American Heart Association

Monthly Archives: March 2015

Differential effect of baseline CTA Collaterals on Clinical Outcome in patients enrolled in the IMS-III trial

Rajbeer Singh Sangha MD

Menon BK, Qazi E, Nambiar V, Foster LD, Yeatts SD, Liebeskind D, et al. for the IMS III Investigators. Differential Effect of Baseline Computed Tomographic Angiography Collaterals on Clinical Outcome in Patients Enrolled in the Interventional Management of Stroke III Trial. Stroke. 2015

There has been increasing evidence that leptomeningeal collaterals play a significant role in determining outcomes during acute ischemic stroke. Collaterals maintain blood flow to the brain that would otherwise rapidly die during an acute ischemic stroke. Previously, collaterals were evaluated using catheter angiography or inferred using perfusion imaging. With the advent of non-invasive CT angiography, it has become possible to visualize collateral status in acute ischemic stroke patients. The authors of this study performed an interesting analysis in light of recent positive endovascular treatment trials like ESCAPE and applied CTA based collateral scoring to the IMS III cohort of patients.

Of the 656 patients who were enrolled in the IMS III study, 306 patients underwent baseline CTA. After exclusion, 185 patients who had intracranial M1 MCA +/- intracranial ICA occlusions were analyzed to ascertain collateral status using three separate scoring systems. Of the 185 patients analyzed, 126 patients were in the endovascular therapy arm and 59 patients were in the IV tPA arm. In multivariable modeling, the three collateral scores were each significant predictors of 90 day mRS 0-2 within their respective models (p-values <0.01 for all scores) while the effect of type of treatment (IV tPA alone vs. endovascular therapy) was not significant (all p values > 0.05). Analysis looking at secondary clinical outcomes included 90 day mrS 0-1 which showed statistically significant difference in rate of good clinical outcome between treatment types, favoring endovascular therapy, noted in patients with intermediate collateral status (p<0.05). 

Further analysis of the IMS-III cohort of patient’s show that collateral status influence outcomes and those with intermediate collaterals seem to benefit the most from endovascular therapy. With the ESCAPE trial, collateral status was used as an inclusion criteria (patients with poor collaterals being excluded from the trial) and outcomes improved significantly in the endovascular group vs the IV tPA group. MR-CLEAN which was a study that did not use collateral status as an inclusion criteria did not have as significant overall good outcomes as the other published endovascular trials. Possibly because they included patients with poor collaterals, who don’t benefit from either endovascular or IV tPA treatments as the infarct grows too rapidly for recanalization to have an effect. Had IMS-III recruited patients based on collateral status as in ESCAPE, we may have had a positive trial three years earlier. As we continue to understand the pathophysiological reasons for the success of the recent endovascular trials, we should continue to fine tune and further explore therapy to maximize our chance of success. Future studies that look at augmenting collaterals during acute ischemic stroke would not only improve the results of these therapies but early initiation of these therapies (in the ambulance) may have neuroprotective effects that should be explored.

By |March 30th, 2015|diagnosis and imaging|Comments Off on Differential effect of baseline CTA Collaterals on Clinical Outcome in patients enrolled in the IMS-III trial

The stress of it all: Examining the hemodynamics of AVMs before and after treatment

Mark L. McAllister, MD

Alaraj A, Shakur SF, Amin-Hanjani S, Mostafa H, Khan S, Aletich VA, et al. Changes in Wall Shear Stress of Cerebral Arteriovenous Malformation Feeder Arteries After Embolization and Surgery. Stroke. 2015

Cerebral AVMs are a concern to the stroke neurologist because of their propensity to present as an intracerebral hemorrhage. The connections of arteries directly to veins without the intervention of a high resistance capillary network alter normal cerebral hemodynamics. How the long term changes in vessel characteristics including vascular remodeling respond to the abnormal physics caused by AVMS is not fully understood.

