From the Department of Neurology (S.F.-H., L.O., M.K., C.E., T.G.), Medical University of Graz, Austria; Department of Statistical Science (G.A.), University College London, United Kingdom; Department of Neurology (M.B.G., D.J.S.), University Hospital Bern, Inselspital, University of Bern, Switzerland; Institute for Medical Informatics, Statistics and Documentation (G.W.), Medical University of Graz, Austria; Stroke Research Centre (S.F.-H., W.Z., Y.D., M.L., H.O., P.S.N., L.P., R.M., K.T., R.J.S., D.J.W.), Department of Brain Repair & Rehabilitation, UCL Queen Square Institute of Neurology, United Kingdom; Division of Neuroradiology, Vascular and Interventional Radiology (O.N.), Department of Radiology, Medical University of Graz, Austria; and Neuroradiological Academic Unit (H.R.J.), Department of Brain Repair & Rehabilitation, UCL Queen Square Institute of Neurology, United Kingdom.
Neurology. 2024 Nov 26;103(10):e209950. doi: 10.1212/WNL.0000000000209950. Epub 2024 Oct 31.
Although most spontaneous intracerebral hemorrhages (ICHs) are due to cerebral small vessel diseases (SVDs), between 1 in 7 and 1 in 10 are due to a macrovascular cause. Rapid diagnosis has important therapeutic and prognostic implications but sometimes requires digital subtraction angiography (DSA), an invasive procedure which cannot be performed in all patients. MRI provides optimal sensitivity for markers of SVD but was not included in previous risk stratification scores. We aimed to create and validate a risk stratification score for macrovascular causes of ICH including MRI findings to guide diagnosis and further investigations.
We pooled data from 2 large observational study cohorts (London/United Kingdom and Graz/Austria) of consecutive patients with ICH who had brain MRI and at least 1 angiographic modality within 90 days of symptom onset. The primary outcome was a macrovascular cause of ICH (arteriovenous malformation/dural arteriovenous fistula, aneurysm, cavernoma, or cerebral venous thrombosis), with the diagnosis based on neurovascular multidisciplinary meetings. Using lasso logistic regression, we built the MRI Assessment of the Causes of intRacerebral haemOrrhage (MACRO) score to assess the probability of a macrovascular cause. We performed internal validation using bootstrapping and external validation in an independent cohort (Bern/Switzerland).
We included 1,043 patients with ICH (mean age 66 years, 42% female), 78 of whom had a macrovascular cause (7.5%). The final score includes age (0-39, 40-69, or ≥70), location of ICH (lobar, deep, or infratentorial), and SVD markers on MRI (≥1 microbleed, ≥1 lacune, presence of cortical superficial siderosis, or white matter hyperintensities using the Fazekas scale). The MACRO score showed an optimism-adjusted -statistic of 0.90 (95% CI 0.88-0.93), superior to existing CT-based scores ( < 0.001). In external validation, the -statistic was 0.87 (95% CI 0.80-0.94). MACRO scores ≥6 (59.5% of patients) indicated a very low risk of a macrovascular cause (0.2%), while scores ≤2 (9% of patients) indicated a high risk (48.9%).
The MRI-based MACRO score shows excellent performance in predicting the likelihood of macrovascular causes of spontaneous intracerebral hemorrhage, making it useful in guiding further investigations. Important limitations include the observational study design and the performance of DSA in a minority of patients.
尽管大多数自发性脑出血（ICH）是由脑小血管疾病（SVD）引起的，但仍有 1/7 至 1/10 是由大血管原因引起的。快速诊断具有重要的治疗和预后意义，但有时需要进行数字减影血管造影（DSA），而并非所有患者都能进行这种有创性检查。MRI 对 SVD 的标志物具有最佳的敏感性，但在以前的风险分层评分中并未包括。我们旨在创建和验证ICH 大血管病因的风险分层评分，包括 MRI 结果，以指导诊断和进一步检查。
我们汇集了来自两个大型观察性研究队列（伦敦/英国和格拉茨/奥地利）的数据，这些队列连续纳入了ICH 患者，这些患者在症状发作后 90 天内进行了脑部 MRI 检查和至少 1 种血管造影方式。主要结局是ICH 的大血管病因（动静脉畸形/硬脑膜动静脉瘘、动脉瘤、海绵状血管瘤或脑静脉血栓形成），其诊断基于神经血管多学科会议。我们使用套索逻辑回归建立了 MRI 评估颅内出血的病因（MACRO）评分，以评估大血管病因的可能性。我们使用 bootstrap 进行内部验证，并在一个独立的队列（瑞士伯尔尼）中进行外部验证。
我们纳入了 1043 例 ICH 患者（平均年龄 66 岁，42%为女性），其中 78 例有大血管病因（7.5%）。最终的评分包括年龄（0-39 岁、40-69 岁或≥70 岁）、ICH 部位（叶性、深部或幕下）和 MRI 上的 SVD 标志物（≥1 个微出血、≥1 个腔隙、皮质表面铁沉积或 Fazekas 量表的脑白质高信号）。MACRO 评分的调整后 -统计量为 0.90（95%CI 0.88-0.93），优于现有的基于 CT 的评分（<0.001）。在外部验证中，-统计量为 0.87（95%CI 0.80-0.94）。MACRO 评分≥6（59.5%的患者）提示大血管病因的可能性极低（0.2%），而评分≤2（9%的患者）提示大血管病因的可能性很高（48.9%）。
基于 MRI 的 MACRO 评分在预测自发性脑出血的大血管病因方面表现出优异的性能，使其在指导进一步检查方面具有实用价值。重要的局限性包括观察性研究设计和少数患者进行 DSA 检查。
