Predicting hematoma growth in spontaneous intracerebral hemorrhage: A simplified non-contrast computed tomography based five-point grading approach

Abstract

BACKGROUND

Intracerebral hemorrhage (ICH) comprises 9%-27% of stroke patients. Hematoma expansion (HE) occurs in approximately 20% of patients following ICH, typically within the first 24 hours. HE increases mortality and long-term disability in these patients and is being investigated as a therapeutic target to improve the outcome in these patients by limiting HE. Non-contrast computed tomography (NCCT) has potential in predicting HE, which can identify the individuals at risk.

AIM

To evaluate NCCT markers for predicting HE in patients with ICH and to develop a simple, practical grading system for risk stratification.

METHODS

This prospective observational study evaluated 192 patients with spontaneous ICH who underwent a baseline NCCT within four hours of admission, followed by a follow-up scan after six hours or earlier if there was clinical deterioration. Hematoma volumes and imaging characteristics that predicted HE were evaluated. A simple five-point grading system score was created to predict HE. In this scoring system, five imaging parameters were evaluated, with each parameter assigned a score of either 0 or 1. The parameters included: (1) Baseline hematoma volume ≥ 30 mL vs < 30 mL; (2) Presence or absence of intraventricular hemorrhage; (3) Presence or absence of the island sign; (4) Presence or absence of the black hole sign; and (5) Presence or absence of the swirl sign.

RESULTS

Of the 192 patients studied, HE was seen in 106 (55.2%). The mean baseline hematoma volume was significantly greater among patients in the HE group (44.1 mL) compared to those in the non-HE group (12.2 mL), with a P-value < 0.05. Additionally, imaging biomarkers such as the island sign, swirl sign, and black hole sign were observed with significantly higher frequency in the HE group relative to the non-HE cohort (all P-values < 0.05). The island sign was strongly associated with HE [odds ratio (OR) 13.7; 95% confidence interval (CI): 10.15-16.37; P < 0.001]. Similarly, the black hole sign (OR 9.4; 95%CI: 7.4-11.62; P < 0.001) and the swirl sign (OR 5.2; 95%CI: 3.72-6.53; P < 0.001) emerged as significant predictors of HE. Initial hematoma volume ≥ 30 mL also showed a significant association (OR 1.9; 95%CI: 1.41-2.74; P = 0.039). A five-point predictive scoring model demonstrated a strong positive association between increasing scores and the probability of HE. Specifically, the likelihood of HE corresponding to scores of 0, 1, 2, 3, 4, and 5 was 7.4%, 37.5%, 75%, 85%, 93.3%, and 100%, respectively.

CONCLUSION

The five variables demonstrated statistically significant associations with HE. This simple and practical 5-point prediction score can enable identification of patients at elevated risk of HE based on baseline NCCT findings. This can facilitate timely recognition of high-risk individuals who may benefit from targeted anti-expansion therapy.

Keywords: Spontaneous intracerebral hemorrhage; Hematoma expansion; Non-contrast computed tomography predictors; Swirl sign; Island sign; Black hole sign

Core Tip: Hematoma expansion (HE) in spontaneous intracerebral hemorrhage (ICH) is a major predictor of short-term mortality and long-term morbidity. Early identification of patients at risk for HE allows timely initiation of targeted anti-expansion therapies to limit hematoma growth. In this study, we evaluated non-contrast computed tomography (NCCT) markers for predicting HE after ICH and developed a simple five-point predictive scoring system. This score, based solely on NCCT findings, is practical, easy to use, and particularly valuable in resource-limited settings for guiding the management of these patients.