Predicting hematoma expansion after primary intracerebral hemorrhage

JAMA Neurol. 2014 Feb;71(2):158-64. doi: 10.1001/jamaneurol.2013.5433.


Importance: Many clinical trials focus on restricting hematoma expansion following acute intracerebral hemorrhage (ICH), but selecting those patients at highest risk of hematoma expansion is challenging.

Objective: To develop a prediction score for hematoma expansion in patients with primary ICH.

Design, setting, and participants: Prospective cohort study at 2 urban academic medical centers among patients having primary ICH with available baseline and follow-up computed tomography for volumetric analysis (817 patients in the development cohort and 195 patients in the independent validation cohort).

Main outcomes and measures: Hematoma expansion was assessed using semiautomated software and was defined as more than 6 mL or 33% growth. Covariates were tested for association with hematoma expansion using univariate and multivariable logistic regression. A 9-point prediction score was derived based on the regression estimates and was subsequently tested in the independent validation cohort.

Results: Hematoma expansion occurred in 156 patients (19.1%). In multivariable analysis, predictors of expansion were as follows: warfarin sodium use, the computed tomography angiography spot sign, and shorter time to computed tomography (≤ 6 vs >6 hours) (P < .001 for all), as well as baseline ICH volume (<30 [reference], 30-60 [P = .03], and >60 [P = .005] mL). The incidence of hematoma expansion steadily increased with higher scores. In the independent validation cohort (n = 195), our prediction score performed well and showed strong association with hematoma expansion (odds ratio, 4.59; P < .001 for a high vs low score). The C statistics for the score were 0.72 for the development cohort and 0.77 for the independent validation cohort.

Conclusions and relevance: A 9-point prediction score for hematoma expansion was developed and independently validated. The results open a path for individualized treatment and trial design in ICH aimed at patients at highest risk of hematoma expansion with maximum potential for therapeutic benefit.

Publication types

  • Multicenter Study
  • Research Support, N.I.H., Extramural

MeSH terms

  • Aged
  • Aged, 80 and over
  • Cerebral Hemorrhage / diagnostic imaging*
  • Cerebral Hemorrhage / epidemiology*
  • Cohort Studies
  • Female
  • Follow-Up Studies
  • Hematoma, Subdural, Intracranial / diagnostic imaging*
  • Hematoma, Subdural, Intracranial / epidemiology*
  • Humans
  • Male
  • Middle Aged
  • Prospective Studies
  • Radiography