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Intracerebral
Hemorrhage (ICH)
Understanding the CT imaging
features for development of deep
learning networks, ranging from
restoration, segmentation,
prognosis and prescriptive
purposes
Petteri Teikari, PhD
High-dimensionalNeurology,Queen’sSquareof
Neurology,UCL,London
https://www.linkedin.com/in/petteriteikari/
Version “06/10/20“
Forwhoisthis“literaturereview
forvisuallyorientatedpeople”
for?
”A bitofeverythingrelatedto headCT
deeplearning,focusedonintracerebral
hemorrhage(ICH) analysis”
Itisassumedthatthereader isfamiliar
with deeplearning/computervision, but
lessso withcomputerizedtomography
(CT)andICH
https://www.linkedin.com/in/andriyburkov
WhatisICH?
”hemorrhagic stroke”
SpontaneousIntracerebralHemorrhage(ICH)
https://www.grepmed.com/images/4925/intracerebral-suba
rachnoid-hemorrhage-comparison-diagnosis-neurology-ep
idural
http://doi.org/10.13140/RG.2.1.1572.8167
”HemorrhagicStroke” , lesscommon than ischemic stroke, the “layman definition” of stroke
“Spontaneous”, asin opposed to, traumaticbrain hemorrhage caused bya blowto the head (“traumatic brain injury”, TBI)
https://www.strokeinfo.org/stroke-treatme
nts-hemorrhagic-stroke/
https://mc.ai/building-an-algorithm-to-detect-differe
nt-types-of-intracranial-brain-hemorrhage-using-de
ep/
https://mayfieldclinic.com/pe-ich.htm
https://aneskey.com/intracerebral-hemorrhagic-stroke/
TheICHBasics fromAnesthesiaKey
Thetypicalhemorrhagelocation
basedonetiology
Primarymechanicalinjury → Secondaryinjuries
PathophysiologicalMechanismsand PotentialTherapeutic
TargetsinIntracerebralHemorrhage
ZhiweiShao etal.(FrontPharmacol.2019; 10: 1079,Sept2019)
https://dx.doi.org/10.3389%2Ffphar.2019.01079
Intracerebral hemorrhage (ICH) is a subtype of hemorrhagic stroke with high mortality
and morbidity. The resulting hematoma within brain parenchyma induces a series of
adverse events causing primary and secondary brain injury. The mechanism of
injuryafterICHisverycomplicatedandhasnot yet beenilluminated.
This review discusses some key pathophysiology mechanisms in ICH such as
oxidative stress (OS), inflammation, iron toxicity, and thrombin formation.
Thecorrespondingtherapeutic targetsandtherapeuticstrategiesarealsoreviewed.
The initial pathological damage of cerebral hemorrhage to brain is the mechanical
compression caused by hematoma. The hematoma mass can increase intracranial
pressure, compressing brain and thereby potentially affecting blood flow, and
subsequentlyleadingtobrainhernia(Keepet al.,2012).
Subsequently, brain hernia and brain edema cause secondary injury, which may be
associatedwithpooroutcomeandmortalityinICHpatients(Yangetal.,2016).
Unfortunately, the common treatment of brain edema (steroids, mannitol, glycerol, and
hyperventilation) cannot effectively reduce intracranial pressure or prevent secondary
brain injury (Cordonnieret al., 2018). Truly effective clinical treatments are very
limited, mainly because the problem of transforming preclinical research into clinical
application has not yet been solved. Therefore, a multi-target neuroprotective
therapy will make clinically effective treatment strategies possible, but also requires
furtherstudy.
Pro-andanti-inflammatorycytokinesinsecondarybraininjuryafter ICH.
Mechanismsoferythrocyte
lysates and thrombin in
secondarybrain injuryafter ICH.
The Keap1–Nrf2–ARE pathway. Keap1 is an OS sensor
and negatively regulates Nrf2. Once exposed to reactive
oxygen species (ROS), the activated Nrf2 translocates to the
nucleus, binds to antioxidant response element (ARE),
heterodimerizes with one of the small Maf (musculo-
aponeurotic fibrosarcoma oncogene homolog) proteins, and
enhances the upregulation of cytoprotective, antioxidant,
anti-inflammatory, and detoxification genes that mediate cell
survival.
”Time isBrain” Neural injury(and your imagingfeatures*)
and depend on the time since initialhematoma
Intracerebral haemorrhage
DrAdnanIQureshi,ADavidMendelow, DanielFHanley
TheLancetVolume373,Issue9675,9–15May2009,Pages1632-1644
https://doi.org/10.1016/S0140-6736(09)60371-8
Cascadeofneuralinjuryinitiatedbyintracerebralhaemorrhage Thestepsinthefirst
4harerelatedtothedirecteffectofthehaematoma,laterstepstotheproductsreleasedfrom
thehaematoma.BBB=blood–brainbarrier.MMP=matrixmetallopeptidase.TNF=tumour
necrosisfactor.PMN=polymorphonuclearcells.
ProgressionofhaemotomaandoedemaonCT
Top:hyperacuteexpansion of haematoma ina patientwithintracerebral haemorrhageon serial CTscans.
Smallhaematoma detected in thebasal ganglia and thalamus (A). Expansion of haematoma after151 min
(B). Continued progression of haematoma after another 82min(C). Stabilisationof haematomaafter
another 76 min (D). Bottom:progressionof haematomaand perihaematomaloedema in apatientwith
intracerebralhaemorrhageonserialCT scans. Thefirstscan (E)wasacquired beforetheintracerebral
haemorrhage. Perihaematoma oedemaishighlighted in green to facilitaterecognitionof progressionof
oedema. At4h aftersymptomonsetthereisa small haematoma inthebasal ganglia (F). Expansionof
haematoma with extension into thelateral ventricleand newmass-effectand midlineshiftat14h (G).
Worsening hydrocephalusand earlyperihaematomal oedema at28 h (H). Continued mass-effectwith
prominentperihaematomal oedema at73 h (I).Resolving haematoma with moreprominent
perihaematomal oedema at7days (J).
or how much is the timereallybrain?
Influenceoftimetoadmissiontoa
comprehensivestrokecentreonthe
outcomeofpatientswithintracerebral
haemorrhage(Jan 2020)
Luis Prats-Sánchez, MarinaGuasch-Jiménez, IgnasiGich, Elba Pascual-Goñi, Noelia Flores, Pol Camps-Renom, Daniel
Guisado-Alonso, Alejandro Martínez-Domeño, Raquel Delgado-Mederos, Ana Rodríguez-Campello, Angel Ois,
AlejandraGómez-Gonzalez, ElisaCuadrado-Godia, JaumeRoquer, JoanMartí-Fàbregas
https://doi.org/10.1177%2F2396987320901616
In patients with spontaneous intracerebral
haemorrhage, it is uncertain if diagnostic and
therapeutic measures are time-sensitive on
their impact on the outcome. We sought to
determine the influence of the time to admission to
a comprehensive stroke centre on the outcome of
patients with acute intracerebral haemorrhage.
Our results suggest that in patients with
intracerebral haemorrhage and known symptom
onset who are admitted to a comprehensive stroke
centre, an early admission (≤110 min) does not
influencetheoutcomeat90 days.
Distributionofpropensity
scoreblocksbytimeto
admission.Foreachpair
ofblocks,theboxonthe
leftrepresentsthegroup
ofpatientswithan
admission≤110 minand
theoneontheright
representsthegroupwho
wasadmitted > 110 min.
ManagementofICH less options than for ischemic stroke
Intracerebral haemorrhage
DrAdnanIQureshi,ADavidMendelow, DanielFHanley
TheLancetVolume373,Issue9675,9–15May2009,Pages1632-1644
https://doi.org/10.1016/S0140-6736(09)60371-8
haemorrhage
Oddsratiofordeathor disabilityinpatientswithlobar intracerebral
haemorrhagetreatedsurgicallyor conservatively. BoxesarePeto'soddsratio
(OR),linesare95% CI.Adapted with permission from LippincottWilliamsandWilkins
Clinical evidencesuggeststheimportanceof threemanagementtasksin intracerebralhaemorrhage:
stopping thebleeding,81 removing theclot,70 and controlling cerebral perfusion pressure.
92 Theprecision needed to achievethesegoalsand thedegreeof benefitattributableto eachclinical goal
would bepreciselydefined whentheresultsof trialsinprogress becomeavailable. AnNIHworkshop150
 identified theimportanceof animal modelsof intracerebral haemorrhageand of humanpathology
studies.Useof real-time, high-fieldMRI with three-dimensional imagingand high-resolution tissue
probesisanotherpriority.Trialsof acuteblood-pressuretreatment and coagulopathyreversal arealso
medical priorities.And trialsof minimallyinvasivesurgicaltechniquesincluding mechanical and
pharmacologicaladjunctsaresurgical priorities. TheSTICH II trial should determinethebenefitof
craniotomyforlobarhaemorrhage. Abetter understanding of methodological challenges, including
establishmentofresearchnetworksandmultispecialty approaches, isalso needed.150 New
information created in eachof theseareasshould add substantially to ourknowledgeabout theefficacy
of treatmentfor intracerebral haemorrhage.
Bestcareisprevention with blood pressuremedication
Intracerebralhaemorrhage:currentapproaches
toacute management
Prof CharlotteCordonnier, Prof AndrewDemchuk,Wendy Ziai,Prof CraigS
Anderson
TheLancetVolume392, Issue10154,6–12October2018,Pages1257-1268
https://doi.org/10.1016/S0140-6736(18)31878-6
ICH, as a heterogeneous disease, certain clinical and imaging features help identify
the cause, prognosis, and how to manage the disease. Survival and recovery
from intracerebral haemorrhage are related to the site, mass effect, and intracranial
pressure from the underlying haematoma, and by subsequent cerebral oedema from
perihaematomal neurotoxicity or inflammation and complications from prolonged
neurological dysfunction.
A moderate level of evidence supports there being beneficial effects of active
management goals with avoidance of early palliative care orders, well-coordinated
specialist stroke unit care, targeted neurointensive and surgical interventions, early
control ofelevated blood pressure, and rapid reversal of abnormal coagulation.
The concept of time is brain, developed for the management of acute ischaemic
stroke, applies readily to the management of acute intracerebral
haemorrhage. Initiation of haemostatic treatment within the first few hours after
onset, using deferral or waiver of informed consent or even earlier initiation using a
prehospital settingwith mobile stroke unit technologies, require evaluation.
For patients with intracerebral haemorrhage presenting at later or unwitnessed time
windows, refining the approach of spot sign detection through newer imaging
techniques, such as multi-phase CT angiography (Rodriguez-Lunaet al. 2017),
might prove useful, ashasbeen shown with theuse ofCTperfusion in the detection of
viable cerebral ischaemia in patients with acute ischaemic stroke who present in a
late window (Alberset al. 2018;Nogueiraetal. 2018).
Ultimately, the best treatment of intracerebral haemorrhage isprevention and
effective detection, management, and control of hypertension across the
community and in high-risk groups will have the greatest effect on reducing the
burden ofintracerebral haemorrhage worldwide.
ICH High fatality still
EuropeanStrokeOrganisation(ESO)Guidelines
fortheManagementofSpontaneous
Intracerebral Hemorrhage (August 2014)
ThorstenSteiner, RustamAl-ShahiSalman, Ronnie Beer, Hanne Christensen, Charlotte Cordonnier, Laszlo Csiba, Michael Forsting, Sagi
Harnof, CatharinaJ. M. Klijn, Derk Krieger, A. David Mendelow, Carlos Molina, Joan Montaner, Karsten Overgaard, JesperPetersson,
Risto O. Roine, Erich Schmutzhard, KarstenSchwerdtfeger, ChristianStapf, Turgut Tatlisumak, Brenda M. Thomas, Danilo Toni, Andreas
Unterberg, Markus Wagner
https://doi.org/10.1111%2Fijs.12309
Intracerebral hemorrhage (ICH) accounted for 9% to 27% of all strokes
worldwide in the last decade, with high early case fatality and poor functional
outcome. In view of recent randomized controlled trials (RCTs) of the
management of ICH, the European Stroke Organisation (ESO) has updated its
evidence-basedguidelinesforthemanagementofICH.
We found moderate- to high-quality evidence to support strong
recommendations for managing patients with acute ICH on an acute
stroke unit, avoiding hemostatic therapy for acute ICH not associated with
antithrombotic drug use, avoiding graduated compression stockings, using
intermittent pneumatic compression in immobile patients, and using blood
pressureloweringforsecondaryprevention.
We found moderate-quality evidence to support weak recommendations for
intensive lowering of systolic blood pressure to <140 mmHg within six-hours of
ICH onset, early surgery for patients with a Glasgow Coma Scale score 9–12, and
avoidanceofcorticosteroids.
These guidelines inform the management of ICH based on evidence for the
effects of treatments in RCTs. Outcome after ICH remains poor, prioritizing
furtherRCTsofinterventionstoimproveoutcome.
Age-standardizedincidenceofhemorrhagicstrokeper 100000person-years
for 1990(a),2005(b),and2010(c).FromFeigin etal.(1).
1990
2005
2010
CTtypicallythefirstscandone andMRIlater where accessible
MRI offersbetterimagequality,butthecost ofthetechnologylimitsitsavailability
Intracerebralhemorrhage: an
update ondiagnosisandtreatment
IsabelC. Hostettler,DavidJ.Seiffge&DavidJ.Werringet
al.(12Jun 2019) UCLStrokeResearchCentre,DepartmentofBrain Repairand
Rehabilitation,UCLInstituteofNeurologyandtheNationalHospitalforNeurologyandNeurosurgery,
London,UK
ExpertReviewofNeurotherapeuticsVolume19,2019-
Issue7 https://doi.org/10.1080/14737175.2019.1623671
Expert opinion: In recent years, significant
advances have been made in deciphering
causes, understanding pathophysiology, and
improving acute treatment and prevention of ICH.
However, the clinical outcome remains poor
andmany challenges remain.
Acute interventions delivered rapidly
(including medical therapies – targeting
hematoma expansion, hemoglobin toxicity,
inflammation, edema, anticoagulant reversal –
and minimally invasive surgery) are likely to
improveacuteoutcomes.
Improved classification of the underlying
arteriopathies (fromneuroimaging and genetic
studies) and prognosis should allow tailored
prevention strategies (including sustained
blood pressure control and optimized
antithrombotic therapy) to further improve
longer-termoutcomeinthisdevastatingdisease.
A) ModifiedBostoncriteria,B)CTEdinburghcriteria.
ICHcarepathway.
Pathwaytodecideonintra-arterial
digitalsubtractionangiography(IADSA)
tofurtherinvestigateICHcause
(adaptedfromWilsonetal.2017).
small vesseldiseases(SVD),intra-arterial digital
subtraction angiography(IADSA),WhiteMatter
Hyperintensities(WMH)
Angiographyalsoforhemorrhagic stroke
Hemorrhagic Stroke (2014)
JuliusGriauzde,ElliotDickersonandJoseph J.
Gemmete Department of Radiology,Radiology Resident,University of
Michigan
http://doi.org/10.1007/978-1-4614-9212-2_46-1
Non-contrast computed tomography has
long been the initial imaging tool in the acute
neurologic patient. As MRI technology and
angiographic imaging has evolved, they too
have proven to be beneficial in narrowing the
differentialdiagnosisandtriaging patientcare.
Several biological and physical characteristics
contribute significantly to the appearance of
blood products on neuroimaging. To
adequately interpret images in the patient with
hemorrhagic stroke, the evaluator must have a
knowledge of the interplay between imaging
modalitiesandintracranialbloodproducts.
Additionally, an understanding of technical
parameters as well as the limitations of
imagingmodalities canbehelpfulinavoiding
pitfalls. Recognition of typical imaging patterns
and clinical presentations can further aid the
evaluatorinrapiddiagnosisanddirectedcare.
Computedtomographyangiography (CTA)
Magneticresonanceangiography (MRA)
TimeofFlightMRA (TOFMRA),initssimplestform,
takesadvantageoftheflowofblood
Contrast-EnhancedMRA (CEMRA)employsfast
spoiledgradient-recalledecho-basedsequences
(FSPGR)andtheparamagneticpropertiesof
gadoliniumtointensifythesignalwithinvessels
“Brainistime” alsofor theappearance of the blood
Evolution ofbloodproductson MRI (Derived fromafigurecreated by Dr. Frank Gaillard as
presented on http://radiopaedia.org/articles/ageing-blood-on-mri ,withpermission)
http://doi.org/10.1007/978-1-4614-9212-2_46-1:
TheappearanceoftheICH atdifferentperiodsoftimedepends
considerablyuponanumber offactors. Forinstance,in earlyphases,
thehematocritandproteinlevelsofthehematomawilldramaticallyalter
theCTattenuationinthehematoma.In laterphases,factorssuchas
oxygentensionatthehematomawilldeterminehowquickly
deoxyhemoglobintransitionsintomethemoglobinandhowquicklyred
bloodcellsfinallylyseanddecreasethefieldinhomogeneityeffectsof
sequesteredmethemoglobin. Theintegrityoftheblood-brainbarrier
alsohelpstodeterminethedegreetowhichhemosiderin-laden
macrophagesremaintrappedintheparenchymacausinghemosiderin
staininglongafterthevastmajorityofthehematomamasshasbeen
resorbed[Parizeletal.2001].
Intracranial
hemorrhage made
easy- asemiological
approach on CT and
MRI
http://doi.org/10.1594/ecr2
014/C-1120
:CTappearanceof
ageingblood.Several
factorswhich vary
dependingon thestageof
thebleeding
Evolution of CTdensityof
intracranial haemorrhage
(diagram)Case contributed by 
Assoc Prof FrankGaillard
https://radiopaedia.org/cases/evolutio
n-of-ct-density-of-intracranial-haemor
rhage-diagram
AppearanceofBloodonComputedTomographyand
MagneticResonanceImagingScansbyStage
http://doi.org/10.1007/s13311-010-0009-x
Whatpredicts
theoutcomeafterICH?
ICHScore the simplisticbaseline for prognosis
ICHScore subcomponents:Glasgow ComaScale (GCS)
https://www.firstaidforfree.com/glasgow-coma-scale-gcs-first-aiders/
https://emottawablog.com/2018/07/gcs-remastered-recent-
updates-to-the-glasgow-coma-scale-gcs-p/
ICHScore subcomponents:Hematomavolume
Howtomeasureinpractice? Notethat deeplearningsegmentation networksarenot reallyin use
RyanHakimi,DO,MSAssistantProfessor
https://slideplayer.com/slide/3883134/
Vivien H. Leeetal.(2016)citesthe
●
Kwak’s sABC/2 formula (Kwak et al.
1983,10.1161/01.str.14.4.493, Cited by 252)
●
Kothari’s ABC/2 formula(Kothari et al.
1996,  10.1161/01.str.27.8.1304, Cited by 1653) 
Excellent accuracy of ABC/2volume formulacompared to computer-
assisted volumetricanalysisof subdural hematomas Sae-Yeon Won et
al. (2018) https://doi.org/10.1371/journal.pone.0199809
TheABC/2methodisasimpleandfastbedsideformulaforthemeasurementof
SDHvolumein atimelymannerwithoutlimitedaccessthrough simpleadaption,
which mayreplacethecomputer-assistedvolumetric measurementintheclinical
andresearch area.
Assessment oftheABC/2MethodofEpidural
HematomaVolume MeasurementasComparedto
Computer-AssistedPlanimetricAnalysis (2015)
https://doi.org/10.1177%2F1099800415577634
ICHScore subcomponents:Intraventicular Hemorrhage
https://www.childrensmn.org/educationmaterials/childrensmn
/article/15353/intraventricular-hemorrhage-in-premature-babi
es/
Jacksonetal.(2013)
https://doi.org/10.1007/s12028-012-9713-1
ICHScore subcomponents:Infratentorial(cerebellar) bleed
https://aneskey.com/intrace
rebral-hemorrhagic-stroke/
Impact of SupratentorialCerebralHemorrhageon the
ComplexityofHeartRate Variabilityin Acute Stroke Chih-Hao
Chen, Sung-Chun Tang,Ding-YuanLee, Jiann-ShingShieh,Dar-Ming Lai,An-YuWu&Jiann-
ShingJengScientificReportsvolume8,Articlenumber: 11473(2018)
https://doi.org/10.1038/s41598-018-29961-y
Acute stroke commonly affects cardiac autonomic responses resulting in reduced
heart rate variability (HRV). Multiscale entropy (MSE) is a novel non-linear
method to quantify the complexity of HRV. This study investigated the influence of
intracerebral hemorrhage (ICH) locations and intraventricular
hemorrhage (IVH) on the complexity of HRV. In summary, more severe stroke
and larger hematomavolumeresulted in lower complexityofHRV.Lobar hemorrhage
andIVHhadgreatimpactsonthecardiacautonomicfunction.
https://neupsykey.com/
diagnosis-and-treatmen
t-of-intracerebral-hemor
rhage/
Location →
functionalmeasures?
We collected ECG analogue data
directly from the bedside monitor
(Philips Intellivue MP70, Koninklijke
Philips N.V., Amsterdam, Netherlands)
foreachpatient. 
ICH Score validationandmodification somewhat ok/suboptimal performance
Modifyingtheintracerebral
hemorrhagescore tosuitthe
needs ofthedevelopingworld
AjayHegde,GirishMenon (Nov2018)
http://doi.org/10.4103/aian.AIAN_419_17
ICH Score failed to accurately predict
mortality in our cohort. ICH is
predominately seen at a younger
age group in India and hence have
better outcomes in comparison to
the west. We propose a minor
modification in the ICH score by
reducing the age criteria by 10 years to
prognosticate the disease better in our
population.
External Validation of the ICH
Score
JenniferL Clarkeetal.(2004)
https://doi.org/10.1385/ncc:1:1:53
The ICH score accurately stratifies
outcome in an external patient cohort.
Thus, the ICH score is a validated
clinical grading scale that can be easily
and rapidly applied at ICH presentation.
Ascale such as the ICH score could be
used to standardize clinical treatment
protocolsorclinical studies.
ValidationofICHScore inalarge
UrbanPopulation
TahaNisaret al.(2018)
https://doi.org/10.1016/j.clineuro.2018.09.007
We conducted a retrospective chart review of
245 adult patients who presented with acute
ICH to University Hospital, Newark. Our study
is one of the largest done at a single urban
center to validate the ICH score. Age ≥ 80
years wasn't statistically significant with
respect to 30-day mortality in our group.
Restratification of the weight of
individual variable in the ICH equation with
modification of the ICH score can potentially
more accurately establish mortality risk.
Nevertheless, the overall prediction of
mortality was accurate and reproducible in
ourstudy.
Validation of the ICH score in
patients with spontaneous
intracerebral haemorrhage
admitted to the intensive care unit
inSouthernSpain
SoniaRodríguez-Fernández etal.(2018)
http://dx.doi.org/10.1136/bmjopen-2018-021719
ICH score shows an acceptable discrimination as a tool to
predict mortality rates in patients with spontaneous ICH
admitted totheICU, but its calibration issuboptimal.
24-HourICHScoreIs aBetter
Predictor of Outcomethan
AdmissionICHScore
AimeeM. Aysenneet al.(2013)
https://doi.org/10.1155/2013/605286
Early determination of the ICH score may
incorrectly estimate the severity and
expected outcome after ICH. Calculations of
the ICH score 24 hours after admission
will better predict earlyoutcomes.
Assessment and comparison of the
max-ICH score and ICH score by
externalvalidation
Felix A.Schmidt,etal.(2018)
https://doi.org/10.1212/WNL.0000000000006117
We tested the hypothesis that the maximally treated
intracerebral hemorrhage (max-ICH) score is superior
to the ICH score for characterizing mortality and functional
outcome prognosis in patients with ICH, particularly those who
receive maximal treatment.
External validation with direct comparison of the ICH score and
max-ICH score shows that their prognostic performance is not
meaningfully different. Alternatives to simple scores are
likely needed to improve prognostic estimates for patient
care decisions.
Yes, so, do you like to use
oversimplified models after all?
ICHScore works forsome parts of the population
OriginalIntracerebralHemorrhageScoreforthePrediction
of Short-Term Mortality inCerebral Hemorrhage:
Systematic Review and Meta-Analysis
Gregório,Tiago; Pipa, Sara;Cavaleiro,Pedro; Atanásio,Gabriel;
Albuquerque,Inês; CastroChaves, Paulo;Azevedo,Luís
Journal of Strokeand CerebrovascularDiseases
Volume29,Issue4,April2020,104630
https://doi.org/10.1097/CCM.0000000000003744
To systematically assess the discrimination and
calibration of the Intracerebral Hemorrhage score for
prediction of short-term mortality (38 studies, 15,509
patients) in intracerebral hemorrhage patients and to study its
determinantsusing heterogeneityanalysis.
Fifty-five studiesprovideddataondiscrimination,and35studies
provided data on calibration. Overall, the Intracerebral
Hemorrhage score discriminated well (pooled C-statistic
0.84; 95% CI, 0.82-0.85) but overestimated mortality
(pooled observed:expected mortality ratio = 0.87; 95% CI, 0.78-
0.97), with high heterogeneity for both estimates (I 80% and
84%,respectively).
The Intracerebral Hemorrhage score is a valid clinical
prediction rule for short-term mortality in intracerebral
hemorrhage patients but discriminated mortality worse in more
severe cohorts. It also overestimated mortality in the highest
Intracerebral Hemorrhage score patients, with significant
inconsistency between cohorts. These results suggest that
mortality for these patients is dependent on factors
not included in the score. Further studies are needed to
determinethesefactors.
StartwithICHscore but then youneed better models?