Using quantitative magnetic resonance angiography (QMRA), Alaraj et al. estimated the wall shear stress (WSS), the force of blood against the cerebrovascular endothelium, in the patients with AVMs before and after treatment. In a cohort of 21 patients undergoing embolization of their AVM, the investigators demonstrated that the WSS was increased in the feeder arteries of the AVM compared to the normal contralateral vessel prior to the procedure. After embolization, the WSS fell to levels comparable to the contralateral vessels.

Additionally, in a subset of 17 patients who underwent resection of the AVM after embolization further reduction of the WSS was demonstrated. The mean WSS forces after surgical receptions demonstrated a trend to be lower than the mean on the contralateral normal vessel, but this did not achieve statistical significance.
Given that WSS has been implicated as a stimulus for vessel remodeling and vessel diameter, noninvasive measurement of WSS using QMRA may represent an intriguing method to monitor the efficacy of treatment for cerebral AVMs. Further, this study is important in that it is contrast to the only other study of WSS in AVMs which found identical WSS in the AVM feeders and normal contralateral vessels. The authors contend that their use of QMRA is more accurate than the TCD used in the 1995 study.

By |March 27th, 2015|pathogenesis|Comments Off on The stress of it all: Examining the hemodynamics of AVMs before and after treatment

Four Year Follow up of Transient Ischemic Attacks, Strokes and Mimics: A Retrospective TIA Clinic Cohort Study

Daniel Korya, MD

Frequently, patients who have transient neurologic symptoms are referred to the emergency department where they may receive further work-up. The usual TIA work-up may ensue after more precise questioning and examination are performed to rule out TIA mimics.

Several studies have been conducted to evaluate the prognosis and outcome of patients after TIA is diagnosed in the hospital or emergency department. The study by Dr. Dutta and colleagues is different because it aimed to determine the prognosis and outcome of patients who were evaluated for TIA at designated daily TIA clinics, based on the EXPRESS study model. 

Although the great majority of patients referred to TIA clinics by non-specialists end up being TIA mimics, there may be a difference in the way they are managed as compared with the ED or hospital. This may be due to the fact that several studies have shown that the TIA mimics are often the result of posterior circulation insufficiency, coronary events or dementia. Therefor a more specialized work-up may be necessary to distinguish these cases.

This study was conducted in the UK and derived data from the TIA clinics of Gloucestershire Royal Hospital (GRH) between April 2010 and May 2012. The majority of practitioners that referred to the GRH were EDs, GPs and paramedics. After a patient was referred to the TIA clinic, they would have their risk factors evaluated, a history and exam would be done along with same-day investigations of CT head, carotid duplex ultrasounds, EKGs as well serum studies. If patients needed MRIs, echocardiograms, Holter monitoring or angiograms, these were done subsequently as required. Patients received treatment the same day as well, with statins, anti-platelet agents or oral anti-coagulants (if AF was diagnosed).

The outcome measures were pre-defined as stroke, MI, any vascular event (TIA, stroke or MI) and all-cause mortality. These were assessed by reviewing hospital records electronically and not by direct patient contact. The investigators looked at subsequent hospital admissions, discharge summaries, outpatient referrals and death. There were no patients lost to follow up and statistical analysis was done by univariate comparison of the TIAs, stokes and mimics with the chi-squared and Kruskal-Wallis tests.

In all, there were 1067 patients that were included in the study who presented to the TIA clinic within the time period of April 2010 and May 2012. Of these patients, 337 were diagnosed with TIA, while 189 were actually strokes and 538 were mimics. The median follow-up period was for 34.9 months. At 90 days, 0.9% of TIAs had a stroke, 2.1% of patients with strokes had a subsequent stroke and 0.2% of mimics had suffered a stroke. Subsequent strokes occurred in 7.1% of patients with TIA, 10.9% of patients with stroke and 2.0% of mimics by the 50-month period of follow up.

Overall, the 90-day risk of subsequent stroke for patients receiving services at these daily TIA clinics was 1.3%. This rate is much lower than that demonstrated by prior studies conducted on TIA patients in the mid-2000s that ranged from 7.5%-9.4%. If these numbers are actually representative of reality, then they imply a reduction of stroke in TIA patients by over 80%!

