Advances in Cerebrovascular Imaging and Interventions

A special issue of Diagnostics (ISSN 2075-4418). This special issue belongs to the section "Medical Imaging and Theranostics".

Deadline for manuscript submissions: 30 September 2024 | Viewed by 7763

Special Issue Editor


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Guest Editor
Department of Radioogy and Biomedica Imaging, Yale University, 333 Cedar Street, P.O. Box 208042, New Haven, CT 06520, USA
Interests: cerebrovascular disease; neuroradiology; artificial intelligence; thrombectomy

Special Issue Information

Dear Colleagues, 

Recent advances in neuroimaing technologies, artificial intelligence and emergence of novel imaging biomarkers set the groundwork for the translation of quantitative and emerging imaging techniques to clinical practice to inform diagnosis, treatment planning, disease monitoring, prognostication, and clinical trial design. As a natural progression, many of the new technologies can inform treatment decisions and improve outcome prediction in patients with cerebrovascular disease. In this issue, we will cover the most recent advances in cerebrovascular imaging and interventions.

Dr. Seyedmehdi Payabvash
Guest Editor

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Keywords

  • cerebrovascular disease
  • stroke
  • transient ischemic attack
  • intracerebral hemorrhage
  • brain microhemorrhage
  • genomics
  • radiomics
  • artificial intelligence
  • MRI
  • CT
  • perfusion imaging
  • thrombectomy
  • hemostatic therapy
  • prevention

Published Papers (10 papers)