Management ofIntracerebral
Hemorrhage:JACCFocusSeminar
MatthewSchrag,HowardKirshner
Journalof theAmerican CollegeofCardiology
Volume75,Issue15,21April2020
https://doi.org/10.1016/j.jacc.2019.10.066
The most widely used tool for assessing prognosis is the “ICH score,” a scale that predicts
mortality based on hemorrhage size, patient age, Glasgow coma score, hemorrhage location
(infratentorial or supratentorial), and the presence of intraventricular hemorrhage (
Hemphilletal.2001). This score has been widely criticized for overestimating the
mortality associated with ICH, and this is attributed to the high rate of early withdrawal of
medical care in more severe hemorrhages in the cohort, leading to a “self-fulfilling
prophecy”ofearlymortality (Zahuranecetal.2007,Zahuranecetal.2010).
Nevertheless, no high-performing alternative scale or biomarker has
entered routine clinical use, so the ICH score remains a starting point for
clinical prognostication. A recent re-evaluation of this clinical tool found that both
physicians’ and nurses’ subjective predictions of 3-month outcomes made within 24 h
of the hemorrhage outperformed the accuracy of the ICH score, underscoring the
important role of clinician experience and judgement in guiding families (
Hwanget al. 2015).
In addition to hemorrhage size and initial clinical deficits, factors that seem to predict a poor
overall outcome include any early neurological deterioration, hemorrhages in deep locations,
particularly the thalamus, and age/baseline functional status (Yogendrakumaretal.2018;
Sreekrishnanetal.2016; Ullmanetal.2019). When the clinical prognosis is unclear,
physicians should generally advocate for additional time and continued supportive
care(Hemphilletal.2015).
Recovery after intracerebral hemorrhage is often delayed when compared with
ischemic strokes of similar severity, and outcomes may need to be evaluated at
later timepoints to capture the full extent of potential recovery. This is important both
for calibrating patient and family expectations and in the design of outcomes for clinical
trials.
Severalscoresandmeasuresexist
Intracerebralhemorrhage outcome:A
comprehensive update
João Pinho etal.(15March 2019)
https://doi.org/10.1016/j.jns.2019.01.013
The focus of outcome assessment after ICH has been
mortality in most studies, because of the high early case
fatality which reaches 40% in some population-based
studies. The most robust and consistent predictors of early
mortality include age, severity of neurological impairment,
hemorrhage volume and antithrombotic therapy at the time
oftheevent.
Long-term outcome assessment is multifaceted and
includes not only mortality and functional outcome,
but also patient self-assessment of the health-
related quality of life, occurrence of cognitive
impairment, psychiatric disorders, epileptic seizures,
recurrent ICH andsubsequent thromboembolicevents.
Several scores which predict mortality and functional
outcome after ICH have been validated and are useful in
the daily clinical practice, however they must be used in
combination with the clinical judgment for individualized
patients. Management of patients with ICH both in the acute
and chronic phases, requires health care professionals to
have a comprehensive and updated perspective on
outcome, which informs decisions that are needed to be
taken togetherwiththepatient andnext ofkin
Locationspecifiedquitecrudely
http://doi.org/10.1007/978-1-4614-9212-2_46-1
Management of brainstem haemorrhages
DOI: https://doi.org/10.4414/smw.2019.20062
https://aneskey.com/intracerebral-hemorrhagic-stroke/
Too “handwavey”reporting of thelocationatthemoment
IntracerebralHemorrhageLocationandFunctional
OutcomesofPatients: ASystematicLiterature Reviewand
Meta-Analysis
AnirudhSreekrishnan etal. (NeurocriticalCarevolume25,pages384–391,2016)
https://doi.org/10.1177%2F0272989X19879095 - Citedby35
Intracerebral hemorrhage (ICH) has the highest mortality rate among all
strokes. While ICH location, lobar versus non-lobar, has been
established as a predictor of mortality, less is known regarding the
relationship between more specific ICH locations and functional
outcome. This review summarizes current work studying how ICH
location affects outcome, with an emphasis on how studies designate
regionsof interest.
Multiple studies have examined motor-centric outcomes, with few studies
examining quality of life (QoL) or cognition. Better functional outcomes
have been suggested for lobar versus non-lobar ICH; few studies
attempted finer topographic comparisons. This study highlights the
need for improved reporting in ICH outcomes research, including
a detailed description of hemorrhage location, reporting of the full
range of functional outcome scales, and inclusion of cognitive and
QoL outcomes.
Meta-analysisofstudiesdescribingtheoddsratioofpooroutcomesfor
lobar comparedtodeep/non-lobar ICH. a Poor outcomemRS(3,4,5,6)or
GOS(4,3,2,1); b PooroutcomemRS(4,5,6)or GOS(3,2,1); c Poor
outcomemRS(5,6).*Significantresults(p < 0.05)
LobarvsDeep?
https://slideplayer.com/slide/2404245/
NEnglJMed2001;344:1450-1460
http://doi.org/10.1056/NEJM200105103441907
Twogeneralcategoriesintermsofpathophysiology:
--Lobar(towardstheperiphery,typicallylinkedto
cerebralamyloidangiopathy[CAA])
--Deep(inthedeepwhitematter ofthecerebrum,
typicallylinkedtohypertension,HTN)
https://www.cram.com/flashcards/draft-23-16-intracra
nial-hemorrhage-2439833
Long-termrisks higher after lobarICH?
Ten-yearrisksofrecurrentstroke,
disability,dementiaandcostin relationto
siteofprimaryintracerebralhaemorrhage:
population-basedstudy (2019)
LinxinLi,Ramon Luengo-Fernandez,SusannaMZuurbier, NicolaC
Beddows,PhilippaLavallee,LouiseESilver, WilhelmKuker,Peter
MalcolmRothwell
http://dx.doi.org/10.1136/jnnp-2019-322663
Patients with primary intracerebral haemorrhage (ICH)
are at increased long-term risks of recurrent stroke and
other comorbidities. However, available estimates
come predominantly from hospital-based studies with
relatively short follow-up. Moreover, there are also
uncertainties about the influence of ICH location
on risks of recurrent stroke, disability, dementia and
qualityoflife.
Methods In a population-based study (Oxford Vascular
Study/2002–2018) of patients with a first ICH with
follow-up to 10 years, we determined the long-term
risks of recurrent stroke, disability, quality of life,
dementia and hospital care costs stratified by
haematomalocation.
ICHcanbecategorisedinto lobarandnon-lobaraccording tothehaematomalocation.
Giventhedifferentbalanceofpathologiesfor lobarversusnon-lobar ICH,thelong-term
prognosisofICHcouldbeexpectedtodiffer byhaematomalocation.However,whilesome
studiessuggestedthathaematomalocationwasassociatedwithrecurrentstroke,others
havenot.
Compared with non-lobarICH, thesubstantially higher 10-year
risks of recurrent stroke, dementiaand lower QALYs after lobar
ICH highlighttheneedformoreeffectiveprevention for
this patient group.
(top) Ten-year risks of recurrent stroke, disability or death stratified
by haematoma location. (right) Ten-year mean healthcare costs
overtimeafterprimaryintracerebralhaemorrhage.
HematomaEnlargement deepvs lobar, volume?
Hematoma enlargement characteristicsin
deep versuslobarintracerebralhemorrhage
Jochen A.Sembill etal. (04March2020)
https://doi.org/10.1002/acn3.51001
Hematoma enlargement (HE) is associated with
clinical outcomes after supratentorial intracerebral
hemorrhage (ICH). This study evaluates whether HE
characteristics and association with functional
outcome differ in deep versus lobarICH.
HE occurrence does not differ among deep and lobar
ICH. However, compared to lobar ICH, HE after deep
ICH is of greater extent in OAC ICH, occurs earlier‐ICH, occurs earlier 
and may be of greater clinical relevance. Overall,
clinical significance is more apparent after
small–medium compared to large sized‐sized 
bleedings.
These data may be valuable for both routine clinical
management as well as for designing future studies
on hemostatic and blood pressure management
aming at minimizing HE. However, further studies
with improved design are needed to replicate these
findings and to investigate the pathophysiological
mechanismsaccounting fortheseobservations. Study flowchart. Altogether, individual level data from 3,580 spontaneous ICH patients were analyzed to identify 1,954
supratentorial ICH patients eligible for outcome analyses. Data were provided by two parts of a German wide observational‐ICH, occurs earlier 
studies(RETRACE I and II) conducted at 22 participatingtertiarycenters, and byone single center universityhospital registry.‐ICH, occurs earlier
IntracerebralHemorrhage:ClinicalManifestationsRelatedtoSite.
https://clinicalgate.com/intracerebral-hemorrhage/
https://all-about-hipertency.blogspot.com/2003/0
8/hypertensive-hemorrhagic-stroke.html
https://radiologyassistant.nl/neuroradiology/non-
traumatic-intracranial-haemorrhage-in-adults
Otherfactors you shouldtake into account
BrianA.Stettler,
MDAssistant
Professor
https://slideplayer.c
om/slide/3129821/
Subfalcial herniation, midline shiftand uncal
herniation secondary tolarge subdural hematomain
the left hemisphere.
https://www.startradiology.com/internships/neurology/brain/ct-brain-
hemorrhage/
Hydrocephalus
https://kidshealth.or
g/en/parents/hydro
cephalus.html
RiskFactorsHypertension thelargest risk factor
RiskFactorsof IntracerebralHemorrhage:
ACase-ControlStudy
HanneSallinen, ArtoPietilä,VeikkoSalomaa,DanielStrbian
Journal of Strokeand Cerebrovascular Diseases
Volume29,Issue4,April2020,104630
https://doi.org/10.1016/j.jstrokecerebrovasdis.2019.104630
Hypertension is a well-known risk factor for
intracerebral hemorrhage (ICH). On many of the other
potential risk factors, such as smoking, diabetes,
and alcohol intake, results are conflicting. We
assessed risk factors of ICH, taking also into account
priordepression andfatigue.
Analyzing all cases and controls, the cases had more
hypertension, history of heart attack, lipid-lowering
medication, and reported more frequently fatigue prior
to ICH. In persons aged less than 70 years,
hypertension and fatigue were more common among
cases. In persons aged greater than or equal to 70
years, factors associated with risk of ICH were fatigue
prior to ICH, use of lipid-lowering medication, and
overweight.
Hypertension was associated with risk of ICH
among all patients and in the group of patients under
70 years. Fatigue prior to ICH was more common
among all ICH cases.
StrokeorIntensive CareUnit for ICH patients
Strokeunitadmissionisassociatedwith better
outcomeandlowermortality inpatientswith
intracerebral hemorrhage
MaM. N. Ungerer P. Ringleb B.Reuter C.Stock F.Ippen S. Hyrenbach I.Bruder P
Martus C. Gumbinger theAGSchlaganfall
https://doi.org/10.1111/ene.14164 (Feb2020)
There is no clear consensus among current guidelines on the preferred
admission ward [i.e. intensive care unit (ICU) or stroke unit (SU)] for
patients with intracerebral hemorrhage. Based on expert opinion, the American
Heart Association and European Stroke Organization recommend treatment in
neurological/neuroscience ICUs (NICUs) or SUs. The European Stroke
Organization guideline states that there are no studies available directly
comparingoutcomesbetween ICUsandSUs.
We performed an observational study comparing outcomes of 10 811
consecutive non comatose patients with intracerebral hemorrhage according‐ICH, occurs earlier 
to admission ward [ICUs, SUs and normal wards (NWs)]. Primary outcomes
were the modified Rankin Scale score at discharge and intrahospital mortality.
An additional analysiscomparedNICUswithSus.
Treatment in SUs was associated with better functional outcome and reduced
mortality compared with ICUs and NWs. Our findings support the current
guideline recommendations to treat patients with intracerebral
hemorrhage in SUs or NICUs and suggest that some patients may further
benefit from NICU treatment.
MobileStrokeUnitReduces
TimetoTreatment
JULY03,2018
https://www.itnonline.com/articl
e/mobile-stroke-unit-reduces-ti
me-treatment
Formorefine-grainedpredictions
youprobablywanttousebetter imagingmodalities?
PredictingMotorOutcomeinAcute
Intracerebral Hemorrhage (May 2019)
J.Puig, G.Blasco,M.Terceño,P.Daunis-i-Estadella,G.Schlaug,M.Hernandez-
Perez,V.Cuba, G.Carbó,J.Serena,M.Essig, C.R.Figley, K.Nael,C.Leiva-
Salinas, S.PedrazaandY.Silva
https://doi.org/10.3174/ajnr.A6038
Predicting motor outcome following
intracerebral hemorrhage is challenging. We
tested whether the combination of
clinical scores and Diffusion tensor
imaging (DTI)-based assessment of
corticospinal tract damage within the first 12
hours of symptom onset after intracerebral
hemorrhage predicts motor outcome at 3
months.
Combined assessment of motor function
and posterior limb of the internal capsule
damage during acute intracerebral
hemorrhage accurately predicts motor
outcome.
Assessing corticospinal tract involvement with diffusion tensor tractography superimposed on gradient
recalled echo and FLAIR images. In the upper row, the corticospinal tract wasaffected by ICH (passes through
it) at the level of the corona radiata and posterior limb of the internal capsule. Note that in lower row, the
corticospinal tract was displaced slightly forward but preserved around the intracerebral hematoma. Vol
indicatesvolume.
Exampleof ROI objectmapsusedto measure
intracerebral hematoma(blue)and perihematomal
edema(yellow)volumes.
CombiningmNIHSSand PLICaffected by ICH in the first
12 hours of onset can accurately predict motor outcome.
The reliability of DTI in denoting very early damage to
the CST could make it a prognostic biomarker
useful for determining management strategies
to improve outcome in the hyperacute stage.
Our approach eliminates the need for advanced
postprocessing techniques that are time-
consuming and require greater specialization, so it can
be applied more widely and benefit more patients.
Prospective large-scale studies are warranted to
validate these findings and determine whether this
information could be used to stratify risk in patients with
ICH.
Cliniciansliketohuntforthe“(linear)magicalbiomarkers”
opposed tononlinear multivariate modelswith higher capacity(and higher probability tooverfitaswell)
Early hematomaretractionin
intracerebralhemorrhageis
uncommonanddoesnotpredict
outcome
AnaC.Klahr,MaheshKate,JaymeKosior,Brian
Buck,AshfaqShuaib,DerekEmery,KennethButcher
Published: October9,2018
https://doi.org/10.1371/journal.pone.0205436
Citedby2 -Relatedarticles
Clot retraction in intracerebral hemorrhage (ICH)
has been described and postulated to be
related to effective hemostasis and
perihematoma edema (PHE) formation. The
incidence and quantitative extent of hematoma
retraction (HR) is unknown. Our aim was to
determine the incidence of HR between baseline
and time of admission. We also tested the
hypothesis that patients with HR had higher PHE
volumeandgoodprognosis.
Early HR is rare and associated with IVH, but not
with PHE or clinical outcome. There was no
relationship between HR, PHE, and patient
prognosis. Therefore, HR is unlikely to be a useful
endpointinclinicalICHstudies.
PerihematomalEdema(PHE) Diagnostic value?
NeoplasticandNon-NeoplasticCausesof Acute
IntracerebralHemorrhageonCT:The
DiagnosticValueofPerihematomalEdema
Jawed Nawabi, UtaHanning, Gabriel Broocks, Gerhard Schön, TanjaSchneider, Jens
Fiehler, Christian Thaler & Susanne Gellissen
ClinicalNeuroradiology(2019)
https://doi.org/10.1007/s00062-019-00774-4
The aim of this study was to investigate the
diagnostic value of perihematomal
edema (PHE) volume in non-enhanced
computed tomography (NECT) to
discriminate neoplastic and non-neoplastic
causes of acute intracerebral hemorrhage
(ICH).
Relative PHE with a cut-off of >0.50 is a
specific and simple indicator for
neoplastic causes of acute ICH and a
potential tool for clinical implementation. This
observation needs to be validated in an
independentpatientcohort.
Two representative cases of region of interest object maps used to measure intracerebral
hemorrhage (ICH), volume (Vol ICH) and total hemorrhage (Vol ICH+PHE)
volume. a Neoplastic and non-neoplastic ICH volume (red) and b total hemorrhage volume
(grey) on non-enhanced CT (NECT) delineated with an edge detection
algorithm. c Neoplastic and non-neoplastic PHE (green) calculated by subtraction of total
hemorrhagevolumeandICHvolume(Vol PHE= Vol ICH+PHE− Vol ICH)
Youngpatients tendto recover better(seems obvious)
Isnontraumaticintracerebral hemorrhage
different betweenyoungandelderly
patients?
NaRaeYang,Ji HeeKim,Jun Hyong Ahn,JaeKeun Oh,In BokChang
&JoonHo Song NeurosurgicalReviewvolume43, pages781–
791(2020)https://doi.org/10.1007/s10143-019-01120-5
Only a few studies have reported
nontraumatic intracerebral hemorrhage in
young patients notwithstanding its fatal
and devastating characteristics. This study
investigated the clinical characteristics and
outcome of nontraumatic intracerebral
hemorrhage in young patients in
comparison to thoseof theelderly.
Nontraumatic intracerebral hemorrhage in
younger patients appears to be
associated with excessive alcohol
consumption and high BMI. Younger
patients had similar short-term
mortality but more favorable
functional outcome than the elderly.
DistributionofmodifiedRankinScalescoresatthelastfollow-upforeachgroup
Genotype-baseddifferencesexist
Racial/ethnicdisparitiesinthe riskof intracerebral
hemorrhage recurrence
AudreyC.Leasure,ZacharyA.King,VictorTorres-Lopez,SantoshB.Murthy,HoomanKamel,AshkanShoamanesh,Rustam
Al-Shahi Salman,JonathanRosand,WendyC.Ziai, DanielF.Hanley,DanielWoo,CharlesC.Matouk,LaurenH.Sansing,
Guido J.Falcone,KevinN.Sheth
Neurology December12,2019
https://doi.org/10.1212/WNL.0000000000008737
To estimate the risk of intracerebral hemorrhage (ICH) recurrence in a
large, diverse, US-based population and to identify racial/ethnic and
socioeconomic subgroups at higher risk. Black and Asian patients
had a higher risk of ICH recurrence than white patients, whereas
private insurance was associated with reduced risk compared to those
with Medicare.
Further research is needed to determine the drivers of these
disparities. While this is the largest study of ICH recurrence in a United
States–based, racially and ethnically diverse population, our study has
several limitations related to the use of administrative data that require
consideration. First, there is a possibility of misclassification of the
exposures and outcomes. The attribution of race/ethnicity that is not
based on direct self-report may not be accurate; for example, patients
who belong to 2 or more racial/ethnic categories may be classified
based on phenotypic descriptions and may not reflect true
ancestry. In terms of outcome classification, we relied on ICD-9-CM
codes to identify our outcome of recurrent ICH. However, we used
previously validated diagnosis codes that have high positive predictive
valuesfor identifyingprimaryICH
asICHnotthatwellunderstood sonewmechanismsareproposed
Globalbraininflammationinstroke
Kaibin Shi etal.(LancetNeurology,July2019)
https://doi.org/10.1016/S1474-4422(19)30078-X
Stroke, including acute ischaemic stroke (AIS) and
intracerebral haemorrhage (ICH), results in
neuronal cell death and the release of factors
such as damage-associated molecular patterns
(DAMPs) that elicit localised inflammation in the
injured brain region. Such focal brain
inflammation aggravates secondary brain
injury by exacerbating blood–brain barrier damage,
microvascular failure, brain oedema, oxidative stress,
andbydirectlyinducingneuronalcell death.
In addition to inflammation localised to the injured
brain region, a growing body of evidence suggests
that inflammatory responses after a stroke occur and
persist throughout the entire brain. Global brain
inflammation might continuously shape the
evolving pathology after a stroke and affect the
patients'long-termneurologicaloutcome.
Future efforts towards understanding the
mechanisms governing the emergence of so-called
global brain inflammation would facilitate modulation
of this inflammation as a potential therapeutic
strategyforstroke.
MMPsinICH? In emerging theories
Matrix MetalloproteinasesinAcute
IntracerebralHemorrhage
SimonaLattanzi, MarioDi Napoli,SilviaRicci &Afshin A.Divani
Neurotherapeutics(January2020)
https://doi.org/10.1007/s13311-020-00839-0
So far, clinical trials on ICH have mainly targeted primary
cerebral injury and have substantially failed to improve
clinicaloutcomes.
The understanding of the pathophysiology of early and delayed
injury after ICH is, hence, of paramount importance to identify
potential targets of intervention and develop effective
therapeutic strategies. Matrix metalloproteinases (MMPs)
represent a ubiquitous superfamily of structurally related zinc-
dependent endopeptidases able to degrade any component of
the extracellular matrix. They are upregulated after ICH, in
which different cell types, including leukocytes, activated
microglia, neurons, and endothelial cells, are involved in their
synthesis and secretion. The role of MMPs as a potential target
for the treatment of ICH has been widely discussed in the last
decade. The impact of MMPs on extracellular matrix
destruction and blood–brain barrier BBB disruption in
patientssufferingfromICHhasbeen ofinterest.
The aim of this review is to summarize the available
experimental and clinical evidence about the role of MMPs in
brain injury following spontaneous ICH and provide critical
insightsintotheunderlyingmechanisms.
Overall, there is substantially converging evidence from
experimental studies to suggest that early and short-
term inhibition of MMPs after ICH can be an
effective strategy to reduce cerebral damage
and improve the outcome, whereas long-term
treatment may be associated with more harm than
benefit. It is, however, worth to notice that, so far, we do
not have a clear understanding of the time-specific
role that the different MMPs assume within the
pathophysiology of secondary brain injury and recovery
after ICH. In addition, most of the studies exploring
pharmacological strategies to modulate MMPs can
only provide indirect evidence of the benefit to target
MMP activity.
The prospects for effective therapeutic targeting of
MMPs require the establishment of conditions to
specifically modulate a given MMP isoform, or asubset of
MMPs, in a given spatio-temporal context (Rivera2019).
Further research is warranted to better understand the
interactions between MMPs and their molecular
and cellular environments, determine the optimal
timing of MMPs inhibition for achieving a favorable
therapeutic outcome, and implement the discovery of
innovative selective agents to spare harmful effects
before therapeutic strategies targeting MMPs can be
successfully incorporated into routine practice (
Lattaniet al. 2018;Hostettler et al. 2019).
Whatarethetreatmentsfor
ICH and can wedo prescriptive
modeling(“precision medicine”),
and tailor thetreatment
individually?
Hemostatic
Therapy
Overview
Managementof Intracerebral
Hemorrhage:JACCFocusSeminar
MatthewSchrag,HowardKirshner
JournaloftheAmerican CollegeofCardiology
Volume75, Issue15,21April2020
https://doi.org/10.1016/j.jacc.2019.10.066
AnimalmodelsofICH exist of courseas well
Intracerebral haemorrhage:from clinicalsettingsto
animalmodelsQian Bai et al.(2020)
http://dx.doi.org/10.1136/svn-2020-000334
Effective treatment for ICH is still scarce. However, clinical
therapeutic strategies includes medication and surgery. Drug
therapy is the most common treatment for ICH. This includes
prevention of ICH based on treating an individual’s underlying
risk factors, for example, control of hypertension. Hyperglycaemia
in diabetics is common after stroke; managing glucose level may
reduce the stroke size. Oxygen is given as needed. Surgery can be
used to prevent ICH by repairing vascular damage or
malformations in and around the brain, or to treat acute ICH by
evacuating the haematoma; however, the benefit of surgical
treatment is still controversial due to very few controlled
randomised trials. Rehabilitation may help overcome disabilities
thatresultfromICHdamage.
Despite great advances in ischaemia stroke, no prominent improvement
in the morbidity and mortality after ICH have been realised. The current
understanding of ICH is still limited, and the models do not
completely mirror the human condition. Novel effective modelling is
required to mimic spontaneous ICH in humans and allow for effective
studies on mechanisms and treatment of haematoma expansion and
secondary braininjury.
GenomicsforStrokerecovery #1
Geneticriskfactorsfor
spontaneousintracerebral
haemorrhage AmandaM.Carpenter,I.
P. Singh,ChiragD. Gandhi,CharlesJ.
Prestigiacomo(NatureReviews
Neurology2016)
https://doi.org/10.1038/nrneurol.2015.226
Familial aggregation of ICH has been
observed, and the heritability of ICH
risk has been estimated at 44%.
Few genes have been found to be
associated with ICH at the population
level, and much of the evidence for
genetic risk factors for ICH comes
from single studies conducted in
relatively small and homogenous
populations. In this Review, we
summarize the current knowledge of
genetic variants associated with primary
spontaneousICH.
Although evidence for genetic
contributions to the risk of ICH exists, we
donot yet fully understand how and
to what extent this information can be
utilizedto preventandtreatICH.
GenomicsforStrokerecovery #2
Geneticunderpinnings ofrecoveryafter
stroke:anopportunity for genediscovery,
riskstratification,andprecisionmedicine
Julián N.Acostaetal. (September2019)
https://doi.org/10.1186/s13073-019-0671-5
As the number of stroke survivors continues to increase,
identification of therapeutic targets for stroke
recovery has become a priority in stroke genomics
research. The introduction of high-throughput
genotyping technologies and novel analytical tools has
significantly advanced our understanding of the genetic
underpinningsofstrokerecovery.
In summary, functional outcome and recovery
constitute important endpoints for genetic studies
of stroke. The combination of improving statistical power
and novel analytical tools will surely lead to the discovery
of novel pathophysiological mechanisms
underlying stroke recovery. Information on these
newly discoveredpathwayscan beusedto develop new
rehabilitation interventions and precision-
medicine strategies aimed at improving management
options for stroke survivors. The continuous growth and
strengthening of existing dedicated collaborations and the
utilization of standardized approaches to ascertain
recovery-related phenotypes will be crucial for the
successofthispromisingfield.