Why was this number so low compared to historical rates? The investigators believed that this was due to the earlier and more focused treatment of stroke risk factors. These patients received their prescriptions in-hand after their evaluation and were quickly and appropriately assessed in these specialized clinics.

These results sound encouraging and are hinting toward the potential benefit of developing more daily TIA clinics. However, this study should be reproduced in a prospective manner with actual patient assessment and evaluation as opposed to a review of electronic medical records. At any rate, the dramatic reduction of subsequent stroke or MI after TIA as compared to historical controls is promising!
By |March 26th, 2015|prognosis|Comments Off on Four Year Follow up of Transient Ischemic Attacks, Strokes and Mimics: A Retrospective TIA Clinic Cohort Study

Cerebral blood flow and cerebral small vessel disease: the chicken and egg situation

Chirantan Banerjee, MD

van der Veen PH, Muller M, Vincken KL, Hendrikse J, Mali WPTM, van der Graaf Y, et al. Longitudinal Relation Between Cerebral Small-Vessel Disease And Cerebral Blood Flow: The SMART-MR Study. Stroke. 2015

Leukoaraiosis has been studied in several retrospective as well as prospective studies, and its importance cannot be denied. It has been associated not only with future ischemic (most commonly lacunar) strokes, but also intracerebral hemorrhage, as well as cognitive and gait outcomes. It is now well accepted as an important neuroimaging correlate of cerebral small vessel disease.

Several cross-sectional studies over the years found an association between white matter hyperintensities (WMHs)/lacunes and decreased cerebral blood flow (CBF), with several of them hypothesizing that decreased CBF leads to cerebral small vessel disease (CSVD). But the question remains, “Which came first, decreased CBF or CSVD?”

In Stroke, van der Veen et al. investigate the association between WMHs/lacunes and CBF longitudinally over four years of follow-up. Five hundred seventy-five out of 1309 patients with coronary artery disease, cerebrovascular disease, peripheral arterial disease, or an abdominal aortic aneurysm referred to their center in Netherlands were enrolled. Two blinded investigators adjudicated WMHs and lacunes on MRI at baseline and during follow-up. Phase contrast MR flow measurements were used to measure CBF/100ml. The authors carried out bidirectional analyses prospectively, testing associations of baseline CBF with progression of periventricular and deep WMH volume/lacunes over time, as well as baseline periventricular and deep WMH volume/lacunes with decline in pCBF over time. The models were adjusted for important confounders, including age, sex, HTn, DM, hyperlidemia etc., as well as non-lacunar infarcts. Interestingly, there was no association between baseline CBF and progression of WMHs/lacunes. However, baseline periventricular and deep WMHs, but not lacunes were associated with decline in CBF over time. The authors reflect that more WMHs (as opposed to lacunes) may lead to widespread decreased brain activity and impaired nitric oxide generation, thus requiring less CBF over time. The lack of association between baseline CBF and progression of WMH brings more questions than answers, and makes us wonder what other factors play a role in their pathogenesis. Cerebral autoregulation architecture, genetics, and amyloid are plausible contributors.

The authors do help us clarify the chicken and egg situation somewhat in this case, but the results generate more hypotheses than they solve. Further longitudinal or randomized studies are needed to help us better characterize the relationship between leukoaraiosis and CBF.

By |March 25th, 2015|diagnosis and imaging|Comments Off on Cerebral blood flow and cerebral small vessel disease: the chicken and egg situation

The PHASES score for prediction of intracranial aneurysm growth

The authors of this study make the argument that for most small aneurysms in the anterior circulation, the predicted risk of rupture is much smaller than the risk of treatment complications, and therefore many of these small aneurysms are left untreated. However, a small proportion of these aneurysms do rupture and because these aneurysms by far outnumber other aneurysms, most instances of aneurysmal subarachnoid hemorrhage come from small aneurysms in the anterior circulation. Thus, the need for a better risk prediction model is required. The PHASES score is a model that provides absolute risks of rupture for aneurysms based on six easily retrievable factors which include population, hypertension, age, size of aneurysm, earlier SAH from another aneurysm, site of aneurysm. The score was utilized in this study to see if it is a predictor of aneurysm growth.

