Acute Intracerebral Hemorrhage: Who's at Risk for Expansion?

Mark J. Alberts, MD


March 07, 2014

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Hello. Welcome to this Medscape stroke update. My name is Dr. Mark Alberts, Vice Chair of Neurology at University of Texas-Southwestern in Dallas, Texas.

Today I would like to talk about a very interesting study published in JAMA Neurology[1] on December 23, 2013. This study, done by a group at Massachusetts General Hospital and Brigham and Women's Hospital in Boston, looked at the issue of hematoma expansion in patients with a primary intracerebral hemorrhage (ICH). Overall, this was a large study, with 817 patients in the initial cohort and 195 patients in a validation cohort after they had determined predictors of ICH expansion.

They found that expansion of ICH occurred in about 19% of patients. They were able to identify 4 clinical and radiologic factors that were highly predictive of ICH expansion. These included the use of warfarin, the time to obtaining a CT scan (earlier vs later was more predictive of ICH expansion), the volume of the ICH, and the presence of a spot sign on CT angiography. For this study, they defined expansion of the bleed as the bleed growing by 6 mL (33%) or more.

Using all of these factors, they developed a 9-point prediction scale for the ICH expanding. They found that if the score was 0, there was a 6% risk for the bleed expanding (which in and of itself is pretty high), but if the score went up to 7, the risk for the ICH expanding increased to 46%.

Besides the ICH expanding, they also looked at overall mortality, and again the score was highly predictive. A score of 1 led to an in-hospital mortality of 13%, whereas a score of 5 led to an in-hospital mortality of 34%.

This study had some limitations. Serial CT scans were not often done routinely on the basis of clinical needs of the patient. Another limitation is that obviously, patients with significant renal dysfunction did not undergo CT angiography because of concerns about dye toxicity.

Nonetheless, this was a large, well-done study with an internal validation cohort, and that validation cohort had a c-statistic of 0.77, meaning that it did a fairly good job of predicting the risk for occurrence of ICH expansion using the 4 parameters.

Because ICH expansion has very severe consequences, this could be another useful tool that will help us both in treating patients and in selecting patients for inclusion in trials aimed at reducing the risk for ICH expansion.

Thank you for joining me for this Medscape Stroke update.


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