Geneticriskof Spontaneousintracerebralhemorrhage: Systematic
review andfuture directions KolawoleWasiuet al.(15December2019)
https://doi.org/10.1016/j.jns.2019.116526
Given this limited information on the genetic contributors to spontaneous intracerebral hemorrhage (SICH),
more genomic studies are needed to provide additional insights into the pathophysiology of SICH, and
develop targeted preventive and therapeutic strategies. This call for additional investigation of the
pathogenesis of SICH is likely to yield more discoveries in the unexplored indigenous African populations
whichalsohaveagreaterpredilection.
Multilevelomics for thediscoveryofbiomarkersandtherapeutic
targetsforstroke Joan Montaneretal. (22April2020)
https://doi.org/10.1016/j.jns.2019.116526
Despite many years of research, no biomarkers for stroke are available to use in clinical practice. Progress in high-
throughput technologies has provided new opportunities to understand the pathophysiology of thiscomplex disease, and
these studies have generated large amounts of data and information at different molecular levels. We summarize how
proteomics, metabolomics, transcriptomics and genomics are all contributing to the identification of new candidate
biomarkers that could be developed and used in clinical stroke management.
Influencesof geneticvariantsonstrokerecovery:ameta-analysisof
the 31,895 cases NikhilMathetal.(29 July2019)
https://doi.org/10.1007/s10072-019-04024-w
17p12InfluencesHematomaVolume andOutcome inSpontaneous
IntracerebralHemorrhage SandroMarini etal.(30Jul2018)
https://doi.org/10.1016/j.jns.2019.116526
Surgicalmanagement not that wellunderstoodeither
Surgery forspontaneousintracerebral
hemorrhage(Feb 2020)
AirtonLeonardode OliveiraManoel
https://doi.org/10.1186/s13054-020-2749-2
Spontaneous intracerebral hemorrhage is a devastating disease,
accounting for 10 to 15% of all types of stroke; however, it is
associated with disproportionally higher rates of
mortality and disability. Despite significant progress in the
acute management of these patients, the ideal surgical
management is still to be determined. Surgical hematoma
drainage has many theoretical benefits, such as the prevention of
mass effect and cerebral herniation, reduction in intracranial
pressure, and the decrease of excitotoxicity and neurotoxicity of
blood products.
Mechanismsofsecondarybraininjury
after ICH.MLS-midlineshift; IVH-
intraventricular hemorrhage
Case 02 of open craniotomy for hematoma
drainage. a, b Day 1—Large hematoma in the left
cerebral hemisphere leading to collapse of the left
lateral ventricle with a midline shift of 12 mm, with a
large left ventricular and third ventricle flooding, as
well as diffuse effacement of cortical sulci of that
hemisphere. c–e Day 2—Left frontoparietal
craniotomy, with well-positioned bone fragment,
aligned and fixed with metal clips. Reduction of the
left frontal/frontotemporal intraparenchymal
hematic content, with remnant hematic residues
and air foci in this region. There was a significant
reduction in the mass effect, with a decrease in
lateral ventricular compression and a reduction in
the midline shift. Bifrontal pneumocephalus
causing shift and compressing the adjacent
parenchyma. f–h Day 36—Resolution of residual
hematic residues and pneumocephalus.
Encephalomalacia in the left frontal/frontotemporal
region. Despite the good surgical results, the
patient remainedin vegetativestate
Open craniotomy. Patient lies on an
operating table and receives general
anesthesia. The head is set in a three-pin
skull fixation device attached to the
operating table, in order to hold the head
standing still. Once the anesthesia and
positioning are established, skin is
prepared, cleaned with an antiseptic
solution, and incised typically behind the
hairline. Then, both skin and muscles are
dissected and lifted off the skull. Once
the bone is exposed, burr holes are built
in by a special drill. The burr holes are
made to permit the entrance of the
craniotome. The craniotomy flap is lifted
and removed, uncovering the dura mater.
The bone flap is stored to be replaced at
the end of the procedure. The duramater
is then opened to expose the brain
parenchyma. Surgical retractors are
used to open a passage to assess the
hematoma. After the hematoma is
drained, the retractors are removed, the
dura mater is closed, and the bone flap is
positioned, aligned, and fixed with metal
clips. Finally, the skin is sutured
Real-timesegmentationforICHsurgery?
Intraoperative CT and cone-beamCT
imagingforminimallyinvasive
evacuationofspontaneous
intracerebralhemorrhage
NilsHecht etal.(ActaNeurochirurgica2020)
https://doi.org/10.1007/s00701-020-04284-y
Minimally invasive surgery (MIS) for evacuation
of spontaneous intracerebral hemorrhage (ICH)
has shown promise but there remains a need
for intraoperative performance assessment
considering the wide range of evacuation
effectiveness. In this feasibility study, we
analyzed the benefit of intraoperative 3-
dimensional imaging during navigated
endoscopy-assisted ICH evacuation by
mechanicalclotfragmentationandaspiration.
Routine utilization of intraoperative
computerized tomography (iCT) or
cone-beam CT (CBCT) imaginginMIS for
ICH permits direct surgical performance
assessment and the chance for immediate
re-aspiration, which may optimize targeting of
an ideal residual hematoma volume and reduce
secondary revision rates.
CTAnatomical
Background
Non-ContrastCT What areyouseeing?
An Evidence-Based Approach To Imaging Of Acute
Neurological Conditions (2007)
https://www.ebmedicine.net/media_library/marketi
ngLandingPages/1207.pdf
HUUnits Absoluteunits“meansomething”
CT Scan basically a density measurement device
https://www.sciencedirect.com/topics/medicine-and-dentistry/hounsfield-scale
A, AxialCTslice, viewedwithbrainwindowsettings.Noticeinthegrayscalebar attherightsideof
thefigurethatthefullrangeofshadesfromblacktowhitehasbeendistributedoveranarrowHUrange,
fromzero(pureblack)to+100HU(purewhite).Thisallowsfinediscriminationoftissueswithinthis
densityrange,butattheexpenseofevaluationoftissuesoutsideofthisrange.Alargesubduralhematoma
iseasilydiscriminatedfromnormalbrain,eventhoughthetwotissuesdiffer indensitybylessthan100HU.
Anytissuesgreater than+100HUindensitywillappear purewhite,eveniftheir densitiesaredramatically
different.Consequently,theinternalstructureofbonecannotbeseenwiththiswindowsetting.Fat(-
50HU) andair (-1000HU)cannotbedistinguishedwiththissetting,asbothhavedensitieslessthanzero
HUandarepureblack. 
B, ThesameaxialCT slice viewedwithabone
windowsetting.Nowthescalebarattherightside
ofthefigureshowsthegrayscaletobedistributed
over averywideHUrange,from-450HU(pure
black)to+1050HU(purewhite).Air caneasilybe
discriminatedfromsofttissuesonthissetting
becauseitisassignedpureblack,whilesofttissues
aredarkgray.Detailsof bonecanbeseen,
becausealargeportionofthetotalrangeofgray
shadesisdevotedtodensitiesintherangeofbone.
Softtissuedetailislostinthiswindowsetting,
becausetherangeofsofttissuedensities(-50HUto
around+100HU)representsanarrowportionofthe
grayscale.
HUUnits ”water1000x ~1kg/l
denserthanair ~1g/l
”
ClinicalCT quick introonwhatyousee
How to interpret an unenhanced CT Brain scan.Part 1:Basicprinciplesof Computed
Tomography and relevant neuroanatomy (2016)
http://www.southsudanmedicaljournal.com/archive/august-2016/how-to-interpret-an-unenhanced-ct-brain-sca
n.-part-1-basic-principles-of-computed-tomography-and-relevant-neuroanatomy.html
CutsandGantryTilt Clinical CT typically havequite thickcuts
https://slideplayer.com/slide/5990473/ ComputedTomographyII–
RAD473PublishedbyMelindaWiggins
https://slideplayer.com/slide/7831746/
Designpatternformulti-modal
coordinatespaces
Figure4:PlanningthelocationoftheCTslices,
withtiltedgantry.Thegantryistiltedtoavoid
radiatingtheeyes,whilecapturingamaximum
ofrelevantanatomicaldata.
https://www.researchgate.net/publication/22
8672978_Design_pattern_for_multi-modal_co
ordinate_spaces
Tiltingthegantryfor CT-guided spineprocedures
https://doi.org/10.1007/s11547-013-0344-1 Gantry tilt. Use of bolsters. Gantry-
needle alignment. a, b Range of gantry angulation, which is ±30° on most scanners.
Spine curvature and spatial orientation can be modified using bolsters and wedges.
A bolster under the lower abdomen (c) flattens the lordotic curvature and reduces
the L5–S1 disc plane obliquity; under the chest (d) flattens the thoracic kyphosis and
reduces the upper thoracic pedicles' obliquity; under the hips (e) increases the
lordosis and brings the long-axis of the sacrum closer to the axial plane. The desired
needle path for spinal accesses can be paralleled by gantry tilt (solid lines on c– e)
relative to straight axial orientation (dashed lines on c– e). f Gantry-needle alignment,
with laser beam precisely bisecting the needle at the hub and the skin entry point.
Maintaining this alignment keeps the needle in plane and allows visualization of the
entireneedlethroughoutitstrajectoryon asingleCTslice
DiagnosingstrokeswithimagingCT,MRI,andAngiography|KhanAcademy
https://www.khanacademy.org/science/health-and-medicine/circulatory-system-diseases/stroke/v/diagnosing-strokes-with-imaging-ct-mri-and-angiography
CTSkullWindowmicrostructureofbonemightbiasyourbrainmodel?
Estimationof skulltablethicknesswithclinicalCTandvalidation
withmicroCThttp://doi.org/10.1111/joa.12259
Lossof bonemineraldensityfollowing
sepsisusingHounsfieldunitsby
computedtomography
http://doi.org/10.1002/ams2.401
Opportunistic
osteoporosis
screeningvia the
measurement of
frontalskull
Hounsfieldunits
derived from brain
computed
tomographyimages
https://doi.org/10.1371/jour
nal.pone.0197336 TheADAM-pelvisphantom-ananthropomorphic,
deformableandmultimodalphantomforMrgRT
http://doi.org/10.1088/1361-6560/aafd5f
ConstructionandanalysisofaheadCT-scan databaseforcraniofacialreconstruction
FrançoiseTilotta, Frédéric Richard, Joan Alexis Glaunès, Maxime Berar, Servane Gey, Stéphane Verdeille, Yves
Rozenholc, Jean-François Gaudy https://hal-descartes.archives-ouvertes.fr/hal-00278579/document
CT Bonevery useful for brain imaging/stimulationsimulation models e.g. ultrasoundandNIRS
MeasurementsoftheRelationship BetweenCT
HounsfieldUnitsand AcousticVelocityandHow It
ChangesWithPhotonEnergy and Reconstruction
Method
Webb TD, LeungSA, RosenbergJ, Ghanouni P, Dahl JJ, PelcNJ, PaulyKB
IEEETransactions onUltrasonics, Ferroelectrics,and FrequencyControl, 01Jul 2018,
65(7):1111-1124 https://doi.org/10.1109/tuffc.2018.2827899
Transcranial magnetic resonance-guided focused ultrasound
continues to gain traction as a noninvasive treatment option for a
variety of pathologies. Focusing ultrasound through the skull
can be accomplished by adding a phase correction to each element
of a hemispherical transducer array. The phase corrections are
determined with acoustic simulations that rely on speed of sound
estimates derived from CT scans. While several studies have
investigated the relationship between acoustic velocity and
CT Hounsfield units (HUs), these studies havelargely ignored the
impact of X-ray energy, reconstruction method, and reconstruction
kernel on the measured HU, and therefore the estimated velocity, and
nonehavemeasuredtherelationshipdirectly.
As measured by the R-squared value, the results show that CT is
able to account for 23%-53% of the variation in velocity in
the human skull. Both the X-ray energy and the reconstruction
technique significantly alter the R-squared value and the linear
relationship between HU and speed of sound in bone. Accounting for
these variations will lead to more accurate phase corrections
and more efficient transmission of acoustic energy through
theskull.
The impact of CT energy as measured by the dual energy scan on the GE system with a bone kernel. a) The dotted
line shows the HU calculated using Equation (1) and linear attenuation values from NIST. The circles show the average HU measured
in the densest sample of cortical boneas measured by the averageHU (red), theaverageHU value of all thefragments fromtheinner
and outer tables (yellow), and the average HU value of all the fragments from the medullary bone (purple). Error bars show the
standard deviation.b) Speedof soundasa functionof HUfor fivedifferentenergies.
Comparison of the measurements presented in this paper to prior models. a)
Comparison to prior modelsusing data from the monochromatic images acquired
with the dual energy scan on the GE system. b) Comparison to prior models
using standard CT scans with unknown effective energies. In order to estimate
Aubry’s model at each energy, an effective energy of 2/3 of the peak tube voltage
wasassumed.
Further work needs to be done to
characterize either an average
relationship across a patient
population or a method for adapting
velocity estimates to specific
patient skulls. Such a study will
require a large number of skulls and is
outside the scope of the present
work. 
Future studies should examine
improvements in velocity estimates
and phase corrections (e.g. using
ultrashort echo time (UTE) MRI)
will lead to the more efficient transfer
of acoustic energy through the skull,
resulting in a decrease in the energy
required to achieve ablation at the
focalspot.
Muscle/FatCTalsouseful
(a) The relationship between graylevel and Hounsfieldunits(HU) determinedby windowlevel (WL), windowwidth
(WW),andbitdepthper pixel(BIT).(b)TheeffectofdifferentWL,WW,andBITconfigurationsonthesameimage
Pixel-LevelDeepSegmentation:ArtificialIntelligenceQuantifiesMuscleonComputed TomographyforBodyMorphometricAnalysis
HyunkwangLee&FabianM.Troschel&ShaheinTajmir&GeorgFuchs&JuliaMario&FlorianJ.Fintelmann&SynhoDo
JDigitImaging,http://doi.org/10.1007/s10278-017-9988-z
Body Composition as a Predictor of Toxicity in
Patients Receiving Anthracycline and Taxane–
Based Chemotherapy for Early-Stage Breast
Cancer
http://doi.org/10.1158/1078-0432.CCR-16-2266
Quantitativeanalysisofskeletalmuscleby
computedtomographyimaging—Stateof the
art https://doi.org/10.1016/j.jot.2018.10.004
Baseof Skull AxialCT: Wherebrainstrippingcoulduse deeplearning
Baseofskull, axialCT
1) Nasalspineoffrontalbone
2) Eyeball
3) Frontalprocessofzygomaticbone
4) Ethmoidalaircells
5) Temporalfossa
6) Greater wingofsphenoidbone
7) Sphenoidalsinus
8) Zygomaticprocessoftemporalbone
9) Headofmandible
10) Carotidcanal,firstpart
11) Jugular foramen,posteriortointrajugular
process
12) Posterior border ofjugularforamen
13) Sigmoidsinus
14) Lateralpartofoccipitalbone
15) Hypoglossalcanal
16) Foramenmagnum
17) Nasalseptum
18) Nasalcavity
19) Bodyofsphenoidbone
20) Foramenlacerum
21) Foramenovale
22) Foramenspinosum
23) Sphenopetrousfissure/Eustachiantube
24) Carotidcanal,secondpart
25) Aircellsintemporalbone
26) Apexofpetrousbone
27) Petro-occipitalfissure
RadiologyKey
FastestRadiologyInsightEngine
https://radiologykey.com/skull/
CSFSpacesas seen by CT
An Evidence-Based Approach To Imaging Of Acute
Neurological Conditions (2007)
https://www.ebmedicine.net/media_library/marketi
ngLandingPages/1207.pdf
AirinBrain as seen by CT
Airdefines anatomicalshapes usefuloutside ICH analysis→
Amultiscale imagingand modelling
dataset of thehumaninner ear
Gerber etal.(2017)ScientificDatavolume
4,Articlenumber: 170132 (2017)
https://doi.org/10.1038/sdata.2017.132
BE-FNet:3DBoundingBox
EstimationFeature Pyramid
NetworkforAccurateand Efficient
Maxillary Sinus Segmentation
Zhuofu Deng etal. (2020)
https://doi.org/10.1155/2020/5689301
Maxillary sinus segmentation plays an important
role in the choice of therapeutic strategies for
nasal disease and treatment monitoring.
Difficulties in traditional approaches deal with
extremely heterogeneous intensity caused by
lesions, abnormal anatomy structures, and
blurringboundariesofcavity
Development ofCT-basedmethods
for longitudinalanalysesof
paranasalsinusosteitisin
granulomatosiswithpolyangiitis
SigrunSkaarHolme etal.(2019)
https://doi.org/10.1186/s12880-019-0315-7
Eventhough progressiverhinosinusitiswith
osteitisisamajor clinicalproblemin
granulomatosiswithpolyangiitis(GPA),thereare
nostudiesonhowGPA-relatedosteitisdevelops
overtime, andnoquantitativemethods for
longitudinalassessment.Here, weaimedto
identifysimpleandrobustCT-basedmethodsfor
captureandquantificationoftime-dependent
changesinGPA-relatedparanasalsinusosteitis
Gray/WhiteMatter Contrast not as nice as with MRI
An Evidence-Based Approach To Imaging Of Acute Neurological Conditions
(2007)
https://www.ebmedicine.net/media_library/marketingLandingPages/1207.pdf
Comparison between brain-deadpatients' and normalcontrolsubjects'CTscans: 1, normal control CTscan;2, CT
scan with lossof WM/GMdifferentiation; 3, CTscan with reversed GM/WMratio.
GrayMatter-White Matter De-Differentiation on Brain Computed TomographyPredictsBrain Death Occurrence.
https://doi.org/10.1016/j.transproceed.2016.05.006
Calcifications choroidplexusandpinealglandverycommonlocations
IntracranialcalcificationsonCT: an
updated reviewCharbelSaade,ElieNajem,Karl
Asmar, RidaSalman,BassamElAchkar,LenaNaffaa(2019)
http://doi.org/10.3941/jrcr.v13i8.3633
In a study that was done by Yalcin et al.(2016) that
focused on determining the location and extent of
intracranial calcificationsin 11,941 subjects, the
pineal gland was found to be the most common
site of physiologic calcifications (71.6%) followed
by the choroid plexus (70.2%) with male
dominance in both sites with a mean age of 47.3
and 49.8 respectively. However, the choroid
plexus was found to be the most common site
of physiologic calcification after the 5th
decade and second most common after the
pineal gland in subjects aged between 15-45
years. According to Yalcin et al. (2016) dural
calcifications were seen in up to 12.5% of the
studied population with the majority found in male
patients. Basal ganglia calcifications were
found in only 1.3% in the same study conducted
by Yalcin et al.(2016)Yalcin etal. (2016).
Interestingly, BGC were reported to be more
prevalent among females than males with a mean
age of 52.
Examples of patterns of calcification and related terminology. (a)
dots, (b) lines, (c) conglomerate or mass-like, (d) rock-like, (e)
blush,(f)gyriform/band-like,(g) stippled(h) reticular.
Calcifications #2
An Evidence-Based Approach To Imaging Of Acute Neurological Conditions
(2007)
https://www.ebmedicine.net/media_library/marketingLandingPages/1207.pdf
Pinealglandofa72-year-oldmale.
Image a revealstheoutlinedpinealglandon
sagittalplaneandimage b demonstratesthe3-
dimensionalimageandvolumeofthetissue.
Greenareasonimage c and d exhibitthe
restrictedparenchymabyexcludingallthe
calcifiedtissuesfromtheslices.
http://doi.org/10.5334/jbr-btr.892
Pinealglandofa35-year-oldfemale.
Image a and b revealtheoutlinedpinealglandon
sagittal(a)andaxial(b)planesonnoncontrast
computerizedtomographyimages.Greenareas
onimage c exhibittherestrictedparenchymaby
excludingallthecalcifiedtissuesfromtheslices.
Imaged demonstratesthe3-dimensionalimage
andvolumeofnoncalcifedpinealtissue.
Weassumethatoptimizedvolumetryofactive
pinealtissueandthereforeahighercorrelation
of melatoninandpinealparenchymacan
potentiallybeimprovedbyacombinationof
MRandCT imaging inadditionto serum
melatoninlevels.Moreover,inordertoimprove
MRquantificationofpinealcalcifications,the
combinedapproachwouldpossiblyallowan
optimizationandcalibrationofMRIsequencesby
CTandthenperhapsevenmakeCT
unnecessary 
Massesrealor hacked“adversarialattacks”
An Evidence-Based Approach To Imaging Of Acute Neurological Conditions
(2007)
https://www.ebmedicine.net/media_library/marketingLandingPages/1207.pdf
by BrittanyGoetting — Thursday,April04,2019,09:24PMEDT
TerrifyingMalwareAltersCTScansTo
LookLikeCancer,FoolsRadiologists
https://hothardware.com/news/malware-creates-fake-cancerous-nodes-in-ct-scans
... Unfortunately, this vital technology is vulnerable to hackers. Researchers recently
designed malware that can add or take away fake cancerous nodules from CT and MRI
scans. Researchers at the University Cyber Security Research Center in Israel
developed malware that can modify CT and MRI scans. During their research, they
showed radiologists real lung CT scans, 70 of which had been altered. At least three
radiologistswerefooled nearlyeverytime.
Pituitaryapoplexy: twoverydifferent
presentationswithoneunifying diagnosis
CTbrainscanshowinga
hyperdensemassarising
fromthepituitaryfossa,
representingpituitary
macroadenomawith
haemorrhage
http://doi.org/10.1258/shorts.201
0.100073
CerebralAbscess
Low density due to cerebral inflammatory disease. A, Typical appearance of a cerebral abscess: round,
low-density cavity (arrow) surrounded by low-density vasogenic edema. Differentiation from other cavitary
lesions such as radionecrotic cysts or cystic neoplasms often requires clinical/laboratory correlation, with help
often provided by contrast-enhanced and diffusion weighted MRI. B, Progressive multifocal
leukoencephalopathy. Whereas white matter low density is nonspecific, involvement of the subcortical
U-shaped fibers in the AIDS patient can help differentiate this disorder from HIV encephalitis. C,
Toxoplasmosis. Patchy white matterlowdensity(asterisks) in an immunocompromisedpatientwith
alteredmentalstatus.
https://radiologykey.com/analysis-of-density-signal-intensity-and-echogenicity/
https://www.slideshare.net/Raeez/cns-infections-radiology
Clinicalstagesofhumanbrainabscesseson
serial CTscans aftercontrastinfusion
Computerized tomographic,neuropathological,
andclinicalcorrelations(1983)
https://doi.org/10.3171/jns.1983.59.6.0972
Ischemicstroke hypodensity (CSF-like looks)→
An Evidence-Based Approach To Imaging Of Acute Neurological Conditions (2007)
https://www.ebmedicine.net/media_library/marketingLandingPages/1207.pdf
CTscansliceof thebrain showingaright-hemispheric cerebralinfarct(left
sideofimage).https://en.wikipedia.org/wiki/Cerebral_infarction
BrainSymmetry midline shift frommass effect #1
An Evidence-Based Approach To Imaging Of Acute
Neurological Conditions (2007)
https://www.ebmedicine.net/media_library/marketi
ngLandingPages/1207.pdf
https://en.wikipedi
a.org/wiki/Midline
_shift
https://www.slideshare.net/drlokeshmahar/approach-to-head-ct
BrainSymmetry midline shift #2:Estimate with ICP
Automated Midline Shift and
Intracranial Pressure
Estimation based on Brain CT
Images
Wenan Chen, Ashwin Belle,CharlesCockrell, KevinR. Ward,
Kayvan Najarian
J.Vis. Exp.(74),e3871,doi:10.3791/3871(2013).
https://www.jove.com/video/3871
In this paper we present an automated system
based mainly on the computed tomography
(CT) images consisting of two main
components: the midline shift
estimation and intracranial pressure
(ICP) pre-screening system. To estimate the
midline shift, first an estimation of the ideal
midline is performed based on the symmetry
of the skull and anatomical features in the brain
CTscan.
Then, segmentation of the ventricles from the
CT scan is performed and used as a guide for
the identification of the actual midline through
shapematching.
These processes mimic the
measuringprocess by physicians and
have shown promising results in the
evaluation. In the second component, more
features are extracted related to ICP, such as
the texture information, blood amount from CT
scans and other recorded features, such as
age, injury severity score to estimate the ICP
arealsoincorporated.
Theresultof theideal midline
detection.Thered lineisthe
approximateideal midline. The
two rectangular boxescover
theboneprotrusionand the
lowerfalxcerebri respectively.
Theseboxesareused to
reducetheregionsof interest.
Thegreen dash lineisthefinal
detected ideal midline, which
capturestheboneprotrusion
and thelowerfalxcerebri
accurately.
BrainSymmetry midline shift #3:Detection algorithms
Themiddlesliceandtheanatomicalmarkers. 
Adeformedmidlineexampleandtheanatomicalmidlineshiftmarker 
https://doi.org/10.1016/j.compmedimag.2013.11.001 (2014) ASimple,Fastand FullyAutomated ApproachforMidlineShift Measurement on
BrainComputedTomography Huan-ChihWang, Shih-Hao Ho,Furen Xiao,Jen-Hai Chou
https://arxiv.org/abs/1703.00797
IncorporatingTask-Specific Structural KnowledgeintoCNNs forBrainMidlineShift
Detection MaximPisovetal.(2019)
https://doi.org/10.1007/978-3-030-33850-3_4
https://github.com/neuro-ml/midline-shift-detection
CommercialCTScanners
Siemens hot in London
Intracerebral Hemorrhage (ICH): Understanding the CT imaging features
Siemens Unveils AI
Apps for Automatic
MRI Image
Segmentation
DECEMBER 4TH, 2019  MEDGADGET EDITORS 
NEUROLOGY, NEUROSURGERY, RADIOLOGY, 
UROLOGY
The AI-Rad Companion Brain MR for
Morphometry Analysis, without any manual
intervention, segments brain images from
MRI exams, calculates brain volume, and
automatically marks volume deviations in
result tables that neurologists rely on for
diagnostics and therapeutics. The last part it
does by comparing the levels of gray matter,
white matter, and cerebrospinal fluid in a
given patient’s brain to normal levels. This
can help with diagnosing Alzheimer’s,
Parkinson’s, and other diseases.
https://www.medgadget.com/2019/12/siemens-unveils-ai-
apps-for-automatic-mri-image-segmentation.html
Siemenscouldprovide similartoolforCTtoo
https://global.canon/en/technology/interview/ct/index.html
CTSystemReceivesFDAClearanceforAI-BasedImageReconstruction
Technology 07Nov2019CanonMedicalSystemsUSA,Inc.(Tustin,CA,USA) hasreceived510(k)clearancefor itsAdvancedIntelligentClear-IQEngine(AiCE)for the
AquilionPrecision https://www.medimaging.net/industry-news/articles/294779910/ct-system-receives-fda-clearance-for-ai-based-image-reconstruction-technology.html
Canon Medical is releasing a
new high-end digital PET/CT
scanner at the upcoming
RSNA conference in Chicago.