The authors analyzed a multicenter cohort of patients with unruptured intracranial aneurysms and follow-up imaging with computed tomography angiography or magnetic resonance angiography. They included 557 patients with 734 unruptured aneurysms. Eighty-nine (12%) aneurysms in 87 patients showed growth during a median follow-up of 2.7 patient-years (range 0.5-10.8). Using this cohort, they performed univariable and multivariable Cox regression analyses for the predictors of the PHASES score at baseline, with aneurysm growth as outcome. Per point increase in PHASES score hazard ratio (HR) for aneurysm growth was 1.32 (95% CI: 1.22-1.43). With the lowest quartile of the PHASES score (0-1) as reference, HRs for the second [PHASES 2-3] 1.07 (95% CI: 0.49-2.32), the third [PHASES 4] 2.29 (95% CI: 1.05-4.95), and the fourth quartile [PHASES 5-14] 2.85 (95% CI: 1.43-5.67).
It was concluded that this study shows that the PHASES risk score, which provides 5-year absolute risks of aneurysmal rupture, can also be used to identify aneurysms with a high relative risk of aneurysm growth. Despite the strengths of the study, while the PHASES score can be utilized as another surrogate marker for identification of aneurysms that have a higher risk of growth and also an aneurysms risk for rupture, it should be utilized with caution. This score will require further confirmation of its validity before it is implemented on a larger scale as aneurysms should not needlessly be treated give the risks and complications associated with the procedure.
By |March 24th, 2015|prognosis|Comments Off on The PHASES score for prediction of intracranial aneurysm growth

The Times Are A-Changin’: Trends in Endovascular Therapy and Clinical Outcomes in the Nationwide Registry

Vikas Pandey, MD
Endovascular therapy has always been a promising and alluring option during acute ischemic strokes given the rather basic principle that if there is a clot in the cerebral vessels affecting perfusion to a region of the brain, manually removing this clot should prevent further ischemia and provide overall benefit to the patient. The harsh reality is that due to quantifiable factors such as time from symptom onset and to recanalization, variably interpreted factors such as amount of penumbra and early ischemic changes on CT, and as of yet unknown factors such as genetics, persistence and efficacy of collateral circulation and other reactions occurring at the biochemical level, the overall advantage of endovascular therapy has been difficult to ascertain. The publication of randomized trials in 2013 showing no added benefit of intra-arterial fibrinolysis called into question whether such therapy should be further supported by medical centers or reimbursed by third-party payers. However, recent trials such as MR CLEAN and ESCAPE have again shifted the landscape toward endovascular therapy and its benefit in lowering stroke disability and morbidity. 
To gain knowledge into how endovascular therapies have been utilized, and the clinical outcomes resulting from these procedures, the group from across the US and Canada set out to review the Get With The Guidelines Stroke data from 1087 hospitals from 2003 to 2013. The type of endovascular therapy has evolved over time from initially being more geared toward intra-arterial fibrinolysis and angioplasty/stenting to later on in the data set where techniques of mechanical clot and stent retrievers were used. The authors found that 454 hospitals (41.8%) provided endovascular therapy to at least one patient during the study period and that a total of 1.6% of all ischemic stroke patients received endovascular therapy. During the same period, 8.0% of all of the ischemic stroke patients received IV TPA alone without endovascular therapy. In general, there was an increase over time of the proportion of hospitals providing endovascular therapy from 2003 to 2012, with a drop in 2013. Along the same lines, the proportion of patients treated with endovascular therapy at hospitals providing this therapy increased from 0.7% to 2% from 2003 to 2012, with again a drop in 2013. Clinically, mortality was lower in hospitals that offered more endovascular therapy and there was a decrease over time of in-hospital mortality (29.6% in 2004 to 16.2% in 2013). There was also a decrease in symptomatic ICH and increase in independent ambulation over time. 
 The data shows that endovascular therapy has been trending toward decreased in-house mortality and improved patient outcome and this has been finally exemplified in the newer interventional trials. The slight drop in endovascular utilization in 2013 can be correlated to the publication of the negative interventional trials, but now that trial data has been published to the counterpoint, an expected upswing in utilization for centers that already have the means of endovascular therapy and a clamoring for biplane angiography suites and interventionalists is sure to follow. The question no longer is if endovascular therapy is beneficial, but rather for who is endovascular therapy the most beneficial and it is this process of patient selection on the basis of viable penumbra tissue, presence of good collateral circulation, and systems-based changes to ensure the fastest door to groin/recanalization times that will cement assessment for endovascular treatment as a necessity for every acute ischemic stroke that comes into the hospital.

