Prediction and prognostication of neurological deterioration in patients with acute ICH: a hospital-based cohort study

Ovesen, Christian; Christensen, Anders; Havsteen, Inger; Hansen, Christine Krarup; Rosenbaum, Sverre; Christensen, Hanne

doi:10.1136/bmjopen-2015-008563

Cited by 34 publications

(28 citation statements)

References 33 publications

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“…But we note that the PPV was reported in one of these studies 18 , and it consistent with our current findings. There have also been additional spot sign publications since our initial search strategy 39 . This was unavoidable due to the prolonged timelines required to acquire regulatory approvals necessary for access to patient-level data, particularly across national jurisdictions.…”

Section: Discussionmentioning

confidence: 99%

Predicting Intracerebral Hemorrhage Growth With the Spot Sign

Dowlatshahi

Brouwers

Demchuk

et al. 2016

Stroke

104

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Background and Purpose Hematoma expansion following acute intracerebral hemorrhage (ICH) is common and is associated with early deterioration and poor clinical outcome. The CT angiography (CTA) spot sign is a promising predictor of expansion, however frequency and predictive values are variable across studies, possibly due to 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 five pre-defined 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 CTs for hematoma expansion analysis. The overall spot sign frequency was 26%, decreasing from 39% within two hours of onset to 13% beyond eight 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 ICH 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 ICH, and will help refine clinical prediction rules for ICH expansion.

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Section: Discussionmentioning

confidence: 99%

Predicting Intracerebral Hemorrhage Growth With the Spot Sign

Dowlatshahi

Brouwers

Demchuk

et al. 2016

Stroke

104

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“…As only 4 studies focussed upon ICH in isolation, there is limited data about ICH-END incidence in relation to biomarkers, but amongst the 3 using a higher threshold, 12.2% deteriorated, comparable to ischaemic stroke. In cohort studies, END rates up to 30% have been reported following ICH [58], but differences are likely to reflect whether the clinical setting is a stroke unit without pre-selection or a specialist neurosurgical unit. Overall, incidence of END fell with advancing study publication year, independently of neurological threshold and time window.…”

Section: Discussionmentioning

confidence: 99%

“…These should include reports of standardised clinical and radiological data, such as the Alberta Stroke Program Early CT Score [66] for ischaemic stroke and haematoma volume for ICH [58]. Other novel biomarkers with a promising pathophysiological basis were considered by single studies, but have not been further developed.…”

Section: Recommendationsmentioning

confidence: 99%

A Systematic Review and Meta-Analysis of Molecular Biomarkers Associated with Early Neurological Deterioration Following Acute Stroke

Martin

Price

2018

Cerebrovasc Dis

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Background: Early neurological deterioration (END) following acute stroke is associated with poorer long-term outcomes. Identification of patients at risk could assist early monitoring and treatment decisions. This review summarised the evidence describing non-radiological biomarkers for END. Summary: Electronic searches from January 1990 to March 2017 identified studies reporting a blood/cerebrospinal fluid (CSF)/urine biomarker measurement within 24 h of acute stroke and at least 2 serial assessments of clinical neurological status (< 24 h and < 7 days). Out of 12,895 citations, 82 studies were included, mostly focusing on ischaemic stroke. Using higher neurological thresholds, the n-weighted END incidence for ischaemic stroke was 11.9% (95% CI 11.4–12.4%) and 18.6% (17.9–19.2%) for lower thresholds. Incidence decreased with advancing study publication year (Pearson r-squared 0.23 and 0.15 for higher and lower threshold studies). After classification into 3 broad categories, meta-analysis showed that biomarkers associated with increased END risk (n; fixed-effects mean difference; 95% CI) were “metabolic” (glucose [n = 9,481; 0.90 mmol/L; 0.74–1.06], glycosylated haemoglobin [n = 3,146; 0.33%; 0.19–0.46], low-density lipoprotein [n = 4,839; 0.13 mmol/L; 0.06–0.21], total cholesterol [n = 4,762; 0.21 mmol/L; 0.11–0.31], triglycerides [n = 4,820; 0.11 mmol/L; 0.06–0.17], urea [n = 1,351; 0.55 mmol/L; 0.14–0.96], decreasing albumin [n = 513; 0.33 g/dL; 0.05–0.61]); “inflammatory and excitotoxic” (plasma glutamate [n = 688; 60.13 µmol/L; 50.04–70.22], CSF glutamate [n = 369; 7.50 µmol/L; 6.76–8.23], homocysteine [n = 824; 2.15 µmol/L; 0.68–3.61], leucocytes [n = 3,766; 0.54 × 10⁹/L; 0.34–0.74], high-sensitivity C-reactive protein [n = 1,707; 3.79 mg/L; 1.23–6.35]); and “coagulation/haematological” (fibrinogen [n = 3,132; 0.32 g/L; 0.25–0.40]; decreasing haemoglobin [n = 3,586; 2.38 g/L; 0.15–4.60]). Key Messages: Declining incidence of END may represent improving care standards; however, it remains a frequent occurrence. Although statistical associations exist between biomarkers and an increased risk of END, the most promising still need prospective evaluation to determine their additional value relative to baseline radiological and clinical characteristics.

