Noncontrast Computed Tomography Hypodensities Predict Poor Outcome in Intracerebral Hemorrhage Patients.
Noncontrast computed tomographic (CT) hypodensities have been shown to be associated with hematoma expansion in intracerebral hemorrhage (ICH), but their impact on functional outcome is yet to be determined. We evaluated whether baseline noncontrast CT hypodensities are associated with poor clinical outcome.



We performed a retrospective review of a prospectively collected cohort of consecutive patients with primary ICH presenting to a single academic medical center between 1994 and 2016. The presence of CT hypodensities was assessed by 2 independent raters on the baseline CT. Unfavorable outcome was defined as a modified Rankin score >3 at 90 days. The associations between CT hypodensities and unfavorable outcome were investigated using uni- and multivariable logistic regression models.



During the study period, 1342 patients presented with ICH and 800 met restrictive inclusion criteria (baseline CT available for review, and 90-day outcome available). Three hundred and four (38%) patients showed hypodensities on CT, and 520 (65%) patients experienced unfavorable outcome. In univariate analysis, patients with unfavorable outcome were more likely to demonstrate hypodensities (48% versus 20%; P<0.0001). After adjustment for age, admission Glasgow coma scale, warfarin use, intraventricular hemorrhage, baseline ICH volume, and location, CT hypodensities were found to be independently associated with an increase in the odds of unfavorable outcome (odds ratio 1.70, 95% confidence interval [1.10-2.65]; P=0.018).



The presence of noncontract CT hypodensities at baseline independently predicts poor outcome and comes as a useful and widely available addition to our ability to predict ICH patients' clinical evolution.
From the Hemorrhagic Stroke Research Program, Department of Neurology, Massachusetts General Hospital Stroke Research Center, Harvard Medical School, Boston (G.B., A.M., H.B.B., A.C., M.J.J., E.A., O.P.-N., A.A., A. Vashkevich, K.M.S., J.R., A. Viswanathan, M.E.G., S.M.G., J.N.G.); Department of Neurosurgery, Brain Center Rudolf Magnus, University Medical Center Utrecht, Utrecht University, The Netherlands (H.B.B.); Stroke Service, Department of Neuroscience and Behavioral Sciences, Ribeirao Pre- to School of Medicine, University of Sao Paulo (O.P.-N.); Division of Neurocritical Care and Emergency Neurology, Massachusetts General Hospital, Harvard Medical School, Boston (J.R., J.N.G.); Department of Emergency Medicine, Massachusetts General Hospital, Boston (J.N.G.). gregoireboulouis@gmail.com.
Gregoire
G
Boulouis
From the Hemorrhagic Stroke Research Program, Department of Neurology, Massachusetts General Hospital Stroke Research Center, Harvard Medical School, Boston (G.B., A.M., H.B.B., A.C., M.J.J., E.A., O.P.-N., A.A., A. Vashkevich, K.M.S., J.R., A. Viswanathan, M.E.G., S.M.G., J.N.G.); Department of Neurosurgery, Brain Center Rudolf Magnus, University Medical Center Utrecht, Utrecht University, The Netherlands (H.B.B.); Stroke Service, Department of Neuroscience and Behavioral Sciences, Ribeirao Pre- to School of Medicine, University of Sao Paulo (O.P.-N.); Division of Neurocritical Care and Emergency Neurology, Massachusetts General Hospital, Harvard Medical School, Boston (J.R., J.N.G.); Department of Emergency Medicine, Massachusetts General Hospital, Boston (J.N.G.).
Andrea
A
Morotti
From the Hemorrhagic Stroke Research Program, Department of Neurology, Massachusetts General Hospital Stroke Research Center, Harvard Medical School, Boston (G.B., A.M., H.B.B., A.C., M.J.J., E.A., O.P.-N., A.A., A. Vashkevich, K.M.S., J.R., A. Viswanathan, M.E.G., S.M.G., J.N.G.); Department of Neurosurgery, Brain Center Rudolf Magnus, University Medical Center Utrecht, Utrecht University, The Netherlands (H.B.B.); Stroke Service, Department of Neuroscience and Behavioral Sciences, Ribeirao Pre- to School of Medicine, University of Sao Paulo (O.P.-N.); Division of Neurocritical Care and Emergency Neurology, Massachusetts General Hospital, Harvard Medical School, Boston (J.R., J.N.G.); Department of Emergency Medicine, Massachusetts General Hospital, Boston (J.N.G.).
