Morotti Andrea, Li Qi, Nawabi Jawed, Mazzacane Federico, Schlunk Frieder, Shoamanesh Ashkan, Busto Giorgio, Cavallini Anna, Palmerini Francesco, Paciaroni Maurizio, Gurol Edip M, Viswanathan Anand, Casetta Ilaria, Piccolo Laura, Fainardi Enrico, Greenberg Steven M, Padovani Alessandro, Zini Andrea, Rosand Jonathan, Broderick Joseph P, Dowlatshahi Dar, Goldstein Joshua N
Department of Clinical and Experimental Sciences, Neurology Unit, University of Brescia, Italy (A.M., A.P.).
Department of Continuity of Care and Frailty, Neurology Unit, ASST Spedali Civili Brescia University Hospital, Italy (A.M., A.P.).
Stroke. 2025 May;56(5):1224-1231. doi: 10.1161/STROKEAHA.124.049008. Epub 2025 Mar 20.
BACKGROUND: The prognostic impact of intracerebral hemorrhage (ICH) volume varies according to location, with smaller volume tolerance in deep ICH, and hematoma expansion (HE) contributes to final ICH volume. We tested the hypothesis that HE influences outcome only when the final ICH volume achieves a critical threshold that differs according to ICH location. METHODS: Retrospective analysis of patients with supratentorial ICH admitted at 10 centers in North America and China (development cohort) and Europe (replication cohort). HE was defined as growth >33% and/or >6 mL. Location-specific (lobar versus deep) volume cutoffs for the prediction of poor outcomes were derived using receiver operating characteristic curves and the Youden index. The prognostic impact of HE stratified by location and final volume was explored with logistic regression (poor outcome: 90-day modified Rankin Scale score of 4-6), accounting for age, Glasgow Coma Scale, baseline volume, intraventricular hemorrhage, and admission center. RESULTS: We identified 1774 patients with ICH in the development cohort and 1746 in the replication cohort. A total of 1058 (mean age, 68 years; 47.8% men) and 1423 (mean age, 71 years; 44.7% men) subjects met the inclusion criteria, respectively. The optimal final ICH volume cutoff for poor outcome differed by location: ≥36 mL for lobar and ≥17 mL for deep ICH. HE with final volume below the cutoff was not associated with higher odds of poor outcome compared with patients without HE (adjusted odds ratio, 1.85 [95% CI, 0.78-4.38]; =0.163 in lobar ICH; adjusted odds ratio, 0.85 [95% CI, 0.38-1.89]; =0.685 in deep ICH). The combination of HE and final volume over the critical threshold was, however, significantly associated with poor prognosis, and the magnitude of this effect was substantial (adjusted odds ratio, 8.55 [95% CI, 2.87-25.48]; <0.001 in lobar ICH; adjusted odds ratio, 10.34 [95% CI, 2.86-37.44]; <0.001 in deep ICH). These findings were confirmed in the replication cohort. CONCLUSIONS: HE significantly impacts severe outcomes only when the final ICH volume exceeds a critical target threshold, and this threshold is lower in deep versus lobar ICH. These findings might inform clinical practice and future trials.
背景：脑出血（ICH）体积的预后影响因部位而异，深部脑出血的体积耐受性较小，血肿扩大（HE）会导致最终的ICH体积增加。我们检验了这样一个假设，即只有当最终的ICH体积达到根据ICH部位而不同的临界阈值时，HE才会影响预后。 方法：对北美和中国10个中心（开发队列）以及欧洲（验证队列）收治的幕上ICH患者进行回顾性分析。HE定义为血肿增长>33%和/或>6 mL。使用受试者工作特征曲线和尤登指数得出用于预测不良预后的特定部位（脑叶与深部）体积截断值。采用逻辑回归分析（不良预后：90天改良Rankin量表评分为4 - 6分）探讨按部位和最终体积分层的HE的预后影响，同时考虑年龄、格拉斯哥昏迷量表评分、基线体积、脑室内出血和入院中心。 结果：我们在开发队列中确定了1774例ICH患者，在验证队列中确定了1746例。分别有1058例（平均年龄68岁；男性占47.8%）和1423例（平均年龄71岁；男性占44.7%）受试者符合纳入标准。不良预后的最佳最终ICH体积截断值因部位而异：脑叶出血为≥36 mL，深部脑出血为≥17 mL。与无HE的患者相比，最终体积低于截断值的HE与不良预后的较高几率无关（调整后的优势比，1.85 [95%CI，0.78 - 4.38]；脑叶ICH中P = 0.163；调整后的优势比，0.85 [95%CI，0.38 - 1.89]；深部ICH中P = 0.685）。然而，HE与超过临界阈值的最终体积相结合与不良预后显著相关，且这种影响的程度很大（调整后的优势比，8.55 [95%CI，2.87 - 25.48]；脑叶ICH中P < 0.001；调整后的优势比，10.34 [95%CI，2.86 - 37.44]；深部ICH中P < 0.001）。这些发现在验证队列中得到了证实。 结论：只有当最终的ICH体积超过临界目标阈值时，HE才会显著影响严重预后，且深部ICH的这个阈值低于脑叶ICH。这些发现可能为临床实践和未来试验提供参考。
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