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Independent Validation of the Hematoma Expansion Prediction Score: A Non-contrast Score Equivalent in Accuracy to the Spot Sign

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An Invited Editorial Commentary to this article was published on 03 June 2019

Abstract

Background and Purpose

The computed tomography angiography (CTA) spot sign is widely used to assess the risk of hematoma expansion following acute intracerebral hemorrhage (ICH). However, not all patients can receive intravenous contrast nor are all hospital systems equipped with this technology. We aimed to independently validate the Hematoma Expansion Prediction (HEP) Score, an 18-point non-contrast prediction scale, in an external cohort and compare its diagnostic capability to the CTA spot sign.

Methods

We performed a retrospective analysis of the predicting hematoma growth and outcome in intracerebral hemorrhage using contrast bolus CT (PREDICT) Cohort Study. Primary outcome was significant hematoma expansion (≥ 6 mL or ≥ 33%). We generated a receiver operating characteristic (ROC) curve comparing the HEP score to significant expansion. We calculated sensitivity, specificity, positive and negative predictive values (PPV/NPV) for each score point. We determined independent predictors of significant hematoma expansion via logistic regression.

Results

A total of 292 patients were included in primary analysis. Hematoma growth of ≥ 6 mL or ≥ 33% occurred in 94 patients (32%). The HEP score was associated with significant expansion (adjusted odds ratio [aOR] 1.14, 95% confidence interval [CI] 1.01–1.30). ROC curves comparing HEP score to significant expansion had an area under the curve of 0.64 (95% CI 0.57–0.71). Youden’s method showed an optimum score of 4. HEP Scores ≥ 4 (n = 100, sensitivity 49%, specificity 73%, PPV 46%, NPV 75%, aOR 1.99, 95% CI 1.09–3.64) accurately predicted significant expansion. PPV increased with higher HEP scores, but at the cost of lower sensitivity. The diagnostic characteristics of the spot sign (n = 82, Sensitivity 49%, Specificity 81%, PPV 55%, NPV 76%, aOR 2.95, 95% CI 1.61–5.42) were similar to HEP scores ≥ 4.

Conclusion

The HEP score is predictive of significant expansion (≥ 6 mL or ≥ 33%) and is comparable to the spot sign in diagnostic accuracy. Non-contrast prediction tools may have a potential role in the recruitment of patients in future intracerebral hemorrhage trials.

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Funding

There was no support for this work.

Author information

Author notes

  1. Cheemun Lum: Deceased.

Authors and Affiliations

  1. Ottawa Stroke Program, Division of Neurology, Department of Medicine (Neurology), University of Ottawa, Rome C2182, The Ottawa Hospital: Civic Campus, 1053 Carling Avenue, Ottawa, ON, K1Y4E9, Canada

    Vignan Yogendrakumar & Dar Dowlatshahi

  2. Ottawa Methods Center, University of Ottawa, Ottawa, Canada

    Tim Ramsay & Dean A. Fergusson

  3. Ottawa Hospital Research Institute, University of Ottawa, Ottawa, Canada

    Tim Ramsay, Dean A. Fergusson & Dar Dowlatshahi

  4. Calgary Stroke Program, Department of Clinical Neurosciences, Department of Radiology, Hotchkiss Brain Institute, University of Calgary, Calgary, Canada

    Andrew M. Demchuk & Michael D. Hill

  5. Division of Neuroradiology and Department of Medical Imaging, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Canada

    Richard I. Aviv

  6. Department of Neurology, Hospital Universitari Vall d’Hebron, Barcelona, Spain

    David Rodriguez-Luna & Carlos A. Molina

  7. Department of Neurology, Dr. Josep Trueta University Hospital, Institut d’Investigació Biomèdica Girona (IDIBGi) Foundation, Girona, Spain

    Yolanda Silva Blas

  8. Department of Neurology, Elblandklinikum Meissen Academic Teaching Hospital of the Technische University, Dresden, Germany

    Imanuel Dzialowski

  9. 2nd Department of Neurology, Institute of Psychiatry and Neurology, Warsaw, Poland

    Adam Kobayashi

  10. Department of Experimental and Clinical Pharmacology, Institute of Psychiatry and Neurology, Warsaw, Poland

    Adam Kobayashi

  11. Department of Medicine, Charles LeMoyne Hospital, University of Sherbrooke, Longueuil, Canada

    Jean-Martin Boulanger

  12. Department of Diagnostic Imaging (Neuroradiology Section), University of Ottawa, Ottawa, Canada

    Cheemun Lum

  13. Department of Neurology, Dalhousie University, Halifax, Canada

    Gord Gubitz

  14. Department of Neurology, All India Institute of Medical Sciences, New Delhi, India

    Padma Srivastava & Rohit Bhatia

  15. Apollo Gleneagles Hospitals, Kolkata, India

    Jayanta Roy

  16. Department of Neurology, Boston Medical Center, Boston, USA

    Carlos S. Kase

  17. Department of Neurology, Beth Israel Deaconess Medical Centre, Boston, USA

    Magdy Selim

Authors
  1. Vignan Yogendrakumar
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  2. Tim Ramsay
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  3. Dean A. Fergusson
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  6. David Rodriguez-Luna
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  19. Magdy Selim
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  20. Dar Dowlatshahi
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Consortia

the PREDICT/Sunnybrook CTA Study Group

Contributions

This manuscript complies with the instructions provided by Neurocritical Care. All authors meet the requirements for authorship. Their roles and contributions to this manuscript are listed below: VY and DD were involved in protocol/project development, data analysis, and manuscript writing/editing. TR contributed to data analysis and manuscript writing/editing. AMD, RIA, DR-L, CAM, YSB, ID, AK, J-MB, CL, GG, PS, JR, CSK, RB were involved in data collection or management. MDH contributed to data collection or management and manuscript writing/editing. DF contributed to manuscript writing/editing. MS was involved in protocol/project development and manuscript writing/editing.

Corresponding author

Correspondence to Vignan Yogendrakumar.

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Conflicts of Interest

Andrew M. Demchuk reports grants from NovoNordisk Canada, during the conduct of the study; Jean-Martin Boulanger reports other from Pfizer, other from Novartis, outside the submitted work; Cheemun Lum has deceased; Michael D. Hill reports personal fees from Merck, non-financial support from Hoffmann-La Roche Canada Ltd, grants from Covidien (Medtronic), grants from Boehringer-Ingleheim, grants from Stryker Inc., grants from Medtronic LLC, grants from NoNO Inc., outside the submitted work; In addition, Hill has a patent Systems and Methods for Assisting in Decision-Making and Triaging for Acute Stroke Patients pending to US Patent office Number: 62/086,077 and owns stock in Calgary Scientific Incorporated, a company that focuses on medical imaging software, is a director of the Canadian Federation of Neurological Sciences, a not-for-profit group and has received grant support from Alberta Innovates Health Solutions, CIHR, Heart & Stroke Foundation of Canada, National Institutes of Neurological Disorders and Stroke; Magdy Selim reports grants from NIH/NINDS, during the conduct of the study and the remaining authors have nothing to disclose.

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Local research ethics board approval was obtained at all enrolling sites, and written informed consent was obtained from all participants.

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Yogendrakumar, V., Ramsay, T., Fergusson, D.A. et al. Independent Validation of the Hematoma Expansion Prediction Score: A Non-contrast Score Equivalent in Accuracy to the Spot Sign. Neurocrit Care 31, 1–8 (2019). https://doi.org/10.1007/s12028-019-00740-5

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