The Cartesion Prime Digital
PET/CT combines Canon’s
Aquilion Prime SP CT
scanner and the SiPM (silicon
photomultiplier) PET detector,
providing high resolution
imaging and easy operator
control, according to the
company.
Productpage:
 CartesionPrime DigitalPET/CT
EpicaSeeFactorCT3Multi-Modality
SystemWinsFDAClearance
OCTOBER8TH,2019
https://www.medgadget.com/2019/10/epica-seefactorct3-multi-modality-system-wins-fda-clearance.html
The SeeFactorCT3 produces sliceless CT images, unlike typical CT systems, which
means that there’s no interpolation involved and therefore less chance of introducing
artifacts.Isotropicimaging resolution goesdownto 0.1millimetersinsoft andhard
tissues and lesions that are only 0.2 millimeter in diameter can be detected. Thanks to
the company’s “Pulsed Technology,” the system can perform high resolution imaging
while reducing the overall radiation delivered. Much of this is possible thanks to a
dynamic flat panel detector that captures image sequences accurately and at high
fidelity.
A big advantage of the SeeFactorCT3 is its mobility, since it can be wheeled in and
out of ORs, through hospital halls, and even taken inside patient rooms. When set for
transport,thedeviceisnarrowenoughtobepushedthroughatypicalopendoor.
RoyalPhilipsextends
diagnosticimaging
portfolio
DIAGNOSTICDEVICESDIAGNOSTICIMAGING
By NSMedicalStaffWriter  01Mar 2019
https://www.nsmedicaldevices.com/news/philips-incisive-ct-imagi
ng-system/
The system is being offered with ‘Tube for Life’
guarantee, as it will replace the Incisive’s X-ray tube, the
key component of any CT system, at no additional cost
throughout the entire life of the system, potentially
lowering operating expensesbyabout$400,000.
Additionally, the system features the company’s iDose4
Premium Package which includes two technologies that
can improve image quality, iDose4 and metal
artifactreductionfor large orthopedicimplants(O-MAR).
iDose4 can improve image quality through artifact
prevention and increased spatial resolution at low dose.
O-MAR reduces artifacts caused by large orthopedic
implants. Together they produce high image quality with
reducedartifacts.
The system’s 70 kV scan mode is touted to offer
improved low-contrast detectability and confidence at
lowdose.
https://youtu.be/izXI3qry8kY
Intracerebral Hemorrhage (ICH): Understanding the CT imaging features
Intracerebral Hemorrhage (ICH): Understanding the CT imaging features
PortableCTs CereTom
Reviewof Portable CT withAssessmentof
aDedicated HeadCT Scanner
Z.Rumboldt, W.Huda and J.W.All
AmericanJournal ofNeuroradiology October
2009, 30 (9) 1630-1636
https://doi.org/10.3174/ajnr.A1603 - Citedby91
This article reviews a number of portable CT
scanners for clinical imaging. These include
the CereTom, Tomoscan, xCAT ENT, and
OTOscan. The Tomoscan scanner consists
of a gantry with multisection detectors and a
detachable table. It can perform a full-body
scanning, or the gantry can be used without
the table to scan the head. The xCAT ENT is a
conebeam CT scanner that is intended for
intraoperative scanning of cranial bones and
sinuses. The OTOscan is a multisection CT
scanner intended for imaging in ear, nose, and
throat settings and can be used to assess
boneandsofttissueofthehead.
We also specifically evaluated the technical
and clinical performance of the CereTom, a
scanner designed specifically for
neuroradiologicheadimaging.
https://doi.org/10.1097/JNN.0b013e3181ce5c5b
GinatandGupta(2014)
https://doi.org/10.1146/annurev-bioeng
-121813-113601
CT“Startup”Scanners
addressing“market inefficiencies”andgoing smaller and cheaper
FutureofCTFromEnergycounting(EID)toPhotoncounting(PCD)?
TheFuture of ComputedTomography
Personalized,Functional,and Precise
Alkadhi,HatemandEuler, André
Investigative Radiology:September 2020 -Volume 55- Issue 9- p 545-555
http://doi.org/10.1097/RLI.0000000000000668
Modern medicine cannot be imagined without the
diagnostic capabilities of computed tomography
(CT). Although the past decade witnessed a
tremendous increase in scan speed, volume
coverage, and temporal resolution, along with a
considerable reduction of radiation dose, current
trends in CT aim toward more patient-
centric, tailored imaging approaches that
deliver diagnostic information being personalized
to each individual patient. Functional CT with
dual-and multienergy, as well as dynamic,
perfusion imaging became clinical reality and will
further prosper in the near future, and upcoming
photon-counting detectors will deliver images
ataheretoforeunmatchedspatialresolution.
This article aims to provide an overview of current
trends in CT imaging, taking into account the
potential of photon-counting detector systems,
and seeks to illustrate how the future of CT will
beshaped.
CTStartup NanoxfromIsraelGreatideaifthiswouldworkassaid? #1
https://www.mobihealthnews.com/news/nanoxs-digital-x-ray-system-wins-26m-investors
The end goal is to deliver a
robust imaging system that
can drive earlier disease
detection, especially in regions
where traditional systems
are either too costly or too
complicated to roll out
broadly.
Looking at the longer term,
Nanox said that it will be seeking
regulatory approval for its
platform, and then deploying its
globally under a pay-per-scan
business model that it says will
enable cheaper medical imaging
and screening for private and
publicprovider systems.
CTStartup NanoxfromIsraelGreatideaifthiswouldworkassaid? #2
MuddyWatersResearch@
muddywatersre
MW is short $NNOX. We
conclude that $NNOX
has no product to sell
other than its stock.
Like $NKLA, NNOX
appears to have faked its
demo video. A convicted
felon appears to be behind
the IPO. A US partner has
been requesting images
for 6 months to no avail
"But NNOX gets much worse," the report
says. "A convicted felon, who crashed an
$8 billion market cap dotcom into the
ground, was seemingly instrumental in
plucking NNOX out of obscurity and
bringing its massively exaggerated story
to the U.S. NNOX touts distribution
partnerships that supposedly amount to
$180.8 million in annual commitments.
Almost all of the company’s partnerships
give reason for skepticism."
MartyStempniak |September18,2020| HealthcareEconomics&Policy
Nanoxhitwithclass actionlawsuitamidcriticism
labeling imaging startupas ‘Theranos2.0’
https://www.radiologybusiness.com/topics/healthcare-economics
The news comes just weeks after the Israeli firm completed a successful initial public offering
that raised $190 million. Nanox has inked a series of deals in several countries to provide its
novel imaging system, claiming to offer high-end medical imaging at a fraction of the cost and
footprint. But analysts at Citron Research raised red flags Tuesday, Sept. 15, claiming the
company is merely a “stock promotion” amassing millions without any FDA approvals or
scientific evidence.
Citron’s analysis—titled “A Complete Farce on the Market: Theranos 2.0”—drew
widespread attention, with several law firms soliciting investors looking to sue Nanox over its
claims. Plaintiff Matthew White and law firm Rosen Law are one of the first to follow
through, filing a proposed securities class action in New York on Wednesday.
He claims the company made false statements to both the SEC and investors to inflate its
stock value, Bloomberg Law reported. White and his attorneys also allege Nanox fabricated
commercial agreements and made misleading statements about its imaging technology.
Several other law firms also announced their own lawsuits on behalf of investors Friday. 
Nanox did not respond to a Radiology Business request for comment. However, the Neve Ilan,
Israel-based company posted a statement to its webpage Wednesday, Sept. 16, addressing the
“unusual trading activities” after investors dumped the stock en masse in response to
Citron’s concerns.
CommercialCTDetectors
Ifyouwantto build your own CT scanner
FromAdvancesinComputedTomography Imaging Technology
Ginatand Gupta(2014) https://doi.org/10.1146/annurev-bioeng-121813-113601
From A typical multidetector CT scanner consists of a mosaic of scintillators that
convert X-rays into light in the visible spectrum, a photodiode array that
converts the light into an electrical signal, a switching array that enables switching
between channels, and a connector that conveys the signal to a data acquisition
system(Figure6).
The multiple channels between the detectors acquire multiple sets of projection data
for each rotation of the scanner gantry. The channels can sample different detector
elementssimultaneouslyandcancombinethesignals.
The detector elements can vary in size, and hybrid detectors that comprise narrow
(0.5-mm, 0.625-mm, or 0.75-mm) detectors in the center with wider (1.0-mm, 1.25-mm,
or 1.5-mm)detectorsflankedalongthesidesarecommonlyused(Saini2004).
Third-generation CT scanners featured rotate-rotate geometry,
whereby the tube and the detectors rotated together around the patient.
In conjunction with a wide X-ray fan beam that encompassed the entire
patient cross-section and an array of detectors to intercept the beam,
scan times of less than 5 s could be achieved. However, third-generation
CT scanners were prone to ring artifacts that resulted in drift in the
calibration of one detector relative to the other detectors. Fourth-
generation scanners featured stationary ring detectors and a rotating
fan-beam X-ray tube (Figure 5), which mitigated the issues related
to ring artifacts. However, the ring-detector arrangement limited the
useofscatterreduction.
leakage current MOS switch ASICs and ultra-low noise pre-amplification ASICs.
Our modern, automated, high-precision assembly process guarantees our
productsareofhighreliabilityandstability.
With our core competences in photodiode, ASIC and assembly technologies we
offer products in different assembly levels, ranging from photodiode chips to full
detector modules. Our strong experience in designing and developing CT
detector modules ensures that customized solutions are quickly and cost-
efficientlyinuseatour customers.
CTPhysics+Tech
Acquisition Sinogram Reconstruction→ →
Fransson(2019): Although many different reconstruction methods are available there are mainly two categories, filtered back-
projection (FBP) and iterative reconstruction (IR). FBP is a simpler method than IR and it takes less time to compute, but artifacts are more
frequent and dominant (Stiller2018). The image that provide the anatomical information is said to exist in the image domain. By applying
a mathematical operation, called the Fourier transform, on the image data it is transformed into the projection domain. In the projection
domain image processing is performed with the use of filters, or kernels, in order to enhance the image in various ways, such as reducing
the noise level. When the processing is completed the Inverse Fourier transform is applied on the data in order to acquire the anatomical
imagethatisdesired.
Acquisition Sinogram Reconstruction→ →
Stiller2018:Basicsofiterativereconstructionmethodsincomputedtomography:Avendor-independentoverview
Sinogram ImageSpace→
MachineFriendly MachineLearning:InterpretationofComputed
TomographyWithout Image Reconstruction
HyunkwangLee,ChaoHuang,SehyoYune,ShaheinH.Tajmir,MyeongchanKim&SynhoDo
Department ofRadiology,Massachusetts General Hospital,Boston;JohnA.Paulson SchoolofEngineeringand AppliedSciences,Harvard University,
ScientificReportsvolume9,Articlenumber: 15540(2019)
https://doi.org/10.1038/s41598-019-51779-5
Examples of reconstructed images and sinograms with different labels for (a), body part recognition
and (b), ICH detection. From left to right: original CT images, windowed CT images, sinograms with
360 projections by 729 detector pixels, and windowed sinograms 360 × 729. In the last row, an
example CT with hemorrhage is annotated with a dotted circle in image-space with the region of
interest converted into the sinogram domain using Radon transform. This area is highlighted in red on
thesinogramin thefifthcolumn.
Reconstructionfrom sparsemeasurements
common problem in all scanning-based imaging
Zhuetal.(2018) Nature"Imagereconstructionbydomain-transformmanifold learning" https://doi.org/10.1038/nature25988
Radonprojection;Spiralnon-CartesianFourier;UndersampledFourier;MisalignedFourier-  Citedby238 -https://youtu.be/o-vt1Ld6v-M-
https://github.com/chongduan/MRI-AUTOMAP
They describe the technique - dubbed AUTOMAP
(automated transform by manifold approximation) - in a
paper published today in the journal Nature.
"An essential part of the clinical imaging pipeline is image
reconstruction, which transforms the raw data coming
off the scanner into images forradiologists to evaluate,"
https://phys.org/news/2018-03-arti
ficial-intelligence-technique-quality-
medical.html
PET+CTJoint Reconstruction
Improvingthe Accuracy ofSimultaneously
Reconstructed ActivityandAttenuationMapsUsing
Deep Learning
DonghwiHwang,Kyeong YunKim,SeungKwanKang,SeonghoSeo,Jin
ChulPaeng,DongSooLeeandJaeSungLee
JNucl Med2018;59:1624–1629
http://doi.org/10.2967/jnumed.117.202317
Simultaneous reconstruction of activity and attenuation using
the maximum-likelihood reconstruction of activity and
attenuation (MLAA) augmented by time-of-flight information
is a promising method for PET attenuation correction.
However, it still suffers from several problems, including
crosstalk artifacts, slow convergence speed, and noisy
attenuation maps (μ-maps). In this work, we developed deep
convolutional neural networks (CNNs) to overcome these
MLAA limitations, and we verified their feasibility using a
clinical brain PET dataset.
There are someexistingworks on applying deeplearningto predict CT
m-maps based on T1-weighted MR images or a combination of Dixon
and zero-echo-time images (51,52). The approach using the Dixon and
zero-echo-time images would be more physically relevant than the T1-
weighted MRI-based approach because the Dixon and zero-echo-
time sequences provide more direct information on the tissue
composition than does the T1 sequence. The method proposed in this
study has the same physical relevance as the Dixon or zero-echo-time
approachbut doesnot requiretheacquisitionofadditionalMRimages.
Reconstructionexample forPET from sinograms
DirectPET:FullSize Neural
NetworkPET Reconstruction
fromSinogramData
William Whiteley, WingK. Luk, JensGregor Siemens Medical
Solutions USA
https://arxiv.org/abs/1908.07516
This paper proposes a new more
efficient network design called
DirectPET which is capable of
reconstructing a multi-slice Positron
Emission Tomography (PET) image
volume (i.e., 16x400x400) by
addressing the computational
challenges through a specially
designed Radon inversion layer. We
compare the proposed method to the
benchmark Ordered Subsets
Expectation Maximization
(OSEM) algorithm using signal-to-
noise ratio, bias, mean absolute error
and structural similarity measures.
Line profiles and full-width half-
maximum measurements are
also providedforasampleoflesions.
Looking toward future work, there are many possibilities in
network architecture, loss functions and training optimization to
explore, which will undoubtedly lead to more efficient
reconstructions and even higher quality images. However, the
biggest challenge with producing medical images is providing
overall confidence on neural network reconstruction on
unseensamples
ImprovingtheAccuracy ofSimultaneouslyReconstructedActivity and AttenuationMapsUsingDeepLearning
JNuclMed2018;59:1624–1629 http://doi.org/10.2967/jnumed.117.202317
CTArtifacts
BeamHardeningArtifactfoundoftenatlowerslicesnearbrainstemwithsmallspacessurroundedby bone
Beamhardeningartifact(left),andpartialvolumeeffect(right)
http://doi.org/10.13140/RG.2.1.2575.3122
UnderstandingandMitigatingUnexpectedArtifactsinHeadCTs:APracticalExperience
FlaviusD.RaslauJ.ZhangJ.Riley-GrahamE.J.Escott(2016)
http://doi.org/10.3174/ng.2160146
BeamHardening. The most commonly encountered artifact in CT
scanning is beam hardening, which causes the edges of an object to appear
brighter thanthecenter, evenifthematerialisthe same throughout
The artifact derives its name from its underlying cause: the increase in mean X-ray energy, or “hardening” of
the X-ray beam as it passes through the scanned object. Because lower-energy X-rays are attenuated more readily
than higher-energy X-rays, a polychromatic beam passing through an object preferentially loses the lower-
energy parts of its spectrum. The end result is a beam that, though diminished in overall intensity, has a higher
average energy than the incident beam. This also means that, as the beam passes through an object, the effective
attenuation coefficient of any material diminishes, thus making short ray paths proportionally more attenuating than
long ray paths. In X-ray CT images of sufficiently attenuating material, this process generally manifests itself
as an artificial darkening at the center of long ray paths, and a corresponding brightening near the edges.
In objects with roughly circular cross sections this process can cause the edge to appear brighter than the interior,
but in irregular objects it is commonly difficult to differentiate between beam hardening artifacts and
actualmaterial variations.
MotionArtifacts as inmostofimagingwhen thesubjectmovesduringthe acquisition
There are several steps to be taken to prevent the
voluntary movement of the body during scanning while
it is difficult to prevent involuntary movement. Some
modern scanning devices have some features that
reducetheresultingartifacts
Ameretal.(2018)researchgate.net
ArtifactsinCT:recognitionandavoidance.
BarrettandKeat(2004)
https://doi.org/10.1148/rg.246045065
Freeze!RevisitingCTmotionartifacts:Formation,recognitionand remedies.
semanticscholar.org
CTbrain withseveremotionartifact
https://radiopaedia.org/images/4974802
StreakArtifactsfrom high density structures
An Evidence-Based Approach To Imaging Of Acute Neurological Conditions (2007)
https://www.ebmedicine.net/media_library/marketingLandingPages/1207.pdf
Dr BalajiAnvekar'sNeuroradiologyCases:StreakartifactsCT
http://www.neuroradiologycases.com/2011/10/streak-artifacts.html
Hegazy, M.A.A., Cho, M.H., Cho, M.H. et al.
U-netbasedmetalsegmentation
onprojectiondomainfor metal
artifact reductionindentalCT
(2019)
https://doi.org/10.1007/s13534-019-00
110-2
RingArtifacts from high density structures
CTartifacts:causes andreduction
techniques (2012)
FEdwardBoas&DominikFleischmann Department
ofRadiology, StanfordUniversitySchoolofMedicine,
300PasteurDrive, Stanford,CA94305, USA
https://www.openaccessjournals.com/articles/ct-artif
acts-causes-and-reduction-techniques.html http://doi.org/10.1088/0031-9155/46/12/309
ZebraandStair-stepArtifacts
CTartifacts:causesand reductiontechniques (2012)
FEdwardBoas&DominikFleischmannDepartment ofRadiology,StanfordUniversitySchoolofMedicine
https://www.openaccessjournals.com/articles/ct-artifacts-causes-and-reduction-techniques.html
Zebra and stair-step artifacts. (A) Zebra artifacts (alternating high and low noise
slices, arrows) due to helical interpolation. These are more prominent at the periphery
of the field of view. (B) Stair-step artifacts (arrows) seen with helical and
multidetector rowCT.Thesearealsomoreprominentnear theperipheryofthefieldof
view.Therefore,itisimportanttoplace theobjectofinterestnear thecenter ofthefield
ofview.
Zebrastripes
https://radiopaedia.org/articles/zebra-stripes-1?lang=gb
AndrewMurphy  and ◉ and  Dr J.RayBallinger etal.
Zebrastripes/artifacts appear asalternatingbrightanddarkbandsinaMRIimage.Theterm
hasbeenusedtodescribeseveraldifferentkindofartifactscausingsomeconfusion.
Artifactsthathavebeendescribedasazebraartifactincludethefollowing:
●
Moirefringes 
●
Zero-fillartifact
●
Spikeink-space 
Zebrastripeshavebeendescribedassociatedwith susceptibilityartifacts.
InCTthereisalsoazebraartifactfrom3Dreconstructionsandazebrasignfrom
haemorrhageinthecerebellar sulci.
Itthereforeseemsprudenttouse"zebra"withatermlike"stripes"rather than"artifacts".
Bonediscontinuities from factures
An Evidence-Based Approach To Imaging Of Acute Neurological Conditions (2007)
https://www.ebmedicine.net/media_library/marketingLandingPages/1207.pdf
https://www.ncbi.nlm.nih.gov/pubmed/21691535
Bonefractures in practice
DoctorExplains Serious UFCEyeInjuryforKarolinaKowalkiewicz - UFC FightNight168
Brian Sutterer,https://youtu.be/XwvoNsypP-I
OrbitalFloorfracture
muscleorfatgoingtomaxillarysinus
https://en.wikipedia.org/wiki/Orbital_blowout_fracture
Networks trainedfor fractures as well
DeepConvolutionalNeural
NetworksforAutomatic
DetectionofOrbitalBlowout
Fractures
D.Ng,L.Churilov,P. Mitchell, R.DowlingandB.Yan
American Journalof NeuroradiologyFebruary2018,39
(2)232-237; https://doi.org/10.3174/ajnr.A5465
Orbital blow out fracture is a common
disease in emergency department and a
delay or failure in diagnosis can lead to
permanent visual changes. This study aims to
evaluate the ability of an automatic orbital
blowout fractures detection system based on
computedtomography(CT) data.
The limitations of this work should be
mentioned. First, our method was developed
and evaluated on data from a single-tertiary
hospital. Thus, further assessment of large
data from other centers is required to increase
the generalizability of the findings, which will be
addressed in a future work. Fracture location is
also an important parameter in accurate
diagnosis and planning for surgical
management. With further improvements and
clinical verification, an optimized model could be
implemented in the development of computer-
aideddecisionsystems.
Preprocessing of DICOM data. A, Original pixel values visualized on a CT slice. B, Effect after finding the largest link
area. C, Image with bone window limitation. D, Binary image of a CT slice. E, Image clipped with the maximum outer
rectangular frame.CT,computedtomography.
