Sherry Boschert

LOS ANGELES – A prospective, multicenter study validated the "spot sign" on CT angiography as a common finding in patients with intracerebral hemorrhage that is predictive of significant hematoma growth and early death.

Close to one-third of these patients who present early to an emergency department have spot signs on CT angiogram (CTA), and nearly 60% of them die within the first 3 months, Dr. Andrew M. Demchuk reported at the International Stroke Conference.

The study enrolled 268 patients with an intracerebral hemorrhage (ICH) less than 100 mL in size who arrived at an emergency department within 6 hours of symptom onset. At baseline, patients at 11 centers in six countries underwent non–contrast enhanced CT (NCCT) imaging and a first-pass CTA in the head of the Circle of Willis through the entire hematoma volume. A follow-up NCCT scan was performed at 24 hours, with clinical follow-up at 24 hours and at 3 months.

A neuroradiologist at the University of Toronto who did not know follow-up information interpreted the CT angiograms for each patient, using a predetermined definition of the spot sign. Separately, investigators at the University of Calgary (Alta.) performed hematoma volumetric analyses of each ICH and intraventricular hemorrhage (IVH), using quantitative tomography without knowing any of the NCCT results.

At baseline, 80 patients (30%) had a spot sign, according to Dr. Demchuk of the University of Calgary and his associates. They noted that there may have been a slight predilection for more spot signs in patients with lobar ICH, but the spot sign was seen frequently regardless of ICH location. The incidence of a spot sign varied from 25% to 41% in different regions of the brain.

The median time from onset of symptoms to baseline CT imaging was 138 minutes.

A quarter of patients with spot signs deteriorated rapidly, he noted. Four died before the 24-hour NCCT, seven underwent surgery before the 24-hour CT, and nine were treated with off-label recombinant activated factor VII (rFVIIa). In a previous trial, hemostatic therapy with rFVIIa reduced the risk of hematoma expansion but did not improve overall outcomes (N. Engl. J. Med. 2008;358:2127-37). Another three treatment trials are now underway that base rFVIIa treatment on CTA findings, noted Dr. Demchuk, director of the Calgary Stroke Program for Alberta Health Services.

In the current study, called PREDICT (Predicting Hematoma Growth and Outcome in Intracerebral Hemorrhage Using Contrast Bolus CT), 27% of 228 patients who had a 24-hour follow-up NCCT available had spot signs at baseline. The size of ICH or IVH at baseline in patients with the spot sign was roughly double the size of the hematoma in those without the spot sign.

In multiple analyses that used 10 different definitions of hematoma growth, expansion was significantly more likely to occur in patients with a spot sign. "There’s a lot of debate in the literature, still, in terms of what’s the best growth criteria. It doesn’t matter what growth criteria you use. All of them had a much higher frequency in the setting of a spot sign than without a spot sign," Dr. Demchuk said at the conference, which was sponsored by the American Heart Association.

Among 176 patients with 3-month follow-up data, clinical outcomes were significantly worse in those with spot signs at baseline. Early neurologic worsening was seen in 38% of those with spot signs and 13% of those without. Mortality was greater in patients with spot signs (59%) than in those without (26%). The difference in mortality was early and dramatic, with most of the divergence between groups occurring within 30 days.

The study defined a spot sign according to six criteria: The shape is spotlike, serpiginous, or linear. The spot is located within the margin of a parenchymal hematoma without connection to an outside vessel, and is greater than 1.5 mm in diameter in at least one dimension. The density of the spot sign is at least double the density of the hematoma. Single or multiple spot signs could be present, and these must not be caused by calcific deposition (hyperdensity in the same location on NCCT).

Having more than one spot sign predicted even greater growth. Patients with more than one spot sign had triple the growth in hematoma, compared with patients without a spot sign, Dr. Demchuk said. The use of a "spot sign score" calculation, which has been proposed by previous researchers, did not correlate with hematoma growth in this study.

The spot sign did not seem to be as helpful in predicting hematoma growth in patients on warfarin, especially those with an elevated international normalized ratio (INR) at baseline, he added. The study included about 15 patients on warfarin who had an INR greater than 1.5 at baseline. Hematoma expansion in this subgroup was three times more likely to occur than in patients who were not on warfarin, whether a spot sign was present or not.

The study was funded by the Canadian Stroke Consortium and by Novo Nordisk, which is developing rFVIIa. Dr. Demchuk did not receive any personal financial support from Novo Nordisk.

LOS ANGELES – A prospective, multicenter study validated the "spot sign" on CT angiography as a common finding in patients with intracerebral hemorrhage that is predictive of significant hematoma growth and early death.

Close to one-third of these patients who present early to an emergency department have spot signs on CT angiogram (CTA), and nearly 60% of them die within the first 3 months, Dr. Andrew M. Demchuk reported at the International Stroke Conference.

The study enrolled 268 patients with an intracerebral hemorrhage (ICH) less than 100 mL in size who arrived at an emergency department within 6 hours of symptom onset. At baseline, patients at 11 centers in six countries underwent non–contrast enhanced CT (NCCT) imaging and a first-pass CTA in the head of the Circle of Willis through the entire hematoma volume. A follow-up NCCT scan was performed at 24 hours, with clinical follow-up at 24 hours and at 3 months.

A neuroradiologist at the University of Toronto who did not know follow-up information interpreted the CT angiograms for each patient, using a predetermined definition of the spot sign. Separately, investigators at the University of Calgary (Alta.) performed hematoma volumetric analyses of each ICH and intraventricular hemorrhage (IVH), using quantitative tomography without knowing any of the NCCT results.

At baseline, 80 patients (30%) had a spot sign, according to Dr. Demchuk of the University of Calgary and his associates. They noted that there may have been a slight predilection for more spot signs in patients with lobar ICH, but the spot sign was seen frequently regardless of ICH location. The incidence of a spot sign varied from 25% to 41% in different regions of the brain.

The median time from onset of symptoms to baseline CT imaging was 138 minutes.

A quarter of patients with spot signs deteriorated rapidly, he noted. Four died before the 24-hour NCCT, seven underwent surgery before the 24-hour CT, and nine were treated with off-label recombinant activated factor VII (rFVIIa). In a previous trial, hemostatic therapy with rFVIIa reduced the risk of hematoma expansion but did not improve overall outcomes (N. Engl. J. Med. 2008;358:2127-37). Another three treatment trials are now underway that base rFVIIa treatment on CTA findings, noted Dr. Demchuk, director of the Calgary Stroke Program for Alberta Health Services.

In the current study, called PREDICT (Predicting Hematoma Growth and Outcome in Intracerebral Hemorrhage Using Contrast Bolus CT), 27% of 228 patients who had a 24-hour follow-up NCCT available had spot signs at baseline. The size of ICH or IVH at baseline in patients with the spot sign was roughly double the size of the hematoma in those without the spot sign.

In multiple analyses that used 10 different definitions of hematoma growth, expansion was significantly more likely to occur in patients with a spot sign. "There’s a lot of debate in the literature, still, in terms of what’s the best growth criteria. It doesn’t matter what growth criteria you use. All of them had a much higher frequency in the setting of a spot sign than without a spot sign," Dr. Demchuk said at the conference, which was sponsored by the American Heart Association.

Among 176 patients with 3-month follow-up data, clinical outcomes were significantly worse in those with spot signs at baseline. Early neurologic worsening was seen in 38% of those with spot signs and 13% of those without. Mortality was greater in patients with spot signs (59%) than in those without (26%). The difference in mortality was early and dramatic, with most of the divergence between groups occurring within 30 days.

The study defined a spot sign according to six criteria: The shape is spotlike, serpiginous, or linear. The spot is located within the margin of a parenchymal hematoma without connection to an outside vessel, and is greater than 1.5 mm in diameter in at least one dimension. The density of the spot sign is at least double the density of the hematoma. Single or multiple spot signs could be present, and these must not be caused by calcific deposition (hyperdensity in the same location on NCCT).

Having more than one spot sign predicted even greater growth. Patients with more than one spot sign had triple the growth in hematoma, compared with patients without a spot sign, Dr. Demchuk said. The use of a "spot sign score" calculation, which has been proposed by previous researchers, did not correlate with hematoma growth in this study.

The spot sign did not seem to be as helpful in predicting hematoma growth in patients on warfarin, especially those with an elevated international normalized ratio (INR) at baseline, he added. The study included about 15 patients on warfarin who had an INR greater than 1.5 at baseline. Hematoma expansion in this subgroup was three times more likely to occur than in patients who were not on warfarin, whether a spot sign was present or not.

The study was funded by the Canadian Stroke Consortium and by Novo Nordisk, which is developing rFVIIa. Dr. Demchuk did not receive any personal financial support from Novo Nordisk.

LOS ANGELES – A prospective, multicenter study validated the "spot sign" on CT angiography as a common finding in patients with intracerebral hemorrhage that is predictive of significant hematoma growth and early death.

Close to one-third of these patients who present early to an emergency department have spot signs on CT angiogram (CTA), and nearly 60% of them die within the first 3 months, Dr. Andrew M. Demchuk reported at the International Stroke Conference.

The study enrolled 268 patients with an intracerebral hemorrhage (ICH) less than 100 mL in size who arrived at an emergency department within 6 hours of symptom onset. At baseline, patients at 11 centers in six countries underwent non–contrast enhanced CT (NCCT) imaging and a first-pass CTA in the head of the Circle of Willis through the entire hematoma volume. A follow-up NCCT scan was performed at 24 hours, with clinical follow-up at 24 hours and at 3 months.

