and functional outcome. We hypothesized that irregular hematoma shape and density heterogeneity, reflecting active, multifocal bleeding or a variable bleeding time course, would predict ICH growth. Methods-Three raters examined baseline sub-3-hour CT brain scans of 90 patients in the placebo arm of a Phase IIb trial of recombinant activated Factor VII in ICH. Each rater, blinded to growth data, independently applied novel 5-point categorical scales of density and shape to randomly presented baseline CT images of ICH. Density and shape were defined as either homogeneous/regular (Category 1 to 2) or heterogeneous/irregular (Category 3 to 5). Within-and between-rater reliability was determined for these scales. Growth was assessed as a continuous variable and using 3 binary definitions: (1) any ICH growth; (2) Ն33% or Ն12.5 mL ICH growth; and (3) radial growth Ͼ1 mm between baseline and 24-hour CT scan. Patients were divided into tertiles of baseline ICH volume: "small" (0 to 10 mL), "medium" (10 to 25 mL), and "large" (25 to 106 mL). Results-Inter-and intrarater agreements for the novel scales exceeded 85% (Ϯ1 category). Median growth was significantly higher in the large-volume group compared with the small group (PϽ0.001) and in heterogeneous compared with homogeneous ICH (Pϭ0.008). Median growth trended higher in irregular ICHs compared with regular ICHs (Pϭ0.084). Small ICHs were more regularly shaped (43%) than medium (17%) and large (3%) ICHs (PϽ0.001). Small ICHs were more homogeneous (73%) compared with medium (37%) and large (17%) ICHs (PϽ0.001). Adjusting for baseline ICH volume and time to scan, density heterogeneity, but not shape irregularity, independently predicted ICH growth (Pϭ0.046) on a continuous growth scale. Conclusions-LargeICHs were significantly more irregular in shape, heterogeneous in density, and had greater growth.Density heterogeneity independently predicted ICH growth using some definitions. Key Words: density Ⅲ growth Ⅲ intracerebral hemorrhage Ⅲ recombinant activated factor VII Ⅲ predictors Ⅲ shape I ntracerebral hemorrhage (ICH) is the most sinister stroke subtype with a high early mortality. 1,2 Despite this, there is convincing evidence that aggressive care can bring about meaningful recovery, even in the worst initial prognostic groups. 3,4 CT scanning remains the standard diagnostic technique for ICH. Hematoma growth occurs in Ͼ70% of patients on CT performed within 3 hours of symptom onset and independently predicts mortality and functional outcome. 5 Hemostatic therapy has been demonstrated to attenuate ICH growth in 2 pivotal studies of recombinant activated Factor VII administered within 4 hours of symptom onset. 6,7 In contrast, the clinical outcomes in these trials were discordant and the positive results were not replicated in the second, larger trial. 6,7 Attenuated hematoma growth has also been suggested in an acute blood pressure reduction trial. 8 Hence, hematoma growth is a key therapeu...

Quantitative CT Densitometry for Predicting Intracerebral Hemorrhage Growth

“…The current results expand on previous findings regarding qualitative density heterogeneity 14 and show that significant prognostic information is available from qCTD of NCCT. The strengths of this study include the use of a high-quality CT dataset and scans obtained within 3 hours of symptom onset, the time most likely to demonstrate ICH growth.…”

“…26 The dynamic expansion of ICH was recognized in the pre-CT era, 27 and subsequently, by using CT, was shown to be maximal in the first few hours following symptom onset. 28 A primary hemorrhagic insult to the brain occurs at ictus with fresh, hypoattenuated liquid blood rapidly clotting to appear hyperattenuated on CT. 29 Larger bleeds have been shown to be more heterogeneous in attenuation at baseline CT. 14 Kim et al 11 found that a low-attenuation "swirl sign" within hematomas on noncontrast CT was associated with increased mortality on univariate but not multivariate analysis. Secondary neural damage is then brought about by edema and blood-breakdown products.…”

“…14 We therefore set out to create new predictive models of hematoma growth on the basis of noncontrast CT, by using CT densitometry, and compared a variety of models with existing predictors, BV and TTS. We hypothesized that qCTD would enhance the prediction of hematoma growth and would be able to do so rapidly and with minimal operator intervention.…”

Black Hole Sign

“…In a study of 90 patients, Barras et al 17 found that large hematomas were more heterogeneous in density and more likely to expand than small hematomas. The authors concluded that density heterogeneity independently predicted hematoma growth in patients with ICH.…”

Glyceryl Trinitrate for Acute Intracerebral Hemorrhage

“…for the presence of hemorrhage, its location in the brain, the presence and amount of mass effect, the presence of blood in the subarachnoid space or ventricles, and underlying changes in the brain, including cerebral atrophy, 16 leukoaraiosis, 16 and the presence of old lesions. Hematoma volume (measured manually by ABC/2 formula 17 using Osirix software 18 on a 26-inch Apple iMac), shape and density (using an ordered 5-point categorical scale), 19 shape index (perimeter of hematoma/4π×area), 20 density index (SD/mean attenuation), 21 and the presence of blood in the subarachnoid space or ventricles using the Graeb score, and its modified version 22,23 were also measured. All imaging assessments were performed by K.K.…”