Abstract 105: Diagnostic Accuracy of MRI in Spontaneous Intra-cerebral Hemorrhage (DASH) - Final Results
Authors: Wijman Christine A , Snider Ryan W , Venkatasubramanian Chitra , Finley-Caulfield Anna , Buckwalter Marion , Eyngorn Irina , Fischbein Nancy , Gean Alisa D , Hanley Daniel F , Kase Carlos S , Kleinman Jonathan T , Schwartz Neil E , Lansberg Maarten G , Albers Gregory W , Mlynash Michael , Kemp Stephanie , Thai Demi , Narayana Rashmi , Marks Michael , Bammer Roland , Moseley Michael 
Published: March 2022

Background:
The optimal diagnostic evaluation for patients with a spontaneous intracerebral hemorrhage (ICH) or intraventricular hemorrhage (IVH) remains controversial. We aimed to assess the utility of early magnetic resonance imaging (MRI) in the diagnosis and management of these patients.

Methods:
Consecutive patients with spontaneous ICH or IVH were prospectively enrolled in this NIH funded study. Patients were excluded if they had a known (pre-existing) ICH source, a known inability to undergo MRI (e.g. pacemaker) or a Glasgow coma scale score ≤5. In addition to non-contrast brain CT and laboratory testing (including a toxicology screen and EKG), patients underwent gadolinium-enhanced MRI/MRA. Catheter angiography was pursued if the patient met pre-specified criteria. Survivors returned for a 90 day follow-up clinic visit with a repeat MRI. Based on clinical admission data and the initial head CT a presumed ICH cause was assigned by the treating neurocritical care/stroke neurologist. A choice was made out of 12 pre-specified etiologies. After subsequent review of the MRI, the neurologist was given the opportunity to modify the presumed ICH cause. The ‘gold standard’ ICH etiology was determined by a panel of two outside, independent and blinded ICH clinician experts after review of the complete medical record, first without the MRI results, reference standard 1 (RS1), and then with the MRI results, reference standard 2 (RS2). Changes in diagnostic category, diagnostic confidence and management were systematically recorded. The diagnostic yield of MRI was determined for each of the 12 diagnostic categories.

Results:
180 consecutive patients were prospectively enrolled. All patients underwent at least one MRI. No adverse events occurred during MRI acquisition. In 20 patients the MRI was obtained after surgical hematoma evacuation. Mean age was 62±17 years, 47% were female, and 71% had a history of hypertension. Median (IQR) GCS was 14 (10-15). Median and mean ICH volumes were 12 mL (4-35) and 24 (±28) mL. Hematoma location was lobar in 46% and deep in 39% of patients; 43% had associated IVH. Based on RS2, the final ICH diagnosis was hypertension in 44% and cerebral amyloid angiopathy in 13% of patients. MRI led to a change in diagnostic category in 14% of patients using RS1 as the reference, and 18% using RS2. MRI resulted in an improvement in diagnostic confidence in an additional 23% and 26% of patients, respectively. Management was changed in 13% of patients. Within diagnostic categories, the yield of MRI was highest for establishing diagnoses of ICH secondary to cerebral venous thrombosis (56%), ischemic stroke with hemorrhagic transformation (43%), cerebral amyloid angiopathy (35%), neoplasms (33%), and vascular malformations (31%).

Conclusions:
The results of this study demonstrate substantial additive clinical benefit of early routine MRI in patients with spontaneous ICH and/or IVH.