The frequency of imaging markers adjusted for time since symptom onset in intracerebral hemorrhage: A novel predictor for hematoma expansion

Abstract

Background: Hematoma expansion (HE) is common in patients with intracerebral hemorrhage (ICH), and associated with a worse outcome. Imaging makers and shorter time from symptom onset are both associated with HE, but prognostic scores based on these parameters individually have not been satisfactory. We hypothesized that a score including both imaging markers of expansion, and time of onset, would improve prediction. Methods: Patients with supratentorial ICH within 6 h after onset were consecutively recruited from six centers between January 2018 and August 2022. Three markers were used: hypodensities, the blend sign, and the island sign. We first defined FIM as the relationship between the number of imaging markers and OCT. The time adjusted frequency of imaging markers (FIM) was defined as the ratio of the number of imaging markers to the onset-to-initial imaging time. Multivariate analysis was performed to determine the relationship between FIM and HE. Receiver operating curve analysis was used to identify potential threshold values of FIM that optimally predict HE. In addition, the sensitivity, specificity, positive and negative predictive values (PPVs and NPVs), and the area under the curve (AUC) of the optimal cut-off in predicting HE were calculated. Results: In total, 1488 patients were eligible for inclusion, of whom 418 had incident HE. Multivariate analysis showed that age, male sex, baseline Glasgow Coma Scale score, presence of intraventricular hemorrhage, and FIM were independent predictors of HE (odds ratio [OR] = 0.98, 95% confidence interval [CI]: 0.97–0.99; OR = 1.73, 95% CI: 1.28–2.35; OR = 0.87, 95% CI: 0.83–0.92; OR = 0.42, 95% CI: 0.28–0.62; OR = 7.82, 95% CI: 5.86–10.42, respectively). The optimal cut-off point for FIM in predicting HE was 0.63, with sensitivity, specificity, PPV, NPV, and AUC values of 0.69, 0.89, 0.71, 0.88, and 0.83, respectively. Conclusions: The FIM adjusted for time since symptom onset is a significant predictor of HE. Its use may allow improved prediction of those patients with ICH who develop HE, and the score may be clinically applicable in the management of patients with ICH.

Is the frequency of imaging markers still a predictor for revised intracerebral hemorrhage expansion?

“…Surprisingly, the prediction performance did not significantly reduce based on the definition of RHE compared with the conventional definition of hematoma expansion (AUC = 0.80 vs. 0.83). 7 The findings of our study complement the influence of FIM on IVH growth and RHE, and facilitate stroke physicians identify individuals with a high-risk of hemorrhagic growth who may benefit from early intervention.…”

“…The search for imaging markers that could predict the risk of hemorrhagic growth after ICH has been a hot research topic, such as density and shape features on non-contrast CT. 16,17 Although attractive, the predictive performance of a single sign usually does not perform well. 17 A first proposal for FIM in 2023 was by Song et al, 7 which is defined as the ratio of imaging markers to onset-to-CT time. They found that the novel index positively predicts hematoma expansion, with a good performance when the optimal FIM cutoff value is 0.63.…”

“…According to our previous study, FIM was calculated as the ratio of the number of imaging markers to the onset-to-CT time. 7 Neuroimaging markers in the current analysis were hypodensities 8 (hypodense area completely encased within the hematoma without concern for its size, morphology, or density), blend sign 9 (hyperand hypo-attenuating regions of the hematoma with a density difference of ⩾18 Hounsfield Unit and an identifiable border), and island sign 10 (the presence of ⩾3 scattered or ⩾4 connected small hematomas around the main hematoma). Presence of one or more marker was defined as the presence of ⩾1 of the above-mentioned markers, as previously reported.…”

“…[4][5][6] Recently, an indicator termed the frequency of imaging markers (FIM) has been proposed for the prediction of hematoma expansion with better performance. 7 It is not clear whether the FIM can be used in predicting IVH growth or RHE. In this study, we aimed to confirm the links of FIM and IVH growth or RHE and further test their predictive performance.…”

Added Value of Frequency of Imaging Markers for Prediction of Outcome After Intracerebral Hemorrhage: A Secondary Analysis of Existing Data

“…The indicator of frequency of imaging markers (FIM), which is regarded as an independent predictor of HE, was rst proposed by Song et al in 2023 [7]. There is likely to be a link between FIM and functional neurological outcome in patients with ICH, but evidence is lacking.…”