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      Blend sign predicts poor outcome in patients with intracerebral hemorrhage

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          Abstract

          Introduction

          Blend sign has been recently described as a novel imaging marker that predicts hematoma expansion. The purpose of our study was to investigate the prognostic value of CT blend sign in patients with ICH.

          Objectives and methods

          Patients with intracerebral hemorrhage who underwent baseline CT scan within 6 hours were included. The presence of blend sign on admission nonenhanced CT was independently assessed by two readers. The functional outcome was assessed by using the modified Rankin Scale (mRS) at 90 days.

          Results

          Blend sign was identified in 40 of 238 (16.8%) patients on admission CT scan. The proportion of patients with a poor functional outcome was significantly higher in patients with blend sign than those without blend sign (75.0% versus 47.5%, P = 0.001). The multivariate logistic regression analysis demonstrated that age, intraventricular hemorrhage, admission GCS score, baseline hematoma volume and presence of blend sign on baseline CT independently predict poor functional outcome at 90 days. The CT blend sign independently predicts poor outcome in patients with ICH (odds ratio 3.61, 95% confidence interval [1.47–8.89];p = 0.005).

          Conclusions

          Early identification of blend sign is useful in prognostic stratification and may serve as a potential therapeutic target for prospective interventional studies.

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          Most cited references25

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          Recombinant activated factor VII for acute intracerebral hemorrhage.

          Intracerebral hemorrhage is the least treatable form of stroke and is associated with high mortality. Among patients who undergo computed tomography (CT) within three hours after the onset of intracerebral hemorrhage, one third have an increase in the volume of the hematoma related to subsequent bleeding. We sought to determine whether recombinant activated factor VII (rFVIIa) can reduce hematoma growth after intracerebral hemorrhage. We randomly assigned 399 patients with intracerebral hemorrhage diagnosed by CT within three hours after onset to receive placebo (96 patients) or 40 microg of rFVIIa per kilogram of body weight (108 patients), 80 microg per kilogram (92 patients), or 160 microg per kilogram (103 patients) within one hour after the baseline scan. The primary outcome measure was the percent change in the volume of the intracerebral hemorrhage at 24 hours. Clinical outcomes were assessed at 90 days. Hematoma volume increased more in the placebo group than in the rFVIIa groups. The mean increase was 29 percent in the placebo group, as compared with 16 percent, 14 percent, and 11 percent in the groups given 40 microg, 80 microg, and 160 microg of rFVIIa per kilogram, respectively (P=0.01 for the comparison of the three rFVIIa groups with the placebo group). Growth in the volume of intracerebral hemorrhage was reduced by 3.3 ml, 4.5 ml, and 5.8 ml in the three treatment groups, as compared with that in the placebo group (P=0.01). Sixty-nine percent of placebo-treated patients died or were severely disabled (as defined by a modified Rankin Scale score of 4 to 6), as compared with 55 percent, 49 percent, and 54 percent of the patients who were given 40, 80, and 160 microg of rFVIIa, respectively (P=0.004 for the comparison of the three rFVIIa groups with the placebo group). Mortality at 90 days was 29 percent for patients who received placebo, as compared with 18 percent in the three rFVIIa groups combined (P=0.02). Serious thromboembolic adverse events, mainly myocardial or cerebral infarction, occurred in 7 percent of rFVIIa-treated patients, as compared with 2 percent of those given placebo (P=0.12). Treatment with rFVIIa within four hours after the onset of intracerebral hemorrhage limits the growth of the hematoma, reduces mortality, and improves functional outcomes at 90 days, despite a small increase in the frequency of thromboembolic adverse events. Copyright 2005 Massachusetts Medical Society.
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            Early hemorrhage growth in patients with intracerebral hemorrhage.

            The goal of the present study was to prospectively determine how frequently early growth of intracerebral hemorrhage occurs and whether this early growth is related to early neurological deterioration. We performed a prospective observational study of patients with intracerebral hemorrhage within 3 hours of onset. Patients had a neurological evaluation and CT scan performed at baseline, 1 hour after baseline, and 20 hours after baseline. Substantial growth in the volume of parenchymal hemorrhage occurred in 26% of the 103 study patients between the baseline and 1-hour CT scans. An additional 12% of patients had substantial growth between the 1- and 20-hour CT scans. Hemorrhage growth between the baseline and 1-hour CT scans was significantly associated with clinical deterioration, as measured by the change between the baseline and 1-hour Glasgow Coma Scale and National Institutes of Health Stroke Scale scores. No baseline clinical or CT prediction of hemorrhage growth was identified. Substantial early hemorrhage growth in patients with intracerebral hemorrhage is common and is associated with neurological deterioration. Randomized treatment trials are needed to determine whether this early natural history of ongoing bleeding and frequent neurological deterioration can be improved.
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              Blend Sign on Computed Tomography: Novel and Reliable Predictor for Early Hematoma Growth in Patients With Intracerebral Hemorrhage.