“Signs”
Clinician-invented
handcrafted features
Intracerebral Hemorrhage (ICH): Understanding the CT imaging features
Intracerebral Hemorrhage (ICH): Understanding the CT imaging features
Intracerebral Hemorrhage (ICH): Understanding the CT imaging features
Intracerebral Hemorrhage (ICH): Understanding the CT imaging features
Intracerebral Hemorrhage (ICH): Understanding the CT imaging features
Intracerebral Hemorrhage (ICH): Understanding the CT imaging features
Intracerebral Hemorrhage (ICH): Understanding the CT imaging features
Intracerebral Hemorrhage (ICH): Understanding the CT imaging features
Intracerebral Hemorrhage (ICH): Understanding the CT imaging features
Intracerebral Hemorrhage (ICH): Understanding the CT imaging features
Intracerebral Hemorrhage (ICH): Understanding the CT imaging features
Intracerebral Hemorrhage (ICH): Understanding the CT imaging features
Intracerebral Hemorrhage (ICH): Understanding the CT imaging features
Intracerebral Hemorrhage (ICH): Understanding the CT imaging features
Intracerebral Hemorrhage (ICH): Understanding the CT imaging features
Intracerebral Hemorrhage (ICH): Understanding the CT imaging features
Intracerebral Hemorrhage (ICH): Understanding the CT imaging features
Intracerebral Hemorrhage (ICH): Understanding the CT imaging features
Intracerebral Hemorrhage (ICH): Understanding the CT imaging features
Intracerebral Hemorrhage (ICH): Understanding the CT imaging features
Intracerebral Hemorrhage (ICH): Understanding the CT imaging features
Intracerebral Hemorrhage (ICH): Understanding the CT imaging features
Intracerebral Hemorrhage (ICH): Understanding the CT imaging features
Intracerebral Hemorrhage (ICH): Understanding the CT imaging features
Intracerebral Hemorrhage (ICH): Understanding the CT imaging features
Intracerebral Hemorrhage (ICH): Understanding the CT imaging features
Intracerebral Hemorrhage (ICH): Understanding the CT imaging features
Intracerebral Hemorrhage (ICH): Understanding the CT imaging features
Intracerebral Hemorrhage (ICH): Understanding the CT imaging features
Intracerebral Hemorrhage (ICH): Understanding the CT imaging features
Intracerebral Hemorrhage (ICH): Understanding the CT imaging features
Intracerebral Hemorrhage (ICH): Understanding the CT imaging features
Intracerebral Hemorrhage (ICH): Understanding the CT imaging features
Intracerebral Hemorrhage (ICH): Understanding the CT imaging features
Intracerebral Hemorrhage (ICH): Understanding the CT imaging features
Intracerebral Hemorrhage (ICH): Understanding the CT imaging features
Intracerebral Hemorrhage (ICH): Understanding the CT imaging features
Intracerebral Hemorrhage (ICH): Understanding the CT imaging features
Intracerebral Hemorrhage (ICH): Understanding the CT imaging features
Intracerebral Hemorrhage (ICH): Understanding the CT imaging features
Intracerebral Hemorrhage (ICH): Understanding the CT imaging features
Intracerebral Hemorrhage (ICH): Understanding the CT imaging features
Intracerebral Hemorrhage (ICH): Understanding the CT imaging features
Intracerebral Hemorrhage (ICH): Understanding the CT imaging features
Intracerebral Hemorrhage (ICH): Understanding the CT imaging features
Intracerebral Hemorrhage (ICH): Understanding the CT imaging features
Intracerebral Hemorrhage (ICH): Understanding the CT imaging features
Intracerebral Hemorrhage (ICH): Understanding the CT imaging features
Intracerebral Hemorrhage (ICH): Understanding the CT imaging features
Intracerebral Hemorrhage (ICH): Understanding the CT imaging features
Intracerebral Hemorrhage (ICH): Understanding the CT imaging features
Intracerebral Hemorrhage (ICH): Understanding the CT imaging features
Intracerebral Hemorrhage (ICH): Understanding the CT imaging features
Intracerebral Hemorrhage (ICH): Understanding the CT imaging features
Intracerebral Hemorrhage (ICH): Understanding the CT imaging features
Intracerebral Hemorrhage (ICH): Understanding the CT imaging features
Intracerebral Hemorrhage (ICH): Understanding the CT imaging features
Intracerebral Hemorrhage (ICH): Understanding the CT imaging features
Intracerebral Hemorrhage (ICH): Understanding the CT imaging features
Intracerebral Hemorrhage (ICH): Understanding the CT imaging features
Intracerebral Hemorrhage (ICH): Understanding the CT imaging features
Intracerebral Hemorrhage (ICH): Understanding the CT imaging features
Intracerebral Hemorrhage (ICH): Understanding the CT imaging features
Intracerebral Hemorrhage (ICH): Understanding the CT imaging features
Intracerebral Hemorrhage (ICH): Understanding the CT imaging features
Intracerebral Hemorrhage (ICH): Understanding the CT imaging features
Intracerebral Hemorrhage (ICH): Understanding the CT imaging features
Intracerebral Hemorrhage (ICH): Understanding the CT imaging features
Intracerebral Hemorrhage (ICH): Understanding the CT imaging features
Intracerebral Hemorrhage (ICH): Understanding the CT imaging features
Intracerebral Hemorrhage (ICH): Understanding the CT imaging features
Intracerebral Hemorrhage (ICH): Understanding the CT imaging features
Intracerebral Hemorrhage (ICH): Understanding the CT imaging features
Intracerebral Hemorrhage (ICH): Understanding the CT imaging features
Intracerebral Hemorrhage (ICH): Understanding the CT imaging features
Intracerebral Hemorrhage (ICH): Understanding the CT imaging features
Intracerebral Hemorrhage (ICH): Understanding the CT imaging features
Intracerebral Hemorrhage (ICH): Understanding the CT imaging features
Intracerebral Hemorrhage (ICH): Understanding the CT imaging features
Intracerebral Hemorrhage (ICH): Understanding the CT imaging features
Intracerebral Hemorrhage (ICH): Understanding the CT imaging features
Intracerebral Hemorrhage (ICH): Understanding the CT imaging features
Intracerebral Hemorrhage (ICH): Understanding the CT imaging features
Intracerebral Hemorrhage (ICH): Understanding the CT imaging features
Intracerebral Hemorrhage (ICH): Understanding the CT imaging features
Intracerebral Hemorrhage (ICH): Understanding the CT imaging features
Intracerebral Hemorrhage (ICH): Understanding the CT imaging features
Intracerebral Hemorrhage (ICH): Understanding the CT imaging features
Intracerebral Hemorrhage (ICH): Understanding the CT imaging features
Intracerebral Hemorrhage (ICH): Understanding the CT imaging features
Intracerebral Hemorrhage (ICH): Understanding the CT imaging features
Intracerebral Hemorrhage (ICH): Understanding the CT imaging features
Intracerebral Hemorrhage (ICH): Understanding the CT imaging features
Intracerebral Hemorrhage (ICH): Understanding the CT imaging features
Intracerebral Hemorrhage (ICH): Understanding the CT imaging features
Intracerebral Hemorrhage (ICH): Understanding the CT imaging features
Intracerebral Hemorrhage (ICH): Understanding the CT imaging features
Intracerebral Hemorrhage (ICH): Understanding the CT imaging features
Intracerebral Hemorrhage (ICH): Understanding the CT imaging features
Intracerebral Hemorrhage (ICH): Understanding the CT imaging features
Intracerebral Hemorrhage (ICH): Understanding the CT imaging features
Intracerebral Hemorrhage (ICH): Understanding the CT imaging features
Intracerebral Hemorrhage (ICH): Understanding the CT imaging features
Intracerebral Hemorrhage (ICH): Understanding the CT imaging features
Intracerebral Hemorrhage (ICH): Understanding the CT imaging features
Intracerebral Hemorrhage (ICH): Understanding the CT imaging features
Intracerebral Hemorrhage (ICH): Understanding the CT imaging features
Intracerebral Hemorrhage (ICH): Understanding the CT imaging features
Intracerebral Hemorrhage (ICH): Understanding the CT imaging features
Intracerebral Hemorrhage (ICH): Understanding the CT imaging features
Intracerebral Hemorrhage (ICH): Understanding the CT imaging features
Intracerebral Hemorrhage (ICH): Understanding the CT imaging features
Intracerebral Hemorrhage (ICH): Understanding the CT imaging features
Intracerebral Hemorrhage (ICH): Understanding the CT imaging features
Intracerebral Hemorrhage (ICH): Understanding the CT imaging features
Intracerebral Hemorrhage (ICH): Understanding the CT imaging features
Intracerebral Hemorrhage (ICH): Understanding the CT imaging features
Intracerebral Hemorrhage (ICH): Understanding the CT imaging features
Intracerebral Hemorrhage (ICH): Understanding the CT imaging features
Intracerebral Hemorrhage (ICH): Understanding the CT imaging features
Intracerebral Hemorrhage (ICH): Understanding the CT imaging features
Intracerebral Hemorrhage (ICH): Understanding the CT imaging features
Intracerebral Hemorrhage (ICH): Understanding the CT imaging features
Intracerebral Hemorrhage (ICH): Understanding the CT imaging features
Intracerebral Hemorrhage (ICH): Understanding the CT imaging features
Intracerebral Hemorrhage (ICH): Understanding the CT imaging features
Intracerebral Hemorrhage (ICH): Understanding the CT imaging features
Intracerebral Hemorrhage (ICH): Understanding the CT imaging features
Intracerebral Hemorrhage (ICH): Understanding the CT imaging features
Intracerebral Hemorrhage (ICH): Understanding the CT imaging features
Intracerebral Hemorrhage (ICH): Understanding the CT imaging features
Intracerebral Hemorrhage (ICH): Understanding the CT imaging features
Intracerebral Hemorrhage (ICH): Understanding the CT imaging features
Intracerebral Hemorrhage (ICH): Understanding the CT imaging features
Intracerebral Hemorrhage (ICH): Understanding the CT imaging features
Intracerebral Hemorrhage (ICH): Understanding the CT imaging features
Intracerebral Hemorrhage (ICH): Understanding the CT imaging features
Intracerebral Hemorrhage (ICH): Understanding the CT imaging features
Intracerebral Hemorrhage (ICH): Understanding the CT imaging features
Intracerebral Hemorrhage (ICH): Understanding the CT imaging features
Intracerebral Hemorrhage (ICH): Understanding the CT imaging features
Intracerebral Hemorrhage (ICH): Understanding the CT imaging features
Intracerebral Hemorrhage (ICH): Understanding the CT imaging features
Intracerebral Hemorrhage (ICH): Understanding the CT imaging features
Intracerebral Hemorrhage (ICH): Understanding the CT imaging features
Intracerebral Hemorrhage (ICH): Understanding the CT imaging features
Intracerebral Hemorrhage (ICH): Understanding the CT imaging features
Intracerebral Hemorrhage (ICH): Understanding the CT imaging features
Intracerebral Hemorrhage (ICH): Understanding the CT imaging features
Intracerebral Hemorrhage (ICH): Understanding the CT imaging features
Intracerebral Hemorrhage (ICH): Understanding the CT imaging features
Intracerebral Hemorrhage (ICH): Understanding the CT imaging features
Intracerebral Hemorrhage (ICH): Understanding the CT imaging features
Intracerebral Hemorrhage (ICH): Understanding the CT imaging features
Intracerebral Hemorrhage (ICH): Understanding the CT imaging features
Intracerebral Hemorrhage (ICH): Understanding the CT imaging features
Intracerebral Hemorrhage (ICH): Understanding the CT imaging features
Intracerebral Hemorrhage (ICH): Understanding the CT imaging features
Intracerebral Hemorrhage (ICH): Understanding the CT imaging features
Intracerebral Hemorrhage (ICH): Understanding the CT imaging features
Intracerebral Hemorrhage (ICH): Understanding the CT imaging features
Intracerebral Hemorrhage (ICH): Understanding the CT imaging features
Intracerebral Hemorrhage (ICH): Understanding the CT imaging features
Intracerebral Hemorrhage (ICH): Understanding the CT imaging features
Intracerebral Hemorrhage (ICH): Understanding the CT imaging features
Intracerebral Hemorrhage (ICH): Understanding the CT imaging features
Intracerebral Hemorrhage (ICH): Understanding the CT imaging features
Intracerebral Hemorrhage (ICH): Understanding the CT imaging features
Intracerebral Hemorrhage (ICH): Understanding the CT imaging features
Intracerebral Hemorrhage (ICH): Understanding the CT imaging features
Intracerebral Hemorrhage (ICH): Understanding the CT imaging features
Intracerebral Hemorrhage (ICH): Understanding the CT imaging features
Intracerebral Hemorrhage (ICH): Understanding the CT imaging features
Intracerebral Hemorrhage (ICH): Understanding the CT imaging features
Intracerebral Hemorrhage (ICH): Understanding the CT imaging features
Intracerebral Hemorrhage (ICH): Understanding the CT imaging features
Intracerebral Hemorrhage (ICH): Understanding the CT imaging features
Intracerebral Hemorrhage (ICH): Understanding the CT imaging features

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Intracerebral Hemorrhage (ICH): Understanding the CT imaging features

  • 1. Intracerebral Hemorrhage (ICH) Understanding the CT imaging features for development of deep learning networks, ranging from restoration, segmentation, prognosis and prescriptive purposes Petteri Teikari, PhD High-dimensionalNeurology,Queen’sSquareof Neurology,UCL,London https://www.linkedin.com/in/petteriteikari/ Version “06/10/20“
  • 2. Forwhoisthis“literaturereview forvisuallyorientatedpeople” for? ”A bitofeverythingrelatedto headCT deeplearning,focusedonintracerebral hemorrhage(ICH) analysis” Itisassumedthatthereader isfamiliar with deeplearning/computervision, but lessso withcomputerizedtomography (CT)andICH https://www.linkedin.com/in/andriyburkov
  • 4. SpontaneousIntracerebralHemorrhage(ICH) https://www.grepmed.com/images/4925/intracerebral-suba rachnoid-hemorrhage-comparison-diagnosis-neurology-ep idural http://doi.org/10.13140/RG.2.1.1572.8167 ”HemorrhagicStroke” , lesscommon than ischemic stroke, the “layman definition” of stroke “Spontaneous”, asin opposed to, traumaticbrain hemorrhage caused bya blowto the head (“traumatic brain injury”, TBI) https://www.strokeinfo.org/stroke-treatme nts-hemorrhagic-stroke/ https://mc.ai/building-an-algorithm-to-detect-differe nt-types-of-intracranial-brain-hemorrhage-using-de ep/ https://mayfieldclinic.com/pe-ich.htm
  • 6. Primarymechanicalinjury → Secondaryinjuries PathophysiologicalMechanismsand PotentialTherapeutic TargetsinIntracerebralHemorrhage ZhiweiShao etal.(FrontPharmacol.2019; 10: 1079,Sept2019) https://dx.doi.org/10.3389%2Ffphar.2019.01079 Intracerebral hemorrhage (ICH) is a subtype of hemorrhagic stroke with high mortality and morbidity. The resulting hematoma within brain parenchyma induces a series of adverse events causing primary and secondary brain injury. The mechanism of injuryafterICHisverycomplicatedandhasnot yet beenilluminated. This review discusses some key pathophysiology mechanisms in ICH such as oxidative stress (OS), inflammation, iron toxicity, and thrombin formation. Thecorrespondingtherapeutic targetsandtherapeuticstrategiesarealsoreviewed. The initial pathological damage of cerebral hemorrhage to brain is the mechanical compression caused by hematoma. The hematoma mass can increase intracranial pressure, compressing brain and thereby potentially affecting blood flow, and subsequentlyleadingtobrainhernia(Keepet al.,2012). Subsequently, brain hernia and brain edema cause secondary injury, which may be associatedwithpooroutcomeandmortalityinICHpatients(Yangetal.,2016). Unfortunately, the common treatment of brain edema (steroids, mannitol, glycerol, and hyperventilation) cannot effectively reduce intracranial pressure or prevent secondary brain injury (Cordonnieret al., 2018). Truly effective clinical treatments are very limited, mainly because the problem of transforming preclinical research into clinical application has not yet been solved. Therefore, a multi-target neuroprotective therapy will make clinically effective treatment strategies possible, but also requires furtherstudy. Pro-andanti-inflammatorycytokinesinsecondarybraininjuryafter ICH. Mechanismsoferythrocyte lysates and thrombin in secondarybrain injuryafter ICH. The Keap1–Nrf2–ARE pathway. Keap1 is an OS sensor and negatively regulates Nrf2. Once exposed to reactive oxygen species (ROS), the activated Nrf2 translocates to the nucleus, binds to antioxidant response element (ARE), heterodimerizes with one of the small Maf (musculo- aponeurotic fibrosarcoma oncogene homolog) proteins, and enhances the upregulation of cytoprotective, antioxidant, anti-inflammatory, and detoxification genes that mediate cell survival.
  • 7. ”Time isBrain” Neural injury(and your imagingfeatures*) and depend on the time since initialhematoma Intracerebral haemorrhage DrAdnanIQureshi,ADavidMendelow, DanielFHanley TheLancetVolume373,Issue9675,9–15May2009,Pages1632-1644 https://doi.org/10.1016/S0140-6736(09)60371-8 Cascadeofneuralinjuryinitiatedbyintracerebralhaemorrhage Thestepsinthefirst 4harerelatedtothedirecteffectofthehaematoma,laterstepstotheproductsreleasedfrom thehaematoma.BBB=blood–brainbarrier.MMP=matrixmetallopeptidase.TNF=tumour necrosisfactor.PMN=polymorphonuclearcells. ProgressionofhaemotomaandoedemaonCT Top:hyperacuteexpansion of haematoma ina patientwithintracerebral haemorrhageon serial CTscans. Smallhaematoma detected in thebasal ganglia and thalamus (A). Expansion of haematoma after151 min (B). Continued progression of haematoma after another 82min(C). Stabilisationof haematomaafter another 76 min (D). Bottom:progressionof haematomaand perihaematomaloedema in apatientwith intracerebralhaemorrhageonserialCT scans. Thefirstscan (E)wasacquired beforetheintracerebral haemorrhage. Perihaematoma oedemaishighlighted in green to facilitaterecognitionof progressionof oedema. At4h aftersymptomonsetthereisa small haematoma inthebasal ganglia (F). Expansionof haematoma with extension into thelateral ventricleand newmass-effectand midlineshiftat14h (G). Worsening hydrocephalusand earlyperihaematomal oedema at28 h (H). Continued mass-effectwith prominentperihaematomal oedema at73 h (I).Resolving haematoma with moreprominent perihaematomal oedema at7days (J).
  • 8. or how much is the timereallybrain? Influenceoftimetoadmissiontoa comprehensivestrokecentreonthe outcomeofpatientswithintracerebral haemorrhage(Jan 2020) Luis Prats-Sánchez, MarinaGuasch-Jiménez, IgnasiGich, Elba Pascual-Goñi, Noelia Flores, Pol Camps-Renom, Daniel Guisado-Alonso, Alejandro Martínez-Domeño, Raquel Delgado-Mederos, Ana Rodríguez-Campello, Angel Ois, AlejandraGómez-Gonzalez, ElisaCuadrado-Godia, JaumeRoquer, JoanMartí-Fàbregas https://doi.org/10.1177%2F2396987320901616 In patients with spontaneous intracerebral haemorrhage, it is uncertain if diagnostic and therapeutic measures are time-sensitive on their impact on the outcome. We sought to determine the influence of the time to admission to a comprehensive stroke centre on the outcome of patients with acute intracerebral haemorrhage. Our results suggest that in patients with intracerebral haemorrhage and known symptom onset who are admitted to a comprehensive stroke centre, an early admission (≤110 min) does not influencetheoutcomeat90 days. Distributionofpropensity scoreblocksbytimeto admission.Foreachpair ofblocks,theboxonthe leftrepresentsthegroup ofpatientswithan admission≤110 minand theoneontheright representsthegroupwho wasadmitted > 110 min.
  • 9. ManagementofICH less options than for ischemic stroke Intracerebral haemorrhage DrAdnanIQureshi,ADavidMendelow, DanielFHanley TheLancetVolume373,Issue9675,9–15May2009,Pages1632-1644 https://doi.org/10.1016/S0140-6736(09)60371-8 haemorrhage Oddsratiofordeathor disabilityinpatientswithlobar intracerebral haemorrhagetreatedsurgicallyor conservatively. BoxesarePeto'soddsratio (OR),linesare95% CI.Adapted with permission from LippincottWilliamsandWilkins Clinical evidencesuggeststheimportanceof threemanagementtasksin intracerebralhaemorrhage: stopping thebleeding,81 removing theclot,70 and controlling cerebral perfusion pressure. 92 Theprecision needed to achievethesegoalsand thedegreeof benefitattributableto eachclinical goal would bepreciselydefined whentheresultsof trialsinprogress becomeavailable. AnNIHworkshop150  identified theimportanceof animal modelsof intracerebral haemorrhageand of humanpathology studies.Useof real-time, high-fieldMRI with three-dimensional imagingand high-resolution tissue probesisanotherpriority.Trialsof acuteblood-pressuretreatment and coagulopathyreversal arealso medical priorities.And trialsof minimallyinvasivesurgicaltechniquesincluding mechanical and pharmacologicaladjunctsaresurgical priorities. TheSTICH II trial should determinethebenefitof craniotomyforlobarhaemorrhage. Abetter understanding of methodological challenges, including establishmentofresearchnetworksandmultispecialty approaches, isalso needed.150 New information created in eachof theseareasshould add substantially to ourknowledgeabout theefficacy of treatmentfor intracerebral haemorrhage.
  • 10. Bestcareisprevention with blood pressuremedication Intracerebralhaemorrhage:currentapproaches toacute management Prof CharlotteCordonnier, Prof AndrewDemchuk,Wendy Ziai,Prof CraigS Anderson TheLancetVolume392, Issue10154,6–12October2018,Pages1257-1268 https://doi.org/10.1016/S0140-6736(18)31878-6 ICH, as a heterogeneous disease, certain clinical and imaging features help identify the cause, prognosis, and how to manage the disease. Survival and recovery from intracerebral haemorrhage are related to the site, mass effect, and intracranial pressure from the underlying haematoma, and by subsequent cerebral oedema from perihaematomal neurotoxicity or inflammation and complications from prolonged neurological dysfunction. A moderate level of evidence supports there being beneficial effects of active management goals with avoidance of early palliative care orders, well-coordinated specialist stroke unit care, targeted neurointensive and surgical interventions, early control ofelevated blood pressure, and rapid reversal of abnormal coagulation. The concept of time is brain, developed for the management of acute ischaemic stroke, applies readily to the management of acute intracerebral haemorrhage. Initiation of haemostatic treatment within the first few hours after onset, using deferral or waiver of informed consent or even earlier initiation using a prehospital settingwith mobile stroke unit technologies, require evaluation. For patients with intracerebral haemorrhage presenting at later or unwitnessed time windows, refining the approach of spot sign detection through newer imaging techniques, such as multi-phase CT angiography (Rodriguez-Lunaet al. 2017), might prove useful, ashasbeen shown with theuse ofCTperfusion in the detection of viable cerebral ischaemia in patients with acute ischaemic stroke who present in a late window (Alberset al. 2018;Nogueiraetal. 2018). Ultimately, the best treatment of intracerebral haemorrhage isprevention and effective detection, management, and control of hypertension across the community and in high-risk groups will have the greatest effect on reducing the burden ofintracerebral haemorrhage worldwide.
  • 11. ICH High fatality still EuropeanStrokeOrganisation(ESO)Guidelines fortheManagementofSpontaneous Intracerebral Hemorrhage (August 2014) ThorstenSteiner, RustamAl-ShahiSalman, Ronnie Beer, Hanne Christensen, Charlotte Cordonnier, Laszlo Csiba, Michael Forsting, Sagi Harnof, CatharinaJ. M. Klijn, Derk Krieger, A. David Mendelow, Carlos Molina, Joan Montaner, Karsten Overgaard, JesperPetersson, Risto O. Roine, Erich Schmutzhard, KarstenSchwerdtfeger, ChristianStapf, Turgut Tatlisumak, Brenda M. Thomas, Danilo Toni, Andreas Unterberg, Markus Wagner https://doi.org/10.1111%2Fijs.12309 Intracerebral hemorrhage (ICH) accounted for 9% to 27% of all strokes worldwide in the last decade, with high early case fatality and poor functional outcome. In view of recent randomized controlled trials (RCTs) of the management of ICH, the European Stroke Organisation (ESO) has updated its evidence-basedguidelinesforthemanagementofICH. We found moderate- to high-quality evidence to support strong recommendations for managing patients with acute ICH on an acute stroke unit, avoiding hemostatic therapy for acute ICH not associated with antithrombotic drug use, avoiding graduated compression stockings, using intermittent pneumatic compression in immobile patients, and using blood pressureloweringforsecondaryprevention. We found moderate-quality evidence to support weak recommendations for intensive lowering of systolic blood pressure to <140 mmHg within six-hours of ICH onset, early surgery for patients with a Glasgow Coma Scale score 9–12, and avoidanceofcorticosteroids. These guidelines inform the management of ICH based on evidence for the effects of treatments in RCTs. Outcome after ICH remains poor, prioritizing furtherRCTsofinterventionstoimproveoutcome. Age-standardizedincidenceofhemorrhagicstrokeper 100000person-years for 1990(a),2005(b),and2010(c).FromFeigin etal.(1). 1990 2005 2010
  • 12. CTtypicallythefirstscandone andMRIlater where accessible MRI offersbetterimagequality,butthecost ofthetechnologylimitsitsavailability Intracerebralhemorrhage: an update ondiagnosisandtreatment IsabelC. Hostettler,DavidJ.Seiffge&DavidJ.Werringet al.(12Jun 2019) UCLStrokeResearchCentre,DepartmentofBrain Repairand Rehabilitation,UCLInstituteofNeurologyandtheNationalHospitalforNeurologyandNeurosurgery, London,UK ExpertReviewofNeurotherapeuticsVolume19,2019- Issue7 https://doi.org/10.1080/14737175.2019.1623671 Expert opinion: In recent years, significant advances have been made in deciphering causes, understanding pathophysiology, and improving acute treatment and prevention of ICH. However, the clinical outcome remains poor andmany challenges remain. Acute interventions delivered rapidly (including medical therapies – targeting hematoma expansion, hemoglobin toxicity, inflammation, edema, anticoagulant reversal – and minimally invasive surgery) are likely to improveacuteoutcomes. Improved classification of the underlying arteriopathies (fromneuroimaging and genetic studies) and prognosis should allow tailored prevention strategies (including sustained blood pressure control and optimized antithrombotic therapy) to further improve longer-termoutcomeinthisdevastatingdisease. A) ModifiedBostoncriteria,B)CTEdinburghcriteria. ICHcarepathway. Pathwaytodecideonintra-arterial digitalsubtractionangiography(IADSA) tofurtherinvestigateICHcause (adaptedfromWilsonetal.2017). small vesseldiseases(SVD),intra-arterial digital subtraction angiography(IADSA),WhiteMatter Hyperintensities(WMH)
  • 13. Angiographyalsoforhemorrhagic stroke Hemorrhagic Stroke (2014) JuliusGriauzde,ElliotDickersonandJoseph J. Gemmete Department of Radiology,Radiology Resident,University of Michigan http://doi.org/10.1007/978-1-4614-9212-2_46-1 Non-contrast computed tomography has long been the initial imaging tool in the acute neurologic patient. As MRI technology and angiographic imaging has evolved, they too have proven to be beneficial in narrowing the differentialdiagnosisandtriaging patientcare. Several biological and physical characteristics contribute significantly to the appearance of blood products on neuroimaging. To adequately interpret images in the patient with hemorrhagic stroke, the evaluator must have a knowledge of the interplay between imaging modalitiesandintracranialbloodproducts. Additionally, an understanding of technical parameters as well as the limitations of imagingmodalities canbehelpfulinavoiding pitfalls. Recognition of typical imaging patterns and clinical presentations can further aid the evaluatorinrapiddiagnosisanddirectedcare. Computedtomographyangiography (CTA) Magneticresonanceangiography (MRA) TimeofFlightMRA (TOFMRA),initssimplestform, takesadvantageoftheflowofblood Contrast-EnhancedMRA (CEMRA)employsfast spoiledgradient-recalledecho-basedsequences (FSPGR)andtheparamagneticpropertiesof gadoliniumtointensifythesignalwithinvessels
  • 14. “Brainistime” alsofor theappearance of the blood Evolution ofbloodproductson MRI (Derived fromafigurecreated by Dr. Frank Gaillard as presented on http://radiopaedia.org/articles/ageing-blood-on-mri ,withpermission) http://doi.org/10.1007/978-1-4614-9212-2_46-1: TheappearanceoftheICH atdifferentperiodsoftimedepends considerablyuponanumber offactors. Forinstance,in earlyphases, thehematocritandproteinlevelsofthehematomawilldramaticallyalter theCTattenuationinthehematoma.In laterphases,factorssuchas oxygentensionatthehematomawilldeterminehowquickly deoxyhemoglobintransitionsintomethemoglobinandhowquicklyred bloodcellsfinallylyseanddecreasethefieldinhomogeneityeffectsof sequesteredmethemoglobin. Theintegrityoftheblood-brainbarrier alsohelpstodeterminethedegreetowhichhemosiderin-laden macrophagesremaintrappedintheparenchymacausinghemosiderin staininglongafterthevastmajorityofthehematomamasshasbeen resorbed[Parizeletal.2001]. Intracranial hemorrhage made easy- asemiological approach on CT and MRI http://doi.org/10.1594/ecr2 014/C-1120 :CTappearanceof ageingblood.Several factorswhich vary dependingon thestageof thebleeding Evolution of CTdensityof intracranial haemorrhage (diagram)Case contributed by  Assoc Prof FrankGaillard https://radiopaedia.org/cases/evolutio n-of-ct-density-of-intracranial-haemor rhage-diagram AppearanceofBloodonComputedTomographyand MagneticResonanceImagingScansbyStage http://doi.org/10.1007/s13311-010-0009-x
  • 17. ICHScore subcomponents:Glasgow ComaScale (GCS) https://www.firstaidforfree.com/glasgow-coma-scale-gcs-first-aiders/ https://emottawablog.com/2018/07/gcs-remastered-recent- updates-to-the-glasgow-coma-scale-gcs-p/
  • 18. ICHScore subcomponents:Hematomavolume Howtomeasureinpractice? Notethat deeplearningsegmentation networksarenot reallyin use RyanHakimi,DO,MSAssistantProfessor https://slideplayer.com/slide/3883134/ Vivien H. Leeetal.(2016)citesthe ● Kwak’s sABC/2 formula (Kwak et al. 1983,10.1161/01.str.14.4.493, Cited by 252) ● Kothari’s ABC/2 formula(Kothari et al. 1996,  10.1161/01.str.27.8.1304, Cited by 1653)  Excellent accuracy of ABC/2volume formulacompared to computer- assisted volumetricanalysisof subdural hematomas Sae-Yeon Won et al. (2018) https://doi.org/10.1371/journal.pone.0199809 TheABC/2methodisasimpleandfastbedsideformulaforthemeasurementof SDHvolumein atimelymannerwithoutlimitedaccessthrough simpleadaption, which mayreplacethecomputer-assistedvolumetric measurementintheclinical andresearch area. Assessment oftheABC/2MethodofEpidural HematomaVolume MeasurementasComparedto Computer-AssistedPlanimetricAnalysis (2015) https://doi.org/10.1177%2F1099800415577634
  • 20. ICHScore subcomponents:Infratentorial(cerebellar) bleed https://aneskey.com/intrace rebral-hemorrhagic-stroke/ Impact of SupratentorialCerebralHemorrhageon the ComplexityofHeartRate Variabilityin Acute Stroke Chih-Hao Chen, Sung-Chun Tang,Ding-YuanLee, Jiann-ShingShieh,Dar-Ming Lai,An-YuWu&Jiann- ShingJengScientificReportsvolume8,Articlenumber: 11473(2018) https://doi.org/10.1038/s41598-018-29961-y Acute stroke commonly affects cardiac autonomic responses resulting in reduced heart rate variability (HRV). Multiscale entropy (MSE) is a novel non-linear method to quantify the complexity of HRV. This study investigated the influence of intracerebral hemorrhage (ICH) locations and intraventricular hemorrhage (IVH) on the complexity of HRV. In summary, more severe stroke and larger hematomavolumeresulted in lower complexityofHRV.Lobar hemorrhage andIVHhadgreatimpactsonthecardiacautonomicfunction. https://neupsykey.com/ diagnosis-and-treatmen t-of-intracerebral-hemor rhage/ Location → functionalmeasures? We collected ECG analogue data directly from the bedside monitor (Philips Intellivue MP70, Koninklijke Philips N.V., Amsterdam, Netherlands) foreachpatient. 
