Karissa C Arthur, MD

Kuohn LR, Witsch J, Steiner T, Sheth KN, Kamel H, Navi BB, Merkler AE, Murthy SB, Mayer SA. Early Deterioration, Hematoma Expansion, and Outcomes in Deep Versus Lobar Intracerebral Hemorrhage: The FAST Trial. Stroke. 2022.

Intracranial hemorrhage (ICH) accounts for more than two-thirds of mortality from all stroke subtypes. ICH can be deep or lobar, and it is unclear if these subtypes differ in complications such as hematoma expansion (HE) or early neurologic deterioration (END). It is important to identify these differences as it may lead to different monitoring and treatment approaches. The authors hypothesized that HE and poor functional outcomes would occur more frequently in deep ICH, and END would be more common in patients with lobar hemorrhage.

The authors performed a secondary analysis using data from the FAST trial (Factor VII for Acute Hemorrhagic Stroke), a large, randomized trial with serial neuroimaging and blind volume measurements to assess for differences in HE, END, and functional outcomes between deep and lobar ICH. There were several exclusion criteria of the FAST trial, including GCS of 5 or less, known anticoagulant use or coagulopathy, known thrombotic disease within 30 days, and several others. CT imaging was done within 3 hours of symptom onset, at 24 hours, and 72 hours, and was evaluated by two individual blinded neuroradiologists. HE included hematoma expansion > 33% or 6 mL from baseline in 24 hours. END was defined as GCS decrease by 2 points or increase in NIHSS by at least 4 within 24 hours. Modified Rankin Scale (mRS) was used to assess functional outcome.

Graphic abstract

A total of 728 patients were included in the analysis, of which 623 had deep ICH and 105 lobar. Patients with lobar hemorrhage were more likely to be older, and patients with deep ICH were more likely to have a history of hypertension. Baseline lobar hemorrhages were significantly larger than deep hemorrhages. HE occurred more frequently in lobar ICH (44%) compared with deep (27%) [p<0.001]. END was also more common in patients with lobar ICH (31%) when compared to deep ICH (17%) [p<0.001]. Baseline ICH volume, lower baseline GCS score, and HE were also associated with END. Lobar ICH location was associated with overall worse 90-day functional outcome (OR, 1.56 [95% CI, 1.08–2.27]; P=0.02), as were ICH score, baseline GCS, ICH volume at 24 hours, and IVH volume at 24 hours. When ICH score and IVH volume at 24 hours were adjusted for, the relationship reversed and lobar ICH was inversely associated with poor functional outcome (OR, 0.58 [95% CI, 0.38–0.89]; P=0.01).

The results of this study show that HE and END occurred more frequently in lobar hemorrhages. Overall, patients with lobar hemorrhage also experienced worse functional outcomes; however, when adjusted for ICH score and IVH volume at 24 hours, the relationship reversed. The results suggest that the outcomes of patients with lobar hemorrhage admitted in an early window are driven by larger hemorrhage volume and frequency of HE. Early interventions may be especially important in these patients.