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Background and Purpose— Early hematoma expansion (EHE) in patients with intracerebral hematoma is a promising treatment target. To date, the time course of EHE has remained poorly described. We prospectively investigated the time course of EHE. Methods— We included consecutive patients presenting spontaneous intracerebral hematoma within 4.5 hours. On admission, patients underwent noncontrast computed tomography (CT) and CT angiography. Serial hematoma volume estimations by transcranial B-mode ultrasound were effected through the contralateral transtemporal bone window by obtaining sagittal, transversal, and coronal diameter and calculating the ABC/2-formula. National Institute of Health Stroke Scale and transcranial B-mode ultrasound were performed consecutively every 30 minutes during the first 6 hours and from 6 to 12 hours every 2 hours. Follow-up CT and ultrasound were performed after ≈24 hours. Results— Twenty-five patients with intracerebral hematoma were included; mean (SD) time from onset to CT was 108.6 (45.7) minutes. Ten (40%) patients had EHE. In patients with a final clinically significant hematoma expansion >12.5 mL, all EHE occurred within 6 hours after admission scan. EHE in spot sign positive patients continued during the first 5 hours after CT angiography. In spot sign–negative patients, no significant EHE was observed (Friedman test, P =0.476). Neurological deterioration occurred in 5 (20%) patients and was well temporally correlated with EHE. Transcranial B-mode ultrasound demonstrated good volume estimation compared with the follow-up CT with a maximum absolute volume deviation within 7 mL and minimal systematic error (mean deviation, 1.3 [confidence interval, −0.1 to 2.6] mL). Conclusions— EHE was reliably reflected by transcranial B-mode ultrasound and mainly occurred within the first 7 to 8 hours after symptom onset. Clinical Trial Registration— URL: http://www.clinicaltrials.gov . Unique identifier: NCT01472224.

Introduction: The issue if Computer Tomography (CT) or Magnetic Resonance Imaging (MRI) are ‘best’ in evaluation of patients with symptoms of acute stroke prior to intravenous-tissue-plasminogen-activator treatment (iv-tPA) has been widely discussed; CT-based door-to-needle-times of 20 minutes are feasible and motivated by time-dependent efficacy of iv-tPA, but the more time consuming MRI-based evaluation likely provides additional information on hyper-acute cerebral ischemia and iv-tPA-contraindicating stroke mimicking pathology. Aim: The aim of this study was to compare the delay of iv-tPA-treatment and the level of diagnostic information obtained for patients randomized to CT and MRI-based acute stroke evaluation. Method: Three-hundred-sixty-nine consecutive patients admitted with symptoms of stroke within 4.5 hours from symptom-onset were quasi-randomized to CT or MRI-based evaluation as part of an ongoing single-center trial and treated with iv-tPA if eligible. Door-to-needle-times for patients, allocated to CT and MRI, were compared. Imaging of diagnostic quality and stroke mimicking detected pathology were registered for the two modalities. Results: Door-to-needle-times for CT evaluated patients (median 26 (7-55) min) were significantly faster than for MRI-examined patients (median 36 (11-71) min), p=0.007. Imaging of adequate diagnostic quality was acquired for all patients examined with CT and for 96.4% of patients, without inherent MRI-contraindications, examined with MRI. All patients with discharge diagnoses of intracerebral hemorrhage and intracerebral oncological pathology were identified by the primary scan at admission, regardless if CT or MRI were performed. Conclusion: CT-based evaluation prior to iv-tPA-treatment is faster and as presice as MRI-based evaluation of patients with acute stroke.

Background: Studies have reported neurological detoriation at 24 hours in 20- 40% of patients with symptoms of ischemic stroke. Aim: To asses the frequency of neurological deterioration in patients after fibrinolysis. Methods: A prospective single hospital registry was based on 481 unselected consecutive patients admitted from July 2009- December 2011 with symptoms of acute ischemic stroke within 4.5 hours from symptom onset. Patients fulfilling international guidelines were treated with i.v tPA. Clinical status was assessed by National Institute of Health Stroke Scale (NIHSS) and Computerized Tomography was conducted at admission in all 481 patients and at 24 hours in patients treated with i.v tPA to assess neurological as well as radiological status. Patients were stratified as having neurological deterioration of 1, 2, 3 or > 3 NIHSS points. Results: Three-hundred and twenty three (67.2%) of the admitted stroke patients were treated with i.v tPA (median NIHSS 7, 1-42). At 24 hours, neurological detoriation was observed in 24 of the treated patients (7.4 %) (ΔNIHSS median +2; 1-9). Eleven patients had ΔNIHSS=+1, 3 patients had ΔNIHSS=+2, 4 patients had ΔNIHSS=+3 and 6 patients had ΔNIHSS>+3.Any degree of haemorrhagic transformation was detected in 28 (8.7 %) of the patients treated with i.v tPA (median ΔNIHSS -1.5; -10 - +4), of which 3 were symptomatic (0.9%) (median ΔNIHSS +2, 1-4). Neurological deterioration occurred significantly more often in patients admitted with moderat-severe stroke (p=0.003) and in patients with large vessel occlusions (p=0.041). Conclusion: The neurological deterioration observed in patients treated with i.v tPA was modest and less frequent than previous reported in patients with symptoms of acute stroke prior to general implementation of thrombolysis. Deteriation due to haemorrhagic transformation was rare and of limited scale in this population. If this phenomena is due to better care, selection of patients for treatment in accordance with international guidelines or due to an unknown effect caused by tPA is uncertain.

Background: Spot sign on computed tomography angiography (CTA) is a marker of on-going bleeding and poor outcome in ICH patients. CTA is not as widely available as non-contrast CT (NCCT). The swirl sign is a less well described marker of on-going bleeding on NCCT. We investigated, if the swirl sign can predict spot sign on CTA and as well as its ability to predict poor outcome in ultra-early ICH patients. Method: We included 137 patients with spontaneous ICH admitted within 4.5 hours from symptom onset from April 2009 to January 2013. Standard work up included NCCT and CTA. The swirl sign on NCCT was defined as regions of hypo- or isodensity located within the hyperdens haematoma with brain parenchyma as reference. Modified Rankin Scale (mRS) was assessed at 3 months (out-patient clinic or by telephone). Results: Of the 35 (25.5%) patients with a swirl sign on NCCT, 27 (77%) also had spot sign on CTA. This yields a high specificity and negative predictive value (0.92 and 0.86 respectably) and a slightly lower sensitivity and positive predictive value (0.66 and 0.77 respectably). The swirl sign emerged as a highly significant predictor of the spot sign (OR 15.5 CI: 5.6-42.8), adjusted for admission haematoma volume and time to scan. Swirl sign was associated with poorer median [IQR] outcome after 3 months (5 [4-6] vs. 3 [2-5], p < 0.0001). Swirl sign was an independent predictor of poor outcome (mRS 5-6) (OR 3.28 CI: 1.15-9.34) adjusted for age, admission NIHSS, and admission haematoma volume. The presence of both spot and swirl sign did not add to the prediction of poor outcome. Conclusion: Swirl sign is a valid marker for the presence of spot sign. The swirl sign entails poor outcome irrespective of other independent predictors. Further studies are needed to evaluate the value of the swirl sign in clinical decision-making and trials.