H Bart
HB
Brouwers
From the Hemorrhagic Stroke Research Program, Department of Neurology, Massachusetts General Hospital Stroke Research Center, Harvard Medical School, Boston (G.B., A.M., H.B.B., A.C., M.J.J., E.A., O.P.-N., A.A., A. Vashkevich, K.M.S., J.R., A. Viswanathan, M.E.G., S.M.G., J.N.G.); Department of Neurosurgery, Brain Center Rudolf Magnus, University Medical Center Utrecht, Utrecht University, The Netherlands (H.B.B.); Stroke Service, Department of Neuroscience and Behavioral Sciences, Ribeirao Pre- to School of Medicine, University of Sao Paulo (O.P.-N.); Division of Neurocritical Care and Emergency Neurology, Massachusetts General Hospital, Harvard Medical School, Boston (J.R., J.N.G.); Department of Emergency Medicine, Massachusetts General Hospital, Boston (J.N.G.).
Andreas
A
Charidimou
From the Hemorrhagic Stroke Research Program, Department of Neurology, Massachusetts General Hospital Stroke Research Center, Harvard Medical School, Boston (G.B., A.M., H.B.B., A.C., M.J.J., E.A., O.P.-N., A.A., A. Vashkevich, K.M.S., J.R., A. Viswanathan, M.E.G., S.M.G., J.N.G.); Department of Neurosurgery, Brain Center Rudolf Magnus, University Medical Center Utrecht, Utrecht University, The Netherlands (H.B.B.); Stroke Service, Department of Neuroscience and Behavioral Sciences, Ribeirao Pre- to School of Medicine, University of Sao Paulo (O.P.-N.); Division of Neurocritical Care and Emergency Neurology, Massachusetts General Hospital, Harvard Medical School, Boston (J.R., J.N.G.); Department of Emergency Medicine, Massachusetts General Hospital, Boston (J.N.G.).
Michael J
MJ
Jessel
From the Hemorrhagic Stroke Research Program, Department of Neurology, Massachusetts General Hospital Stroke Research Center, Harvard Medical School, Boston (G.B., A.M., H.B.B., A.C., M.J.J., E.A., O.P.-N., A.A., A. Vashkevich, K.M.S., J.R., A. Viswanathan, M.E.G., S.M.G., J.N.G.); Department of Neurosurgery, Brain Center Rudolf Magnus, University Medical Center Utrecht, Utrecht University, The Netherlands (H.B.B.); Stroke Service, Department of Neuroscience and Behavioral Sciences, Ribeirao Pre- to School of Medicine, University of Sao Paulo (O.P.-N.); Division of Neurocritical Care and Emergency Neurology, Massachusetts General Hospital, Harvard Medical School, Boston (J.R., J.N.G.); Department of Emergency Medicine, Massachusetts General Hospital, Boston (J.N.G.).
Eitan
E
Auriel
From the Hemorrhagic Stroke Research Program, Department of Neurology, Massachusetts General Hospital Stroke Research Center, Harvard Medical School, Boston (G.B., A.M., H.B.B., A.C., M.J.J., E.A., O.P.-N., A.A., A. Vashkevich, K.M.S., J.R., A. Viswanathan, M.E.G., S.M.G., J.N.G.); Department of Neurosurgery, Brain Center Rudolf Magnus, University Medical Center Utrecht, Utrecht University, The Netherlands (H.B.B.); Stroke Service, Department of Neuroscience and Behavioral Sciences, Ribeirao Pre- to School of Medicine, University of Sao Paulo (O.P.-N.); Division of Neurocritical Care and Emergency Neurology, Massachusetts General Hospital, Harvard Medical School, Boston (J.R., J.N.G.); Department of Emergency Medicine, Massachusetts General Hospital, Boston (J.N.G.).