Posted by Vikas Pandey (@DrVikasNeuro)
By |March 23rd, 2015|clinical|Comments Off on The Times Are A-Changin’: Trends in Endovascular Therapy and Clinical Outcomes in the Nationwide Registry

FIM Motor Score Predictive of Good Outcome in Rehab

Duy Le, MD
It is often stated that lack of proof is not proof itself. Such is the case of rehabilitation after stroke. While there is no clear prospective randomized trial showing that rehabilitation is beneficial, by and large, consensus is that it is beneficial for patients. We spend tremendous resources screening and triaging patients to see who would be good acute rehabilitation candidates. But the large looming question still remains: Who actually gets better, and what are predictors of good outcomes at rehab?  

While there is much research left to do regarding rehabilitation post stroke, it’s also quite an exciting venture because there is so much left to learn. Previous work done on rehab post stroke have identified comorbid conditions, demographic information, social status, vocational status, functional limitations and stroke subtype as being predictive factors in outcome after inpatient rehab. However these reports are limited by small sample size and single center reviews.

Brown et al. attempt to up the ante by evaluating the Uniform Data System for Medical Rehabilitation (UDSMR) which contains data collected from the Inpatient Rehabilitation Patient Assessment Instrument (IRF-PAI). They evaluate patients with a diagnosis of stroke from 2005 to 2007. Patients were included if they were older than 18 years of age and were admitted for rehabilitation from an acute care facility. Patients were excluded if they were not living at home prior to acute hospitalization, or had interruption of their rehab stay. 

This study finds that the admission Functional Independence Measurement (FIM) score is the best predictor of patients doing well post rehabilitation (i.e., being discharged home and having a higher change in FIM score from admission to discharge). The FIM score is broken into components; a motor and cognitive portion. It was found that the motor component has a high predictive value of good outcome. 

Weaknesses of this study stem from the inherent nature of a retrospective review. The bias of patient selection for acute rehab itself likely contributes to the outcome of this study. Take for example that the FIM motor component is more predictive of outcomes and that the cognitive portion is not as predictive. Most patients who are selected to attend acute rehab usually have good cognition with ability to participate. Thus, the patient spectrum of poor cognition was not truly evaluated for predictive outcome. Of note, prior reported predictors such as pre-existing medical condition and stroke related comorbid conditions did not substantially contribute poor outcome in this study. Nonetheless, this study still makes strides in the rehabilitation research due to the large sample size on which to draw conclusions. This is a good launching point and a strong data base to continue extrapolating more answers. Again, much work still needs to be done in the realm of research to see what factors influence good outcomes; as this will be crucial to optimize rehabilitation care.

Carotid Intima-Media Thickness and Cognitive Impairment in Older Adults

Rizwan Kalani, MD

The evidence linking atherosclerotic vascular risk factors and cognitive impairment continues to expand. Prior work has suggested that carotid intima-media thickness (CIMT) is a risk factor for cognitive decline, including in patients with Alzheimer’s disease. In this study, Moon et al. evaluated evaluated the association between cardiovascular risk factors–including CIMT–and future risk of mild cognitive impairment (MCI) or dementia in older people.

