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Progressing haemorrhagic stroke: categories, causes, mechanisms and managements.

Chen S, Zeng L, Hu Z - J. Neurol. (2014)

Bottom Line: Haematoma expansion, intraventricular haemorrhage, perihaematomal oedema, and inflammation, can all cause an acute progression of haemorrhagic stroke.Specific 'second peak' of perihaematomal oedema after intracerebral haemorrhage and 'tension haematoma' are the primary causes of subacute progression.For the chronic progressing haemorrhagic stroke, the occult vascular malformations, trauma, or radiologic brain surgeries can all cause a slowly expanding encapsulated haematoma.

View Article: PubMed Central - PubMed

Affiliation: Department of Neurology, Xiangya Second Hospital, Central South University, 139 Renmin Road, Changsha, 410011, Hunan, People's Republic of China.

ABSTRACT
Haemorrhagic stroke is a severe stroke subtype with high rates of morbidity and mortality. Although this condition has been recognised for a long time, the progressing haemorrhagic stroke has not received adequate attention, and it accounts for an even worse clinical outcome than the nonprogressing types of haemorrhagic stroke. In this review article, we categorised the progressing haemorrhagic stroke into acute progressing haemorrhagic stroke, subacute haemorrhagic stroke, and chronic progressing haemorrhagic stroke. Haematoma expansion, intraventricular haemorrhage, perihaematomal oedema, and inflammation, can all cause an acute progression of haemorrhagic stroke. Specific 'second peak' of perihaematomal oedema after intracerebral haemorrhage and 'tension haematoma' are the primary causes of subacute progression. For the chronic progressing haemorrhagic stroke, the occult vascular malformations, trauma, or radiologic brain surgeries can all cause a slowly expanding encapsulated haematoma. The mechanisms to each type of progressing haemorrhagic stroke is different, and the management of these three subtypes differs according to their causes and mechanisms. Conservative treatments are primarily considered in the acute progressing haemorrhagic stroke, whereas surgery is considered in the remaining two types.

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Haematoma heterogeneity and haematoma growth border. These two patients were admitted to our hospital with the impression of spontaneous ICH. Patient 1: a CT on admission shows haematoma heterogeneity with an initial haematoma volume of 15 mL. b Repeated CT after 32 h shows a haematoma volume of 30 mL. Patient 2: c CT on admission shows haematoma growth border (black arrow). d Repeated CT after 10 h shows haematoma expansion with increased midline shift
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Fig3: Haematoma heterogeneity and haematoma growth border. These two patients were admitted to our hospital with the impression of spontaneous ICH. Patient 1: a CT on admission shows haematoma heterogeneity with an initial haematoma volume of 15 mL. b Repeated CT after 32 h shows a haematoma volume of 30 mL. Patient 2: c CT on admission shows haematoma growth border (black arrow). d Repeated CT after 10 h shows haematoma expansion with increased midline shift

Mentions: However, although ASA/AHA recommended CTA or contrast CT to identify the patients at risk for haematoma expansion [122], neither of them is a routinely performed examination at the time of hospital admission in many institutions. Haematoma density heterogeneity could be a substitute for the prediction of haematoma expansion. Haematoma heterogeneity refers to the irregularity of shape and density of the initial haematoma on the CT scan, and researchers have found an association between haematoma heterogeneity and haematoma expansion [13, 81]. Takeda et al. [159] concluded that the presence of haematoma volume above 16 mL, haematoma heterogeneity and 1.5 h of a systolic blood pressure above 160 mmHg together increased the likelihood of haematoma expansion to approximately 59 %. Although its definition was traditionally arbitrary, Ji et al. [81] defined the haematoma heterogeneity as a difference of over 20 HU in CT value between two regions exceeding 10 mm2 in area. Barras et al. used quantitative CT densitometry to measure mean attenuation, square root of variance, coefficient of variation, skewness and kurtosis of the attenuation distribution of the haematoma; they found that the coefficient of variation and the square root of variance, along with the basic haematoma volume, are predictors of greater growth. They suggested that quantitative CT densitometry can be used to identify haematoma heterogeneity [12]. Additionally, Ji et al. described a characteristic ‘haematoma enlargement border’, which was defined as an obvious boundary between high- and low-density regions within the primary haematoma on the CT. The haematoma enlargement border reflects on-going bleeding and its presence may be associated with potential haematoma expansion [81] (Fig. 3).Fig. 3


Progressing haemorrhagic stroke: categories, causes, mechanisms and managements.