A neuroradiologist at the University of Toronto who did not know follow-up information interpreted the CT angiograms for each patient, using a predetermined definition of the spot sign. Separately, investigators at the University of Calgary (Alta.) performed hematoma volumetric analyses of each ICH and intraventricular hemorrhage (IVH), using quantitative tomography without knowing any of the NCCT results.

At baseline, 80 patients (30%) had a spot sign, according to Dr. Demchuk of the University of Calgary and his associates. They noted that there may have been a slight predilection for more spot signs in patients with lobar ICH, but the spot sign was seen frequently regardless of ICH location. The incidence of a spot sign varied from 25% to 41% in different regions of the brain.

The median time from onset of symptoms to baseline CT imaging was 138 minutes.

A quarter of patients with spot signs deteriorated rapidly, he noted. Four died before the 24-hour NCCT, seven underwent surgery before the 24-hour CT, and nine were treated with off-label recombinant activated factor VII (rFVIIa). In a previous trial, hemostatic therapy with rFVIIa reduced the risk of hematoma expansion but did not improve overall outcomes (N. Engl. J. Med. 2008;358:2127-37). Another three treatment trials are now underway that base rFVIIa treatment on CTA findings, noted Dr. Demchuk, director of the Calgary Stroke Program for Alberta Health Services.

In the current study, called PREDICT (Predicting Hematoma Growth and Outcome in Intracerebral Hemorrhage Using Contrast Bolus CT), 27% of 228 patients who had a 24-hour follow-up NCCT available had spot signs at baseline. The size of ICH or IVH at baseline in patients with the spot sign was roughly double the size of the hematoma in those without the spot sign.

In multiple analyses that used 10 different definitions of hematoma growth, expansion was significantly more likely to occur in patients with a spot sign. "There’s a lot of debate in the literature, still, in terms of what’s the best growth criteria. It doesn’t matter what growth criteria you use. All of them had a much higher frequency in the setting of a spot sign than without a spot sign," Dr. Demchuk said at the conference, which was sponsored by the American Heart Association.

Among 176 patients with 3-month follow-up data, clinical outcomes were significantly worse in those with spot signs at baseline. Early neurologic worsening was seen in 38% of those with spot signs and 13% of those without. Mortality was greater in patients with spot signs (59%) than in those without (26%). The difference in mortality was early and dramatic, with most of the divergence between groups occurring within 30 days.

The study defined a spot sign according to six criteria: The shape is spotlike, serpiginous, or linear. The spot is located within the margin of a parenchymal hematoma without connection to an outside vessel, and is greater than 1.5 mm in diameter in at least one dimension. The density of the spot sign is at least double the density of the hematoma. Single or multiple spot signs could be present, and these must not be caused by calcific deposition (hyperdensity in the same location on NCCT).

Having more than one spot sign predicted even greater growth. Patients with more than one spot sign had triple the growth in hematoma, compared with patients without a spot sign, Dr. Demchuk said. The use of a "spot sign score" calculation, which has been proposed by previous researchers, did not correlate with hematoma growth in this study.

The spot sign did not seem to be as helpful in predicting hematoma growth in patients on warfarin, especially those with an elevated international normalized ratio (INR) at baseline, he added. The study included about 15 patients on warfarin who had an INR greater than 1.5 at baseline. Hematoma expansion in this subgroup was three times more likely to occur than in patients who were not on warfarin, whether a spot sign was present or not.

The study was funded by the Canadian Stroke Consortium and by Novo Nordisk, which is developing rFVIIa. Dr. Demchuk did not receive any personal financial support from Novo Nordisk.

LOS ANGELES – A prospective, multicenter study validated the "spot sign" on CT angiography as a common finding in patients with intracerebral hemorrhage that is predictive of significant hematoma growth and early death.

Close to one-third of these patients who present early to an emergency department have spot signs on CT angiogram (CTA), and nearly 60% of them die within the first 3 months, Dr. Andrew M. Demchuk reported at the International Stroke Conference.

The study enrolled 268 patients with an intracerebral hemorrhage (ICH) less than 100 mL in size who arrived at an emergency department within 6 hours of symptom onset. At baseline, patients at 11 centers in six countries underwent non–contrast enhanced CT (NCCT) imaging and a first-pass CTA in the head of the Circle of Willis through the entire hematoma volume. A follow-up NCCT scan was performed at 24 hours, with clinical follow-up at 24 hours and at 3 months.

A neuroradiologist at the University of Toronto who did not know follow-up information interpreted the CT angiograms for each patient, using a predetermined definition of the spot sign. Separately, investigators at the University of Calgary (Alta.) performed hematoma volumetric analyses of each ICH and intraventricular hemorrhage (IVH), using quantitative tomography without knowing any of the NCCT results.

At baseline, 80 patients (30%) had a spot sign, according to Dr. Demchuk of the University of Calgary and his associates. They noted that there may have been a slight predilection for more spot signs in patients with lobar ICH, but the spot sign was seen frequently regardless of ICH location. The incidence of a spot sign varied from 25% to 41% in different regions of the brain.

The median time from onset of symptoms to baseline CT imaging was 138 minutes.

A quarter of patients with spot signs deteriorated rapidly, he noted. Four died before the 24-hour NCCT, seven underwent surgery before the 24-hour CT, and nine were treated with off-label recombinant activated factor VII (rFVIIa). In a previous trial, hemostatic therapy with rFVIIa reduced the risk of hematoma expansion but did not improve overall outcomes (N. Engl. J. Med. 2008;358:2127-37). Another three treatment trials are now underway that base rFVIIa treatment on CTA findings, noted Dr. Demchuk, director of the Calgary Stroke Program for Alberta Health Services.

In the current study, called PREDICT (Predicting Hematoma Growth and Outcome in Intracerebral Hemorrhage Using Contrast Bolus CT), 27% of 228 patients who had a 24-hour follow-up NCCT available had spot signs at baseline. The size of ICH or IVH at baseline in patients with the spot sign was roughly double the size of the hematoma in those without the spot sign.

In multiple analyses that used 10 different definitions of hematoma growth, expansion was significantly more likely to occur in patients with a spot sign. "There’s a lot of debate in the literature, still, in terms of what’s the best growth criteria. It doesn’t matter what growth criteria you use. All of them had a much higher frequency in the setting of a spot sign than without a spot sign," Dr. Demchuk said at the conference, which was sponsored by the American Heart Association.

Among 176 patients with 3-month follow-up data, clinical outcomes were significantly worse in those with spot signs at baseline. Early neurologic worsening was seen in 38% of those with spot signs and 13% of those without. Mortality was greater in patients with spot signs (59%) than in those without (26%). The difference in mortality was early and dramatic, with most of the divergence between groups occurring within 30 days.

The study defined a spot sign according to six criteria: The shape is spotlike, serpiginous, or linear. The spot is located within the margin of a parenchymal hematoma without connection to an outside vessel, and is greater than 1.5 mm in diameter in at least one dimension. The density of the spot sign is at least double the density of the hematoma. Single or multiple spot signs could be present, and these must not be caused by calcific deposition (hyperdensity in the same location on NCCT).

Having more than one spot sign predicted even greater growth. Patients with more than one spot sign had triple the growth in hematoma, compared with patients without a spot sign, Dr. Demchuk said. The use of a "spot sign score" calculation, which has been proposed by previous researchers, did not correlate with hematoma growth in this study.

The spot sign did not seem to be as helpful in predicting hematoma growth in patients on warfarin, especially those with an elevated international normalized ratio (INR) at baseline, he added. The study included about 15 patients on warfarin who had an INR greater than 1.5 at baseline. Hematoma expansion in this subgroup was three times more likely to occur than in patients who were not on warfarin, whether a spot sign was present or not.

The study was funded by the Canadian Stroke Consortium and by Novo Nordisk, which is developing rFVIIa. Dr. Demchuk did not receive any personal financial support from Novo Nordisk.

LOS ANGELES – A prospective, multicenter study validated the "spot sign" on CT angiography as a common finding in patients with intracerebral hemorrhage that is predictive of significant hematoma growth and early death.

Close to one-third of these patients who present early to an emergency department have spot signs on CT angiogram (CTA), and nearly 60% of them die within the first 3 months, Dr. Andrew M. Demchuk reported at the International Stroke Conference.

The study enrolled 268 patients with an intracerebral hemorrhage (ICH) less than 100 mL in size who arrived at an emergency department within 6 hours of symptom onset. At baseline, patients at 11 centers in six countries underwent non–contrast enhanced CT (NCCT) imaging and a first-pass CTA in the head of the Circle of Willis through the entire hematoma volume. A follow-up NCCT scan was performed at 24 hours, with clinical follow-up at 24 hours and at 3 months.

A neuroradiologist at the University of Toronto who did not know follow-up information interpreted the CT angiograms for each patient, using a predetermined definition of the spot sign. Separately, investigators at the University of Calgary (Alta.) performed hematoma volumetric analyses of each ICH and intraventricular hemorrhage (IVH), using quantitative tomography without knowing any of the NCCT results.

At baseline, 80 patients (30%) had a spot sign, according to Dr. Demchuk of the University of Calgary and his associates. They noted that there may have been a slight predilection for more spot signs in patients with lobar ICH, but the spot sign was seen frequently regardless of ICH location. The incidence of a spot sign varied from 25% to 41% in different regions of the brain.

The median time from onset of symptoms to baseline CT imaging was 138 minutes.

