Severe Hematoma Expansion Worsens Outcome in Smaller Intracerebral Hemorrhages

Patients with intracerebral hemorrhage (ICH) have worse outcomes if the hematoma expands severely, but only if the baseline hematoma volume was less than 30 mL, according to study findings published in Neurology.

Previous studies have indicated the need for prevention and management of hematoma expansion. However, those reports often have not distinguished between absolute and relative expansion, have defined hematoma expansion in dichotomous terms, and have not examined whether baseline hematoma volume influences outcomes of hematoma expansion.

For the current study, researchers retrospectively analyzed 2163 patient cases from 8 participating sites in Italy, Germany, Canada, China, and the US. Patients were age 18 and older; had been diagnosed with primary, non-traumatic ICH via computed tomography at baseline; and had follow-up imaging up to 3 days after either symptom onset or time last seen well.

At 3-month follow-up, patients still living completed the modified Rankin Scale (mRS) to measure functional recovery. The data collectors were blind to study goals. Absolute (change in volume) and relative hematoma expansion (percent change in size) in these patients was defined across 4 categories, from none through severe (12.5 mL absolute expansion, or 66% relative expansion).

Three months after initial presentation, nearly 57% of patients had scores between 4 and 6 on the mRS, indicating poor outcomes. Severe absolute (18.3% vs 7.2%; P <.001) and relative (13.9% vs 6.5 %; P <.001) expansion were more common in patients who had poor outcomes than in those with more favorable outcomes; and conversely, greater expansion independently predicted poor outcome. For example, in patients with baseline hematoma volume <15 mL, severe relative (odds ratio [OR], 1.71; 95% CI, 1.07-2.74; P =.025) or absolute (OR, 4.10; 95% CI, 1.80-9.36; P =.001). This relationship held for medium-sized baseline hematomas as well, but not for hematomas larger than 30 mL at initial presentation. Mild or moderate hematoma expansion was not associated with worse outcomes.

“This observation shows the value of focusing on patients with small to moderate ICH size in future studies attempting to show clinical benefit and return to functional independence through reduction of HE [hematoma expansion], despite their overall lower risk of HE compared to larger bleedings,” the researchers wrote.

They also noted, “Further research is also needed to accurately predict severe HE, as most of the currently available prediction tools are based on a dichotomic definition of HE (commonly defined as > 6 mL and or > 33% growth) that does not take into account different degrees of HE severity.”

Limitations of the study included the fact that the results did not account for blood pressure changes during treatment, which could affect hematoma expansion. Also, some severely affected patients may have been excluded by study protocols; and the 90-day follow-up period might have been too brief to capture the full trajectory of patient recovery in hematoma expansion.

Disclosures: Several authors reported research support and consulting fees from pharmaceutical companies and other nongovernmental organizations.