This was done as part of the KLoSHA study (Korean Longitudinal Study on Health and Aging), a population-based prospective cohort study. Three hundred forty-eight subjects, without pre-existing dementia, with available baseline cardiovascular risk factor data, were enrolled and completed a 5 year follow-up evaluation that included cognitive assessment. The mean age (± standard deviation) was 71.7 (± 6.3) years at time of enrollment and 51% were males. Korean versions of the following cognitive tests were completed: 1) consortium to establish a registry for Alzheimer’s disease clinical assessment battery; 2) mini international neuropsychiatric interview; 3) lexical fluency testing, and; 4) digit span. Education and mood were also assessed in these older adults. Cardiovascular risk factors (tobacco exposure, alcohol consumption, body mass index, waist circumference, blood pressure, plasma fasting glucose, plasma insulin, insulin resistance, vitamin B12, cholesterol, renal and hepatic function) were assessed. CIMT (as measured by ultrasound), carotid-femoral pulse wave velocity (PWV) index, and ankle-brachial index (ABI) were recorded.

At time of enrollment, 278 subjects were cognitively normal and 70 had MCI. After the study period, 56 progressed to MCI (50) or dementia (6); 225 of the original cognitively normal 278 individuals remained the same. At baseline, the progression group had higher age, shorter education period, and higher prevalence of hypertension. CIMT was greater in the progression group than in the non-progression group (0.81±0.11 vs 0.77±0.13mm, p=0.023); carotid artery plaque formation was also seen more frequently in the progression group (78.6% vs 63.7%, p=0.02). Other cardiovascular risk factors were not significantly different between the groups. Baseline CIMT was independently associated with development of MCI or dementia in multivariate logistic regression analyses (adjusting for age, education period, hypertension, cognitive parameters, and mood). It was also independently associated with development of MCI from normal cognition. CIMT was greater in cognitively normal subjects who developed MCI compared to those who remained normal at follow-up evaluation (0.82±0.11 vs 0.77±0.14mm, p=0.021). Similarly, carotid artery plaque formation was observed more frequently among those who developed MCI from a normal cognitive status compared to those who remained normal (80.0% vs 63.6%, p=0.026).

This study reaffirmed an association between baseline CIMT and carotid plaque formation with cognitive decline in older individuals. CIMT was superior in predicting clinically significant cognitive decline compared to other atherosclerotic markers (PWV, ABI) and cardiovascular risk factors. Major limitations of this report include the observational design, the fact that only a small number of individuals developed dementia in this study, and low follow-up rate from a significantly larger cohort that was originally enrolled. Future work should include longitudinal assessment of CIMT and cognition over time.

By |March 17th, 2015|diagnosis and imaging|Comments Off on Carotid Intima-Media Thickness and Cognitive Impairment in Older Adults

Antithrombotic Meta-Analysis

Ali Saad, MD

Every few years, a meta-analysis comes along to challenge the practice of the ever-controversial ideal antiplatelet regimen in secondary stroke prevention. This meta-analysis looked at 42,234 patients in 17 trials and echoes the current secondary stroke prevention guidelines from the AHA/ASA. Basically, you should definitely prescribe antiplatelets after a stroke (Class 1, Level A), any of the usual agents will do with no clear superiority of one over the other, and there is no evidence to support long term dual antiplatelet therapy. Cilostazol and dipyridamole + asa as monotherapy did outperform aspirin monotherapy for secondary stroke prevention of any type, but that was only in one trial in each case and the results haven’t been reproduced.