A quarter of patients with spot signs deteriorated rapidly, he noted. Four died before the 24-hour NCCT, seven underwent surgery before the 24-hour CT, and nine were treated with off-label recombinant activated factor VII (rFVIIa). In a previous trial, hemostatic therapy with rFVIIa reduced the risk of hematoma expansion but did not improve overall outcomes (N. Engl. J. Med. 2008;358:2127-37). Another three treatment trials are now underway that base rFVIIa treatment on CTA findings, noted Dr. Demchuk, director of the Calgary Stroke Program for Alberta Health Services.

In the current study, called PREDICT (Predicting Hematoma Growth and Outcome in Intracerebral Hemorrhage Using Contrast Bolus CT), 27% of 228 patients who had a 24-hour follow-up NCCT available had spot signs at baseline. The size of ICH or IVH at baseline in patients with the spot sign was roughly double the size of the hematoma in those without the spot sign.

In multiple analyses that used 10 different definitions of hematoma growth, expansion was significantly more likely to occur in patients with a spot sign. "There’s a lot of debate in the literature, still, in terms of what’s the best growth criteria. It doesn’t matter what growth criteria you use. All of them had a much higher frequency in the setting of a spot sign than without a spot sign," Dr. Demchuk said at the conference, which was sponsored by the American Heart Association.

Among 176 patients with 3-month follow-up data, clinical outcomes were significantly worse in those with spot signs at baseline. Early neurologic worsening was seen in 38% of those with spot signs and 13% of those without. Mortality was greater in patients with spot signs (59%) than in those without (26%). The difference in mortality was early and dramatic, with most of the divergence between groups occurring within 30 days.

The study defined a spot sign according to six criteria: The shape is spotlike, serpiginous, or linear. The spot is located within the margin of a parenchymal hematoma without connection to an outside vessel, and is greater than 1.5 mm in diameter in at least one dimension. The density of the spot sign is at least double the density of the hematoma. Single or multiple spot signs could be present, and these must not be caused by calcific deposition (hyperdensity in the same location on NCCT).

Having more than one spot sign predicted even greater growth. Patients with more than one spot sign had triple the growth in hematoma, compared with patients without a spot sign, Dr. Demchuk said. The use of a "spot sign score" calculation, which has been proposed by previous researchers, did not correlate with hematoma growth in this study.

The spot sign did not seem to be as helpful in predicting hematoma growth in patients on warfarin, especially those with an elevated international normalized ratio (INR) at baseline, he added. The study included about 15 patients on warfarin who had an INR greater than 1.5 at baseline. Hematoma expansion in this subgroup was three times more likely to occur than in patients who were not on warfarin, whether a spot sign was present or not.

The study was funded by the Canadian Stroke Consortium and by Novo Nordisk, which is developing rFVIIa. Dr. Demchuk did not receive any personal financial support from Novo Nordisk.

LOS ANGELES – A prospective, multicenter study validated the "spot sign" on CT angiography as a common finding in patients with intracerebral hemorrhage that is predictive of significant hematoma growth and early death.

Close to one-third of these patients who present early to an emergency department have spot signs on CT angiogram (CTA), and nearly 60% of them die within the first 3 months, Dr. Andrew M. Demchuk reported at the International Stroke Conference.

The study enrolled 268 patients with an intracerebral hemorrhage (ICH) less than 100 mL in size who arrived at an emergency department within 6 hours of symptom onset. At baseline, patients at 11 centers in six countries underwent non–contrast enhanced CT (NCCT) imaging and a first-pass CTA in the head of the Circle of Willis through the entire hematoma volume. A follow-up NCCT scan was performed at 24 hours, with clinical follow-up at 24 hours and at 3 months.

A neuroradiologist at the University of Toronto who did not know follow-up information interpreted the CT angiograms for each patient, using a predetermined definition of the spot sign. Separately, investigators at the University of Calgary (Alta.) performed hematoma volumetric analyses of each ICH and intraventricular hemorrhage (IVH), using quantitative tomography without knowing any of the NCCT results.

At baseline, 80 patients (30%) had a spot sign, according to Dr. Demchuk of the University of Calgary and his associates. They noted that there may have been a slight predilection for more spot signs in patients with lobar ICH, but the spot sign was seen frequently regardless of ICH location. The incidence of a spot sign varied from 25% to 41% in different regions of the brain.

The median time from onset of symptoms to baseline CT imaging was 138 minutes.

A quarter of patients with spot signs deteriorated rapidly, he noted. Four died before the 24-hour NCCT, seven underwent surgery before the 24-hour CT, and nine were treated with off-label recombinant activated factor VII (rFVIIa). In a previous trial, hemostatic therapy with rFVIIa reduced the risk of hematoma expansion but did not improve overall outcomes (N. Engl. J. Med. 2008;358:2127-37). Another three treatment trials are now underway that base rFVIIa treatment on CTA findings, noted Dr. Demchuk, director of the Calgary Stroke Program for Alberta Health Services.

In the current study, called PREDICT (Predicting Hematoma Growth and Outcome in Intracerebral Hemorrhage Using Contrast Bolus CT), 27% of 228 patients who had a 24-hour follow-up NCCT available had spot signs at baseline. The size of ICH or IVH at baseline in patients with the spot sign was roughly double the size of the hematoma in those without the spot sign.

In multiple analyses that used 10 different definitions of hematoma growth, expansion was significantly more likely to occur in patients with a spot sign. "There’s a lot of debate in the literature, still, in terms of what’s the best growth criteria. It doesn’t matter what growth criteria you use. All of them had a much higher frequency in the setting of a spot sign than without a spot sign," Dr. Demchuk said at the conference, which was sponsored by the American Heart Association.

Among 176 patients with 3-month follow-up data, clinical outcomes were significantly worse in those with spot signs at baseline. Early neurologic worsening was seen in 38% of those with spot signs and 13% of those without. Mortality was greater in patients with spot signs (59%) than in those without (26%). The difference in mortality was early and dramatic, with most of the divergence between groups occurring within 30 days.

The study defined a spot sign according to six criteria: The shape is spotlike, serpiginous, or linear. The spot is located within the margin of a parenchymal hematoma without connection to an outside vessel, and is greater than 1.5 mm in diameter in at least one dimension. The density of the spot sign is at least double the density of the hematoma. Single or multiple spot signs could be present, and these must not be caused by calcific deposition (hyperdensity in the same location on NCCT).

Having more than one spot sign predicted even greater growth. Patients with more than one spot sign had triple the growth in hematoma, compared with patients without a spot sign, Dr. Demchuk said. The use of a "spot sign score" calculation, which has been proposed by previous researchers, did not correlate with hematoma growth in this study.

The spot sign did not seem to be as helpful in predicting hematoma growth in patients on warfarin, especially those with an elevated international normalized ratio (INR) at baseline, he added. The study included about 15 patients on warfarin who had an INR greater than 1.5 at baseline. Hematoma expansion in this subgroup was three times more likely to occur than in patients who were not on warfarin, whether a spot sign was present or not.

The study was funded by the Canadian Stroke Consortium and by Novo Nordisk, which is developing rFVIIa. Dr. Demchuk did not receive any personal financial support from Novo Nordisk.

LOS ANGELES – A prospective, multicenter study validated the "spot sign" on CT angiography as a common finding in patients with intracerebral hemorrhage that is predictive of significant hematoma growth and early death.

Close to one-third of these patients who present early to an emergency department have spot signs on CT angiogram (CTA), and nearly 60% of them die within the first 3 months, Dr. Andrew M. Demchuk reported at the International Stroke Conference.

The study enrolled 268 patients with an intracerebral hemorrhage (ICH) less than 100 mL in size who arrived at an emergency department within 6 hours of symptom onset. At baseline, patients at 11 centers in six countries underwent non–contrast enhanced CT (NCCT) imaging and a first-pass CTA in the head of the Circle of Willis through the entire hematoma volume. A follow-up NCCT scan was performed at 24 hours, with clinical follow-up at 24 hours and at 3 months.

A neuroradiologist at the University of Toronto who did not know follow-up information interpreted the CT angiograms for each patient, using a predetermined definition of the spot sign. Separately, investigators at the University of Calgary (Alta.) performed hematoma volumetric analyses of each ICH and intraventricular hemorrhage (IVH), using quantitative tomography without knowing any of the NCCT results.

At baseline, 80 patients (30%) had a spot sign, according to Dr. Demchuk of the University of Calgary and his associates. They noted that there may have been a slight predilection for more spot signs in patients with lobar ICH, but the spot sign was seen frequently regardless of ICH location. The incidence of a spot sign varied from 25% to 41% in different regions of the brain.

The median time from onset of symptoms to baseline CT imaging was 138 minutes.

A quarter of patients with spot signs deteriorated rapidly, he noted. Four died before the 24-hour NCCT, seven underwent surgery before the 24-hour CT, and nine were treated with off-label recombinant activated factor VII (rFVIIa). In a previous trial, hemostatic therapy with rFVIIa reduced the risk of hematoma expansion but did not improve overall outcomes (N. Engl. J. Med. 2008;358:2127-37). Another three treatment trials are now underway that base rFVIIa treatment on CTA findings, noted Dr. Demchuk, director of the Calgary Stroke Program for Alberta Health Services.

In the current study, called PREDICT (Predicting Hematoma Growth and Outcome in Intracerebral Hemorrhage Using Contrast Bolus CT), 27% of 228 patients who had a 24-hour follow-up NCCT available had spot signs at baseline. The size of ICH or IVH at baseline in patients with the spot sign was roughly double the size of the hematoma in those without the spot sign.