Octavio
O
Pontes-Neto
From the Hemorrhagic Stroke Research Program, Department of Neurology, Massachusetts General Hospital Stroke Research Center, Harvard Medical School, Boston (G.B., A.M., H.B.B., A.C., M.J.J., E.A., O.P.-N., A.A., A. Vashkevich, K.M.S., J.R., A. Viswanathan, M.E.G., S.M.G., J.N.G.); Department of Neurosurgery, Brain Center Rudolf Magnus, University Medical Center Utrecht, Utrecht University, The Netherlands (H.B.B.); Stroke Service, Department of Neuroscience and Behavioral Sciences, Ribeirao Pre- to School of Medicine, University of Sao Paulo (O.P.-N.); Division of Neurocritical Care and Emergency Neurology, Massachusetts General Hospital, Harvard Medical School, Boston (J.R., J.N.G.); Department of Emergency Medicine, Massachusetts General Hospital, Boston (J.N.G.).
Alison
A
Ayres
From the Hemorrhagic Stroke Research Program, Department of Neurology, Massachusetts General Hospital Stroke Research Center, Harvard Medical School, Boston (G.B., A.M., H.B.B., A.C., M.J.J., E.A., O.P.-N., A.A., A. Vashkevich, K.M.S., J.R., A. Viswanathan, M.E.G., S.M.G., J.N.G.); Department of Neurosurgery, Brain Center Rudolf Magnus, University Medical Center Utrecht, Utrecht University, The Netherlands (H.B.B.); Stroke Service, Department of Neuroscience and Behavioral Sciences, Ribeirao Pre- to School of Medicine, University of Sao Paulo (O.P.-N.); Division of Neurocritical Care and Emergency Neurology, Massachusetts General Hospital, Harvard Medical School, Boston (J.R., J.N.G.); Department of Emergency Medicine, Massachusetts General Hospital, Boston (J.N.G.).
Anastasia
A
Vashkevich
From the Hemorrhagic Stroke Research Program, Department of Neurology, Massachusetts General Hospital Stroke Research Center, Harvard Medical School, Boston (G.B., A.M., H.B.B., A.C., M.J.J., E.A., O.P.-N., A.A., A. Vashkevich, K.M.S., J.R., A. Viswanathan, M.E.G., S.M.G., J.N.G.); Department of Neurosurgery, Brain Center Rudolf Magnus, University Medical Center Utrecht, Utrecht University, The Netherlands (H.B.B.); Stroke Service, Department of Neuroscience and Behavioral Sciences, Ribeirao Pre- to School of Medicine, University of Sao Paulo (O.P.-N.); Division of Neurocritical Care and Emergency Neurology, Massachusetts General Hospital, Harvard Medical School, Boston (J.R., J.N.G.); Department of Emergency Medicine, Massachusetts General Hospital, Boston (J.N.G.).
Kristin M
KM
Schwab
From the Hemorrhagic Stroke Research Program, Department of Neurology, Massachusetts General Hospital Stroke Research Center, Harvard Medical School, Boston (G.B., A.M., H.B.B., A.C., M.J.J., E.A., O.P.-N., A.A., A. Vashkevich, K.M.S., J.R., A. Viswanathan, M.E.G., S.M.G., J.N.G.); Department of Neurosurgery, Brain Center Rudolf Magnus, University Medical Center Utrecht, Utrecht University, The Netherlands (H.B.B.); Stroke Service, Department of Neuroscience and Behavioral Sciences, Ribeirao Pre- to School of Medicine, University of Sao Paulo (O.P.-N.); Division of Neurocritical Care and Emergency Neurology, Massachusetts General Hospital, Harvard Medical School, Boston (J.R., J.N.G.); Department of Emergency Medicine, Massachusetts General Hospital, Boston (J.N.G.).