  • 21. ICH Score validationandmodification somewhat ok/suboptimal performance Modifyingtheintracerebral hemorrhagescore tosuitthe needs ofthedevelopingworld AjayHegde,GirishMenon (Nov2018) http://doi.org/10.4103/aian.AIAN_419_17 ICH Score failed to accurately predict mortality in our cohort. ICH is predominately seen at a younger age group in India and hence have better outcomes in comparison to the west. We propose a minor modification in the ICH score by reducing the age criteria by 10 years to prognosticate the disease better in our population. External Validation of the ICH Score JenniferL Clarkeetal.(2004) https://doi.org/10.1385/ncc:1:1:53 The ICH score accurately stratifies outcome in an external patient cohort. Thus, the ICH score is a validated clinical grading scale that can be easily and rapidly applied at ICH presentation. Ascale such as the ICH score could be used to standardize clinical treatment protocolsorclinical studies. ValidationofICHScore inalarge UrbanPopulation TahaNisaret al.(2018) https://doi.org/10.1016/j.clineuro.2018.09.007 We conducted a retrospective chart review of 245 adult patients who presented with acute ICH to University Hospital, Newark. Our study is one of the largest done at a single urban center to validate the ICH score. Age ≥ 80 years wasn't statistically significant with respect to 30-day mortality in our group. Restratification of the weight of individual variable in the ICH equation with modification of the ICH score can potentially more accurately establish mortality risk. Nevertheless, the overall prediction of mortality was accurate and reproducible in ourstudy. Validation of the ICH score in patients with spontaneous intracerebral haemorrhage admitted to the intensive care unit inSouthernSpain SoniaRodríguez-Fernández etal.(2018) http://dx.doi.org/10.1136/bmjopen-2018-021719 ICH score shows an acceptable discrimination as a tool to predict mortality rates in patients with spontaneous ICH admitted totheICU, but its calibration issuboptimal. 24-HourICHScoreIs aBetter Predictor of Outcomethan AdmissionICHScore AimeeM. Aysenneet al.(2013) https://doi.org/10.1155/2013/605286 Early determination of the ICH score may incorrectly estimate the severity and expected outcome after ICH. Calculations of the ICH score 24 hours after admission will better predict earlyoutcomes. Assessment and comparison of the max-ICH score and ICH score by externalvalidation Felix A.Schmidt,etal.(2018) https://doi.org/10.1212/WNL.0000000000006117 We tested the hypothesis that the maximally treated intracerebral hemorrhage (max-ICH) score is superior to the ICH score for characterizing mortality and functional outcome prognosis in patients with ICH, particularly those who receive maximal treatment. External validation with direct comparison of the ICH score and max-ICH score shows that their prognostic performance is not meaningfully different. Alternatives to simple scores are likely needed to improve prognostic estimates for patient care decisions. Yes, so, do you like to use oversimplified models after all?
  • 22. ICHScore works forsome parts of the population OriginalIntracerebralHemorrhageScoreforthePrediction of Short-Term Mortality inCerebral Hemorrhage: Systematic Review and Meta-Analysis Gregório,Tiago; Pipa, Sara;Cavaleiro,Pedro; Atanásio,Gabriel; Albuquerque,Inês; CastroChaves, Paulo;Azevedo,Luís Journal of Strokeand CerebrovascularDiseases Volume29,Issue4,April2020,104630 https://doi.org/10.1097/CCM.0000000000003744 To systematically assess the discrimination and calibration of the Intracerebral Hemorrhage score for prediction of short-term mortality (38 studies, 15,509 patients) in intracerebral hemorrhage patients and to study its determinantsusing heterogeneityanalysis. Fifty-five studiesprovideddataondiscrimination,and35studies provided data on calibration. Overall, the Intracerebral Hemorrhage score discriminated well (pooled C-statistic 0.84; 95% CI, 0.82-0.85) but overestimated mortality (pooled observed:expected mortality ratio = 0.87; 95% CI, 0.78- 0.97), with high heterogeneity for both estimates (I 80% and 84%,respectively). The Intracerebral Hemorrhage score is a valid clinical prediction rule for short-term mortality in intracerebral hemorrhage patients but discriminated mortality worse in more severe cohorts. It also overestimated mortality in the highest Intracerebral Hemorrhage score patients, with significant inconsistency between cohorts. These results suggest that mortality for these patients is dependent on factors not included in the score. Further studies are needed to determinethesefactors.
  • 23. StartwithICHscore but then youneed better models? Management ofIntracerebral Hemorrhage:JACCFocusSeminar MatthewSchrag,HowardKirshner Journalof theAmerican CollegeofCardiology Volume75,Issue15,21April2020 https://doi.org/10.1016/j.jacc.2019.10.066 The most widely used tool for assessing prognosis is the “ICH score,” a scale that predicts mortality based on hemorrhage size, patient age, Glasgow coma score, hemorrhage location (infratentorial or supratentorial), and the presence of intraventricular hemorrhage ( Hemphilletal.2001). This score has been widely criticized for overestimating the mortality associated with ICH, and this is attributed to the high rate of early withdrawal of medical care in more severe hemorrhages in the cohort, leading to a “self-fulfilling prophecy”ofearlymortality (Zahuranecetal.2007,Zahuranecetal.2010). Nevertheless, no high-performing alternative scale or biomarker has entered routine clinical use, so the ICH score remains a starting point for clinical prognostication. A recent re-evaluation of this clinical tool found that both physicians’ and nurses’ subjective predictions of 3-month outcomes made within 24 h of the hemorrhage outperformed the accuracy of the ICH score, underscoring the important role of clinician experience and judgement in guiding families ( Hwanget al. 2015). In addition to hemorrhage size and initial clinical deficits, factors that seem to predict a poor overall outcome include any early neurological deterioration, hemorrhages in deep locations, particularly the thalamus, and age/baseline functional status (Yogendrakumaretal.2018; Sreekrishnanetal.2016; Ullmanetal.2019). When the clinical prognosis is unclear, physicians should generally advocate for additional time and continued supportive care(Hemphilletal.2015). Recovery after intracerebral hemorrhage is often delayed when compared with ischemic strokes of similar severity, and outcomes may need to be evaluated at later timepoints to capture the full extent of potential recovery. This is important both for calibrating patient and family expectations and in the design of outcomes for clinical trials.
  • 24. Severalscoresandmeasuresexist Intracerebralhemorrhage outcome:A comprehensive update João Pinho etal.(15March 2019) https://doi.org/10.1016/j.jns.2019.01.013 The focus of outcome assessment after ICH has been mortality in most studies, because of the high early case fatality which reaches 40% in some population-based studies. The most robust and consistent predictors of early mortality include age, severity of neurological impairment, hemorrhage volume and antithrombotic therapy at the time oftheevent. Long-term outcome assessment is multifaceted and includes not only mortality and functional outcome, but also patient self-assessment of the health- related quality of life, occurrence of cognitive impairment, psychiatric disorders, epileptic seizures, recurrent ICH andsubsequent thromboembolicevents. Several scores which predict mortality and functional outcome after ICH have been validated and are useful in the daily clinical practice, however they must be used in combination with the clinical judgment for individualized patients. Management of patients with ICH both in the acute and chronic phases, requires health care professionals to have a comprehensive and updated perspective on outcome, which informs decisions that are needed to be taken togetherwiththepatient andnext ofkin
  • 25. Locationspecifiedquitecrudely http://doi.org/10.1007/978-1-4614-9212-2_46-1 Management of brainstem haemorrhages DOI: https://doi.org/10.4414/smw.2019.20062 https://aneskey.com/intracerebral-hemorrhagic-stroke/
  • 26. Too “handwavey”reporting of thelocationatthemoment IntracerebralHemorrhageLocationandFunctional OutcomesofPatients: ASystematicLiterature Reviewand Meta-Analysis AnirudhSreekrishnan etal. (NeurocriticalCarevolume25,pages384–391,2016) https://doi.org/10.1177%2F0272989X19879095 - Citedby35 Intracerebral hemorrhage (ICH) has the highest mortality rate among all strokes. While ICH location, lobar versus non-lobar, has been established as a predictor of mortality, less is known regarding the relationship between more specific ICH locations and functional outcome. This review summarizes current work studying how ICH location affects outcome, with an emphasis on how studies designate regionsof interest. Multiple studies have examined motor-centric outcomes, with few studies examining quality of life (QoL) or cognition. Better functional outcomes have been suggested for lobar versus non-lobar ICH; few studies attempted finer topographic comparisons. This study highlights the need for improved reporting in ICH outcomes research, including a detailed description of hemorrhage location, reporting of the full range of functional outcome scales, and inclusion of cognitive and QoL outcomes. Meta-analysisofstudiesdescribingtheoddsratioofpooroutcomesfor lobar comparedtodeep/non-lobar ICH. a Poor outcomemRS(3,4,5,6)or GOS(4,3,2,1); b PooroutcomemRS(4,5,6)or GOS(3,2,1); c Poor outcomemRS(5,6).*Significantresults(p < 0.05)
  • 28. Long-termrisks higher after lobarICH? Ten-yearrisksofrecurrentstroke, disability,dementiaandcostin relationto siteofprimaryintracerebralhaemorrhage: population-basedstudy (2019) LinxinLi,Ramon Luengo-Fernandez,SusannaMZuurbier, NicolaC Beddows,PhilippaLavallee,LouiseESilver, WilhelmKuker,Peter MalcolmRothwell http://dx.doi.org/10.1136/jnnp-2019-322663 Patients with primary intracerebral haemorrhage (ICH) are at increased long-term risks of recurrent stroke and other comorbidities. However, available estimates come predominantly from hospital-based studies with relatively short follow-up. Moreover, there are also uncertainties about the influence of ICH location on risks of recurrent stroke, disability, dementia and qualityoflife. Methods In a population-based study (Oxford Vascular Study/2002–2018) of patients with a first ICH with follow-up to 10 years, we determined the long-term risks of recurrent stroke, disability, quality of life, dementia and hospital care costs stratified by haematomalocation. ICHcanbecategorisedinto lobarandnon-lobaraccording tothehaematomalocation. Giventhedifferentbalanceofpathologiesfor lobarversusnon-lobar ICH,thelong-term prognosisofICHcouldbeexpectedtodiffer byhaematomalocation.However,whilesome studiessuggestedthathaematomalocationwasassociatedwithrecurrentstroke,others havenot. Compared with non-lobarICH, thesubstantially higher 10-year risks of recurrent stroke, dementiaand lower QALYs after lobar ICH highlighttheneedformoreeffectiveprevention for this patient group. (top) Ten-year risks of recurrent stroke, disability or death stratified by haematoma location. (right) Ten-year mean healthcare costs overtimeafterprimaryintracerebralhaemorrhage.
  • 29. HematomaEnlargement deepvs lobar, volume? Hematoma enlargement characteristicsin deep versuslobarintracerebralhemorrhage Jochen A.Sembill etal. (04March2020) https://doi.org/10.1002/acn3.51001 Hematoma enlargement (HE) is associated with clinical outcomes after supratentorial intracerebral hemorrhage (ICH). This study evaluates whether HE characteristics and association with functional outcome differ in deep versus lobarICH. HE occurrence does not differ among deep and lobar ICH. However, compared to lobar ICH, HE after deep ICH is of greater extent in OAC ICH, occurs earlier‐ICH, occurs earlier and may be of greater clinical relevance. Overall, clinical significance is more apparent after small–medium compared to large sized‐sized bleedings. These data may be valuable for both routine clinical management as well as for designing future studies on hemostatic and blood pressure management aming at minimizing HE. However, further studies with improved design are needed to replicate these findings and to investigate the pathophysiological mechanismsaccounting fortheseobservations. Study flowchart. Altogether, individual level data from 3,580 spontaneous ICH patients were analyzed to identify 1,954 supratentorial ICH patients eligible for outcome analyses. Data were provided by two parts of a German wide observational‐ICH, occurs earlier studies(RETRACE I and II) conducted at 22 participatingtertiarycenters, and byone single center universityhospital registry.‐ICH, occurs earlier
  • 31. Otherfactors you shouldtake into account BrianA.Stettler, MDAssistant Professor https://slideplayer.c om/slide/3129821/ Subfalcial herniation, midline shiftand uncal herniation secondary tolarge subdural hematomain the left hemisphere. https://www.startradiology.com/internships/neurology/brain/ct-brain- hemorrhage/ Hydrocephalus https://kidshealth.or g/en/parents/hydro cephalus.html
  • 32. RiskFactorsHypertension thelargest risk factor RiskFactorsof IntracerebralHemorrhage: ACase-ControlStudy HanneSallinen, ArtoPietilä,VeikkoSalomaa,DanielStrbian Journal of Strokeand Cerebrovascular Diseases Volume29,Issue4,April2020,104630 https://doi.org/10.1016/j.jstrokecerebrovasdis.2019.104630 Hypertension is a well-known risk factor for intracerebral hemorrhage (ICH). On many of the other potential risk factors, such as smoking, diabetes, and alcohol intake, results are conflicting. We assessed risk factors of ICH, taking also into account priordepression andfatigue. Analyzing all cases and controls, the cases had more hypertension, history of heart attack, lipid-lowering medication, and reported more frequently fatigue prior to ICH. In persons aged less than 70 years, hypertension and fatigue were more common among cases. In persons aged greater than or equal to 70 years, factors associated with risk of ICH were fatigue prior to ICH, use of lipid-lowering medication, and overweight. Hypertension was associated with risk of ICH among all patients and in the group of patients under 70 years. Fatigue prior to ICH was more common among all ICH cases.
  • 33. StrokeorIntensive CareUnit for ICH patients Strokeunitadmissionisassociatedwith better outcomeandlowermortality inpatientswith intracerebral hemorrhage MaM. N. Ungerer P. Ringleb B.Reuter C.Stock F.Ippen S. Hyrenbach I.Bruder P Martus C. Gumbinger theAGSchlaganfall https://doi.org/10.1111/ene.14164 (Feb2020) There is no clear consensus among current guidelines on the preferred admission ward [i.e. intensive care unit (ICU) or stroke unit (SU)] for patients with intracerebral hemorrhage. Based on expert opinion, the American Heart Association and European Stroke Organization recommend treatment in neurological/neuroscience ICUs (NICUs) or SUs. The European Stroke Organization guideline states that there are no studies available directly comparingoutcomesbetween ICUsandSUs. We performed an observational study comparing outcomes of 10 811 consecutive non comatose patients with intracerebral hemorrhage according‐ICH, occurs earlier to admission ward [ICUs, SUs and normal wards (NWs)]. Primary outcomes were the modified Rankin Scale score at discharge and intrahospital mortality. An additional analysiscomparedNICUswithSus. Treatment in SUs was associated with better functional outcome and reduced mortality compared with ICUs and NWs. Our findings support the current guideline recommendations to treat patients with intracerebral hemorrhage in SUs or NICUs and suggest that some patients may further benefit from NICU treatment. MobileStrokeUnitReduces TimetoTreatment JULY03,2018 https://www.itnonline.com/articl e/mobile-stroke-unit-reduces-ti me-treatment
  • 34. Formorefine-grainedpredictions youprobablywanttousebetter imagingmodalities? PredictingMotorOutcomeinAcute Intracerebral Hemorrhage (May 2019) J.Puig, G.Blasco,M.Terceño,P.Daunis-i-Estadella,G.Schlaug,M.Hernandez- Perez,V.Cuba, G.Carbó,J.Serena,M.Essig, C.R.Figley, K.Nael,C.Leiva- Salinas, S.PedrazaandY.Silva https://doi.org/10.3174/ajnr.A6038 Predicting motor outcome following intracerebral hemorrhage is challenging. We tested whether the combination of clinical scores and Diffusion tensor imaging (DTI)-based assessment of corticospinal tract damage within the first 12 hours of symptom onset after intracerebral hemorrhage predicts motor outcome at 3 months. Combined assessment of motor function and posterior limb of the internal capsule damage during acute intracerebral hemorrhage accurately predicts motor outcome. Assessing corticospinal tract involvement with diffusion tensor tractography superimposed on gradient recalled echo and FLAIR images. In the upper row, the corticospinal tract wasaffected by ICH (passes through it) at the level of the corona radiata and posterior limb of the internal capsule. Note that in lower row, the corticospinal tract was displaced slightly forward but preserved around the intracerebral hematoma. Vol indicatesvolume. Exampleof ROI objectmapsusedto measure intracerebral hematoma(blue)and perihematomal edema(yellow)volumes. CombiningmNIHSSand PLICaffected by ICH in the first 12 hours of onset can accurately predict motor outcome. The reliability of DTI in denoting very early damage to the CST could make it a prognostic biomarker useful for determining management strategies to improve outcome in the hyperacute stage. Our approach eliminates the need for advanced postprocessing techniques that are time- consuming and require greater specialization, so it can be applied more widely and benefit more patients. Prospective large-scale studies are warranted to validate these findings and determine whether this information could be used to stratify risk in patients with ICH.
  • 35. Cliniciansliketohuntforthe“(linear)magicalbiomarkers” opposed tononlinear multivariate modelswith higher capacity(and higher probability tooverfitaswell) Early hematomaretractionin intracerebralhemorrhageis uncommonanddoesnotpredict outcome AnaC.Klahr,MaheshKate,JaymeKosior,Brian Buck,AshfaqShuaib,DerekEmery,KennethButcher Published: October9,2018 https://doi.org/10.1371/journal.pone.0205436 Citedby2 -Relatedarticles Clot retraction in intracerebral hemorrhage (ICH) has been described and postulated to be related to effective hemostasis and perihematoma edema (PHE) formation. The incidence and quantitative extent of hematoma retraction (HR) is unknown. Our aim was to determine the incidence of HR between baseline and time of admission. We also tested the hypothesis that patients with HR had higher PHE volumeandgoodprognosis. Early HR is rare and associated with IVH, but not with PHE or clinical outcome. There was no relationship between HR, PHE, and patient prognosis. Therefore, HR is unlikely to be a useful endpointinclinicalICHstudies.
  • 36. PerihematomalEdema(PHE) Diagnostic value? NeoplasticandNon-NeoplasticCausesof Acute IntracerebralHemorrhageonCT:The DiagnosticValueofPerihematomalEdema Jawed Nawabi, UtaHanning, Gabriel Broocks, Gerhard Schön, TanjaSchneider, Jens Fiehler, Christian Thaler & Susanne Gellissen ClinicalNeuroradiology(2019) https://doi.org/10.1007/s00062-019-00774-4 The aim of this study was to investigate the diagnostic value of perihematomal edema (PHE) volume in non-enhanced computed tomography (NECT) to discriminate neoplastic and non-neoplastic causes of acute intracerebral hemorrhage (ICH). Relative PHE with a cut-off of >0.50 is a specific and simple indicator for neoplastic causes of acute ICH and a potential tool for clinical implementation. This observation needs to be validated in an independentpatientcohort. Two representative cases of region of interest object maps used to measure intracerebral hemorrhage (ICH), volume (Vol ICH) and total hemorrhage (Vol ICH+PHE) volume. a Neoplastic and non-neoplastic ICH volume (red) and b total hemorrhage volume (grey) on non-enhanced CT (NECT) delineated with an edge detection algorithm. c Neoplastic and non-neoplastic PHE (green) calculated by subtraction of total hemorrhagevolumeandICHvolume(Vol PHE= Vol ICH+PHE− Vol ICH)
  • 37. Youngpatients tendto recover better(seems obvious) Isnontraumaticintracerebral hemorrhage different betweenyoungandelderly patients? NaRaeYang,Ji HeeKim,Jun Hyong Ahn,JaeKeun Oh,In BokChang &JoonHo Song NeurosurgicalReviewvolume43, pages781– 791(2020)https://doi.org/10.1007/s10143-019-01120-5 Only a few studies have reported nontraumatic intracerebral hemorrhage in young patients notwithstanding its fatal and devastating characteristics. This study investigated the clinical characteristics and outcome of nontraumatic intracerebral hemorrhage in young patients in comparison to thoseof theelderly. Nontraumatic intracerebral hemorrhage in younger patients appears to be associated with excessive alcohol consumption and high BMI. Younger patients had similar short-term mortality but more favorable functional outcome than the elderly. DistributionofmodifiedRankinScalescoresatthelastfollow-upforeachgroup
  • 38. Genotype-baseddifferencesexist Racial/ethnicdisparitiesinthe riskof intracerebral hemorrhage recurrence AudreyC.Leasure,ZacharyA.King,VictorTorres-Lopez,SantoshB.Murthy,HoomanKamel,AshkanShoamanesh,Rustam Al-Shahi Salman,JonathanRosand,WendyC.Ziai, DanielF.Hanley,DanielWoo,CharlesC.Matouk,LaurenH.Sansing, Guido J.Falcone,KevinN.Sheth Neurology December12,2019 https://doi.org/10.1212/WNL.0000000000008737 To estimate the risk of intracerebral hemorrhage (ICH) recurrence in a large, diverse, US-based population and to identify racial/ethnic and socioeconomic subgroups at higher risk. Black and Asian patients had a higher risk of ICH recurrence than white patients, whereas private insurance was associated with reduced risk compared to those with Medicare. Further research is needed to determine the drivers of these disparities. While this is the largest study of ICH recurrence in a United States–based, racially and ethnically diverse population, our study has several limitations related to the use of administrative data that require consideration. First, there is a possibility of misclassification of the exposures and outcomes. The attribution of race/ethnicity that is not based on direct self-report may not be accurate; for example, patients who belong to 2 or more racial/ethnic categories may be classified based on phenotypic descriptions and may not reflect true ancestry. In terms of outcome classification, we relied on ICD-9-CM codes to identify our outcome of recurrent ICH. However, we used previously validated diagnosis codes that have high positive predictive valuesfor identifyingprimaryICH
  • 39. asICHnotthatwellunderstood sonewmechanismsareproposed Globalbraininflammationinstroke Kaibin Shi etal.(LancetNeurology,July2019) https://doi.org/10.1016/S1474-4422(19)30078-X Stroke, including acute ischaemic stroke (AIS) and intracerebral haemorrhage (ICH), results in neuronal cell death and the release of factors such as damage-associated molecular patterns (DAMPs) that elicit localised inflammation in the injured brain region. Such focal brain inflammation aggravates secondary brain injury by exacerbating blood–brain barrier damage, microvascular failure, brain oedema, oxidative stress, andbydirectlyinducingneuronalcell death. In addition to inflammation localised to the injured brain region, a growing body of evidence suggests that inflammatory responses after a stroke occur and persist throughout the entire brain. Global brain inflammation might continuously shape the evolving pathology after a stroke and affect the patients'long-termneurologicaloutcome. Future efforts towards understanding the mechanisms governing the emergence of so-called global brain inflammation would facilitate modulation of this inflammation as a potential therapeutic strategyforstroke.