In multiple analyses that used 10 different definitions of hematoma growth, expansion was significantly more likely to occur in patients with a spot sign. "There’s a lot of debate in the literature, still, in terms of what’s the best growth criteria. It doesn’t matter what growth criteria you use. All of them had a much higher frequency in the setting of a spot sign than without a spot sign," Dr. Demchuk said at the conference, which was sponsored by the American Heart Association.

Among 176 patients with 3-month follow-up data, clinical outcomes were significantly worse in those with spot signs at baseline. Early neurologic worsening was seen in 38% of those with spot signs and 13% of those without. Mortality was greater in patients with spot signs (59%) than in those without (26%). The difference in mortality was early and dramatic, with most of the divergence between groups occurring within 30 days.

The study defined a spot sign according to six criteria: The shape is spotlike, serpiginous, or linear. The spot is located within the margin of a parenchymal hematoma without connection to an outside vessel, and is greater than 1.5 mm in diameter in at least one dimension. The density of the spot sign is at least double the density of the hematoma. Single or multiple spot signs could be present, and these must not be caused by calcific deposition (hyperdensity in the same location on NCCT).

Having more than one spot sign predicted even greater growth. Patients with more than one spot sign had triple the growth in hematoma, compared with patients without a spot sign, Dr. Demchuk said. The use of a "spot sign score" calculation, which has been proposed by previous researchers, did not correlate with hematoma growth in this study.

The spot sign did not seem to be as helpful in predicting hematoma growth in patients on warfarin, especially those with an elevated international normalized ratio (INR) at baseline, he added. The study included about 15 patients on warfarin who had an INR greater than 1.5 at baseline. Hematoma expansion in this subgroup was three times more likely to occur than in patients who were not on warfarin, whether a spot sign was present or not.

The study was funded by the Canadian Stroke Consortium and by Novo Nordisk, which is developing rFVIIa. Dr. Demchuk did not receive any personal financial support from Novo Nordisk.

LOS ANGELES – A prospective, multicenter study validated the "spot sign" on CT angiography as a common finding in patients with intracerebral hemorrhage that is predictive of significant hematoma growth and early death.

Close to one-third of these patients who present early to an emergency department have spot signs on CT angiogram (CTA), and nearly 60% of them die within the first 3 months, Dr. Andrew M. Demchuk reported at the International Stroke Conference.

The study enrolled 268 patients with an intracerebral hemorrhage (ICH) less than 100 mL in size who arrived at an emergency department within 6 hours of symptom onset. At baseline, patients at 11 centers in six countries underwent non–contrast enhanced CT (NCCT) imaging and a first-pass CTA in the head of the Circle of Willis through the entire hematoma volume. A follow-up NCCT scan was performed at 24 hours, with clinical follow-up at 24 hours and at 3 months.

A neuroradiologist at the University of Toronto who did not know follow-up information interpreted the CT angiograms for each patient, using a predetermined definition of the spot sign. Separately, investigators at the University of Calgary (Alta.) performed hematoma volumetric analyses of each ICH and intraventricular hemorrhage (IVH), using quantitative tomography without knowing any of the NCCT results.

At baseline, 80 patients (30%) had a spot sign, according to Dr. Demchuk of the University of Calgary and his associates. They noted that there may have been a slight predilection for more spot signs in patients with lobar ICH, but the spot sign was seen frequently regardless of ICH location. The incidence of a spot sign varied from 25% to 41% in different regions of the brain.

The median time from onset of symptoms to baseline CT imaging was 138 minutes.

A quarter of patients with spot signs deteriorated rapidly, he noted. Four died before the 24-hour NCCT, seven underwent surgery before the 24-hour CT, and nine were treated with off-label recombinant activated factor VII (rFVIIa). In a previous trial, hemostatic therapy with rFVIIa reduced the risk of hematoma expansion but did not improve overall outcomes (N. Engl. J. Med. 2008;358:2127-37). Another three treatment trials are now underway that base rFVIIa treatment on CTA findings, noted Dr. Demchuk, director of the Calgary Stroke Program for Alberta Health Services.

In the current study, called PREDICT (Predicting Hematoma Growth and Outcome in Intracerebral Hemorrhage Using Contrast Bolus CT), 27% of 228 patients who had a 24-hour follow-up NCCT available had spot signs at baseline. The size of ICH or IVH at baseline in patients with the spot sign was roughly double the size of the hematoma in those without the spot sign.

In multiple analyses that used 10 different definitions of hematoma growth, expansion was significantly more likely to occur in patients with a spot sign. "There’s a lot of debate in the literature, still, in terms of what’s the best growth criteria. It doesn’t matter what growth criteria you use. All of them had a much higher frequency in the setting of a spot sign than without a spot sign," Dr. Demchuk said at the conference, which was sponsored by the American Heart Association.

Among 176 patients with 3-month follow-up data, clinical outcomes were significantly worse in those with spot signs at baseline. Early neurologic worsening was seen in 38% of those with spot signs and 13% of those without. Mortality was greater in patients with spot signs (59%) than in those without (26%). The difference in mortality was early and dramatic, with most of the divergence between groups occurring within 30 days.

The study defined a spot sign according to six criteria: The shape is spotlike, serpiginous, or linear. The spot is located within the margin of a parenchymal hematoma without connection to an outside vessel, and is greater than 1.5 mm in diameter in at least one dimension. The density of the spot sign is at least double the density of the hematoma. Single or multiple spot signs could be present, and these must not be caused by calcific deposition (hyperdensity in the same location on NCCT).

Having more than one spot sign predicted even greater growth. Patients with more than one spot sign had triple the growth in hematoma, compared with patients without a spot sign, Dr. Demchuk said. The use of a "spot sign score" calculation, which has been proposed by previous researchers, did not correlate with hematoma growth in this study.

The spot sign did not seem to be as helpful in predicting hematoma growth in patients on warfarin, especially those with an elevated international normalized ratio (INR) at baseline, he added. The study included about 15 patients on warfarin who had an INR greater than 1.5 at baseline. Hematoma expansion in this subgroup was three times more likely to occur than in patients who were not on warfarin, whether a spot sign was present or not.

The study was funded by the Canadian Stroke Consortium and by Novo Nordisk, which is developing rFVIIa. Dr. Demchuk did not receive any personal financial support from Novo Nordisk.

LOS ANGELES – A prospective, multicenter study validated the "spot sign" on CT angiography as a common finding in patients with intracerebral hemorrhage that is predictive of significant hematoma growth and early death.

Close to one-third of these patients who present early to an emergency department have spot signs on CT angiogram (CTA), and nearly 60% of them die within the first 3 months, Dr. Andrew M. Demchuk reported at the International Stroke Conference.

The study enrolled 268 patients with an intracerebral hemorrhage (ICH) less than 100 mL in size who arrived at an emergency department within 6 hours of symptom onset. At baseline, patients at 11 centers in six countries underwent non–contrast enhanced CT (NCCT) imaging and a first-pass CTA in the head of the Circle of Willis through the entire hematoma volume. A follow-up NCCT scan was performed at 24 hours, with clinical follow-up at 24 hours and at 3 months.

A neuroradiologist at the University of Toronto who did not know follow-up information interpreted the CT angiograms for each patient, using a predetermined definition of the spot sign. Separately, investigators at the University of Calgary (Alta.) performed hematoma volumetric analyses of each ICH and intraventricular hemorrhage (IVH), using quantitative tomography without knowing any of the NCCT results.

At baseline, 80 patients (30%) had a spot sign, according to Dr. Demchuk of the University of Calgary and his associates. They noted that there may have been a slight predilection for more spot signs in patients with lobar ICH, but the spot sign was seen frequently regardless of ICH location. The incidence of a spot sign varied from 25% to 41% in different regions of the brain.

The median time from onset of symptoms to baseline CT imaging was 138 minutes.

A quarter of patients with spot signs deteriorated rapidly, he noted. Four died before the 24-hour NCCT, seven underwent surgery before the 24-hour CT, and nine were treated with off-label recombinant activated factor VII (rFVIIa). In a previous trial, hemostatic therapy with rFVIIa reduced the risk of hematoma expansion but did not improve overall outcomes (N. Engl. J. Med. 2008;358:2127-37). Another three treatment trials are now underway that base rFVIIa treatment on CTA findings, noted Dr. Demchuk, director of the Calgary Stroke Program for Alberta Health Services.

In the current study, called PREDICT (Predicting Hematoma Growth and Outcome in Intracerebral Hemorrhage Using Contrast Bolus CT), 27% of 228 patients who had a 24-hour follow-up NCCT available had spot signs at baseline. The size of ICH or IVH at baseline in patients with the spot sign was roughly double the size of the hematoma in those without the spot sign.

In multiple analyses that used 10 different definitions of hematoma growth, expansion was significantly more likely to occur in patients with a spot sign. "There’s a lot of debate in the literature, still, in terms of what’s the best growth criteria. It doesn’t matter what growth criteria you use. All of them had a much higher frequency in the setting of a spot sign than without a spot sign," Dr. Demchuk said at the conference, which was sponsored by the American Heart Association.

Among 176 patients with 3-month follow-up data, clinical outcomes were significantly worse in those with spot signs at baseline. Early neurologic worsening was seen in 38% of those with spot signs and 13% of those without. Mortality was greater in patients with spot signs (59%) than in those without (26%). The difference in mortality was early and dramatic, with most of the divergence between groups occurring within 30 days.