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Research

17 pages, 2026 KiB  
Article
MRI-Based Assessment of Risk for Stroke in Moyamoya Angiopathy (MARS-MMA): An MRI-Based Scoring System for the Severity of Moyamoya Angiopathy
by Leonie Zerweck, Constantin Roder, Ganna Blazhenets, Peter Martus, Johannes Thurow, Patrick Haas, Arne Estler, Georg Gohla, Christer Ruff, Nadja Selo, Urs Würtemberger, Nadia Khan, Uwe Klose, Ulrike Ernemann, Philipp T. Meyer and Till-Karsten Hauser
Diagnostics 2024, 14(13), 1437; https://doi.org/10.3390/diagnostics14131437 - 5 Jul 2024
Viewed by 370
Abstract
Before revascularization, moyamoya patients require hemodynamic evaluation. In this study, we evaluated the scoring system Prior Infarcts, Reactivity and Angiography in Moyamoya Disease (PIRAMID). We also devised a new scoring system, MRI-Based Assessment of Risk for Stroke in Moyamoya Angiopathy (MARS-MMA), and [...] Read more.
Before revascularization, moyamoya patients require hemodynamic evaluation. In this study, we evaluated the scoring system Prior Infarcts, Reactivity and Angiography in Moyamoya Disease (PIRAMID). We also devised a new scoring system, MRI-Based Assessment of Risk for Stroke in Moyamoya Angiopathy (MARS-MMA), and compared the scoring systems with respect to the capability to predict impaired [15O]water PET cerebral perfusion reserve capacity (CPR). We evaluated 69 MRI, 69 DSA and 38 [15O]water PET data sets. The PIRAMID system was validated by ROC curve analysis with neurological symptomatology as a dependent variable. The components of the MARS-MMA system and their weightings were determined by binary logistic regression analysis. The comparison of PIRAMID and MARS-MMA was performed by ROC curve analysis. The PIRAMID score correlated well with the symptomatology (AUC = 0.784). The MARS-MMA system, including impaired breath-hold-fMRI, the presence of the Ivy sign and arterial wall contrast enhancement, correlated slightly better with CPR impairment than the PIRAMID system (AUC = 0.859 vs. 0.827, Akaike information criterion 140 vs. 146). For simplified clinical use, we determined three MARS-MMA grades without loss of diagnostic performance (AUC = 0.855). The entirely MRI-based MARS-MMA scoring system might be a promising tool to predict the risk of stroke. Full article
(This article belongs to the Special Issue Advances in Cerebrovascular Imaging and Interventions)
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12 pages, 3125 KiB  
Article
Dynamic Perviousness Has Predictive Value for Clot Fibrin Content in Acute Ischemic Stroke
by Vania Anagnostakou, Daniel Toth, Gergely Bertalan, Susanne Müller, Regina R. Reimann, Mark Epshtein, Jawid Madjidyar, Patrick Thurner, Tilman Schubert, Susanne Wegener and Zsolt Kulcsar
Diagnostics 2024, 14(13), 1387; https://doi.org/10.3390/diagnostics14131387 - 29 Jun 2024
Viewed by 361
Abstract
Dynamic perviousness is a novel imaging biomarker, with clot density measurements at multiple timepoints to allow longer contrast to thrombus interaction. We investigated the correlations between dynamic perviousness and clot composition in the setting of acute ischemic stroke. Thirty-nine patients with large vessel [...] Read more.
Dynamic perviousness is a novel imaging biomarker, with clot density measurements at multiple timepoints to allow longer contrast to thrombus interaction. We investigated the correlations between dynamic perviousness and clot composition in the setting of acute ischemic stroke. Thirty-nine patients with large vessel occlusion (LVO) undergoing mechanical thrombectomy (MT) were analyzed. Patients received a three-phase CT imaging pre-thrombectomy and histopathological analysis of retrieved clots. Clot densities for every phase and change in densities between phases were calculated, leading to four patterns of dynamic perviousness: no contrast uptake, early contrast uptake with and without washout and late uptake. Clots were categorized into three groups based on dominant histologic composition: red blood cell (RBC)-rich, fibrin/platelet-rich and mixed. Clot composition was correlated with dynamic perviousness using the Kruskal–Wallis test and Pearson’s correlation analysis. The dynamic perviousness categories showed a significant difference between fibrin-rich clots when compared to RBC-rich plus mixed groups. The uptake without washout category had significantly fewer fibrin clots compared to the uptake with washout (p = 0.036), and nearly significantly fewer fibrin clots when compared to the no uptake category (p = 0.057). Contrast uptake with different patterns of contrast washout showed significant differences of the likelihood for fibrin-rich clots. Full article
(This article belongs to the Special Issue Advances in Cerebrovascular Imaging and Interventions)
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11 pages, 3001 KiB  
Article
