Hematoma enlargement characteristics in deep versus lobar intracerebral hemorrhage
Hematoma enlargement characteristics in deep versus lobar intracerebral hemorrhage
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DOI：
10.1002/acn3.51001
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发表时间：
2020-03-01
影响因子：
5.3
通讯作者：
Huttner, Hagen B.
中科院分区：
文献类型：
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作者：
Sembill, Jochen A.;Kuramatsu, Joji B.;Huttner, Hagen B.
目的探讨幕上脑出血（ICH）后血肿扩大（HE）与临床预后的关系。本研究评估了脑深部与脑叶ICH的HE特征及其与功能结局的相关性是否存在差异。方法对2006年1月至2015年12月期间来自德国范围队列研究的个体患者数据进行汇总分析（RETRACE，I + II）在22家参与中心调查与口服抗凝剂（OAC）相关的ICH，和来自一项研究非OAC-ICH患者的单中心登记研究（UKER-ICH）。总共有1954例幕上ICH患者有资格进行结局分析，这些分析分别进行或对照OAC，即维生素K拮抗剂（VKA，n = 1186）和非维生素K拮抗剂口服抗凝剂（NOAC，n = 107）。使用倾向评分匹配、考克斯回归建模和多变量建模来解决混杂问题。主要结局为HE的发生、程度和时间结果在非OAC-ICH患者中，脑深部出血与脑叶出血后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.肺叶：+74% [37-124]，P = 0.65），但VKA-ICH和NOAC-ICH患者在深部ICH后显示出更大的HE程度[VKA-ICH，深部：+94% [54-199] vs.肺叶：+56% [35-116]，P < 0.001; NOAC-ICH，深部：+74% [56-123] vs.肺叶：+40% [21-49]，P = 0.001）。与脑叶ICH患者相比，深部ICH患者在发病后的前13.5小时内具有更高的HE风险（风险比[HR]：1.85 [1.03-3.31]，P = 0.04），其次是风险较低（13.5-26.5 h，HR：0.46 [0.23-0.89]，P = 0.02），此后的风险相同（HR：0.96 [0.56-1.65]，P = 0.89）。在深部HE后，不良结局的比值比更高（4.31 [2.71-6.86]，P < 0.001）与脑叶性脑出血比较（2.82 [1.71-4.66]，P < 0.001），并且仅在小-中等剂量后显著（第一体积-四分之一，深部：3.09 [1.52-6.29]，P < 0.01;肺叶：3.86 [1.35-11.04]，P = 0.01），与大面积ICH相反（第四体积-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）。然而，与脑叶ICH相比，OAC-ICH中深度ICH后的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，与大尺寸眼睑相比，小尺寸眼睑后的临床意义更明显。
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.