The study defined a spot sign according to six criteria: The shape is spotlike, serpiginous, or linear. The spot is located within the margin of a parenchymal hematoma without connection to an outside vessel, and is greater than 1.5 mm in diameter in at least one dimension. The density of the spot sign is at least double the density of the hematoma. Single or multiple spot signs could be present, and these must not be caused by calcific deposition (hyperdensity in the same location on NCCT).

Having more than one spot sign predicted even greater growth. Patients with more than one spot sign had triple the growth in hematoma, compared with patients without a spot sign, Dr. Demchuk said. The use of a "spot sign score" calculation, which has been proposed by previous researchers, did not correlate with hematoma growth in this study.

The spot sign did not seem to be as helpful in predicting hematoma growth in patients on warfarin, especially those with an elevated international normalized ratio (INR) at baseline, he added. The study included about 15 patients on warfarin who had an INR greater than 1.5 at baseline. Hematoma expansion in this subgroup was three times more likely to occur than in patients who were not on warfarin, whether a spot sign was present or not.

The study was funded by the Canadian Stroke Consortium and by Novo Nordisk, which is developing rFVIIa. Dr. Demchuk did not receive any personal financial support from Novo Nordisk.

SAN FRANCISCO – New curricula will help psychiatry residents who grew up in a Web 2.0 world think about the Internet and electronic media in more professional ways, and how the connectivity to which they are accustomed can pose problems for psychiatrists.

The American Association of Directors of Psychiatry Residency Training (AADPRT) offers the curricula on its website to its members. Portions of it, such as some of the resources provided, will be publicly available, Dr. Sandra M. DeJong said at the annual meeting of the American College of Psychiatrists. A podcast about "Professionalism and the Internet" also is accessible there.

"If you’ve grown up with this technology, it truly is second nature to you" and the potential pitfalls are not always obvious to young trainees, Dr. DeJong, who is chair of the AADPRT Task Force on Professionalism and the Internet, said in a discussion session at the meeting.

For example, e-mailing between psychiatrists and patients "sets up all kinds of problematic boundary issues," she said in a separate interview. AADPRT President Sheldon Benjamin said in an interview that a frequent scenario involves mental health professionals who choose to participate in social networks such as Facebook and thereby make available information about themselves that patients otherwise could not access. When a patient asks to "friend" a psychiatrist on Facebook, any response or lack of it can be problematic.

"Social networking and Web 2.0, this ability to create new content by dint of your connections to other people, has created new dilemmas for psychiatric education, for hospital administration, and for psychiatrists in practice," said Dr. Benjamin, director of neuropsychiatry and professor of psychiatry and neurology at the University of Massachusetts, Worcester.

"Dr. DeJong and I are not suggesting that psychiatrists run from new technology and the Internet. Not at all," he said. The new curricula are not designed to deliver absolute rules or guidelines but rather to help residents think through the professional ramifications of social media and electronic technology and make better-informed decisions.

Students and residents sometimes don’t realize that information about themselves online can have professional consequences. Dr. Glen O. Gabbard, who co-led a discussion session about the Internet and social media at the meeting, said information posted on Facebook accounts sometimes has influenced decisions to not accept a medical student to a residency program, or to not offer a resident a job.

Although other medical specialties are beginning to produce guidelines on the use of social networking, psychiatry has few resources for guidance, Dr. DeJong and Dr. Benjamin said. The American Medical Association’s decade-old guidelines on the use of e-mail say little about higher standards needed when dealing with mental health or substance abuse issues, and the AMA’s 2010 Policy on Professionalism in the Use of Social Media also is not specific to psychiatrists.

The new AADPRT curricula focus on 36 vignettes that cover a variety of media and topics, including confidentiality, liability, academic honesty, and managing technology in psychotherapy. "We found that everybody had a story" about a clinical problem involving the Internet or social media, "and that the stories are really what galvanized people’s interest," said Dr. DeJong of Harvard Medical School, Boston.

A list of resources from medical journals, mainstream media, and the Internet accompany each vignette.

"Hopefully, we’ll be able to continue to update" the curricula as the world of Web 2.0 – and psychiatrists’ place in it – evolves, Dr. DeJong said. "It’s very much a moving target."

Dr. DeJong is a paid contributor to the nonprofit website "Children’s Emotional Health Link." Dr. Benjamin and Dr. Gabbard reported no relevant financial disclosures.

SAN FRANCISCO – New curricula will help psychiatry residents who grew up in a Web 2.0 world think about the Internet and electronic media in more professional ways, and how the connectivity to which they are accustomed can pose problems for psychiatrists.

The American Association of Directors of Psychiatry Residency Training (AADPRT) offers the curricula on its website to its members. Portions of it, such as some of the resources provided, will be publicly available, Dr. Sandra M. DeJong said at the annual meeting of the American College of Psychiatrists. A podcast about "Professionalism and the Internet" also is accessible there.

"If you’ve grown up with this technology, it truly is second nature to you" and the potential pitfalls are not always obvious to young trainees, Dr. DeJong, who is chair of the AADPRT Task Force on Professionalism and the Internet, said in a discussion session at the meeting.

For example, e-mailing between psychiatrists and patients "sets up all kinds of problematic boundary issues," she said in a separate interview. AADPRT President Sheldon Benjamin said in an interview that a frequent scenario involves mental health professionals who choose to participate in social networks such as Facebook and thereby make available information about themselves that patients otherwise could not access. When a patient asks to "friend" a psychiatrist on Facebook, any response or lack of it can be problematic.

"Social networking and Web 2.0, this ability to create new content by dint of your connections to other people, has created new dilemmas for psychiatric education, for hospital administration, and for psychiatrists in practice," said Dr. Benjamin, director of neuropsychiatry and professor of psychiatry and neurology at the University of Massachusetts, Worcester.

"Dr. DeJong and I are not suggesting that psychiatrists run from new technology and the Internet. Not at all," he said. The new curricula are not designed to deliver absolute rules or guidelines but rather to help residents think through the professional ramifications of social media and electronic technology and make better-informed decisions.

Students and residents sometimes don’t realize that information about themselves online can have professional consequences. Dr. Glen O. Gabbard, who co-led a discussion session about the Internet and social media at the meeting, said information posted on Facebook accounts sometimes has influenced decisions to not accept a medical student to a residency program, or to not offer a resident a job.

Although other medical specialties are beginning to produce guidelines on the use of social networking, psychiatry has few resources for guidance, Dr. DeJong and Dr. Benjamin said. The American Medical Association’s decade-old guidelines on the use of e-mail say little about higher standards needed when dealing with mental health or substance abuse issues, and the AMA’s 2010 Policy on Professionalism in the Use of Social Media also is not specific to psychiatrists.

The new AADPRT curricula focus on 36 vignettes that cover a variety of media and topics, including confidentiality, liability, academic honesty, and managing technology in psychotherapy. "We found that everybody had a story" about a clinical problem involving the Internet or social media, "and that the stories are really what galvanized people’s interest," said Dr. DeJong of Harvard Medical School, Boston.

A list of resources from medical journals, mainstream media, and the Internet accompany each vignette.

"Hopefully, we’ll be able to continue to update" the curricula as the world of Web 2.0 – and psychiatrists’ place in it – evolves, Dr. DeJong said. "It’s very much a moving target."

Dr. DeJong is a paid contributor to the nonprofit website "Children’s Emotional Health Link." Dr. Benjamin and Dr. Gabbard reported no relevant financial disclosures.

SAN FRANCISCO – New curricula will help psychiatry residents who grew up in a Web 2.0 world think about the Internet and electronic media in more professional ways, and how the connectivity to which they are accustomed can pose problems for psychiatrists.

The American Association of Directors of Psychiatry Residency Training (AADPRT) offers the curricula on its website to its members. Portions of it, such as some of the resources provided, will be publicly available, Dr. Sandra M. DeJong said at the annual meeting of the American College of Psychiatrists. A podcast about "Professionalism and the Internet" also is accessible there.

"If you’ve grown up with this technology, it truly is second nature to you" and the potential pitfalls are not always obvious to young trainees, Dr. DeJong, who is chair of the AADPRT Task Force on Professionalism and the Internet, said in a discussion session at the meeting.

For example, e-mailing between psychiatrists and patients "sets up all kinds of problematic boundary issues," she said in a separate interview. AADPRT President Sheldon Benjamin said in an interview that a frequent scenario involves mental health professionals who choose to participate in social networks such as Facebook and thereby make available information about themselves that patients otherwise could not access. When a patient asks to "friend" a psychiatrist on Facebook, any response or lack of it can be problematic.

"Social networking and Web 2.0, this ability to create new content by dint of your connections to other people, has created new dilemmas for psychiatric education, for hospital administration, and for psychiatrists in practice," said Dr. Benjamin, director of neuropsychiatry and professor of psychiatry and neurology at the University of Massachusetts, Worcester.

"Dr. DeJong and I are not suggesting that psychiatrists run from new technology and the Internet. Not at all," he said. The new curricula are not designed to deliver absolute rules or guidelines but rather to help residents think through the professional ramifications of social media and electronic technology and make better-informed decisions.

Students and residents sometimes don’t realize that information about themselves online can have professional consequences. Dr. Glen O. Gabbard, who co-led a discussion session about the Internet and social media at the meeting, said information posted on Facebook accounts sometimes has influenced decisions to not accept a medical student to a residency program, or to not offer a resident a job.

Although other medical specialties are beginning to produce guidelines on the use of social networking, psychiatry has few resources for guidance, Dr. DeJong and Dr. Benjamin said. The American Medical Association’s decade-old guidelines on the use of e-mail say little about higher standards needed when dealing with mental health or substance abuse issues, and the AMA’s 2010 Policy on Professionalism in the Use of Social Media also is not specific to psychiatrists.

