LOS ANGELES – MRI results showing brain lesions on diffusion-weighted imaging after primary intracerebral hemorrhage predicted a more than sixfold increase in risk of poor function 1 year later in a prospective, longitudinal study of 62 patients.
A combination of diffusion-weighted imaging (DWI) MRI results, glucose levels at baseline, and scores on the National Institutes of Health Stroke Scale (NIHSS) provided 86% accuracy in predicting good or poor outcome 1 year later, Dr. Richard E. Burgess said at the International Stroke Conference sponsored by the American Heart Association.
Richard E. Burgess
Recent studies have shown that remote ischemic lesions in patients with intracerebral hemorrhage are more common than previously thought. In the study by Dr. Burgess and his associates, 29% of patients had lesions on DWI when scanned a median of 2 days after primary intracerebral hemorrhage.
That rate is "in accord with other studies," said Dr. Burgess of Georgetown University, Washington, D.C. One recent study reported lesions on DWI in up to 30% of patients after intracerebral hemorrhage. A separate study found an association between these lesions and intracerebral hemorrhage related to cerebral amyloid angiopathy.
Patients in the current study had a median of two lesions each; 68% were deep lesions and 32% were lobar. The lesions were ipsilateral in 50% of patients, contralateral in 17%, and bilateral in 33%.
The location of the intracerebral hemorrhage was deep in 68% of patients, and the mean hemorrhage volume was 27 cc.
In the study, called the Differences in the Imaging of Primary Hemorrhage Based on Ethnicity or Race (DECIPHER) study, all patients underwent a history, a neurologic examination, multiple MRI sequences, and a battery of predictive outcome scales at baseline. The MRI exam was repeated at 30 days, 1 year, and 3 years, and the outcome scales assessments were repeated at these time points and at 2 and 4 years.
The investigators assessed outcomes at 1 year using a modified Rankin Scale and designated patients as having either a good outcome (scoring 0-3 on the scale) or a poor outcome (scores of 4-6).
The study participants had a mean age of 62 years and a median NIHSS score of 5 at baseline; 52% were women, 66% were black, and 84% had hypertension.
Three factors at baseline significantly predicted poor outcome at 1 year in a multivariate analysis, Dr. Burgess said. The presence of DWI lesions increased the risk for a poor outcome 6.6-fold, compared with no lesions on DWI. A higher NIHSS score increased the risk for a poor outcome by 15%. A higher glucose level increased the risk by 2%. Combined with older age, which was not a significant factor by itself, the combined factors correctly predicted 1-year outcome in 86% of patients.
Overall, among 43 patients who were predicted to have a good outcome at 1 year, 40 did and 3 had a poor outcome, for 93% accuracy in predictions. Among 19 patients who were predicted to have a poor outcome, 13 did and 6 had a good outcome, for a 68% accuracy rate, he said.
In univariate analyses, the mean NIHSS score at baseline was significantly different between patients with good outcomes (score of 5) and bad outcomes (score of 14). Baseline glucose scores also differed significantly, measuring 113 mg/dL in the good-outcome group and 149 mg/dL in the poor-outcome group. Age also differed significantly in a univariate analysis, with a mean age of 60 years in patients with good outcomes and 67 years in those with poor outcomes.
"History, neurologic exam, laboratory data, and imaging findings – all have a role to play in predicting outcomes in patients," Dr. Burgess said. A larger study is needed to confirm the usefulness of acute MRI in this role and to assess other factors, including intracerebral hemorrhage volume and Glasgow Coma Scale score, that this small study could not properly analyze.
The MRI protocol in the study included DWI with apparent diffusion coefficient and fluid-attenuated inversion recovery sequences.
Dr. Burgess said he had no relevant financial disclosures.