Clinical and Hemodynamic Features of Aneurysm Rupture in Coil Embolization of Intracranial Aneurysms
by Tomoaki Suzuki, Hitoshi Hasegawa, Kohei Shibuya, Hidemoto Fujiwara and Makoto Oishi
Diagnostics 2024, 14(11), 1203; https://doi.org/10.3390/diagnostics14111203 - 6 Jun 2024
Viewed by 497
Abstract
Intraprocedural rupture (IPR) during coil embolization (CE) of an intracranial aneurysm is a significant clinical concern that necessitates a comprehensive understanding of its clinical and hemodynamic predictors. Between January 2012 and December 2023, 435 saccular cerebral aneurysms were treated with CE at our [...] Read more.
Intraprocedural rupture (IPR) during coil embolization (CE) of an intracranial aneurysm is a significant clinical concern that necessitates a comprehensive understanding of its clinical and hemodynamic predictors. Between January 2012 and December 2023, 435 saccular cerebral aneurysms were treated with CE at our institution. The inclusion criterion was extravasation or coil protrusion during CE. Postoperative data were used to confirm rupture points, and computational fluid dynamics (CFD) analysis was performed to assess hemodynamic characteristics, focusing on maximum pressure (Pmax) and wall shear stress (WSS). IPR occurred in six aneurysms (1.3%; three ruptured and three unruptured), with a dome size of 4.7 ± 1.8 mm and a D/N ratio of 1.5 ± 0.5. There were four aneurysms in the internal carotid artery (ICA), one in the anterior cerebral artery, and one in the middle cerebral artery. ICA aneurysms were treated using adjunctive techniques (three balloon-assisted, one stent-assisted). Two aneurysms (M1M2 and A1) were treated simply, yet had relatively small and misaligned domes. CFD analysis identified the rupture point as a flow impingement zone with Pmax in five aneurysms (83.3%). Time-averaged WSS was locally reduced around this area (1.3 ± 0.7 [Pa]), significantly lower than the aneurysmal dome (p < 0.01). Hemodynamically unstable areas have fragile, thin walls with rupture risk. A microcatheter was inserted along the inflow zone, directed towards the caution area. These findings underscore the importance of identifying hemodynamically unstable areas during CE. Adjunctive techniques should be applied with caution, especially in small aneurysms with axial misalignment, to minimize the rupture risk. Full article
(This article belongs to the Special Issue Advances in Cerebrovascular Imaging and Interventions)
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8 pages, 707 KiB  
Article
Dynamic Perviousness: A Novel Imaging Marker for Predicting Mechanical Thrombectomy Outcomes in Acute Ischemic Stroke
by Daniel F. Toth, Gergely Bertalan, Priska Heinz, Jawid Madjidyar, Patrick Thurner, Tilman Schubert and Zsolt Kulcsar
Diagnostics 2024, 14(11), 1197; https://doi.org/10.3390/diagnostics14111197 - 6 Jun 2024
Viewed by 453
Abstract
Background: The predictive value of thrombus standard perviousness (SP) in acute ischemic stroke (AIS) for the technical success rates of mechanical thrombectomy (MT) or functional outcomes is not yet conclusive. We investigated the relationship between dynamic perviousness (DP) and revascularization results using time-dependent [...] Read more.
Background: The predictive value of thrombus standard perviousness (SP) in acute ischemic stroke (AIS) for the technical success rates of mechanical thrombectomy (MT) or functional outcomes is not yet conclusive. We investigated the relationship between dynamic perviousness (DP) and revascularization results using time-dependent enhancement curve types determined with computed tomography (CT). Methods: A retrospective analysis of 137 AIS patients was performed. DP was calculated as the thrombus attenuation increase (TAI) using three time points and categorized into four groups: (1) no enhancement (CNE); (2) late enhancement (CLE); (3) early enhancement with washout (CW); (4) early enhancement without washout (CNW). Associations with the technical success rate and functional outcomes were assessed. Results: Late enhancement (CLE) had approximately two times higher odds for successful MT as compared to clots with other enhancement dynamics. The odds ratios (logistic regression model with CNW as the reference) for the TICI III scores were 4.04 (p = 0.067), 1.82 (p = 0.3), and 1.69 (p = 0.4) for CLE, CW, and CNE, respectively. The NIHSS scores at discharge and mRS scores at three months showed regression coefficients (linear regression model with CNW as reference) of −3.05 (p = 0.10), −1.17 (p = 0.51), and −1.24 (p = 0.47); and −1.30 (p = 0.097), −0.85 (p = 0.25), and −0.15 (p = 0.83) for CLE, CW, and CNE, respectively. Conclusions: Thrombi with late enhancement patterns showed a higher revascularization rate and better outcomes as compared to clots with early uptake or no washout. Full article
(This article belongs to the Special Issue Advances in Cerebrovascular Imaging and Interventions)
