Division of Neurology, Department of Medicine, Queen Mary Hospital (K.-C.T., S.-M.F., W.C.Y.L., I.Y.H.L., Y.-K.W., K.-K.Y., R.C.N.L., R.T.F.C., S.-L.H., K.-H.C., K.-K.L.), LKS Faculty of Medicine, The University of Hong Kong, Hong Kong SAR.
Division of Neurosurgery, Department of Surgery, Queen Mary Hospital (O.M.Y.C., A.C.O.T., G.K.K.L.), LKS Faculty of Medicine, The University of Hong Kong, Hong Kong SAR.
Stroke. 2023 Jun;54(6):1548-1557. doi: 10.1161/STROKEAHA.122.041246. Epub 2023 May 22.
BACKGROUND: Major intracerebral hemorrhage (ICH) trials have largely been unable to demonstrate therapeutic benefit in improving functional outcomes. This may be partly due to the heterogeneity of ICH outcomes based on their location, where a small strategic ICH could be debilitating, thus confounding therapeutic effects. We aimed to determine the ideal hematoma volume cutoff for different ICH locations in predicting ICH outcomes. METHODS: We retrospectively analyzed consecutive ICH patients enrolled in the University of Hong Kong prospective stroke registry from January 2011 to December 2018. Patients with premorbid modified Rankin Scale score >2 or who underwent neurosurgical intervention were excluded. ICH volume cutoff, sensitivity, and specificity in predicting respective 6-month neurological outcomes (good [modified Rankin Scale score 0-2], poor [modified Rankin Scale score 4-6], and mortality) for specific ICH locations were determined using receiver operating characteristic curves. Separate multivariate logistic regression models were also conducted for each location-specific volume cutoff to determine whether these cutoffs were independently associated with respective outcomes. RESULTS: Among 533 ICHs, the volume cutoff for good outcome according to ICH location was 40.5 mL for lobar, 32.5 mL for putamen/external capsule, 5.5 mL for internal capsule/globus pallidus, 6.5 mL for thalamus, 17 mL for cerebellum, and 3 mL for brainstem. ICH smaller than the cutoff for all supratentorial sites had higher odds of good outcomes (all <0.05). Volumes exceeding 48 mL for lobar, 41 mL for putamen/external capsule, 6 mL for internal capsule/globus pallidus, 9.5 mL for thalamus, 22 mL for cerebellum, and 7.5 mL for brainstem were at greater risk of poor outcomes (all <0.05). Mortality risks were significantly higher for volumes that exceeded 89.5 mL for lobar, 42 mL for putamen/external capsule, and 21 mL for internal capsule/globus pallidus (all <0.001). All receiver operating characteristic models for location-specific cutoffs had good discriminant values (area under the curve >0.8), except in predicting good outcome for cerebellum. CONCLUSIONS: ICH outcomes differed with location-specific hematoma size. Location-specific volume cutoff should be considered in patient selection for ICH trials.
背景： 大多数颅内出血 (ICH) 试验未能证明在改善功能结局方面具有治疗益处。这可能部分是由于基于位置的 ICH 结局存在异质性，其中小的战略性 ICH 可能会导致身体残疾，从而混淆治疗效果。我们旨在确定不同 ICH 位置的血肿体积截定点，以预测 ICH 结局。
方法： 我们回顾性分析了 2011 年 1 月至 2018 年 12 月期间参加香港大学前瞻性卒中登记处的连续 ICH 患者。排除了有预先存在的改良 Rankin 量表评分 >2 或接受神经外科干预的患者。使用受试者工作特征曲线确定特定 ICH 部位的血肿体积截定点对各自 6 个月神经结局（良好[改良 Rankin 量表评分 0-2]、不良[改良 Rankin 量表评分 4-6]和死亡率）的预测价值。还针对每个部位特异性体积截定点进行了单独的多变量逻辑回归模型，以确定这些截定点是否与各自的结局独立相关。
结果： 在 533 例 ICH 中，根据 ICH 部位确定的良好结局的体积截定点为：叶部 40.5 mL，壳核/外囊 32.5 mL，内囊/苍白球 5.5 mL，丘脑 6.5 mL，小脑 17 mL，脑干 3 mL。所有幕上部位的 ICH 体积小于截定点时，其良好结局的可能性更高（均<0.05）。叶部超过 48 mL、壳核/外囊超过 41 mL、内囊/苍白球超过 6 mL、丘脑超过 9.5 mL、小脑超过 22 mL、脑干超过 7.5 mL 的 ICH 发生不良结局的风险更高（均<0.05）。叶部超过 89.5 mL、壳核/外囊超过 42 mL 和内囊/苍白球超过 21 mL 的 ICH 死亡率显著升高（均<0.001）。除了预测小脑的良好结局外，所有部位特异性截定点的受试者工作特征模型都具有良好的鉴别价值（曲线下面积>0.8）。
结论： ICH 结局因部位而异。ICH 试验中应考虑基于部位的血肿大小的体积截定点。
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