Chen S, Zeng L, Hu Z - J. Neurol. (2014)

Haematoma heterogeneity and haematoma growth border. These two patients were admitted to our hospital with the impression of spontaneous ICH. Patient 1: a CT on admission shows haematoma heterogeneity with an initial haematoma volume of 15 mL. b Repeated CT after 32 h shows a haematoma volume of 30 mL. Patient 2: c CT on admission shows haematoma growth border (black arrow). d Repeated CT after 10 h shows haematoma expansion with increased midline shift
© Copyright Policy - OpenAccess
Related In: Results  -  Collection

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Fig3: Haematoma heterogeneity and haematoma growth border. These two patients were admitted to our hospital with the impression of spontaneous ICH. Patient 1: a CT on admission shows haematoma heterogeneity with an initial haematoma volume of 15 mL. b Repeated CT after 32 h shows a haematoma volume of 30 mL. Patient 2: c CT on admission shows haematoma growth border (black arrow). d Repeated CT after 10 h shows haematoma expansion with increased midline shift
Mentions: However, although ASA/AHA recommended CTA or contrast CT to identify the patients at risk for haematoma expansion [122], neither of them is a routinely performed examination at the time of hospital admission in many institutions. Haematoma density heterogeneity could be a substitute for the prediction of haematoma expansion. Haematoma heterogeneity refers to the irregularity of shape and density of the initial haematoma on the CT scan, and researchers have found an association between haematoma heterogeneity and haematoma expansion [13, 81]. Takeda et al. [159] concluded that the presence of haematoma volume above 16 mL, haematoma heterogeneity and 1.5 h of a systolic blood pressure above 160 mmHg together increased the likelihood of haematoma expansion to approximately 59 %. Although its definition was traditionally arbitrary, Ji et al. [81] defined the haematoma heterogeneity as a difference of over 20 HU in CT value between two regions exceeding 10 mm2 in area. Barras et al. used quantitative CT densitometry to measure mean attenuation, square root of variance, coefficient of variation, skewness and kurtosis of the attenuation distribution of the haematoma; they found that the coefficient of variation and the square root of variance, along with the basic haematoma volume, are predictors of greater growth. They suggested that quantitative CT densitometry can be used to identify haematoma heterogeneity [12]. Additionally, Ji et al. described a characteristic ‘haematoma enlargement border’, which was defined as an obvious boundary between high- and low-density regions within the primary haematoma on the CT. The haematoma enlargement border reflects on-going bleeding and its presence may be associated with potential haematoma expansion [81] (Fig. 3).Fig. 3

Bottom Line: Haematoma expansion, intraventricular haemorrhage, perihaematomal oedema, and inflammation, can all cause an acute progression of haemorrhagic stroke.Specific 'second peak' of perihaematomal oedema after intracerebral haemorrhage and 'tension haematoma' are the primary causes of subacute progression.For the chronic progressing haemorrhagic stroke, the occult vascular malformations, trauma, or radiologic brain surgeries can all cause a slowly expanding encapsulated haematoma.

View Article: PubMed Central - PubMed

Affiliation: Department of Neurology, Xiangya Second Hospital, Central South University, 139 Renmin Road, Changsha, 410011, Hunan, People's Republic of China.

ABSTRACT
Haemorrhagic stroke is a severe stroke subtype with high rates of morbidity and mortality. Although this condition has been recognised for a long time, the progressing haemorrhagic stroke has not received adequate attention, and it accounts for an even worse clinical outcome than the nonprogressing types of haemorrhagic stroke. In this review article, we categorised the progressing haemorrhagic stroke into acute progressing haemorrhagic stroke, subacute haemorrhagic stroke, and chronic progressing haemorrhagic stroke. Haematoma expansion, intraventricular haemorrhage, perihaematomal oedema, and inflammation, can all cause an acute progression of haemorrhagic stroke. Specific 'second peak' of perihaematomal oedema after intracerebral haemorrhage and 'tension haematoma' are the primary causes of subacute progression. For the chronic progressing haemorrhagic stroke, the occult vascular malformations, trauma, or radiologic brain surgeries can all cause a slowly expanding encapsulated haematoma. The mechanisms to each type of progressing haemorrhagic stroke is different, and the management of these three subtypes differs according to their causes and mechanisms. Conservative treatments are primarily considered in the acute progressing haemorrhagic stroke, whereas surgery is considered in the remaining two types.

Show MeSH
Related in: MedlinePlus