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12 pages, 1276 KiB  
Article
ABCD2-I Score Predicts Unplanned Emergency Department Revisits within 72 Hours Due to Recurrent Acute Ischemic Stroke
by Wei-Zhen Lu, Hui-An Lin, Sen-Kuang Hou and Sheng-Feng Lin
Diagnostics 2024, 14(11), 1118; https://doi.org/10.3390/diagnostics14111118 - 28 May 2024
Viewed by 535
Abstract
Background: the ABCD2 score is valuable for predicting early stroke recurrence after a transient ischemic attack (TIA), and Doppler ultrasound can aid in expediting stroke triage. The study aimed to investigate whether combining the ABCD2 score with carotid duplex results can enhance the [...] Read more.
Background: the ABCD2 score is valuable for predicting early stroke recurrence after a transient ischemic attack (TIA), and Doppler ultrasound can aid in expediting stroke triage. The study aimed to investigate whether combining the ABCD2 score with carotid duplex results can enhance the identification of early acute ischemic stroke after TIA. Methods: we employed a retrospective cohort design for this study, enrolling patients diagnosed with TIA who were discharged from the emergency department (ED). The modified ABCD2-I (c50) score, which incorporates a Doppler ultrasound assessment of internal carotid artery stenosis > 50%, was used to evaluate the risk of acute ischemic stroke within 72 h. Patients were categorized into three risk groups: low risk (with ABCD2 and ABCD2-I scores = 0–4), moderate risk (ABCD2 score = 4–5 and ABCD2-I score = 5–7), and high risk (ABCD2 score = 6–7 and ABCD2-I score = 8–9). Results: between 1 January 2014, and 31 December 2019, 1124 patients with new neurological deficits were screened, with 151 TIA patients discharged from the ED and included in the analysis. Cox proportional hazards analysis showed that patients in the high-risk group, as per the ABCD2-I (c50) score, were significantly associated with revisiting the ED within 72 h due to acute ischemic stroke (HR: 3.12, 95% CI: 1.31–7.41, p = 0.0102), while the ABCD2 alone did not show significant association (HR: 1.12, 95% CI: 0.57–2.22, p = 0.7427). Conclusion: ABCD2-I (c50) scores effectively predict early acute ischemic stroke presentations to the ED within 72 h after TIA. Full article
(This article belongs to the Special Issue Advances in Cerebrovascular Imaging and Interventions)
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14 pages, 3254 KiB  
Article
Radiomic Features of Acute Cerebral Hemorrhage on Non-Contrast CT Associated with Patient Survival
by Saif Zaman, Fiona Dierksen, Avery Knapp, Stefan P. Haider, Gaby Abou Karam, Adnan I. Qureshi, Guido J. Falcone, Kevin N. Sheth and Seyedmehdi Payabvash
Diagnostics 2024, 14(9), 944; https://doi.org/10.3390/diagnostics14090944 - 30 Apr 2024
Cited by 1 | Viewed by 909
Abstract
The mortality rate of acute intracerebral hemorrhage (ICH) can reach up to 40%. Although the radiomics of ICH have been linked to hematoma expansion and outcomes, no research to date has explored their correlation with mortality. In this study, we determined the admission [...] Read more.
The mortality rate of acute intracerebral hemorrhage (ICH) can reach up to 40%. Although the radiomics of ICH have been linked to hematoma expansion and outcomes, no research to date has explored their correlation with mortality. In this study, we determined the admission non-contrast head CT radiomic correlates of survival in supratentorial ICH, using the Antihypertensive Treatment of Acute Cerebral Hemorrhage II (ATACH-II) trial dataset. We extracted 107 original radiomic features from n = 871 admission non-contrast head CT scans. The Cox Proportional Hazards model, Kaplan–Meier Analysis, and logistic regression were used to analyze survival. In our analysis, the “first-order energy” radiomics feature, a metric that quantifies the sum of squared voxel intensities within a region of interest in medical images, emerged as an independent predictor of higher mortality risk (Hazard Ratio of 1.64, p < 0.0001), alongside age, National Institutes of Health Stroke Scale (NIHSS), and baseline International Normalized Ratio (INR). Using a Receiver Operating Characteristic (ROC) analysis, “the first-order energy” was a predictor of mortality at 1-week, 1-month, and 3-month post-ICH (all p < 0.0001), with Area Under the Curves (AUC) of >0.67. Our findings highlight the potential role of admission CT radiomics in predicting ICH survival, specifically, a higher “first-order energy” or very bright hematomas are associated with worse survival outcomes. Full article
(This article belongs to the Special Issue Advances in Cerebrovascular Imaging and Interventions)
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12 pages, 836 KiB  
Article
Could Phosphorous MR Spectroscopy Help Predict the Severity of Vasospasm? A Pilot Study
