Hematoma Expansion in Intracerebral Hemorrhage: Who are the Super-expanders?
Tiffany Eatz1, Sebastian Koch2, Berje Shammassian3, Lili Zhou4, Nicole Sur2, Gillian Gordon-Perue2, Amedeo Merenda5, Ayham Alkhachroum6
1Neurology, Neuroendovascular Surgery, University of Miami Miller School of Medicine, 2University of Miami, 3LSUHSC - New Orleans/University Medical Center, 4University of Miami Miller School of Medicine, 5Univeristy of Miami Miller School of Medicine, 6Columbia University Medical Center
Objective:
We aimed to identify a group of patients most at risk for severe expansion of acute intracerebral hemorrhage (ICH), who we labeled as "super-expanders."
Background:
While some studies have shown that ICH expansion correlates with poor outcomes, characteristics of patients with severe hematoma expansion have not been definitively characterized. Super-expanders are a group of ICH patients most likely to benefit from aggressive intervention to prevent deterioration.
Design/Methods:
We retrospectively reviewed baseline clinical and radiological features in consecutive ICH patients admitted over a three-year period to a comprehensive stroke center. Hematoma expansion was defined conventionally as a > 33% increase in hematoma volume or a > 6ml increase in absolute hematoma volume between the baseline and 24-hour follow-up brain CT. Severe hematoma expansion was defined as a > 50% increase in ICH volume associated with a decrease in the Glasgow Coma Scale of at least four points. We used Random Forest (RF) to generate importance plots searching for the determinants of super-expanders in ICH. In addition, a multivariable logistic regression model was done to examine independent factors associated with super-expanders.
Results:
Hematoma expansion occurred in 97 of the analyzed 417 (23%) patients, of which 15 (4%) were deemed super-expanders. Per univariate analysis, super-expanders were more likely to have lobar hemorrhage, spot sign, and increased in-hospital mortality. Using RF analysis the following were identified as important determinants of super-expansion: age, platelet count, and presence of a spot sign. Per multivariable model, only spot sign was an independent predictor for super-expansion [age (OR = 1.43, CI=0.61, 3.37), spot sign (OR = 6.25, CI=2.30-17.00), lobar location (OR = 4.63, CI= 0.92-23.42)].
Conclusions:
We found a low incidence of 4% of severe hematoma expansion in ICH. Super-expanders were not definitively differentiated via the clinical/radiological characteristics examined. We encourage future studies focused on illuminating effective early identification of super-expanders.
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