The new AADPRT curricula focus on 36 vignettes that cover a variety of media and topics, including confidentiality, liability, academic honesty, and managing technology in psychotherapy. "We found that everybody had a story" about a clinical problem involving the Internet or social media, "and that the stories are really what galvanized people’s interest," said Dr. DeJong of Harvard Medical School, Boston.

A list of resources from medical journals, mainstream media, and the Internet accompany each vignette.

"Hopefully, we’ll be able to continue to update" the curricula as the world of Web 2.0 – and psychiatrists’ place in it – evolves, Dr. DeJong said. "It’s very much a moving target."

Dr. DeJong is a paid contributor to the nonprofit website "Children’s Emotional Health Link." Dr. Benjamin and Dr. Gabbard reported no relevant financial disclosures.

SAN FRANCISCO – New curricula will help psychiatry residents who grew up in a Web 2.0 world think about the Internet and electronic media in more professional ways, and how the connectivity to which they are accustomed can pose problems for psychiatrists.

The American Association of Directors of Psychiatry Residency Training (AADPRT) offers the curricula on its website to its members. Portions of it, such as some of the resources provided, will be publicly available, Dr. Sandra M. DeJong said at the annual meeting of the American College of Psychiatrists. A podcast about "Professionalism and the Internet" also is accessible there.

"If you’ve grown up with this technology, it truly is second nature to you" and the potential pitfalls are not always obvious to young trainees, Dr. DeJong, who is chair of the AADPRT Task Force on Professionalism and the Internet, said in a discussion session at the meeting.

For example, e-mailing between psychiatrists and patients "sets up all kinds of problematic boundary issues," she said in a separate interview. AADPRT President Sheldon Benjamin said in an interview that a frequent scenario involves mental health professionals who choose to participate in social networks such as Facebook and thereby make available information about themselves that patients otherwise could not access. When a patient asks to "friend" a psychiatrist on Facebook, any response or lack of it can be problematic.

"Social networking and Web 2.0, this ability to create new content by dint of your connections to other people, has created new dilemmas for psychiatric education, for hospital administration, and for psychiatrists in practice," said Dr. Benjamin, director of neuropsychiatry and professor of psychiatry and neurology at the University of Massachusetts, Worcester.

"Dr. DeJong and I are not suggesting that psychiatrists run from new technology and the Internet. Not at all," he said. The new curricula are not designed to deliver absolute rules or guidelines but rather to help residents think through the professional ramifications of social media and electronic technology and make better-informed decisions.

Students and residents sometimes don’t realize that information about themselves online can have professional consequences. Dr. Glen O. Gabbard, who co-led a discussion session about the Internet and social media at the meeting, said information posted on Facebook accounts sometimes has influenced decisions to not accept a medical student to a residency program, or to not offer a resident a job.

Although other medical specialties are beginning to produce guidelines on the use of social networking, psychiatry has few resources for guidance, Dr. DeJong and Dr. Benjamin said. The American Medical Association’s decade-old guidelines on the use of e-mail say little about higher standards needed when dealing with mental health or substance abuse issues, and the AMA’s 2010 Policy on Professionalism in the Use of Social Media also is not specific to psychiatrists.

The new AADPRT curricula focus on 36 vignettes that cover a variety of media and topics, including confidentiality, liability, academic honesty, and managing technology in psychotherapy. "We found that everybody had a story" about a clinical problem involving the Internet or social media, "and that the stories are really what galvanized people’s interest," said Dr. DeJong of Harvard Medical School, Boston.

A list of resources from medical journals, mainstream media, and the Internet accompany each vignette.

"Hopefully, we’ll be able to continue to update" the curricula as the world of Web 2.0 – and psychiatrists’ place in it – evolves, Dr. DeJong said. "It’s very much a moving target."

Dr. DeJong is a paid contributor to the nonprofit website "Children’s Emotional Health Link." Dr. Benjamin and Dr. Gabbard reported no relevant financial disclosures.

SAN FRANCISCO – New curricula will help psychiatry residents who grew up in a Web 2.0 world think about the Internet and electronic media in more professional ways, and how the connectivity to which they are accustomed can pose problems for psychiatrists.

The American Association of Directors of Psychiatry Residency Training (AADPRT) offers the curricula on its website to its members. Portions of it, such as some of the resources provided, will be publicly available, Dr. Sandra M. DeJong said at the annual meeting of the American College of Psychiatrists. A podcast about "Professionalism and the Internet" also is accessible there.

"If you’ve grown up with this technology, it truly is second nature to you" and the potential pitfalls are not always obvious to young trainees, Dr. DeJong, who is chair of the AADPRT Task Force on Professionalism and the Internet, said in a discussion session at the meeting.

For example, e-mailing between psychiatrists and patients "sets up all kinds of problematic boundary issues," she said in a separate interview. AADPRT President Sheldon Benjamin said in an interview that a frequent scenario involves mental health professionals who choose to participate in social networks such as Facebook and thereby make available information about themselves that patients otherwise could not access. When a patient asks to "friend" a psychiatrist on Facebook, any response or lack of it can be problematic.

"Social networking and Web 2.0, this ability to create new content by dint of your connections to other people, has created new dilemmas for psychiatric education, for hospital administration, and for psychiatrists in practice," said Dr. Benjamin, director of neuropsychiatry and professor of psychiatry and neurology at the University of Massachusetts, Worcester.

"Dr. DeJong and I are not suggesting that psychiatrists run from new technology and the Internet. Not at all," he said. The new curricula are not designed to deliver absolute rules or guidelines but rather to help residents think through the professional ramifications of social media and electronic technology and make better-informed decisions.

Students and residents sometimes don’t realize that information about themselves online can have professional consequences. Dr. Glen O. Gabbard, who co-led a discussion session about the Internet and social media at the meeting, said information posted on Facebook accounts sometimes has influenced decisions to not accept a medical student to a residency program, or to not offer a resident a job.

Although other medical specialties are beginning to produce guidelines on the use of social networking, psychiatry has few resources for guidance, Dr. DeJong and Dr. Benjamin said. The American Medical Association’s decade-old guidelines on the use of e-mail say little about higher standards needed when dealing with mental health or substance abuse issues, and the AMA’s 2010 Policy on Professionalism in the Use of Social Media also is not specific to psychiatrists.

The new AADPRT curricula focus on 36 vignettes that cover a variety of media and topics, including confidentiality, liability, academic honesty, and managing technology in psychotherapy. "We found that everybody had a story" about a clinical problem involving the Internet or social media, "and that the stories are really what galvanized people’s interest," said Dr. DeJong of Harvard Medical School, Boston.

A list of resources from medical journals, mainstream media, and the Internet accompany each vignette.

"Hopefully, we’ll be able to continue to update" the curricula as the world of Web 2.0 – and psychiatrists’ place in it – evolves, Dr. DeJong said. "It’s very much a moving target."

Dr. DeJong is a paid contributor to the nonprofit website "Children’s Emotional Health Link." Dr. Benjamin and Dr. Gabbard reported no relevant financial disclosures.

SAN FRANCISCO – New curricula will help psychiatry residents who grew up in a Web 2.0 world think about the Internet and electronic media in more professional ways, and how the connectivity to which they are accustomed can pose problems for psychiatrists.

The American Association of Directors of Psychiatry Residency Training (AADPRT) offers the curricula on its website to its members. Portions of it, such as some of the resources provided, will be publicly available, Dr. Sandra M. DeJong said at the annual meeting of the American College of Psychiatrists. A podcast about "Professionalism and the Internet" also is accessible there.

"If you’ve grown up with this technology, it truly is second nature to you" and the potential pitfalls are not always obvious to young trainees, Dr. DeJong, who is chair of the AADPRT Task Force on Professionalism and the Internet, said in a discussion session at the meeting.

For example, e-mailing between psychiatrists and patients "sets up all kinds of problematic boundary issues," she said in a separate interview. AADPRT President Sheldon Benjamin said in an interview that a frequent scenario involves mental health professionals who choose to participate in social networks such as Facebook and thereby make available information about themselves that patients otherwise could not access. When a patient asks to "friend" a psychiatrist on Facebook, any response or lack of it can be problematic.

"Social networking and Web 2.0, this ability to create new content by dint of your connections to other people, has created new dilemmas for psychiatric education, for hospital administration, and for psychiatrists in practice," said Dr. Benjamin, director of neuropsychiatry and professor of psychiatry and neurology at the University of Massachusetts, Worcester.

"Dr. DeJong and I are not suggesting that psychiatrists run from new technology and the Internet. Not at all," he said. The new curricula are not designed to deliver absolute rules or guidelines but rather to help residents think through the professional ramifications of social media and electronic technology and make better-informed decisions.

Students and residents sometimes don’t realize that information about themselves online can have professional consequences. Dr. Glen O. Gabbard, who co-led a discussion session about the Internet and social media at the meeting, said information posted on Facebook accounts sometimes has influenced decisions to not accept a medical student to a residency program, or to not offer a resident a job.

Although other medical specialties are beginning to produce guidelines on the use of social networking, psychiatry has few resources for guidance, Dr. DeJong and Dr. Benjamin said. The American Medical Association’s decade-old guidelines on the use of e-mail say little about higher standards needed when dealing with mental health or substance abuse issues, and the AMA’s 2010 Policy on Professionalism in the Use of Social Media also is not specific to psychiatrists.

