Predicting Hematoma Expansion After Primary Intracerebral Hemorrhage

TLDR

Many clinical trials aim to limit hematoma expansion after acute intracerebral hemorrhage, yet identifying patients at highest risk remains difficult. The study sought to create a prediction score for hematoma expansion in patients with primary ICH. A prospective cohort of 817 patients (development) and 195 patients (validation) underwent baseline and follow‑up CT volumetric analysis, with expansion defined as >6 mL or 33% growth, and covariates were evaluated via univariate and multivariable logistic regression. The resulting 9‑point score, based on warfarin use, CT angiography spot sign, early CT timing, and baseline volume, achieved C‑statistics of 0.72 and 0.77 in development and validation cohorts, an odds ratio of 4.59 for high versus low scores, and demonstrated that expansion risk rises steadily with higher scores.

Abstract

Many clinical trials focus on restricting hematoma expansion following acute intracerebral hemorrhage (ICH), but selecting those patients at highest risk of hematoma expansion is challenging.To develop a prediction score for hematoma expansion in patients with primary ICH.Prospective cohort study at 2 urban academic medical centers among patients having primary ICH with available baseline and follow-up computed tomography for volumetric analysis (817 patients in the development cohort and 195 patients in the independent validation cohort).Hematoma expansion was assessed using semiautomated software and was defined as more than 6 mL or 33% growth. Covariates were tested for association with hematoma expansion using univariate and multivariable logistic regression. A 9-point prediction score was derived based on the regression estimates and was subsequently tested in the independent validation cohort.Hematoma expansion occurred in 156 patients (19.1%). In multivariable analysis, predictors of expansion were as follows: warfarin sodium use, the computed tomography angiography spot sign, and shorter time to computed tomography (≤ 6 vs >6 hours) (P < .001 for all), as well as baseline ICH volume (<30 [reference], 30-60 [P = .03], and >60 [P = .005] mL). The incidence of hematoma expansion steadily increased with higher scores. In the independent validation cohort (n = 195), our prediction score performed well and showed strong association with hematoma expansion (odds ratio, 4.59; P < .001 for a high vs low score). The C statistics for the score were 0.72 for the development cohort and 0.77 for the independent validation cohort.A 9-point prediction score for hematoma expansion was developed and independently validated. The results open a path for individualized treatment and trial design in ICH aimed at patients at highest risk of hematoma expansion with maximum potential for therapeutic benefit.