David Rodriguez-Luna

Plasmatic retinol-binding protein 4 and glial fibrillary acidic protein as biomarkers to differentiate ischemic stroke and intracerebral hemorrhage

A rapid differentiation of acute ischemic stroke and intracerebral hemorrhage (ICH) is essential for an adequate treatment and to promote a better outcome. Our aim was to identify new plasma biomarkers to differentiate stroke subtypes and to combine their diagnostic ability with other biomarkers already described for this clinical indication.

Small intracerebral hemorrhages have a low spot sign prevalence and are less likely to expand

Background Hematoma expansion is a major predictor of morbidity and mortality after intracerebral hemorrhage (ICH). Both baseline hematoma volume and the CT-angiogram (CTA) spot sign predict hematoma expansion. Because the CTA spot sign may represent foci of active hemorrhage, we hypothesized that patients with smaller baseline hematoma volumes are less likely to be spot sign positive, and therefore less likely to expand. Aim We sought to validate our prior finding that small hematomas are unlikely to expand, and to determine the relationship between baseline hematoma volume, spot sign status, and risk of hematoma expansion. Methods Data were from the prospective PREDICT ICH study. Patients presenting within 6 h of symptom onset with completed baseline CT, CTA, and follow-up CT were included. Baseline hematoma volume was categorized a priori (<3 mL, 3–10 mL, 10–20 mL, >20 mL). The primary outcome was significant hematoma expansion (≥6 mL, ≥12.5 mL or ≥33%) and secondary outcomes were early neurological worsening, good clinical outcome (modified Rankin Scale 0–3), and mortality at 90 days. Results Among 315 patients meeting the inclusion criteria, baseline hematoma volume category predicted absolute hematoma expansion (p < 0.001), spot sign prevalence (p < 0.001), early neurologic worsening (p = 0.002), clinical outcome (p < 0.001), and mortality (p < 0.001). Very small hematomas (<3 mL) were unlikely to be spot positive (7.7%), unlikely to expand (2.6%), and were associated with a 73% chance of good clinical outcome. Spot sign appeared to be most predictive of expansion in the 3–10 mL baseline hematoma volume category. Conclusion Very small hematomas are unlikely to expand and have a low spot sign prevalence. Hemostatic therapy trials may be best targeted at hemorrhages >3 mL in volume.

Prehospital Systolic Blood Pressure Is Related to Intracerebral Hemorrhage Volume on Admission

Background and Purpose— Ultra-early blood pressure (BP) management in the prehospital setting could improve the efficacy of this treatment on attenuating intracerebral hemorrhage (ICH) expansion. We aimed to determine the association of prehospital systolic BP (SBP) with ICH volume, ultra-early hematoma growth, and the spot sign on admission. Methods— We conducted a retrospective study of a prospective database of 219 consecutive patients with spontaneous ICH admitted to the emergency department of a tertiary stroke center during a 3-year period. Prehospital SBP and ICH volume, ultra-early hematoma growth (ICH volume/onset-to-imaging time), and presence of the spot sign on admission were prospectively recorded. Primary outcome was ICH volume on admission. Secondary outcomes included ultra-early hematoma growth and frequency of the spot sign in patients scanned within 6 hours from symptom onset (hyperacute group). Results— Prehospital SBP was positively correlated with both SBP (r=0.552; P<0.001) and ICH volume (&rgr;=0.189; P=0.006) on admission. Patients with ICH volume above the median value presented higher prehospital SBP (172.3±35.0 versus 163.7±27.8 mm Hg; P=0.049). This association remained significant in adjusted multiple logistic regression analysis (odds ratio, 1.01 for a 1-U increase in SBP; 95% confidence interval, 1.01–1.02; P=0.018). In the hyperacute group (n=126), prehospital SBP was unrelated to ultra-early hematoma growth (&rgr;=0.115; P=0.203) nor the presence of the spot sign (172.2±27.6 versus 171.8±31.6 mm Hg; P=0.959). Conclusions— Prehospital SBP is correlated with SBP on admission and independently associated with ICH volume on admission. These findings support the rationale of testing whether prehospital initiation of BP-lowering attenuates ICH expansion.

Combining Spot Sign and Intracerebral Hemorrhage Score to Estimate Functional Outcome: Analysis From the PREDICT Cohort

Background and Purpose— The intracerebral hemorrhage (ICH) score is the most commonly used grading scale for stratifying functional outcome in patients with acute ICH. We sought to determine whether a combination of the ICH score and the computed tomographic angiography spot sign may improve outcome prediction in the cohort of a prospective multicenter hemorrhage trial. Methods— Prospectively collected data from 241 patients from the observational PREDICT study (Prediction of Hematoma Growth and Outcome in Patients With Intracerebral Hemorrhage Using the CT-Angiography Spot Sign) were analyzed. Functional outcome at 3 months was dichotomized using the modified Rankin Scale (0–3 versus 4–6). Performance of (1) the ICH score and (2) the spot sign ICH score—a scoring scale combining ICH score and spot sign number—was tested. Results— Multivariable analysis demonstrated that ICH score (odds ratio, 3.2; 95% confidence interval, 2.2–4.8) and spot sign number (n=1: odds ratio, 2.7; 95% confidence interval, 1.1–7.4; n>1: odds ratio, 3.8; 95% confidence interval, 1.2–17.1) were independently predictive of functional outcome at 3 months with similar odds ratios. Prediction of functional outcome was not significantly different using the spot sign ICH score compared with the ICH score alone (spot sign ICH score area under curve versus ICH score area under curve: P=0.14). Conclusions— In the PREDICT cohort, a prognostic score adding the computed tomographic angiography–based spot sign to the established ICH score did not improve functional outcome prediction compared with the ICH score.