The new AADPRT curricula focus on 36 vignettes that cover a variety of media and topics, including confidentiality, liability, academic honesty, and managing technology in psychotherapy. "We found that everybody had a story" about a clinical problem involving the Internet or social media, "and that the stories are really what galvanized people’s interest," said Dr. DeJong of Harvard Medical School, Boston.

A list of resources from medical journals, mainstream media, and the Internet accompany each vignette.

"Hopefully, we’ll be able to continue to update" the curricula as the world of Web 2.0 – and psychiatrists’ place in it – evolves, Dr. DeJong said. "It’s very much a moving target."

Dr. DeJong is a paid contributor to the nonprofit website "Children’s Emotional Health Link." Dr. Benjamin and Dr. Gabbard reported no relevant financial disclosures.

LOS ANGELES - A body mass index of less than 18.5 or greater than 30 kg/m² was associated with increased risk for deep intracerebral hemorrhage in a case-control study of 772 adults.

The findings differed by sex, with increased risk seen in males with BMI of less than 18.5 or greater than 30 kg/m² but only in females with BMI greater than 30 kg/m², Dr. Jonathan Rosand said at the International Stroke Conference.

There appeared to be no association between BMI and risk for lobar intracerebral hemorrhage (ICH), said Dr. Rosand, director of the neuroscience intensive care unit and of the division of neurocritical care and emergency neurology at Harvard Medical School, Boston.

ICHs routinely get categorized based on whether they occur in the cortical or subcortical regions (lobar ICH) or in the deep brain structures or brain stem (deep ICH). Extremes of BMI have been associated with increased incidence of ICH in previous studies. Dr. Rosand and his associates studied the effect of BMI on the risk of the subtypes of ICH by comparing consecutive patients with either lobar (188) or deep ICH (196) who were admitted to Massachusetts General Hospital, Boston, with a control group of 388 individuals matched for age and ethnicity.

All patients were older than 18 years. CT imaging at the time of admission determined the ICH location. Investigators calculated BMI based on subjects’ height and weight at enrollment and divided subjects into four BMI quartiles: less than 18.5, 19-24, 25-30, and greater than 30.

Male sex, BMI less than 18.5, and BMI greater than 30 were significantly associated with an increased risk for deep ICH in both univariate and multivariate analyses. Some traditional risk factors for deep ICH – hypertension and consumption of more than 3 ounces of alcohol per day – also were associated with significantly increased risk in the two analyses. Diabetes mellitus was a risk factor only in univariate analysis.

The risk for deep ICH was 34% higher in males, nearly twice as high in patients with either a BMI of less than 18.5 or greater than 30, four times higher in patients with hypertension, and nearly three times higher in patients consuming more than 3 ounces of alcohol per day, compared with patients without those characteristics, in a multivariate analysis.

A subsequent sex-stratified analysis found a 75% higher risk for deep ICH in females with a BMI greater than 30, compared with females with a BMI of 19-24. The risk for deep ICH was 81% higher in males with BMI greater than 30 and nearly three times higher in males with a BMI less than 18.5, compared with males with a BMI of 19-24.

"There does appear to be, at least in these data, a difference in the effect of BMI on risk of deep ICH in men compared with women," Dr. Rosand said at the conference, sponsored by the American Heart Association.

Risk for lobar ICH did not vary significantly based on BMI in either a univariate or multivariate analysis.

The association of deep ICH with of hypertension, BMI, and possibly diabetes raises the possibility that deep ICH is linked to the metabolic syndrome, but this hypothesis requires further study, he said.

The current study was limited by its size and by the fact that it did not match controls to patients by sex.

Dr. Rosand said he had no relevant conflicts of interest.

LOS ANGELES - A body mass index of less than 18.5 or greater than 30 kg/m² was associated with increased risk for deep intracerebral hemorrhage in a case-control study of 772 adults.

The findings differed by sex, with increased risk seen in males with BMI of less than 18.5 or greater than 30 kg/m² but only in females with BMI greater than 30 kg/m², Dr. Jonathan Rosand said at the International Stroke Conference.

There appeared to be no association between BMI and risk for lobar intracerebral hemorrhage (ICH), said Dr. Rosand, director of the neuroscience intensive care unit and of the division of neurocritical care and emergency neurology at Harvard Medical School, Boston.

ICHs routinely get categorized based on whether they occur in the cortical or subcortical regions (lobar ICH) or in the deep brain structures or brain stem (deep ICH). Extremes of BMI have been associated with increased incidence of ICH in previous studies. Dr. Rosand and his associates studied the effect of BMI on the risk of the subtypes of ICH by comparing consecutive patients with either lobar (188) or deep ICH (196) who were admitted to Massachusetts General Hospital, Boston, with a control group of 388 individuals matched for age and ethnicity.

All patients were older than 18 years. CT imaging at the time of admission determined the ICH location. Investigators calculated BMI based on subjects’ height and weight at enrollment and divided subjects into four BMI quartiles: less than 18.5, 19-24, 25-30, and greater than 30.

Male sex, BMI less than 18.5, and BMI greater than 30 were significantly associated with an increased risk for deep ICH in both univariate and multivariate analyses. Some traditional risk factors for deep ICH – hypertension and consumption of more than 3 ounces of alcohol per day – also were associated with significantly increased risk in the two analyses. Diabetes mellitus was a risk factor only in univariate analysis.

The risk for deep ICH was 34% higher in males, nearly twice as high in patients with either a BMI of less than 18.5 or greater than 30, four times higher in patients with hypertension, and nearly three times higher in patients consuming more than 3 ounces of alcohol per day, compared with patients without those characteristics, in a multivariate analysis.

A subsequent sex-stratified analysis found a 75% higher risk for deep ICH in females with a BMI greater than 30, compared with females with a BMI of 19-24. The risk for deep ICH was 81% higher in males with BMI greater than 30 and nearly three times higher in males with a BMI less than 18.5, compared with males with a BMI of 19-24.

"There does appear to be, at least in these data, a difference in the effect of BMI on risk of deep ICH in men compared with women," Dr. Rosand said at the conference, sponsored by the American Heart Association.

Risk for lobar ICH did not vary significantly based on BMI in either a univariate or multivariate analysis.

The association of deep ICH with of hypertension, BMI, and possibly diabetes raises the possibility that deep ICH is linked to the metabolic syndrome, but this hypothesis requires further study, he said.

The current study was limited by its size and by the fact that it did not match controls to patients by sex.

Dr. Rosand said he had no relevant conflicts of interest.

LOS ANGELES - A body mass index of less than 18.5 or greater than 30 kg/m² was associated with increased risk for deep intracerebral hemorrhage in a case-control study of 772 adults.

The findings differed by sex, with increased risk seen in males with BMI of less than 18.5 or greater than 30 kg/m² but only in females with BMI greater than 30 kg/m², Dr. Jonathan Rosand said at the International Stroke Conference.

There appeared to be no association between BMI and risk for lobar intracerebral hemorrhage (ICH), said Dr. Rosand, director of the neuroscience intensive care unit and of the division of neurocritical care and emergency neurology at Harvard Medical School, Boston.

ICHs routinely get categorized based on whether they occur in the cortical or subcortical regions (lobar ICH) or in the deep brain structures or brain stem (deep ICH). Extremes of BMI have been associated with increased incidence of ICH in previous studies. Dr. Rosand and his associates studied the effect of BMI on the risk of the subtypes of ICH by comparing consecutive patients with either lobar (188) or deep ICH (196) who were admitted to Massachusetts General Hospital, Boston, with a control group of 388 individuals matched for age and ethnicity.

All patients were older than 18 years. CT imaging at the time of admission determined the ICH location. Investigators calculated BMI based on subjects’ height and weight at enrollment and divided subjects into four BMI quartiles: less than 18.5, 19-24, 25-30, and greater than 30.

Male sex, BMI less than 18.5, and BMI greater than 30 were significantly associated with an increased risk for deep ICH in both univariate and multivariate analyses. Some traditional risk factors for deep ICH – hypertension and consumption of more than 3 ounces of alcohol per day – also were associated with significantly increased risk in the two analyses. Diabetes mellitus was a risk factor only in univariate analysis.

The risk for deep ICH was 34% higher in males, nearly twice as high in patients with either a BMI of less than 18.5 or greater than 30, four times higher in patients with hypertension, and nearly three times higher in patients consuming more than 3 ounces of alcohol per day, compared with patients without those characteristics, in a multivariate analysis.

A subsequent sex-stratified analysis found a 75% higher risk for deep ICH in females with a BMI greater than 30, compared with females with a BMI of 19-24. The risk for deep ICH was 81% higher in males with BMI greater than 30 and nearly three times higher in males with a BMI less than 18.5, compared with males with a BMI of 19-24.

"There does appear to be, at least in these data, a difference in the effect of BMI on risk of deep ICH in men compared with women," Dr. Rosand said at the conference, sponsored by the American Heart Association.

Risk for lobar ICH did not vary significantly based on BMI in either a univariate or multivariate analysis.

The association of deep ICH with of hypertension, BMI, and possibly diabetes raises the possibility that deep ICH is linked to the metabolic syndrome, but this hypothesis requires further study, he said.

The current study was limited by its size and by the fact that it did not match controls to patients by sex.

Dr. Rosand said he had no relevant conflicts of interest.

LOS ANGELES - A body mass index of less than 18.5 or greater than 30 kg/m² was associated with increased risk for deep intracerebral hemorrhage in a case-control study of 772 adults.

The findings differed by sex, with increased risk seen in males with BMI of less than 18.5 or greater than 30 kg/m² but only in females with BMI greater than 30 kg/m², Dr. Jonathan Rosand said at the International Stroke Conference.

