Researchers find 4 factors to predict continued bleeding after ICH

New research published in The Lancet Neurology suggests four factors can help physicians predict whether intracerebral hemorrhage (ICH) patients are likely to experience further bleeding. 

“We have found that four simple measures help doctors to make accurate predictions about the risk of a brain hemorrhage growing,” the researchers, led by Rustam Al-Shahi Salman, PhD, of the University of Edinburgh, said in a prepared statement. “These can be used anywhere in the world. Better prediction can help us identify which patients might benefit from close monitoring and treatment.”

Only one in five individuals survive ICH without permanent damage. Those remaining will either die within a short span of time or are left with long-term disability.

The researchers ICH cases are generally diagnosed using imaging techniques such as computed tomography (CT) or MRI. However, in spite of these methods, it is still difficult to predict which patients will continue bleeding.

Salman and colleagues sought to determine the absolute risk and predictors of ICH growth, develop and validate prediction models and evaluate the added value of CT angiography. They conducted a review of studies that highlight the risk of intracerebral hemorrhage growth. More than 5,400 people were included in the final cohort.  

Upon review, the researchers identified four main factors that were independently associated with continued bleeding in the brain after ICH.

  • A longer time between symptom onset to baseline CT or MRI.
  • More exhibited bleeding that is visible on baseline CT or MRI.
  • Use of antiplatelet medications.
  • Use of anticoagulant medications.

They calculated the risk of continued bleeding was almost doubled in patients who were taking antiplatelet therapies like aspirin. They also found patients who took anticoagulants like warfarin more than tripled their risk of continued bleeding.

Additionally, Salman et al. reviewed the benefits of CT angiography for predicting the risk of continued bleeding. The researchers noted CT angiography “spot signs” added minimal value to the four independent factors, though the presence of spot signs quadrupled their increase in the risk for continued bleeding.

“Since 2011, there has been growing interest in use of the spot sign on CT angiography for predicting intracerebral hemorrhage growth, but the clinical utility of the small increase in discrimination that resource-intensive advanced vascular imaging adds to simple clinical and imaging predictors that are available worldwide is unclear,” Salman et al. wrote.

The authors also noted that an approximate four-hour decrease in time between stroke onset and baseline imaging could help predict if the patient will continue bleeding post initial ICH.

“Our findings about the association between time after intracerebral hemorrhage symptom onset and the probability of intracerebral hemorrhage growth emphasize the importance of extremely rapid assessment, investigation, and randomization in future trials of therapies to improve outcome by limiting intracerebral hemorrhage growth.”