Significance of Hematoma Shape and Density in Intracerebral Hemorrhage

In patients with acute intracerebral hemorrhage (ICH), the volume of hematoma adjusted for the time from the onset of symptoms is a well-recognized predictor of hematoma growth and is a strong predictor of clinical outcome. Other hematoma characteristics, such as shape and density, have also been recently highlighted as outcome predictors: degree of shape irregularity seems related to hematoma growth; and density, described as homogeneous or heterogenous, or as a blend sign, has additionally been shown to be associated with hematoma growth. To date, however, only 1 group has shown a relationship between irregular shape and 30-day mortality in a retrospective study of 106 patients. Therefore, the relevance of these other hematoma parameters to clinical outcome remains uncertain. Using the large Background and Purpose—In patients with acute intracerebral hemorrhage (ICH), the shape and density of the hematoma are associated with its subsequent growth, but the impact of these parameters on clinical outcome is uncertain. Methods—Baseline computed tomographic scans and clinical data were obtained in the Intensive Blood Pressure Reduction in Acute Intracerebral Hemorrhage Trial (INTERACT2). Three independent neurologists blind to clinical data assessed ICH for shape and density using a previously described scale. Shape was defined as irregular when the ICH had ≥2 extra lesions added to the ellipsoid-shaped ICH. Density was heterogeneous when there were ≥3 low-density lesions within the ICH. Outcome measures were death and major disability (modified Rankin scale score of 3–5), combined and separate at 90-day postrandomization. Multivariable logistic regression models were used to determine the significance of hematoma characteristics on outcome. Results—There were 2066 patient computed tomographic scans included in the analysis, with 46% and 38% having irregular and heterogeneous ICH, respectively. Irregular shape was independently associated with death/major disability (adjusted odds ratio, 1.60; 95% confidence interval [CI], 1.29–1.98) and major disability alone (adjusted odds ratio, 1.60; 95% CI, 1.31–1.95), but not with death alone (adjusted odds ratio, 0.97; 95% CI, 0.68–1.39). Heterogeneous density was not associated with clinical outcomes (adjusted odds ratio, 1.06; 95% CI, 0.85–1.33), 1.04 (95% CI, 0.73–1.48), and 1.14 (95% CI, 0.93–1.39), respectively, for death/major disability, death alone, and disability alone). Conclusions—Irregular shape, but not heterogeneous density, is independently associated with poor outcome after ICH. Clinical Trial Registration—URL: http://www.clinicaltrials.gov. Unique identifier: NCT00716079. (Stroke. 2016;47:1227-1232. DOI: 10.1161/STROKEAHA.116.012921.)