Spontaneous intracerebral hemorrhage expansion

Hematoma expansion (HE) occurs in approximately one-third of patients with intracerebral hemorrhage (ICH) and is known to be a strong predictor of neurological deterioration as well as poor functional outcome.

The spot sign and the blend sign are reliable tools for predicting hematoma expansion in ICH patients.

Studies have revealed that hematoma growth mainly occurs during the first 6 h after the onset of spontaneous intracerebral hemorrhage (ICH).

Early achievement of target SBP < 160 mm Hg is associated with a lower risk of hematoma growth in ICH 1).

Poorly controlled diabetes and SBP greater than 200 mm Hg at admission portend a high risk of hematoma expansion 2).

Patient with prior Warfarin use and intraventricular hemorrhage (IVH) are at risk of hematoma expansion. Aggressive measures to prevent hematoma growth are important in these patients 3).

Iron overload plays a key role in secondary bleeding after ICH in Angiotensin II-induced hypertensive mice. Iron chelation during the process of Ang II-induced hypertension suppresses secondary bleeding after ICH 4)

Spontaneous intracerebral hemorrhage expansion occurs in about 30% of patients and is related to poor outcome 5).

Hematoma volume HV>16, hematoma heterogeneity HH, 1.5 h-systolic BP SBP>160) can be a practical tool for prediction of ICH growth in the acute stage. Further prospective studies are warranted to validate the ability of this model to predict clinical outcome 6).

Fluid levels, density heterogeneity, and margin irregularity on noncontrast CT are associated with hematoma expansion at 24 hours. These markers may assist in prediction of outcomes in scenarios where CT angiography is not readily available and may be of future help in refining the predictive value of the CT angiography spot sign 7).

Yamaguchi Y, Koga M, Sato S, Yamagami H, Todo K, Okuda S, Okada Y, Kimura K, Shiokawa Y, Kamiyama K, Itabashi R, Hasegawa Y, Kario K, Fujita K, Kumamoto M, Kamimura T, Ando D, Ide T, Yoshimoto T, Shiozawa M, Matsubara S, Yoshimura S, Nagatsuka K, Toyoda K; for the SAMURAI Study Investigators. Early Achievement of Blood Pressure Lowering and Hematoma Growth in Acute Intracerebral Hemorrhage: Stroke Acute Management with Urgent Risk-Factor Assessment and Improvement-Intracerebral Hemorrhage Study. Cerebrovasc Dis. 2018 Sep 10;46(3-4):116-122. doi: 10.1159/000492728. [Epub ahead of print] PubMed PMID: 30199854.
Kazui S, Naritomi H, Yamamoto H, et al. Enlargement of spontaneous intracerebral hemorrhage. Incidence and time course. Stroke. 1996;27(10):1783–1787.
Yaghi S, Dibu J, Achi E, Patel A, Samant R, Hinduja A. Hematoma expansion in spontaneous intracerebral hemorrhage: predictors and outcome. Int J Neurosci. 2014 Dec;124(12):890-3. doi: 10.3109/00207454.2014.887716. Epub 2014 Feb 28. PubMed PMID: 24472073.
Wang J, Tang XQ, Xia M, Li CC, Guo C, Ge HF, Yin Y, Wang B, Chen WX, Feng H. Iron chelation suppresses secondary bleeding after intracerebral hemorrhage in angiotensin II-infused mice. CNS Neurosci Ther. 2021 Aug 4. doi: 10.1111/cns.13706. Epub ahead of print. PMID: 34346561.
H.B. Brouwers, Y. Chang, G.J. Falcone, X. Cai, A.M. Ayres, T.W. Battey, A. Vashkevich, K.A. McNamara, V. Valant, K. Schwab, S.C. Orzell, L.M. Bresette, S.K. Feske, N.S. Rost, J.M. Romero, A. Viswanathan, S.H. Chou, S.M. Greenberg, J. Rosand, J.N. Goldstein, Predicting hematoma expansion after primary intracerebral hemorrhage, JAMA Neurol. 1 (2) (2014) 158–164.
Takeda R, Ogura T, Ooigawa H, Fushihara G, Yoshikawa S, Okada D, Araki R, Kurita H. A practical prediction model for early hematoma expansion in spontaneous deep ganglionic intracerebral hemorrhage. Clin Neurol Neurosurg. 2013 Jul;115(7):1028-31. doi: 10.1016/j.clineuro.2012.10.016. Epub 2012 Dec 14. PubMed PMID: 23245855.
Blacquiere D, Demchuk AM, Al-Hazzaa M, Deshpande A, Petrcich W, Aviv RI, Rodriguez-Luna D, Molina CA, Silva Blas Y, Dzialowski I, Czlonkowska A, Boulanger JM, Lum C, Gubitz G, Padma V, Roy J, Kase CS, Bhatia R, Hill MD, Dowlatshahi D; PREDICT/Sunnybrook ICH CTA Study Group. Intracerebral Hematoma Morphologic Appearance on Noncontrast Computed Tomography Predicts Significant Hematoma Expansion. Stroke. 2015 Nov;46(11):3111-6. doi: 10.1161/STROKEAHA.115.010566. Epub 2015 Oct 8. PubMed PMID: 26451019.
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