It’s worth noting that the AHA/ASA does provide a recommendation for dual antiplatelet under certain circumstances (Class IIb, Level B): ASA + clopidogrel first 21 days after a minor stroke or TIA based on the CHANCE trial. ASA + clopidogrel first 90 days after a minor stroke or TIA if referable to severe stenosis of a large intracranial artery (SAMPPRIS trial). Because it’s not standard of care, it’s up to the provider’s discretion and level of comfort with the evidence provided by these 2 trials. however, everyone seems to agree that long term dual antiplatelet is not indicated and has an increased risk of bleeding. several trials also looked at cilostazol, which may be an option in patients who have a genetic resistance to or don’t respond clinically to clopidogrel.
The advantage of using a meta-analysis is that it shows long-term dual antiplatelet is not a practice that should be instituted for all comers with lacunar stroke. Limitations of this trial, as with any meta-analysis, include not being able to compare individual agents across all endpoints, not having uniform criteria for defining a lacunar stroke, not knowing the status of the patient’s vessels, or compliance with certain meds (namely dipyridamole due to its notoriety for causing headaches). An important limitation is that “long-term” is not uniformly defined; it could be anywhere from weeks to years, and so this data cannot be used to refute the findings of CHANCE or SAMPPRIS.
How does this paper change my practice? It reinforces that there is no indication for long term antiplatelet use for secondary stroke prevention beyond 3 months and reminds me that cilostazol is an option in my armamentarium of antiplatelet drugs. Stay tuned for the results of the POINT study in 2017.

CT based measurements of peri-hematomal edema in intracerebral hemorrhage: Moving us one step closer

Michelle Christina Johansen, MD

Urday S, Beslow LA, Goldstein DW, Vashkevich A, Ayres AM, Battey TWK, et al. Measurement of Perihematomal Edema in Intracerebral Hemorrhage. Stroke. 2015

Intracerebral hemorrhage (ICH) remains a devastating diagnosis with high morbidity. Hematomal volume has been suggested as a major factor influencing patient functional outcome as has hyperglycemia, coagulation status and statin use. Growing interest has been focused on peri-hematomal edema (PHE) in intracerebral hemorrhage, believing it to be a different entity then the more familiar post ischemic stroke edema, in hopes of better understanding its clinical significance. A recent paper in Stroke looked at the natural history of peri-hematomal edema using MRI. They found that it increased most rapidly in the first 2 days after symptoms and peaked towards the end of the 2nd week, a different time course than edema ischemic stroke, but they were unable to draw any conclusions regarding impact on 3-month functional outcome. Subsequent studies provided conflicting results regarding the validity of changes seen on MRI in predicting true cerebral edema. If PHE is to be a target of further research, we must have a reliable imaging definition.

“Measurement of Peri-hematomal Edema in Intracerebral Hemorrhage” by Urday et al. introduces computed tomography (CT) technology to the discussion. Their study included 20 subjects >18yo with primary spontaneous supratentorial ICH confirmed by CT. 18 subjects with both CT and MRI performed in close association were also included. Two blinded independent raters then measured PHE on the 20 patient’s baseline and 24hr post ICH CT scans. Their measurements were reviewed by two stroke neurologists. In defining PHE, it had to be more hypodense than the same region in the contralateral hemisphere and more hypodense immediately around the hemorrhage area to rule out inclusion of other entities such as remote infarcts.


Intrarater/Interrater reliability was found to be excellent at both baseline and 24hr post ICH. There was one outlier that corresponded to a 118cc frontal lobe hemorrhage suggesting that PHE in large hemorrhages are more difficulty to approximate. PHE volumes in the 18 subjects with both CT and MRI imaging available also did not differ.

The possibility of using CT imaging to reliably approximate peri-hematomal edema moves us one step closer to developing effective treatment strategies. CT is quicker to obtain, more widely available and still more cost effective than MRI imaging. It is also the imaging method of choice when evaluating an acute bleed. Where do we go from here? Larger numbers are needed to confirm the investigator’s findings but perhaps this will open the door to more clinical trials targeting inflammation/edema in hopes of improving a once dismal outlook.

By |March 13th, 2015|diagnosis and imaging|Comments Off on CT based measurements of peri-hematomal edema in intracerebral hemorrhage: Moving us one step closer