  • 40. MMPsinICH? In emerging theories Matrix MetalloproteinasesinAcute IntracerebralHemorrhage SimonaLattanzi, MarioDi Napoli,SilviaRicci &Afshin A.Divani Neurotherapeutics(January2020) https://doi.org/10.1007/s13311-020-00839-0 So far, clinical trials on ICH have mainly targeted primary cerebral injury and have substantially failed to improve clinicaloutcomes. The understanding of the pathophysiology of early and delayed injury after ICH is, hence, of paramount importance to identify potential targets of intervention and develop effective therapeutic strategies. Matrix metalloproteinases (MMPs) represent a ubiquitous superfamily of structurally related zinc- dependent endopeptidases able to degrade any component of the extracellular matrix. They are upregulated after ICH, in which different cell types, including leukocytes, activated microglia, neurons, and endothelial cells, are involved in their synthesis and secretion. The role of MMPs as a potential target for the treatment of ICH has been widely discussed in the last decade. The impact of MMPs on extracellular matrix destruction and blood–brain barrier BBB disruption in patientssufferingfromICHhasbeen ofinterest. The aim of this review is to summarize the available experimental and clinical evidence about the role of MMPs in brain injury following spontaneous ICH and provide critical insightsintotheunderlyingmechanisms. Overall, there is substantially converging evidence from experimental studies to suggest that early and short- term inhibition of MMPs after ICH can be an effective strategy to reduce cerebral damage and improve the outcome, whereas long-term treatment may be associated with more harm than benefit. It is, however, worth to notice that, so far, we do not have a clear understanding of the time-specific role that the different MMPs assume within the pathophysiology of secondary brain injury and recovery after ICH. In addition, most of the studies exploring pharmacological strategies to modulate MMPs can only provide indirect evidence of the benefit to target MMP activity. The prospects for effective therapeutic targeting of MMPs require the establishment of conditions to specifically modulate a given MMP isoform, or asubset of MMPs, in a given spatio-temporal context (Rivera2019). Further research is warranted to better understand the interactions between MMPs and their molecular and cellular environments, determine the optimal timing of MMPs inhibition for achieving a favorable therapeutic outcome, and implement the discovery of innovative selective agents to spare harmful effects before therapeutic strategies targeting MMPs can be successfully incorporated into routine practice ( Lattaniet al. 2018;Hostettler et al. 2019).
  • 41. Whatarethetreatmentsfor ICH and can wedo prescriptive modeling(“precision medicine”), and tailor thetreatment individually?
  • 43. AnimalmodelsofICH exist of courseas well Intracerebral haemorrhage:from clinicalsettingsto animalmodelsQian Bai et al.(2020) http://dx.doi.org/10.1136/svn-2020-000334 Effective treatment for ICH is still scarce. However, clinical therapeutic strategies includes medication and surgery. Drug therapy is the most common treatment for ICH. This includes prevention of ICH based on treating an individual’s underlying risk factors, for example, control of hypertension. Hyperglycaemia in diabetics is common after stroke; managing glucose level may reduce the stroke size. Oxygen is given as needed. Surgery can be used to prevent ICH by repairing vascular damage or malformations in and around the brain, or to treat acute ICH by evacuating the haematoma; however, the benefit of surgical treatment is still controversial due to very few controlled randomised trials. Rehabilitation may help overcome disabilities thatresultfromICHdamage. Despite great advances in ischaemia stroke, no prominent improvement in the morbidity and mortality after ICH have been realised. The current understanding of ICH is still limited, and the models do not completely mirror the human condition. Novel effective modelling is required to mimic spontaneous ICH in humans and allow for effective studies on mechanisms and treatment of haematoma expansion and secondary braininjury.
  • 44. GenomicsforStrokerecovery #1 Geneticriskfactorsfor spontaneousintracerebral haemorrhage AmandaM.Carpenter,I. P. Singh,ChiragD. Gandhi,CharlesJ. Prestigiacomo(NatureReviews Neurology2016) https://doi.org/10.1038/nrneurol.2015.226 Familial aggregation of ICH has been observed, and the heritability of ICH risk has been estimated at 44%. Few genes have been found to be associated with ICH at the population level, and much of the evidence for genetic risk factors for ICH comes from single studies conducted in relatively small and homogenous populations. In this Review, we summarize the current knowledge of genetic variants associated with primary spontaneousICH. Although evidence for genetic contributions to the risk of ICH exists, we donot yet fully understand how and to what extent this information can be utilizedto preventandtreatICH.
  • 45. GenomicsforStrokerecovery #2 Geneticunderpinnings ofrecoveryafter stroke:anopportunity for genediscovery, riskstratification,andprecisionmedicine Julián N.Acostaetal. (September2019) https://doi.org/10.1186/s13073-019-0671-5 As the number of stroke survivors continues to increase, identification of therapeutic targets for stroke recovery has become a priority in stroke genomics research. The introduction of high-throughput genotyping technologies and novel analytical tools has significantly advanced our understanding of the genetic underpinningsofstrokerecovery. In summary, functional outcome and recovery constitute important endpoints for genetic studies of stroke. The combination of improving statistical power and novel analytical tools will surely lead to the discovery of novel pathophysiological mechanisms underlying stroke recovery. Information on these newly discoveredpathwayscan beusedto develop new rehabilitation interventions and precision- medicine strategies aimed at improving management options for stroke survivors. The continuous growth and strengthening of existing dedicated collaborations and the utilization of standardized approaches to ascertain recovery-related phenotypes will be crucial for the successofthispromisingfield. Geneticriskof Spontaneousintracerebralhemorrhage: Systematic review andfuture directions KolawoleWasiuet al.(15December2019) https://doi.org/10.1016/j.jns.2019.116526 Given this limited information on the genetic contributors to spontaneous intracerebral hemorrhage (SICH), more genomic studies are needed to provide additional insights into the pathophysiology of SICH, and develop targeted preventive and therapeutic strategies. This call for additional investigation of the pathogenesis of SICH is likely to yield more discoveries in the unexplored indigenous African populations whichalsohaveagreaterpredilection. Multilevelomics for thediscoveryofbiomarkersandtherapeutic targetsforstroke Joan Montaneretal. (22April2020) https://doi.org/10.1016/j.jns.2019.116526 Despite many years of research, no biomarkers for stroke are available to use in clinical practice. Progress in high- throughput technologies has provided new opportunities to understand the pathophysiology of thiscomplex disease, and these studies have generated large amounts of data and information at different molecular levels. We summarize how proteomics, metabolomics, transcriptomics and genomics are all contributing to the identification of new candidate biomarkers that could be developed and used in clinical stroke management. Influencesof geneticvariantsonstrokerecovery:ameta-analysisof the 31,895 cases NikhilMathetal.(29 July2019) https://doi.org/10.1007/s10072-019-04024-w 17p12InfluencesHematomaVolume andOutcome inSpontaneous IntracerebralHemorrhage SandroMarini etal.(30Jul2018) https://doi.org/10.1016/j.jns.2019.116526
  • 46. Surgicalmanagement not that wellunderstoodeither Surgery forspontaneousintracerebral hemorrhage(Feb 2020) AirtonLeonardode OliveiraManoel https://doi.org/10.1186/s13054-020-2749-2 Spontaneous intracerebral hemorrhage is a devastating disease, accounting for 10 to 15% of all types of stroke; however, it is associated with disproportionally higher rates of mortality and disability. Despite significant progress in the acute management of these patients, the ideal surgical management is still to be determined. Surgical hematoma drainage has many theoretical benefits, such as the prevention of mass effect and cerebral herniation, reduction in intracranial pressure, and the decrease of excitotoxicity and neurotoxicity of blood products. Mechanismsofsecondarybraininjury after ICH.MLS-midlineshift; IVH- intraventricular hemorrhage Case 02 of open craniotomy for hematoma drainage. a, b Day 1—Large hematoma in the left cerebral hemisphere leading to collapse of the left lateral ventricle with a midline shift of 12 mm, with a large left ventricular and third ventricle flooding, as well as diffuse effacement of cortical sulci of that hemisphere. c–e Day 2—Left frontoparietal craniotomy, with well-positioned bone fragment, aligned and fixed with metal clips. Reduction of the left frontal/frontotemporal intraparenchymal hematic content, with remnant hematic residues and air foci in this region. There was a significant reduction in the mass effect, with a decrease in lateral ventricular compression and a reduction in the midline shift. Bifrontal pneumocephalus causing shift and compressing the adjacent parenchyma. f–h Day 36—Resolution of residual hematic residues and pneumocephalus. Encephalomalacia in the left frontal/frontotemporal region. Despite the good surgical results, the patient remainedin vegetativestate Open craniotomy. Patient lies on an operating table and receives general anesthesia. The head is set in a three-pin skull fixation device attached to the operating table, in order to hold the head standing still. Once the anesthesia and positioning are established, skin is prepared, cleaned with an antiseptic solution, and incised typically behind the hairline. Then, both skin and muscles are dissected and lifted off the skull. Once the bone is exposed, burr holes are built in by a special drill. The burr holes are made to permit the entrance of the craniotome. The craniotomy flap is lifted and removed, uncovering the dura mater. The bone flap is stored to be replaced at the end of the procedure. The duramater is then opened to expose the brain parenchyma. Surgical retractors are used to open a passage to assess the hematoma. After the hematoma is drained, the retractors are removed, the dura mater is closed, and the bone flap is positioned, aligned, and fixed with metal clips. Finally, the skin is sutured
  • 47. Real-timesegmentationforICHsurgery? Intraoperative CT and cone-beamCT imagingforminimallyinvasive evacuationofspontaneous intracerebralhemorrhage NilsHecht etal.(ActaNeurochirurgica2020) https://doi.org/10.1007/s00701-020-04284-y Minimally invasive surgery (MIS) for evacuation of spontaneous intracerebral hemorrhage (ICH) has shown promise but there remains a need for intraoperative performance assessment considering the wide range of evacuation effectiveness. In this feasibility study, we analyzed the benefit of intraoperative 3- dimensional imaging during navigated endoscopy-assisted ICH evacuation by mechanicalclotfragmentationandaspiration. Routine utilization of intraoperative computerized tomography (iCT) or cone-beam CT (CBCT) imaginginMIS for ICH permits direct surgical performance assessment and the chance for immediate re-aspiration, which may optimize targeting of an ideal residual hematoma volume and reduce secondary revision rates.
  • 49. Non-ContrastCT What areyouseeing? An Evidence-Based Approach To Imaging Of Acute Neurological Conditions (2007) https://www.ebmedicine.net/media_library/marketi ngLandingPages/1207.pdf
  • 50. HUUnits Absoluteunits“meansomething” CT Scan basically a density measurement device https://www.sciencedirect.com/topics/medicine-and-dentistry/hounsfield-scale A, AxialCTslice, viewedwithbrainwindowsettings.Noticeinthegrayscalebar attherightsideof thefigurethatthefullrangeofshadesfromblacktowhitehasbeendistributedoveranarrowHUrange, fromzero(pureblack)to+100HU(purewhite).Thisallowsfinediscriminationoftissueswithinthis densityrange,butattheexpenseofevaluationoftissuesoutsideofthisrange.Alargesubduralhematoma iseasilydiscriminatedfromnormalbrain,eventhoughthetwotissuesdiffer indensitybylessthan100HU. Anytissuesgreater than+100HUindensitywillappear purewhite,eveniftheir densitiesaredramatically different.Consequently,theinternalstructureofbonecannotbeseenwiththiswindowsetting.Fat(- 50HU) andair (-1000HU)cannotbedistinguishedwiththissetting,asbothhavedensitieslessthanzero HUandarepureblack.  B, ThesameaxialCT slice viewedwithabone windowsetting.Nowthescalebarattherightside ofthefigureshowsthegrayscaletobedistributed over averywideHUrange,from-450HU(pure black)to+1050HU(purewhite).Air caneasilybe discriminatedfromsofttissuesonthissetting becauseitisassignedpureblack,whilesofttissues aredarkgray.Detailsof bonecanbeseen, becausealargeportionofthetotalrangeofgray shadesisdevotedtodensitiesintherangeofbone. Softtissuedetailislostinthiswindowsetting, becausetherangeofsofttissuedensities(-50HUto around+100HU)representsanarrowportionofthe grayscale.
  • 52. ClinicalCT quick introonwhatyousee How to interpret an unenhanced CT Brain scan.Part 1:Basicprinciplesof Computed Tomography and relevant neuroanatomy (2016) http://www.southsudanmedicaljournal.com/archive/august-2016/how-to-interpret-an-unenhanced-ct-brain-sca n.-part-1-basic-principles-of-computed-tomography-and-relevant-neuroanatomy.html
  • 53. CutsandGantryTilt Clinical CT typically havequite thickcuts https://slideplayer.com/slide/5990473/ ComputedTomographyII– RAD473PublishedbyMelindaWiggins https://slideplayer.com/slide/7831746/ Designpatternformulti-modal coordinatespaces Figure4:PlanningthelocationoftheCTslices, withtiltedgantry.Thegantryistiltedtoavoid radiatingtheeyes,whilecapturingamaximum ofrelevantanatomicaldata. https://www.researchgate.net/publication/22 8672978_Design_pattern_for_multi-modal_co ordinate_spaces Tiltingthegantryfor CT-guided spineprocedures https://doi.org/10.1007/s11547-013-0344-1 Gantry tilt. Use of bolsters. Gantry- needle alignment. a, b Range of gantry angulation, which is ±30° on most scanners. Spine curvature and spatial orientation can be modified using bolsters and wedges. A bolster under the lower abdomen (c) flattens the lordotic curvature and reduces the L5–S1 disc plane obliquity; under the chest (d) flattens the thoracic kyphosis and reduces the upper thoracic pedicles' obliquity; under the hips (e) increases the lordosis and brings the long-axis of the sacrum closer to the axial plane. The desired needle path for spinal accesses can be paralleled by gantry tilt (solid lines on c– e) relative to straight axial orientation (dashed lines on c– e). f Gantry-needle alignment, with laser beam precisely bisecting the needle at the hub and the skin entry point. Maintaining this alignment keeps the needle in plane and allows visualization of the entireneedlethroughoutitstrajectoryon asingleCTslice
  • 55. CTSkullWindowmicrostructureofbonemightbiasyourbrainmodel? Estimationof skulltablethicknesswithclinicalCTandvalidation withmicroCThttp://doi.org/10.1111/joa.12259 Lossof bonemineraldensityfollowing sepsisusingHounsfieldunitsby computedtomography http://doi.org/10.1002/ams2.401 Opportunistic osteoporosis screeningvia the measurement of frontalskull Hounsfieldunits derived from brain computed tomographyimages https://doi.org/10.1371/jour nal.pone.0197336 TheADAM-pelvisphantom-ananthropomorphic, deformableandmultimodalphantomforMrgRT http://doi.org/10.1088/1361-6560/aafd5f
  • 56. ConstructionandanalysisofaheadCT-scan databaseforcraniofacialreconstruction FrançoiseTilotta, Frédéric Richard, Joan Alexis Glaunès, Maxime Berar, Servane Gey, Stéphane Verdeille, Yves Rozenholc, Jean-François Gaudy https://hal-descartes.archives-ouvertes.fr/hal-00278579/document
  • 57. CT Bonevery useful for brain imaging/stimulationsimulation models e.g. ultrasoundandNIRS MeasurementsoftheRelationship BetweenCT HounsfieldUnitsand AcousticVelocityandHow It ChangesWithPhotonEnergy and Reconstruction Method Webb TD, LeungSA, RosenbergJ, Ghanouni P, Dahl JJ, PelcNJ, PaulyKB IEEETransactions onUltrasonics, Ferroelectrics,and FrequencyControl, 01Jul 2018, 65(7):1111-1124 https://doi.org/10.1109/tuffc.2018.2827899 Transcranial magnetic resonance-guided focused ultrasound continues to gain traction as a noninvasive treatment option for a variety of pathologies. Focusing ultrasound through the skull can be accomplished by adding a phase correction to each element of a hemispherical transducer array. The phase corrections are determined with acoustic simulations that rely on speed of sound estimates derived from CT scans. While several studies have investigated the relationship between acoustic velocity and CT Hounsfield units (HUs), these studies havelargely ignored the impact of X-ray energy, reconstruction method, and reconstruction kernel on the measured HU, and therefore the estimated velocity, and nonehavemeasuredtherelationshipdirectly. As measured by the R-squared value, the results show that CT is able to account for 23%-53% of the variation in velocity in the human skull. Both the X-ray energy and the reconstruction technique significantly alter the R-squared value and the linear relationship between HU and speed of sound in bone. Accounting for these variations will lead to more accurate phase corrections and more efficient transmission of acoustic energy through theskull. The impact of CT energy as measured by the dual energy scan on the GE system with a bone kernel. a) The dotted line shows the HU calculated using Equation (1) and linear attenuation values from NIST. The circles show the average HU measured in the densest sample of cortical boneas measured by the averageHU (red), theaverageHU value of all thefragments fromtheinner and outer tables (yellow), and the average HU value of all the fragments from the medullary bone (purple). Error bars show the standard deviation.b) Speedof soundasa functionof HUfor fivedifferentenergies. Comparison of the measurements presented in this paper to prior models. a) Comparison to prior modelsusing data from the monochromatic images acquired with the dual energy scan on the GE system. b) Comparison to prior models using standard CT scans with unknown effective energies. In order to estimate Aubry’s model at each energy, an effective energy of 2/3 of the peak tube voltage wasassumed. Further work needs to be done to characterize either an average relationship across a patient population or a method for adapting velocity estimates to specific patient skulls. Such a study will require a large number of skulls and is outside the scope of the present work.  Future studies should examine improvements in velocity estimates and phase corrections (e.g. using ultrashort echo time (UTE) MRI) will lead to the more efficient transfer of acoustic energy through the skull, resulting in a decrease in the energy required to achieve ablation at the focalspot.
  • 58. Muscle/FatCTalsouseful (a) The relationship between graylevel and Hounsfieldunits(HU) determinedby windowlevel (WL), windowwidth (WW),andbitdepthper pixel(BIT).(b)TheeffectofdifferentWL,WW,andBITconfigurationsonthesameimage Pixel-LevelDeepSegmentation:ArtificialIntelligenceQuantifiesMuscleonComputed TomographyforBodyMorphometricAnalysis HyunkwangLee&FabianM.Troschel&ShaheinTajmir&GeorgFuchs&JuliaMario&FlorianJ.Fintelmann&SynhoDo JDigitImaging,http://doi.org/10.1007/s10278-017-9988-z Body Composition as a Predictor of Toxicity in Patients Receiving Anthracycline and Taxane– Based Chemotherapy for Early-Stage Breast Cancer http://doi.org/10.1158/1078-0432.CCR-16-2266 Quantitativeanalysisofskeletalmuscleby computedtomographyimaging—Stateof the art https://doi.org/10.1016/j.jot.2018.10.004
  • 59. Baseof Skull AxialCT: Wherebrainstrippingcoulduse deeplearning Baseofskull, axialCT 1) Nasalspineoffrontalbone 2) Eyeball 3) Frontalprocessofzygomaticbone 4) Ethmoidalaircells 5) Temporalfossa 6) Greater wingofsphenoidbone 7) Sphenoidalsinus 8) Zygomaticprocessoftemporalbone 9) Headofmandible 10) Carotidcanal,firstpart 11) Jugular foramen,posteriortointrajugular process 12) Posterior border ofjugularforamen 13) Sigmoidsinus 14) Lateralpartofoccipitalbone 15) Hypoglossalcanal 16) Foramenmagnum 17) Nasalseptum 18) Nasalcavity 19) Bodyofsphenoidbone 20) Foramenlacerum 21) Foramenovale 22) Foramenspinosum 23) Sphenopetrousfissure/Eustachiantube 24) Carotidcanal,secondpart 25) Aircellsintemporalbone 26) Apexofpetrousbone 27) Petro-occipitalfissure RadiologyKey FastestRadiologyInsightEngine https://radiologykey.com/skull/
  • 60. CSFSpacesas seen by CT An Evidence-Based Approach To Imaging Of Acute Neurological Conditions (2007) https://www.ebmedicine.net/media_library/marketi ngLandingPages/1207.pdf
  • 62. Airdefines anatomicalshapes usefuloutside ICH analysis→ Amultiscale imagingand modelling dataset of thehumaninner ear Gerber etal.(2017)ScientificDatavolume 4,Articlenumber: 170132 (2017) https://doi.org/10.1038/sdata.2017.132 BE-FNet:3DBoundingBox EstimationFeature Pyramid NetworkforAccurateand Efficient Maxillary Sinus Segmentation Zhuofu Deng etal. (2020) https://doi.org/10.1155/2020/5689301 Maxillary sinus segmentation plays an important role in the choice of therapeutic strategies for nasal disease and treatment monitoring. Difficulties in traditional approaches deal with extremely heterogeneous intensity caused by lesions, abnormal anatomy structures, and blurringboundariesofcavity Development ofCT-basedmethods for longitudinalanalysesof paranasalsinusosteitisin granulomatosiswithpolyangiitis SigrunSkaarHolme etal.(2019) https://doi.org/10.1186/s12880-019-0315-7 Eventhough progressiverhinosinusitiswith osteitisisamajor clinicalproblemin granulomatosiswithpolyangiitis(GPA),thereare nostudiesonhowGPA-relatedosteitisdevelops overtime, andnoquantitativemethods for longitudinalassessment.Here, weaimedto identifysimpleandrobustCT-basedmethodsfor captureandquantificationoftime-dependent changesinGPA-relatedparanasalsinusosteitis
  • 63. Gray/WhiteMatter Contrast not as nice as with MRI An Evidence-Based Approach To Imaging Of Acute Neurological Conditions (2007) https://www.ebmedicine.net/media_library/marketingLandingPages/1207.pdf Comparison between brain-deadpatients' and normalcontrolsubjects'CTscans: 1, normal control CTscan;2, CT scan with lossof WM/GMdifferentiation; 3, CTscan with reversed GM/WMratio. GrayMatter-White Matter De-Differentiation on Brain Computed TomographyPredictsBrain Death Occurrence. https://doi.org/10.1016/j.transproceed.2016.05.006
  • 64. Calcifications choroidplexusandpinealglandverycommonlocations IntracranialcalcificationsonCT: an updated reviewCharbelSaade,ElieNajem,Karl Asmar, RidaSalman,BassamElAchkar,LenaNaffaa(2019) http://doi.org/10.3941/jrcr.v13i8.3633 In a study that was done by Yalcin et al.(2016) that focused on determining the location and extent of intracranial calcificationsin 11,941 subjects, the pineal gland was found to be the most common site of physiologic calcifications (71.6%) followed by the choroid plexus (70.2%) with male dominance in both sites with a mean age of 47.3 and 49.8 respectively. However, the choroid plexus was found to be the most common site of physiologic calcification after the 5th decade and second most common after the pineal gland in subjects aged between 15-45 years. According to Yalcin et al. (2016) dural calcifications were seen in up to 12.5% of the studied population with the majority found in male patients. Basal ganglia calcifications were found in only 1.3% in the same study conducted by Yalcin et al.(2016)Yalcin etal. (2016). Interestingly, BGC were reported to be more prevalent among females than males with a mean age of 52. Examples of patterns of calcification and related terminology. (a) dots, (b) lines, (c) conglomerate or mass-like, (d) rock-like, (e) blush,(f)gyriform/band-like,(g) stippled(h) reticular.