Jonathan
J
Rosand
From the Hemorrhagic Stroke Research Program, Department of Neurology, Massachusetts General Hospital Stroke Research Center, Harvard Medical School, Boston (G.B., A.M., H.B.B., A.C., M.J.J., E.A., O.P.-N., A.A., A. Vashkevich, K.M.S., J.R., A. Viswanathan, M.E.G., S.M.G., J.N.G.); Department of Neurosurgery, Brain Center Rudolf Magnus, University Medical Center Utrecht, Utrecht University, The Netherlands (H.B.B.); Stroke Service, Department of Neuroscience and Behavioral Sciences, Ribeirao Pre- to School of Medicine, University of Sao Paulo (O.P.-N.); Division of Neurocritical Care and Emergency Neurology, Massachusetts General Hospital, Harvard Medical School, Boston (J.R., J.N.G.); Department of Emergency Medicine, Massachusetts General Hospital, Boston (J.N.G.).
Anand
A
Viswanathan
From the Hemorrhagic Stroke Research Program, Department of Neurology, Massachusetts General Hospital Stroke Research Center, Harvard Medical School, Boston (G.B., A.M., H.B.B., A.C., M.J.J., E.A., O.P.-N., A.A., A. Vashkevich, K.M.S., J.R., A. Viswanathan, M.E.G., S.M.G., J.N.G.); Department of Neurosurgery, Brain Center Rudolf Magnus, University Medical Center Utrecht, Utrecht University, The Netherlands (H.B.B.); Stroke Service, Department of Neuroscience and Behavioral Sciences, Ribeirao Pre- to School of Medicine, University of Sao Paulo (O.P.-N.); Division of Neurocritical Care and Emergency Neurology, Massachusetts General Hospital, Harvard Medical School, Boston (J.R., J.N.G.); Department of Emergency Medicine, Massachusetts General Hospital, Boston (J.N.G.).
Mahmut E
ME
Gurol
From the Hemorrhagic Stroke Research Program, Department of Neurology, Massachusetts General Hospital Stroke Research Center, Harvard Medical School, Boston (G.B., A.M., H.B.B., A.C., M.J.J., E.A., O.P.-N., A.A., A. Vashkevich, K.M.S., J.R., A. Viswanathan, M.E.G., S.M.G., J.N.G.); Department of Neurosurgery, Brain Center Rudolf Magnus, University Medical Center Utrecht, Utrecht University, The Netherlands (H.B.B.); Stroke Service, Department of Neuroscience and Behavioral Sciences, Ribeirao Pre- to School of Medicine, University of Sao Paulo (O.P.-N.); Division of Neurocritical Care and Emergency Neurology, Massachusetts General Hospital, Harvard Medical School, Boston (J.R., J.N.G.); Department of Emergency Medicine, Massachusetts General Hospital, Boston (J.N.G.).
Steven M
SM
Greenberg
From the Hemorrhagic Stroke Research Program, Department of Neurology, Massachusetts General Hospital Stroke Research Center, Harvard Medical School, Boston (G.B., A.M., H.B.B., A.C., M.J.J., E.A., O.P.-N., A.A., A. Vashkevich, K.M.S., J.R., A. Viswanathan, M.E.G., S.M.G., J.N.G.); Department of Neurosurgery, Brain Center Rudolf Magnus, University Medical Center Utrecht, Utrecht University, The Netherlands (H.B.B.); Stroke Service, Department of Neuroscience and Behavioral Sciences, Ribeirao Pre- to School of Medicine, University of Sao Paulo (O.P.-N.); Division of Neurocritical Care and Emergency Neurology, Massachusetts General Hospital, Harvard Medical School, Boston (J.R., J.N.G.); Department of Emergency Medicine, Massachusetts General Hospital, Boston (J.N.G.).
Joshua N
JN
Goldstein
D000368:Aged; D000369:Aged, 80 and over; D001921:Brain / Q000000981:diagnostic imaging*; D002533:Cerebral Angiography; D002543:Cerebral Hemorrhage / Q000000981:diagnostic imaging*; D005260:Female; D006801:Humans; D007091:Image Processing, Computer-Assisted; D008297:Male; D008875:Middle Aged; D011237:Predictive Value of Tests; D011379:Prognosis; D012189:Retrospective Studies; D014057:Tomography, X-Ray Computed
computed tomography; hematoma expansion; intracerebral hemorrhage; morbidity/mortality; prognosis