Department of Neurology, University of Erlangen-Nürnberg, Schwabachanlage 6, Erlangen, 91054, Germany.
Department of Neuroradiology, University of Erlangen-Nürnberg, Schwabachanlage 6, Erlangen, 91054, Germany.
Ann Clin Transl Neurol. 2020 Mar;7(3):363-374. doi: 10.1002/acn3.51001. Epub 2020 Mar 4.
OBJECTIVE: Hematoma enlargement (HE) is associated with clinical outcomes after supratentorial intracerebral hemorrhage (ICH). This study evaluates whether HE characteristics and association with functional outcome differ in deep versus lobar ICH. METHODS: Pooled analysis of individual patient data between January 2006 and December 2015 from a German-wide cohort study (RETRACE, I + II) investigating ICH related to oral anticoagulants (OAC) at 22 participating centers, and from one single-center registry (UKER-ICH) investigating non-OAC-ICH patients. Altogether, 1954 supratentorial ICH patients were eligible for outcome analyses, which were separately conducted or controlled for OAC, that is, vitamin-K-antagonists (VKA, n = 1186) and non-vitamin-K-antagonist-oral-anticoagulants (NOAC, n = 107). Confounding was addressed using propensity score matching, cox regression modeling and multivariate modeling. Main outcomes were occurrence, extent, and timing of HE (>33%/>6 mL) and its association with 3-month functional outcome. RESULTS: Occurrence of HE was not different after deep versus lobar ICH in patients with non-OAC-ICH (39/356 [11.0%] vs. 36/305 [11.8%], P = 0.73), VKA-ICH (249/681 [36.6%] vs. 183/505 [36.2%], P = 0.91), and NOAC-ICH (21/69 [30.4%] vs. 12/38 [31.6%], P = 0.90). HE extent did not differ after non-OAC-ICH (deep:+59% [40-122] vs. lobar:+74% [37-124], P = 0.65), but both patients with VKA-ICH and NOAC-ICH showed greater HE extent after deep ICH [VKA-ICH, deep: +94% [54-199] vs. lobar: +56% [35-116], P < 0.001; NOAC-ICH, deep: +74% [56-123] vs. lobar: +40% [21-49], P = 0.001). Deep compared to lobar ICH patients had higher HE hazard during first 13.5 h after onset (Hazard ratio [HR]: 1.85 [1.03-3.31], P = 0.04), followed by lower hazard (13.5-26.5 h, HR: 0.46 [0.23-0.89], P = 0.02), and equal hazard thereafter (HR: 0.96 [0.56-1.65], P = 0.89). Odds ratio for unfavorable outcome was higher after HE in deep (4.31 [2.71-6.86], P < 0.001) versus lobar ICH (2.82 [1.71-4.66], P < 0.001), and only significant after small-medium (1st volume-quarter, deep: 3.09 [1.52-6.29], P < 0.01; lobar: 3.86 [1.35-11.04], P = 0.01) as opposed to large-sized ICH (4th volume-quarter, deep: 1.09 [0.13-9.20], P = 0.94; lobar: 2.24 [0.72-7.04], P = 0.17). INTERPRETATION: HE occurrence does not differ among deep and lobar ICH. However, compared to lobar ICH, HE after deep ICH is of greater extent in OAC-ICH, occurs earlier and may be of greater clinical relevance. Overall, clinical significance is more apparent after small-medium compared to large-sized bleedings.
目的:血肿扩大(HE)与幕上脑出血(ICH)后的临床结局相关。本研究评估深部和脑叶 ICH 之间 HE 特征及其与功能结局的相关性是否存在差异。
方法:对 22 个参与中心调查与口服抗凝剂(OAC)相关的 ICH 的德国范围队列研究(RETRACE,I+II)和一个调查非 OAC-ICH 患者的单中心登记处(UKER-ICH)中,2006 年 1 月至 2015 年 12 月期间的个体患者数据进行汇总分析。共有 1954 例幕上 ICH 患者有资格进行结局分析,分别针对 OAC(VKA,n=1186;NOAC,n=107)和非 OAC 进行了分析。混杂因素通过倾向评分匹配、Cox 回归建模和多变量建模来解决。主要结局是 HE(>33%/ >6 mL)的发生、程度和时间及其与 3 个月功能结局的相关性。
结果:在非 OAC-ICH 患者中,深部与脑叶 ICH 后 HE 的发生率无差异(39/356 [11.0%] vs. 36/305 [11.8%],P=0.73)、VKA-ICH(249/681 [36.6%] vs. 183/505 [36.2%],P=0.91)和 NOAC-ICH(21/69 [30.4%] vs. 12/38 [31.6%],P=0.90)。非 OAC-ICH 后 HE 程度无差异(深部:+59%[40-122] vs. 脑叶:+74%[37-124],P=0.65),但 VKA-ICH 和 NOAC-ICH 患者深部 ICH 后 HE 程度更大[VKA-ICH,深部:+94%[54-199] vs. 脑叶:+56%[35-116],P<0.001;NOAC-ICH,深部:+74%[56-123] vs. 脑叶:+40%[21-49],P=0.001]。与脑叶 ICH 患者相比,深部 ICH 患者在发病后前 13.5 小时内 HE 的发生风险更高(风险比[HR]:1.85[1.03-3.31],P=0.04),随后风险降低(13.5-26.5 小时,HR:0.46[0.23-0.89],P=0.02),此后风险相等(HR:0.96[0.56-1.65],P=0.89)。深部 ICH 患者 HE 后不良结局的比值比高于脑叶 ICH(4.31[2.71-6.86],P<0.001),仅在中小体积 ICH (第 1 体积四分之一,深部:3.09[1.52-6.29],P<0.01;脑叶:3.86[1.35-11.04],P=0.01)中具有统计学意义,而在大体积 ICH (第 4 体积四分之一,深部:1.09[0.13-9.20],P=0.94;脑叶:2.24[0.72-7.04],P=0.17)中无统计学意义。
解释:深部和脑叶 ICH 之间 HE 的发生没有差异。然而,与脑叶 ICH 相比,OAC-ICH 后深部 ICH 的 HE 程度更大,发生更早,可能具有更大的临床相关性。总体而言,与大体积出血相比,中小体积出血的临床意义更为明显。
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