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“…[ 21 ] A retrospective cohort study in ICH patients suggested that relatively easy and effective risk stratification of early neurological deterioration is possible at admission based on the presence of a “spot sign” (suggestive of active hemorrhage) on the initial brain CTA imaging or extensive degree of intraventricular hemorrhage, whereas risk stratification of late neurological deterioration is possible based on specific clinical parameters assessed at admission such as degree of comorbidity (Charlson index), stroke severity, and/or degree of intraventricular hemorrhage. [ 22 ]…”

Section: Diagnosis and Management Of The Stroke Patients In Neurointementioning

confidence: 99%

Biomarkers for acute diagnosis and management of stroke in neurointensive care units

et al. 2016

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The effectiveness of current management of critically ill stroke patients depends on rapid assessment of the type of stroke, ischemic or hemorrhagic, and on a patient's general clinical status. Thrombolytic therapy with recombinant tissue plasminogen activator (r-tPA) is the only effective treatment for ischemic stroke approved by the Food and Drug Administration (FDA), whereas no treatment has been shown to be effective for hemorrhagic stroke. Furthermore, a narrow therapeutic window and fear of precipitating intracranial hemorrhage by administering r-tPA cause many clinicians to avoid using this treatment. Thus, rapid and objective assessments of stroke type at admission would increase the number of patients with ischemic stroke receiving r-tPA treatment and thereby, improve outcome for many additional stroke patients. Considerable literature suggests that brain-specific protein biomarkers of glial [i.e. S100 calcium-binding protein B (S100B), glial fibrillary acidic protein (GFAP)] and neuronal cells [e.g., ubiquitin C-terminal hydrolase-L1 (UCH-L1), neuron-specific enolase (NSE), αII-spectrin breakdown products SBDP120, SBDP145, and SBDP150, myelin basic protein (MBP), neurofilament light chain (NF-L), tau protein, visinin-like protein-1 (VLP 1), NR2 peptide] injury that could be detected in the cerebrospinal fluid (CSF) and peripheral blood might provide valuable and timely diagnostic information for stroke necessary to make prompt management and decisions, especially when the time of stroke onset cannot be determined. This information could include injury severity, prognosis of short-term and long-term outcomes, and discrimination of ischemic or hemorrhagic stroke. This chapter reviews the current status of the development of biomarker-based diagnosis of stroke and its potential application to improve stroke care.

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Prediction and prognostication of neurological deterioration in patients with acute ICH: a hospital-based cohort study

Cited by 34 publications

References 33 publications

Predicting Intracerebral Hemorrhage Growth With the Spot Sign

Predicting Intracerebral Hemorrhage Growth With the Spot Sign

A Systematic Review and Meta-Analysis of Molecular Biomarkers Associated with Early Neurological Deterioration Following Acute Stroke

Biomarkers for acute diagnosis and management of stroke in neurointensive care units

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