  • 65. Calcifications #2 An Evidence-Based Approach To Imaging Of Acute Neurological Conditions (2007) https://www.ebmedicine.net/media_library/marketingLandingPages/1207.pdf Pinealglandofa72-year-oldmale. Image a revealstheoutlinedpinealglandon sagittalplaneandimage b demonstratesthe3- dimensionalimageandvolumeofthetissue. Greenareasonimage c and d exhibitthe restrictedparenchymabyexcludingallthe calcifiedtissuesfromtheslices. http://doi.org/10.5334/jbr-btr.892 Pinealglandofa35-year-oldfemale. Image a and b revealtheoutlinedpinealglandon sagittal(a)andaxial(b)planesonnoncontrast computerizedtomographyimages.Greenareas onimage c exhibittherestrictedparenchymaby excludingallthecalcifiedtissuesfromtheslices. Imaged demonstratesthe3-dimensionalimage andvolumeofnoncalcifedpinealtissue. Weassumethatoptimizedvolumetryofactive pinealtissueandthereforeahighercorrelation of melatoninandpinealparenchymacan potentiallybeimprovedbyacombinationof MRandCT imaging inadditionto serum melatoninlevels.Moreover,inordertoimprove MRquantificationofpinealcalcifications,the combinedapproachwouldpossiblyallowan optimizationandcalibrationofMRIsequencesby CTandthenperhapsevenmakeCT unnecessary 
  • 66. Massesrealor hacked“adversarialattacks” An Evidence-Based Approach To Imaging Of Acute Neurological Conditions (2007) https://www.ebmedicine.net/media_library/marketingLandingPages/1207.pdf by BrittanyGoetting — Thursday,April04,2019,09:24PMEDT TerrifyingMalwareAltersCTScansTo LookLikeCancer,FoolsRadiologists https://hothardware.com/news/malware-creates-fake-cancerous-nodes-in-ct-scans ... Unfortunately, this vital technology is vulnerable to hackers. Researchers recently designed malware that can add or take away fake cancerous nodules from CT and MRI scans. Researchers at the University Cyber Security Research Center in Israel developed malware that can modify CT and MRI scans. During their research, they showed radiologists real lung CT scans, 70 of which had been altered. At least three radiologistswerefooled nearlyeverytime. Pituitaryapoplexy: twoverydifferent presentationswithoneunifying diagnosis CTbrainscanshowinga hyperdensemassarising fromthepituitaryfossa, representingpituitary macroadenomawith haemorrhage http://doi.org/10.1258/shorts.201 0.100073
  • 67. CerebralAbscess Low density due to cerebral inflammatory disease. A, Typical appearance of a cerebral abscess: round, low-density cavity (arrow) surrounded by low-density vasogenic edema. Differentiation from other cavitary lesions such as radionecrotic cysts or cystic neoplasms often requires clinical/laboratory correlation, with help often provided by contrast-enhanced and diffusion weighted MRI. B, Progressive multifocal leukoencephalopathy. Whereas white matter low density is nonspecific, involvement of the subcortical U-shaped fibers in the AIDS patient can help differentiate this disorder from HIV encephalitis. C, Toxoplasmosis. Patchy white matterlowdensity(asterisks) in an immunocompromisedpatientwith alteredmentalstatus. https://radiologykey.com/analysis-of-density-signal-intensity-and-echogenicity/ https://www.slideshare.net/Raeez/cns-infections-radiology Clinicalstagesofhumanbrainabscesseson serial CTscans aftercontrastinfusion Computerized tomographic,neuropathological, andclinicalcorrelations(1983) https://doi.org/10.3171/jns.1983.59.6.0972
  • 68. Ischemicstroke hypodensity (CSF-like looks)→ An Evidence-Based Approach To Imaging Of Acute Neurological Conditions (2007) https://www.ebmedicine.net/media_library/marketingLandingPages/1207.pdf CTscansliceof thebrain showingaright-hemispheric cerebralinfarct(left sideofimage).https://en.wikipedia.org/wiki/Cerebral_infarction
  • 69. BrainSymmetry midline shift frommass effect #1 An Evidence-Based Approach To Imaging Of Acute Neurological Conditions (2007) https://www.ebmedicine.net/media_library/marketi ngLandingPages/1207.pdf https://en.wikipedi a.org/wiki/Midline _shift https://www.slideshare.net/drlokeshmahar/approach-to-head-ct
  • 70. BrainSymmetry midline shift #2:Estimate with ICP Automated Midline Shift and Intracranial Pressure Estimation based on Brain CT Images Wenan Chen, Ashwin Belle,CharlesCockrell, KevinR. Ward, Kayvan Najarian J.Vis. Exp.(74),e3871,doi:10.3791/3871(2013). https://www.jove.com/video/3871 In this paper we present an automated system based mainly on the computed tomography (CT) images consisting of two main components: the midline shift estimation and intracranial pressure (ICP) pre-screening system. To estimate the midline shift, first an estimation of the ideal midline is performed based on the symmetry of the skull and anatomical features in the brain CTscan. Then, segmentation of the ventricles from the CT scan is performed and used as a guide for the identification of the actual midline through shapematching. These processes mimic the measuringprocess by physicians and have shown promising results in the evaluation. In the second component, more features are extracted related to ICP, such as the texture information, blood amount from CT scans and other recorded features, such as age, injury severity score to estimate the ICP arealsoincorporated. Theresultof theideal midline detection.Thered lineisthe approximateideal midline. The two rectangular boxescover theboneprotrusionand the lowerfalxcerebri respectively. Theseboxesareused to reducetheregionsof interest. Thegreen dash lineisthefinal detected ideal midline, which capturestheboneprotrusion and thelowerfalxcerebri accurately.
  • 71. BrainSymmetry midline shift #3:Detection algorithms Themiddlesliceandtheanatomicalmarkers.  Adeformedmidlineexampleandtheanatomicalmidlineshiftmarker  https://doi.org/10.1016/j.compmedimag.2013.11.001 (2014) ASimple,Fastand FullyAutomated ApproachforMidlineShift Measurement on BrainComputedTomography Huan-ChihWang, Shih-Hao Ho,Furen Xiao,Jen-Hai Chou https://arxiv.org/abs/1703.00797 IncorporatingTask-Specific Structural KnowledgeintoCNNs forBrainMidlineShift Detection MaximPisovetal.(2019) https://doi.org/10.1007/978-3-030-33850-3_4 https://github.com/neuro-ml/midline-shift-detection
  • 74. Siemens Unveils AI Apps for Automatic MRI Image Segmentation DECEMBER 4TH, 2019  MEDGADGET EDITORS  NEUROLOGY, NEUROSURGERY, RADIOLOGY,  UROLOGY The AI-Rad Companion Brain MR for Morphometry Analysis, without any manual intervention, segments brain images from MRI exams, calculates brain volume, and automatically marks volume deviations in result tables that neurologists rely on for diagnostics and therapeutics. The last part it does by comparing the levels of gray matter, white matter, and cerebrospinal fluid in a given patient’s brain to normal levels. This can help with diagnosing Alzheimer’s, Parkinson’s, and other diseases. https://www.medgadget.com/2019/12/siemens-unveils-ai- apps-for-automatic-mri-image-segmentation.html Siemenscouldprovide similartoolforCTtoo
  • 76. CTSystemReceivesFDAClearanceforAI-BasedImageReconstruction Technology 07Nov2019CanonMedicalSystemsUSA,Inc.(Tustin,CA,USA) hasreceived510(k)clearancefor itsAdvancedIntelligentClear-IQEngine(AiCE)for the AquilionPrecision https://www.medimaging.net/industry-news/articles/294779910/ct-system-receives-fda-clearance-for-ai-based-image-reconstruction-technology.html
  • 77. Canon Medical is releasing a new high-end digital PET/CT scanner at the upcoming RSNA conference in Chicago. The Cartesion Prime Digital PET/CT combines Canon’s Aquilion Prime SP CT scanner and the SiPM (silicon photomultiplier) PET detector, providing high resolution imaging and easy operator control, according to the company. Productpage:  CartesionPrime DigitalPET/CT
  • 78. EpicaSeeFactorCT3Multi-Modality SystemWinsFDAClearance OCTOBER8TH,2019 https://www.medgadget.com/2019/10/epica-seefactorct3-multi-modality-system-wins-fda-clearance.html The SeeFactorCT3 produces sliceless CT images, unlike typical CT systems, which means that there’s no interpolation involved and therefore less chance of introducing artifacts.Isotropicimaging resolution goesdownto 0.1millimetersinsoft andhard tissues and lesions that are only 0.2 millimeter in diameter can be detected. Thanks to the company’s “Pulsed Technology,” the system can perform high resolution imaging while reducing the overall radiation delivered. Much of this is possible thanks to a dynamic flat panel detector that captures image sequences accurately and at high fidelity. A big advantage of the SeeFactorCT3 is its mobility, since it can be wheeled in and out of ORs, through hospital halls, and even taken inside patient rooms. When set for transport,thedeviceisnarrowenoughtobepushedthroughatypicalopendoor.
  • 79. RoyalPhilipsextends diagnosticimaging portfolio DIAGNOSTICDEVICESDIAGNOSTICIMAGING By NSMedicalStaffWriter  01Mar 2019 https://www.nsmedicaldevices.com/news/philips-incisive-ct-imagi ng-system/ The system is being offered with ‘Tube for Life’ guarantee, as it will replace the Incisive’s X-ray tube, the key component of any CT system, at no additional cost throughout the entire life of the system, potentially lowering operating expensesbyabout$400,000. Additionally, the system features the company’s iDose4 Premium Package which includes two technologies that can improve image quality, iDose4 and metal artifactreductionfor large orthopedicimplants(O-MAR). iDose4 can improve image quality through artifact prevention and increased spatial resolution at low dose. O-MAR reduces artifacts caused by large orthopedic implants. Together they produce high image quality with reducedartifacts. The system’s 70 kV scan mode is touted to offer improved low-contrast detectability and confidence at lowdose. https://youtu.be/izXI3qry8kY
  • 82. PortableCTs CereTom Reviewof Portable CT withAssessmentof aDedicated HeadCT Scanner Z.Rumboldt, W.Huda and J.W.All AmericanJournal ofNeuroradiology October 2009, 30 (9) 1630-1636 https://doi.org/10.3174/ajnr.A1603 - Citedby91 This article reviews a number of portable CT scanners for clinical imaging. These include the CereTom, Tomoscan, xCAT ENT, and OTOscan. The Tomoscan scanner consists of a gantry with multisection detectors and a detachable table. It can perform a full-body scanning, or the gantry can be used without the table to scan the head. The xCAT ENT is a conebeam CT scanner that is intended for intraoperative scanning of cranial bones and sinuses. The OTOscan is a multisection CT scanner intended for imaging in ear, nose, and throat settings and can be used to assess boneandsofttissueofthehead. We also specifically evaluated the technical and clinical performance of the CereTom, a scanner designed specifically for neuroradiologicheadimaging. https://doi.org/10.1097/JNN.0b013e3181ce5c5b GinatandGupta(2014) https://doi.org/10.1146/annurev-bioeng -121813-113601
  • 84. FutureofCTFromEnergycounting(EID)toPhotoncounting(PCD)? TheFuture of ComputedTomography Personalized,Functional,and Precise Alkadhi,HatemandEuler, André Investigative Radiology:September 2020 -Volume 55- Issue 9- p 545-555 http://doi.org/10.1097/RLI.0000000000000668 Modern medicine cannot be imagined without the diagnostic capabilities of computed tomography (CT). Although the past decade witnessed a tremendous increase in scan speed, volume coverage, and temporal resolution, along with a considerable reduction of radiation dose, current trends in CT aim toward more patient- centric, tailored imaging approaches that deliver diagnostic information being personalized to each individual patient. Functional CT with dual-and multienergy, as well as dynamic, perfusion imaging became clinical reality and will further prosper in the near future, and upcoming photon-counting detectors will deliver images ataheretoforeunmatchedspatialresolution. This article aims to provide an overview of current trends in CT imaging, taking into account the potential of photon-counting detector systems, and seeks to illustrate how the future of CT will beshaped.
  • 85. CTStartup NanoxfromIsraelGreatideaifthiswouldworkassaid? #1 https://www.mobihealthnews.com/news/nanoxs-digital-x-ray-system-wins-26m-investors The end goal is to deliver a robust imaging system that can drive earlier disease detection, especially in regions where traditional systems are either too costly or too complicated to roll out broadly. Looking at the longer term, Nanox said that it will be seeking regulatory approval for its platform, and then deploying its globally under a pay-per-scan business model that it says will enable cheaper medical imaging and screening for private and publicprovider systems.
  • 86. CTStartup NanoxfromIsraelGreatideaifthiswouldworkassaid? #2 MuddyWatersResearch@ muddywatersre MW is short $NNOX. We conclude that $NNOX has no product to sell other than its stock. Like $NKLA, NNOX appears to have faked its demo video. A convicted felon appears to be behind the IPO. A US partner has been requesting images for 6 months to no avail "But NNOX gets much worse," the report says. "A convicted felon, who crashed an $8 billion market cap dotcom into the ground, was seemingly instrumental in plucking NNOX out of obscurity and bringing its massively exaggerated story to the U.S. NNOX touts distribution partnerships that supposedly amount to $180.8 million in annual commitments. Almost all of the company’s partnerships give reason for skepticism." MartyStempniak |September18,2020| HealthcareEconomics&Policy Nanoxhitwithclass actionlawsuitamidcriticism labeling imaging startupas ‘Theranos2.0’ https://www.radiologybusiness.com/topics/healthcare-economics The news comes just weeks after the Israeli firm completed a successful initial public offering that raised $190 million. Nanox has inked a series of deals in several countries to provide its novel imaging system, claiming to offer high-end medical imaging at a fraction of the cost and footprint. But analysts at Citron Research raised red flags Tuesday, Sept. 15, claiming the company is merely a “stock promotion” amassing millions without any FDA approvals or scientific evidence. Citron’s analysis—titled “A Complete Farce on the Market: Theranos 2.0”—drew widespread attention, with several law firms soliciting investors looking to sue Nanox over its claims. Plaintiff Matthew White and law firm Rosen Law are one of the first to follow through, filing a proposed securities class action in New York on Wednesday. He claims the company made false statements to both the SEC and investors to inflate its stock value, Bloomberg Law reported. White and his attorneys also allege Nanox fabricated commercial agreements and made misleading statements about its imaging technology. Several other law firms also announced their own lawsuits on behalf of investors Friday.  Nanox did not respond to a Radiology Business request for comment. However, the Neve Ilan, Israel-based company posted a statement to its webpage Wednesday, Sept. 16, addressing the “unusual trading activities” after investors dumped the stock en masse in response to Citron’s concerns.
  • 88. FromAdvancesinComputedTomography Imaging Technology Ginatand Gupta(2014) https://doi.org/10.1146/annurev-bioeng-121813-113601 From A typical multidetector CT scanner consists of a mosaic of scintillators that convert X-rays into light in the visible spectrum, a photodiode array that converts the light into an electrical signal, a switching array that enables switching between channels, and a connector that conveys the signal to a data acquisition system(Figure6). The multiple channels between the detectors acquire multiple sets of projection data for each rotation of the scanner gantry. The channels can sample different detector elementssimultaneouslyandcancombinethesignals. The detector elements can vary in size, and hybrid detectors that comprise narrow (0.5-mm, 0.625-mm, or 0.75-mm) detectors in the center with wider (1.0-mm, 1.25-mm, or 1.5-mm)detectorsflankedalongthesidesarecommonlyused(Saini2004). Third-generation CT scanners featured rotate-rotate geometry, whereby the tube and the detectors rotated together around the patient. In conjunction with a wide X-ray fan beam that encompassed the entire patient cross-section and an array of detectors to intercept the beam, scan times of less than 5 s could be achieved. However, third-generation CT scanners were prone to ring artifacts that resulted in drift in the calibration of one detector relative to the other detectors. Fourth- generation scanners featured stationary ring detectors and a rotating fan-beam X-ray tube (Figure 5), which mitigated the issues related to ring artifacts. However, the ring-detector arrangement limited the useofscatterreduction.
  • 89. leakage current MOS switch ASICs and ultra-low noise pre-amplification ASICs. Our modern, automated, high-precision assembly process guarantees our productsareofhighreliabilityandstability. With our core competences in photodiode, ASIC and assembly technologies we offer products in different assembly levels, ranging from photodiode chips to full detector modules. Our strong experience in designing and developing CT detector modules ensures that customized solutions are quickly and cost- efficientlyinuseatour customers.
  • 91. Acquisition Sinogram Reconstruction→ → Fransson(2019): Although many different reconstruction methods are available there are mainly two categories, filtered back- projection (FBP) and iterative reconstruction (IR). FBP is a simpler method than IR and it takes less time to compute, but artifacts are more frequent and dominant (Stiller2018). The image that provide the anatomical information is said to exist in the image domain. By applying a mathematical operation, called the Fourier transform, on the image data it is transformed into the projection domain. In the projection domain image processing is performed with the use of filters, or kernels, in order to enhance the image in various ways, such as reducing the noise level. When the processing is completed the Inverse Fourier transform is applied on the data in order to acquire the anatomical imagethatisdesired.
  • 92. Acquisition Sinogram Reconstruction→ → Stiller2018:Basicsofiterativereconstructionmethodsincomputedtomography:Avendor-independentoverview
  • 93. Sinogram ImageSpace→ MachineFriendly MachineLearning:InterpretationofComputed TomographyWithout Image Reconstruction HyunkwangLee,ChaoHuang,SehyoYune,ShaheinH.Tajmir,MyeongchanKim&SynhoDo Department ofRadiology,Massachusetts General Hospital,Boston;JohnA.Paulson SchoolofEngineeringand AppliedSciences,Harvard University, ScientificReportsvolume9,Articlenumber: 15540(2019) https://doi.org/10.1038/s41598-019-51779-5 Examples of reconstructed images and sinograms with different labels for (a), body part recognition and (b), ICH detection. From left to right: original CT images, windowed CT images, sinograms with 360 projections by 729 detector pixels, and windowed sinograms 360 × 729. In the last row, an example CT with hemorrhage is annotated with a dotted circle in image-space with the region of interest converted into the sinogram domain using Radon transform. This area is highlighted in red on thesinogramin thefifthcolumn.
  • 94. Reconstructionfrom sparsemeasurements common problem in all scanning-based imaging Zhuetal.(2018) Nature"Imagereconstructionbydomain-transformmanifold learning" https://doi.org/10.1038/nature25988 Radonprojection;Spiralnon-CartesianFourier;UndersampledFourier;MisalignedFourier-  Citedby238 -https://youtu.be/o-vt1Ld6v-M- https://github.com/chongduan/MRI-AUTOMAP They describe the technique - dubbed AUTOMAP (automated transform by manifold approximation) - in a paper published today in the journal Nature. "An essential part of the clinical imaging pipeline is image reconstruction, which transforms the raw data coming off the scanner into images forradiologists to evaluate," https://phys.org/news/2018-03-arti ficial-intelligence-technique-quality- medical.html
  • 95. PET+CTJoint Reconstruction Improvingthe Accuracy ofSimultaneously Reconstructed ActivityandAttenuationMapsUsing Deep Learning DonghwiHwang,Kyeong YunKim,SeungKwanKang,SeonghoSeo,Jin ChulPaeng,DongSooLeeandJaeSungLee JNucl Med2018;59:1624–1629 http://doi.org/10.2967/jnumed.117.202317 Simultaneous reconstruction of activity and attenuation using the maximum-likelihood reconstruction of activity and attenuation (MLAA) augmented by time-of-flight information is a promising method for PET attenuation correction. However, it still suffers from several problems, including crosstalk artifacts, slow convergence speed, and noisy attenuation maps (μ-maps). In this work, we developed deep convolutional neural networks (CNNs) to overcome these MLAA limitations, and we verified their feasibility using a clinical brain PET dataset. There are someexistingworks on applying deeplearningto predict CT m-maps based on T1-weighted MR images or a combination of Dixon and zero-echo-time images (51,52). The approach using the Dixon and zero-echo-time images would be more physically relevant than the T1- weighted MRI-based approach because the Dixon and zero-echo- time sequences provide more direct information on the tissue composition than does the T1 sequence. The method proposed in this study has the same physical relevance as the Dixon or zero-echo-time approachbut doesnot requiretheacquisitionofadditionalMRimages.
  • 96. Reconstructionexample forPET from sinograms DirectPET:FullSize Neural NetworkPET Reconstruction fromSinogramData William Whiteley, WingK. Luk, JensGregor Siemens Medical Solutions USA https://arxiv.org/abs/1908.07516 This paper proposes a new more efficient network design called DirectPET which is capable of reconstructing a multi-slice Positron Emission Tomography (PET) image volume (i.e., 16x400x400) by addressing the computational challenges through a specially designed Radon inversion layer. We compare the proposed method to the benchmark Ordered Subsets Expectation Maximization (OSEM) algorithm using signal-to- noise ratio, bias, mean absolute error and structural similarity measures. Line profiles and full-width half- maximum measurements are also providedforasampleoflesions. Looking toward future work, there are many possibilities in network architecture, loss functions and training optimization to explore, which will undoubtedly lead to more efficient reconstructions and even higher quality images. However, the biggest challenge with producing medical images is providing overall confidence on neural network reconstruction on unseensamples
  • 97. ImprovingtheAccuracy ofSimultaneouslyReconstructedActivity and AttenuationMapsUsingDeepLearning JNuclMed2018;59:1624–1629 http://doi.org/10.2967/jnumed.117.202317
  • 99. BeamHardeningArtifactfoundoftenatlowerslicesnearbrainstemwithsmallspacessurroundedby bone Beamhardeningartifact(left),andpartialvolumeeffect(right) http://doi.org/10.13140/RG.2.1.2575.3122 UnderstandingandMitigatingUnexpectedArtifactsinHeadCTs:APracticalExperience FlaviusD.RaslauJ.ZhangJ.Riley-GrahamE.J.Escott(2016) http://doi.org/10.3174/ng.2160146 BeamHardening. The most commonly encountered artifact in CT scanning is beam hardening, which causes the edges of an object to appear brighter thanthecenter, evenifthematerialisthe same throughout The artifact derives its name from its underlying cause: the increase in mean X-ray energy, or “hardening” of the X-ray beam as it passes through the scanned object. Because lower-energy X-rays are attenuated more readily than higher-energy X-rays, a polychromatic beam passing through an object preferentially loses the lower- energy parts of its spectrum. The end result is a beam that, though diminished in overall intensity, has a higher average energy than the incident beam. This also means that, as the beam passes through an object, the effective attenuation coefficient of any material diminishes, thus making short ray paths proportionally more attenuating than long ray paths. In X-ray CT images of sufficiently attenuating material, this process generally manifests itself as an artificial darkening at the center of long ray paths, and a corresponding brightening near the edges. In objects with roughly circular cross sections this process can cause the edge to appear brighter than the interior, but in irregular objects it is commonly difficult to differentiate between beam hardening artifacts and actualmaterial variations.
  • 100. MotionArtifacts as inmostofimagingwhen thesubjectmovesduringthe acquisition There are several steps to be taken to prevent the voluntary movement of the body during scanning while it is difficult to prevent involuntary movement. Some modern scanning devices have some features that reducetheresultingartifacts Ameretal.(2018)researchgate.net ArtifactsinCT:recognitionandavoidance. BarrettandKeat(2004) https://doi.org/10.1148/rg.246045065 Freeze!RevisitingCTmotionartifacts:Formation,recognitionand remedies. semanticscholar.org CTbrain withseveremotionartifact https://radiopaedia.org/images/4974802
  • 101. StreakArtifactsfrom high density structures An Evidence-Based Approach To Imaging Of Acute Neurological Conditions (2007) https://www.ebmedicine.net/media_library/marketingLandingPages/1207.pdf Dr BalajiAnvekar'sNeuroradiologyCases:StreakartifactsCT http://www.neuroradiologycases.com/2011/10/streak-artifacts.html Hegazy, M.A.A., Cho, M.H., Cho, M.H. et al. U-netbasedmetalsegmentation onprojectiondomainfor metal artifact reductionindentalCT (2019) https://doi.org/10.1007/s13534-019-00 110-2
  • 102. RingArtifacts from high density structures CTartifacts:causes andreduction techniques (2012) FEdwardBoas&DominikFleischmann Department ofRadiology, StanfordUniversitySchoolofMedicine, 300PasteurDrive, Stanford,CA94305, USA https://www.openaccessjournals.com/articles/ct-artif acts-causes-and-reduction-techniques.html http://doi.org/10.1088/0031-9155/46/12/309
  • 103. ZebraandStair-stepArtifacts CTartifacts:causesand reductiontechniques (2012) FEdwardBoas&DominikFleischmannDepartment ofRadiology,StanfordUniversitySchoolofMedicine https://www.openaccessjournals.com/articles/ct-artifacts-causes-and-reduction-techniques.html Zebra and stair-step artifacts. (A) Zebra artifacts (alternating high and low noise slices, arrows) due to helical interpolation. These are more prominent at the periphery of the field of view. (B) Stair-step artifacts (arrows) seen with helical and multidetector rowCT.Thesearealsomoreprominentnear theperipheryofthefieldof view.Therefore,itisimportanttoplace theobjectofinterestnear thecenter ofthefield ofview. Zebrastripes https://radiopaedia.org/articles/zebra-stripes-1?lang=gb AndrewMurphy  and ◉ and  Dr J.RayBallinger etal. Zebrastripes/artifacts appear asalternatingbrightanddarkbandsinaMRIimage.Theterm hasbeenusedtodescribeseveraldifferentkindofartifactscausingsomeconfusion. Artifactsthathavebeendescribedasazebraartifactincludethefollowing: ● Moirefringes  ● Zero-fillartifact ● Spikeink-space  Zebrastripeshavebeendescribedassociatedwith susceptibilityartifacts. InCTthereisalsoazebraartifactfrom3Dreconstructionsandazebrasignfrom haemorrhageinthecerebellar sulci. Itthereforeseemsprudenttouse"zebra"withatermlike"stripes"rather than"artifacts".
  • 104. Bonediscontinuities from factures An Evidence-Based Approach To Imaging Of Acute Neurological Conditions (2007) https://www.ebmedicine.net/media_library/marketingLandingPages/1207.pdf https://www.ncbi.nlm.nih.gov/pubmed/21691535
  • 105. Bonefractures in practice DoctorExplains Serious UFCEyeInjuryforKarolinaKowalkiewicz - UFC FightNight168 Brian Sutterer,https://youtu.be/XwvoNsypP-I OrbitalFloorfracture muscleorfatgoingtomaxillarysinus https://en.wikipedia.org/wiki/Orbital_blowout_fracture
  • 106. Networks trainedfor fractures as well DeepConvolutionalNeural NetworksforAutomatic DetectionofOrbitalBlowout Fractures D.Ng,L.Churilov,P. Mitchell, R.DowlingandB.Yan American Journalof NeuroradiologyFebruary2018,39 (2)232-237; https://doi.org/10.3174/ajnr.A5465 Orbital blow out fracture is a common disease in emergency department and a delay or failure in diagnosis can lead to permanent visual changes. This study aims to evaluate the ability of an automatic orbital blowout fractures detection system based on computedtomography(CT) data. The limitations of this work should be mentioned. First, our method was developed and evaluated on data from a single-tertiary hospital. Thus, further assessment of large data from other centers is required to increase the generalizability of the findings, which will be addressed in a future work. Fracture location is also an important parameter in accurate diagnosis and planning for surgical management. With further improvements and clinical verification, an optimized model could be implemented in the development of computer- aideddecisionsystems. Preprocessing of DICOM data. A, Original pixel values visualized on a CT slice. B, Effect after finding the largest link area. C, Image with bone window limitation. D, Binary image of a CT slice. E, Image clipped with the maximum outer rectangular frame.CT,computedtomography.