by Malik Galijasevic, Ruth Steiger, Stephanie Alice Treichl, Wing Man Ho, Stephanie Mangesius, Valentin Ladenhauf, Johannes Deeg, Leonhard Gruber, Miar Ouaret, Milovan Regodic, Lukas Lenhart, Bettina Pfausler, Astrid Ellen Grams, Ondra Petr, Claudius Thomé and Elke Ruth Gizewski
Diagnostics 2024, 14(8), 841; https://doi.org/10.3390/diagnostics14080841 - 18 Apr 2024
Viewed by 634
Abstract
One of the main causes of the dismal prognosis in patients who survive the initial bleeding after aneurysmal subarachnoidal hemorrhage is the delayed cerebral ischaemia caused by vasospasm. Studies suggest that cerebral magnesium and pH may potentially play a role in the pathophysiology [...] Read more.
One of the main causes of the dismal prognosis in patients who survive the initial bleeding after aneurysmal subarachnoidal hemorrhage is the delayed cerebral ischaemia caused by vasospasm. Studies suggest that cerebral magnesium and pH may potentially play a role in the pathophysiology of this adverse event. Using phosphorous magnetic resonance spectrocopy (31P-MRS), we calculated the cerebral magnesium (Mg) and pH levels in 13 patients who suffered from aSAH. The values between the group that developed clinically significant vasospasm (n = 7) and the group that did not (n = 6) were compared. The results of this study show significantly lower cerebral Mg levels (p = 0.019) and higher pH levels (p < 0.001) in the cumulative group (all brain voxels together) in patients who developed clinically significant vasospasm. Further clinical studies on a larger group of carefully selected patients are needed in order to predict clinically significant vasospasm. Full article
(This article belongs to the Special Issue Advances in Cerebrovascular Imaging and Interventions)
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13 pages, 1087 KiB  
Article
Radiomics-Based Prediction of Collateral Status from CT Angiography of Patients Following a Large Vessel Occlusion Stroke
by Emily W. Avery, Anthony Abou-Karam, Sandra Abi-Fadel, Jonas Behland, Adrian Mak, Stefan P. Haider, Tal Zeevi, Pina C. Sanelli, Christopher G. Filippi, Ajay Malhotra, Charles C. Matouk, Guido J. Falcone, Nils Petersen, Lauren H. Sansing, Kevin N. Sheth and Seyedmehdi Payabvash
Diagnostics 2024, 14(5), 485; https://doi.org/10.3390/diagnostics14050485 - 23 Feb 2024
Viewed by 1012
Abstract
Background: A major driver of individual variation in long-term outcomes following a large vessel occlusion (LVO) stroke is the degree of collateral arterial circulation. We aimed to develop and evaluate machine-learning models that quantify LVO collateral status using admission computed tomography angiography (CTA) [...] Read more.
Background: A major driver of individual variation in long-term outcomes following a large vessel occlusion (LVO) stroke is the degree of collateral arterial circulation. We aimed to develop and evaluate machine-learning models that quantify LVO collateral status using admission computed tomography angiography (CTA) radiomics. Methods: We extracted 1116 radiomic features from the anterior circulation territories from admission CTAs of 600 patients experiencing an acute LVO stroke. We trained and validated multiple machine-learning models for the prediction of collateral status based on consensus from two neuroradiologists as ground truth. Models were first trained to predict (1) good vs. intermediate or poor, or (2) good vs. intermediate or poor collateral status. Then, model predictions were combined to determine a three-tier collateral score (good, intermediate, or poor). We used the receiver operating characteristics area under the curve (AUC) to evaluate prediction accuracy. Results: We included 499 patients in training and 101 in an independent test cohort. The best-performing models achieved an averaged cross-validation AUC of 0.80 ± 0.05 for poor vs. intermediate/good collateral and 0.69 ± 0.05 for good vs. intermediate/poor, and AUC = 0.77 (0.67–0.87) and AUC = 0.78 (0.70–0.90) in the independent test cohort, respectively. The collateral scores predicted by the radiomics model were correlated with (rho = 0.45, p = 0.002) and were independent predictors of 3-month clinical outcome (p = 0.018) in the independent test cohort. Conclusions: Automated tools for the assessment of collateral status from admission CTA—such as the radiomics models described here—can generate clinically relevant and reproducible collateral scores to facilitate a timely treatment triage in patients experiencing an acute LVO stroke. Full article
(This article belongs to the Special Issue Advances in Cerebrovascular Imaging and Interventions)
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20 pages, 12103 KiB  
Article
Vertebro-Vertebral Arteriovenous Fistulae: A Case Series of Endovascular Management at a Single Center
by Pattarawit Withayasuk, Ritthikrai Wichianrat, Boonrerk Sangpetngam, Thaweesak Aurboonyawat, Ekawut Chankaew, Saowanee Homsud and Anchalee Churojana