              Early hematoma growth is not uncommon in patients with intracerebral hemorrhage and is an independent predictor of poor functional outcome. The purpose of our study was to report and validate the use of our newly identified computed tomographic (CT) blend sign in predicting early hematoma growth.
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                Author and article information

                Contributors
                Role: ConceptualizationRole: Data curationRole: Funding acquisitionRole: InvestigationRole: ResourcesRole: SupervisionRole: ValidationRole: VisualizationRole: Writing – original draftRole: Writing – review & editing
                Role: Data curationRole: Formal analysisRole: InvestigationRole: MethodologyRole: Validation
                Role: Data curationRole: Formal analysisRole: InvestigationRole: Validation
                Role: Data curationRole: Investigation
                Role: Data curation
                Role: Project administrationRole: Software
                Role: Data curationRole: InvestigationRole: Software
                Role: Software
                Role: Data curationRole: Investigation
                Role: Data curationRole: InvestigationRole: Validation
                Role: Data curationRole: Investigation
                Role: Data curationRole: Investigation
                Role: Project administration
                Role: ConceptualizationRole: MethodologyRole: Project administrationRole: ResourcesRole: SupervisionRole: Writing – review & editing
                Role: Editor
                Journal
                PLoS One
                PLoS ONE
                plos
                plosone
                PLoS ONE
                Public Library of Science (San Francisco, CA USA )
                1932-6203
                22 August 2017
                2017
                : 12
                : 8
                : e0183082
                Affiliations
                [1 ] Department of Neurology, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
                [2 ] Department of Neurology, Yongchuan Hospital of Chongqing Medical University, Chongqing, China
                [3 ] Department of Radiology, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
                [4 ] Department of Radiology, University-Town Hospital of Chongqing Medical University, Chongqing, China
                [5 ] Department of Neurology, Chongqing Jiulongpo People’s Hospital, Chongqing, China
                Universitatsklinikum Freiburg, GERMANY
                Author notes

                Competing Interests: The authors have declared that no competing interests exist.

                Author information
                http://orcid.org/0000-0002-9298-8348
                Article
                PONE-D-17-13210
                10.1371/journal.pone.0183082
                5568736
                28829797
                dfd8594e-a26e-4c25-ba75-fb8185d98874
                © 2017 Li et al

                This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

                History
                : 6 April 2017
                : 29 July 2017
                Page count
                Figures: 2, Tables: 3, Pages: 9
                Funding
                Funded by: This study was supported by a grant from the National Natural Science Foundation of China
                Award ID: 81200899
                Award Recipient :
                This study was supported by a grant from the National Natural Science Foundation of China (grant no. 81200899). Recipient: Qi Li.
                Categories
                Research Article
                Research and Analysis Methods
                Imaging Techniques
                Neuroimaging
                Computed Axial Tomography
                Biology and Life Sciences
                Neuroscience
                Neuroimaging
                Computed Axial Tomography
                Medicine and Health Sciences
                Diagnostic Medicine
                Diagnostic Radiology
                Tomography
                Computed Axial Tomography
                Research and Analysis Methods
                Imaging Techniques
                Diagnostic Radiology
                Tomography
                Computed Axial Tomography
                Medicine and Health Sciences
                Radiology and Imaging
                Diagnostic Radiology
                Tomography
                Computed Axial Tomography
                Medicine and Health Sciences
                Diagnostic Medicine
                Signs and Symptoms
                Hemorrhage
                Medicine and Health Sciences
                Pathology and Laboratory Medicine
                Signs and Symptoms
                Hemorrhage
                Medicine and Health Sciences
                Vascular Medicine
                Hemorrhage
                Medicine and Health Sciences
                Vascular Medicine
                Blood Pressure
                Research and Analysis Methods
                Mathematical and Statistical Techniques
                Statistical Methods
                Regression Analysis
                Physical Sciences
                Mathematics
                Statistics (Mathematics)
                Statistical Methods
                Regression Analysis
                Biology and Life Sciences
                Nutrition
                Diet
                Alcohol Consumption
                Medicine and Health Sciences
                Nutrition
                Diet
                Alcohol Consumption
                Medicine and Health Sciences
                Neurology
                Coma
                Medicine and Health Sciences
                Neurology
                Cerebrovascular Diseases
                Stroke
                Hemorrhagic Stroke
                Medicine and Health Sciences
                Vascular Medicine
                Stroke
                Hemorrhagic Stroke
                Biology and Life Sciences
                Anatomy
                Brain
                Basal Ganglia
                Medicine and Health Sciences
                Anatomy
                Brain
                Basal Ganglia
                Custom metadata
                Data are from the First Affiliated Hospital of Chongqing Medical University ICH study whose authors may be contacted at: Professor Qi Li, Department of Neurology, The First Affiliated Hospital of Chongqing Medical University, email: qili_md@ 123456yahoo.com . The Ethics Committee of the First Affiliated Hospital of Chongqing Medical University imposed restrictions on the raw data sharing policy to protect the privacy of the participants and access of the data requires permission from the Committee. Data requests could be sent after publication to Professor Peng Xie at peng_xie@ 123456yahoo.com . Interested researchers may also request access to the more detailed confidential data from Department of Research Administration at the First Affiliated Hospital of Chongqing Medical University. Tel: +86 23 89012558 email: 1259446388@ 123456qq.com

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