This study compared changes in apparent diffusion coefficients (ADCs) between patients treated with minimally invasive surgery plus recombinant tissue-type plasminogen activator (rt-PA) versus standard medical care alone for intracerebral hemorrhage. The surgical group had significantly lower hematoma volumes and median ADC values one week post-treatment compared to baseline, suggesting reduced blood-brain barrier disruption and edema formation. In contrast, the medical group saw an increase in median ADC values over the same time period. These results provide further evidence that clot removal may help interrupt processes leading to perihematomal edema.

1. Impact of Blood Removal on Perihematomal Apparent Diffusion Coefficients in Patients
Treated with Minimally Invasive Surgery plus rt-PA
W. Andrew Mould*; Braeden Lovett*; John Muschelli; Daniel F. Hanley, MD; J. Ricardo Carhuapoma, MD
Department of Neurology, Division of Brain Injury Outcomes, Johns Hopkins Medical Institutions, Baltimore MD, USA
* Contributed equally
Introduction
Disclosures
Methods
Results
Conclusion
• Perihematomal edema (PHE) has been shown to be an important predictor of
functional outcome in hemorrhagic stroke patients.
• PHE is characterized by various inflammatory processes that disrupt the blood-brain
barrier (BBB).
• Minimally Invasive Surgery (MIS) and recombinant tissue-type plasminogen activator
(rt-PA) administration have been shown to reduce both hematoma and PHE volume.1
• The Apparent Diffusion Coefficient (ADC) is a useful indicator of BBB disruption, and
in turn, PHE formation.
• Previous reports have indicated that PHE formation is associated with an elevated
ADC when compared to that of the homologous, contralateral region.2,3,4
• We hypothesized that hematoma removal will result in lower ADC values when
compared to patients receiving standard medical care alone.
• Time between T1 and T2 was similar between surgical, 7.28(1.68)
days, and medical patients, 6.91(0.84) days (p=0.49) .
• T1 hematoma volume was similar between cohorts: surgical, 41.9
(±17.9) cc, and medical, 35.2 (±14.3) cc (p=0.32).
• T2 hematoma volume was significantly lower in surgically treated
patients, 15.2 (±8.9) cc, when compared to patients receiving
standard medical care, 32.3 (±10.3) cc (p<0.001).
• Median change in average ADC: surgical, a decrease of 30.5
mm2/sec, and medical, an increase of 75.7 mm2/sec (p=0.004).
• A reduction in ADC seen in the surgical cohort compared to the
increase seen in the medical cohort suggests that MIS plus rt-PA
interrupts BBB breakdown thereby mitigating edema formation.
• This research provides further insight into the potential benefits
of clot removal using the MISTIE procedure.
Figure 1. Manual segmentation of total lesion on FLAIR (Red)
Manual segmentation of hematoma on GRE (Yellow)
Automatic segmentation of PHE on ADC (Blue)
• 14 surgical and 10 medical
patients from the two-stage-trial,
Minimally Invasive Surgical
Techniques for Intracerebral
Hemorrhage Evacuation (MISTIE
II), were eligible for this analysis.
• FLAIR and GRE sequences were
collected at baseline (T1) and at
one-week (T2) post ictus to
delineate total lesion (hematoma +
PHE) and hematoma alone.
• PHE region of interest (ROI) on
ADC map generated by subtracting
the GRE ROI from the FLAIR ROI.
• Mean ADC values calculated
automatically using OsiriX
MISTIE is sponsored by NINDS, R01NS046309 and donations from
Genentech Inc. & Codman Inc.
Figure 2 : ICH
volume at baseline
(T1) and one week
(T2) for surgical and
medical cohorts.
Figure 3 : ADC
values for medical
cohort at T1 and T2
Figure 4 : ADC
values for Surgical
cohort at T1 and T2
References
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1. Mould W.A., Carhuapoma J.R.; Muschelli J.; Lane, K. et al. Minimally invasive surgery plus recombinant
tissue-type plasminogen activator for intracerebral hemorrhage evacuation decreases perihematomal
edema. Stroke 2013;44:627-634.
2. Carhuapoma J.R., Barker P.B., Hanley D.F., Wang P., and Beauchamp, N.J. Human brain hemorrhage:
Quantification of perihematoma edema by use of diffusion-weighted MR imaging. ANJR Am. J. Neuroradiol.
2002;23:1322–1326.
3. Olivot J., Mlynash MD, Kleinman BA, Straka M. et al. MRI profile of the perihematomal region in acute
intracerebral hemorrhage. Stroke, 2010;41;2681-2683.
4. Forbes K.P.; Pipe, J.G.; Heiserman, J.E. Diffusion-weighted imagiving provides support for secondary
neuronal damage from intraparenchymal hematoma. Neuroradiology, 2003;45:363-367.
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