Diagnostics 2024, 14(4), 414; https://doi.org/10.3390/diagnostics14040414 - 13 Feb 2024
Cited by 1 | Viewed by 879
Abstract
Objective: Vertebro-vertebral arteriovenous fistulae (VVFs) are a rare disorder characterized by a direct shunt between the extracranial vertebral artery and the veins of the vertebral venous plexus. This study aims to comprehensively review the characteristics and outcomes of endovascular treatments for VVFs at [...] Read more.
Objective: Vertebro-vertebral arteriovenous fistulae (VVFs) are a rare disorder characterized by a direct shunt between the extracranial vertebral artery and the veins of the vertebral venous plexus. This study aims to comprehensively review the characteristics and outcomes of endovascular treatments for VVFs at our center. Methods: A retrospective review was conducted on 14 patients diagnosed with a VVF who underwent endovascular treatment at Siriraj Hospital from January 2000 to January 2023. The study assessed patient demographics, presentation, fistula location, treatment strategies, endovascular techniques employed, and treatment outcomes. Results: Among the 14 patients, 11 (78.6%) were female, with an age range from 25 to 79 years (median: 50 years). Spontaneous VVFs were observed in 64.3% of the cases, including three associated with neurofibromatosis type 1 (NF-1). Iatrogenic injury accounted for two cases, and three patients had VVFs resulting from traffic accidents. A pulsatile neck mass and tinnitus, with or without neurological deficits, were common presenting symptoms. Active bleeding was observed in three cases with vascular injury, while unilateral proptosis, congestive heart failure, and incidental findings each presented in one patient. All the VVFs were successfully obliterated without major treatment complications. Parent vessel sacrifice was performed in 85.7% of the cases, while vertebral artery preservation was achieved in the remaining two patients. Embolic materials included detachable balloons, detachable coils, and n-butyl cyanoacrylate (NBCA) glue. All the presenting symptoms showed improvement, and no morbidity or mortality was observed. Conclusions: Endovascular embolization is a feasible and effective approach for achieving complete VVF obliteration with safety. Parent artery sacrifice should not be reluctantly performed, particularly when adequate collateral circulation is demonstrated. Full article
(This article belongs to the Special Issue Advances in Cerebrovascular Imaging and Interventions)
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14 pages, 1839 KiB  
Article
Time-Dependent Changes in Hematoma Expansion Rate after Supratentorial Intracerebral Hemorrhage and Its Relationship with Neurological Deterioration and Functional Outcome
by Gaby Abou Karam, Min-Chiun Chen, Dorin Zeevi, Bendix C. Harms, Victor M. Torres-Lopez, Cyprien A. Rivier, Ajay Malhotra, Adam de Havenon, Guido J. Falcone, Kevin N. Sheth and Seyedmehdi Payabvash
Diagnostics 2024, 14(3), 308; https://doi.org/10.3390/diagnostics14030308 - 31 Jan 2024
Viewed by 1084
Abstract
Background: Hematoma expansion (HE) following an intracerebral hemorrhage (ICH) is a modifiable risk factor and a treatment target. We examined the association of HE with neurological deterioration (ND), functional outcome, and mortality based on the time gap from onset to baseline CT. Methods: [...] Read more.
Background: Hematoma expansion (HE) following an intracerebral hemorrhage (ICH) is a modifiable risk factor and a treatment target. We examined the association of HE with neurological deterioration (ND), functional outcome, and mortality based on the time gap from onset to baseline CT. Methods: We included 567 consecutive patients with supratentorial ICH and baseline head CT within 24 h of onset. ND was defined as a ≥4-point increase on the NIH stroke scale (NIHSS) or a ≥2-point drop on the Glasgow coma scale. Poor outcome was defined as a modified Rankin score of 4 to 6 at 3-month follow-up. Results: The rate of HE was higher among those scanned within 3 h (124/304, 40.8%) versus 3 to 24 h post-ICH onset (53/263, 20.2%) (p < 0.001). However, HE was an independent predictor of ND (p < 0.001), poor outcome (p = 0.010), and mortality (p = 0.003) among those scanned within 3 h, as well as those scanned 3–24 h post-ICH (p = 0.043, p = 0.037, and p = 0.004, respectively). Also, in a subset of 180/567 (31.7%) patients presenting with mild symptoms (NIHSS ≤ 5), hematoma growth was an independent predictor of ND (p = 0.026), poor outcome (p = 0.037), and mortality (p = 0.027). Conclusion: Despite decreasing rates over time after ICH onset, HE remains an independent predictor of ND, functional outcome, and mortality among those presenting >3 h after onset or with mild symptoms. Full article
(This article belongs to the Special Issue Advances in Cerebrovascular Imaging and Interventions)
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