There appeared to be no association between BMI and risk for lobar intracerebral hemorrhage (ICH), said Dr. Rosand, director of the neuroscience intensive care unit and of the division of neurocritical care and emergency neurology at Harvard Medical School, Boston.

ICHs routinely get categorized based on whether they occur in the cortical or subcortical regions (lobar ICH) or in the deep brain structures or brain stem (deep ICH). Extremes of BMI have been associated with increased incidence of ICH in previous studies. Dr. Rosand and his associates studied the effect of BMI on the risk of the subtypes of ICH by comparing consecutive patients with either lobar (188) or deep ICH (196) who were admitted to Massachusetts General Hospital, Boston, with a control group of 388 individuals matched for age and ethnicity.

All patients were older than 18 years. CT imaging at the time of admission determined the ICH location. Investigators calculated BMI based on subjects’ height and weight at enrollment and divided subjects into four BMI quartiles: less than 18.5, 19-24, 25-30, and greater than 30.

Male sex, BMI less than 18.5, and BMI greater than 30 were significantly associated with an increased risk for deep ICH in both univariate and multivariate analyses. Some traditional risk factors for deep ICH – hypertension and consumption of more than 3 ounces of alcohol per day – also were associated with significantly increased risk in the two analyses. Diabetes mellitus was a risk factor only in univariate analysis.

The risk for deep ICH was 34% higher in males, nearly twice as high in patients with either a BMI of less than 18.5 or greater than 30, four times higher in patients with hypertension, and nearly three times higher in patients consuming more than 3 ounces of alcohol per day, compared with patients without those characteristics, in a multivariate analysis.

A subsequent sex-stratified analysis found a 75% higher risk for deep ICH in females with a BMI greater than 30, compared with females with a BMI of 19-24. The risk for deep ICH was 81% higher in males with BMI greater than 30 and nearly three times higher in males with a BMI less than 18.5, compared with males with a BMI of 19-24.

"There does appear to be, at least in these data, a difference in the effect of BMI on risk of deep ICH in men compared with women," Dr. Rosand said at the conference, sponsored by the American Heart Association.

Risk for lobar ICH did not vary significantly based on BMI in either a univariate or multivariate analysis.

The association of deep ICH with of hypertension, BMI, and possibly diabetes raises the possibility that deep ICH is linked to the metabolic syndrome, but this hypothesis requires further study, he said.

The current study was limited by its size and by the fact that it did not match controls to patients by sex.

Dr. Rosand said he had no relevant conflicts of interest.

LOS ANGELES - A body mass index of less than 18.5 or greater than 30 kg/m² was associated with increased risk for deep intracerebral hemorrhage in a case-control study of 772 adults.

The findings differed by sex, with increased risk seen in males with BMI of less than 18.5 or greater than 30 kg/m² but only in females with BMI greater than 30 kg/m², Dr. Jonathan Rosand said at the International Stroke Conference.

There appeared to be no association between BMI and risk for lobar intracerebral hemorrhage (ICH), said Dr. Rosand, director of the neuroscience intensive care unit and of the division of neurocritical care and emergency neurology at Harvard Medical School, Boston.

ICHs routinely get categorized based on whether they occur in the cortical or subcortical regions (lobar ICH) or in the deep brain structures or brain stem (deep ICH). Extremes of BMI have been associated with increased incidence of ICH in previous studies. Dr. Rosand and his associates studied the effect of BMI on the risk of the subtypes of ICH by comparing consecutive patients with either lobar (188) or deep ICH (196) who were admitted to Massachusetts General Hospital, Boston, with a control group of 388 individuals matched for age and ethnicity.

All patients were older than 18 years. CT imaging at the time of admission determined the ICH location. Investigators calculated BMI based on subjects’ height and weight at enrollment and divided subjects into four BMI quartiles: less than 18.5, 19-24, 25-30, and greater than 30.

Male sex, BMI less than 18.5, and BMI greater than 30 were significantly associated with an increased risk for deep ICH in both univariate and multivariate analyses. Some traditional risk factors for deep ICH – hypertension and consumption of more than 3 ounces of alcohol per day – also were associated with significantly increased risk in the two analyses. Diabetes mellitus was a risk factor only in univariate analysis.

The risk for deep ICH was 34% higher in males, nearly twice as high in patients with either a BMI of less than 18.5 or greater than 30, four times higher in patients with hypertension, and nearly three times higher in patients consuming more than 3 ounces of alcohol per day, compared with patients without those characteristics, in a multivariate analysis.

A subsequent sex-stratified analysis found a 75% higher risk for deep ICH in females with a BMI greater than 30, compared with females with a BMI of 19-24. The risk for deep ICH was 81% higher in males with BMI greater than 30 and nearly three times higher in males with a BMI less than 18.5, compared with males with a BMI of 19-24.

"There does appear to be, at least in these data, a difference in the effect of BMI on risk of deep ICH in men compared with women," Dr. Rosand said at the conference, sponsored by the American Heart Association.

Risk for lobar ICH did not vary significantly based on BMI in either a univariate or multivariate analysis.

The association of deep ICH with of hypertension, BMI, and possibly diabetes raises the possibility that deep ICH is linked to the metabolic syndrome, but this hypothesis requires further study, he said.

The current study was limited by its size and by the fact that it did not match controls to patients by sex.

Dr. Rosand said he had no relevant conflicts of interest.

LOS ANGELES - A body mass index of less than 18.5 or greater than 30 kg/m² was associated with increased risk for deep intracerebral hemorrhage in a case-control study of 772 adults.

The findings differed by sex, with increased risk seen in males with BMI of less than 18.5 or greater than 30 kg/m² but only in females with BMI greater than 30 kg/m², Dr. Jonathan Rosand said at the International Stroke Conference.

There appeared to be no association between BMI and risk for lobar intracerebral hemorrhage (ICH), said Dr. Rosand, director of the neuroscience intensive care unit and of the division of neurocritical care and emergency neurology at Harvard Medical School, Boston.

ICHs routinely get categorized based on whether they occur in the cortical or subcortical regions (lobar ICH) or in the deep brain structures or brain stem (deep ICH). Extremes of BMI have been associated with increased incidence of ICH in previous studies. Dr. Rosand and his associates studied the effect of BMI on the risk of the subtypes of ICH by comparing consecutive patients with either lobar (188) or deep ICH (196) who were admitted to Massachusetts General Hospital, Boston, with a control group of 388 individuals matched for age and ethnicity.

All patients were older than 18 years. CT imaging at the time of admission determined the ICH location. Investigators calculated BMI based on subjects’ height and weight at enrollment and divided subjects into four BMI quartiles: less than 18.5, 19-24, 25-30, and greater than 30.

Male sex, BMI less than 18.5, and BMI greater than 30 were significantly associated with an increased risk for deep ICH in both univariate and multivariate analyses. Some traditional risk factors for deep ICH – hypertension and consumption of more than 3 ounces of alcohol per day – also were associated with significantly increased risk in the two analyses. Diabetes mellitus was a risk factor only in univariate analysis.

The risk for deep ICH was 34% higher in males, nearly twice as high in patients with either a BMI of less than 18.5 or greater than 30, four times higher in patients with hypertension, and nearly three times higher in patients consuming more than 3 ounces of alcohol per day, compared with patients without those characteristics, in a multivariate analysis.

A subsequent sex-stratified analysis found a 75% higher risk for deep ICH in females with a BMI greater than 30, compared with females with a BMI of 19-24. The risk for deep ICH was 81% higher in males with BMI greater than 30 and nearly three times higher in males with a BMI less than 18.5, compared with males with a BMI of 19-24.

"There does appear to be, at least in these data, a difference in the effect of BMI on risk of deep ICH in men compared with women," Dr. Rosand said at the conference, sponsored by the American Heart Association.

Risk for lobar ICH did not vary significantly based on BMI in either a univariate or multivariate analysis.

The association of deep ICH with of hypertension, BMI, and possibly diabetes raises the possibility that deep ICH is linked to the metabolic syndrome, but this hypothesis requires further study, he said.

The current study was limited by its size and by the fact that it did not match controls to patients by sex.

Dr. Rosand said he had no relevant conflicts of interest.

LOS ANGELES - A body mass index of less than 18.5 or greater than 30 kg/m² was associated with increased risk for deep intracerebral hemorrhage in a case-control study of 772 adults.

The findings differed by sex, with increased risk seen in males with BMI of less than 18.5 or greater than 30 kg/m² but only in females with BMI greater than 30 kg/m², Dr. Jonathan Rosand said at the International Stroke Conference.

There appeared to be no association between BMI and risk for lobar intracerebral hemorrhage (ICH), said Dr. Rosand, director of the neuroscience intensive care unit and of the division of neurocritical care and emergency neurology at Harvard Medical School, Boston.

ICHs routinely get categorized based on whether they occur in the cortical or subcortical regions (lobar ICH) or in the deep brain structures or brain stem (deep ICH). Extremes of BMI have been associated with increased incidence of ICH in previous studies. Dr. Rosand and his associates studied the effect of BMI on the risk of the subtypes of ICH by comparing consecutive patients with either lobar (188) or deep ICH (196) who were admitted to Massachusetts General Hospital, Boston, with a control group of 388 individuals matched for age and ethnicity.

All patients were older than 18 years. CT imaging at the time of admission determined the ICH location. Investigators calculated BMI based on subjects’ height and weight at enrollment and divided subjects into four BMI quartiles: less than 18.5, 19-24, 25-30, and greater than 30.

Male sex, BMI less than 18.5, and BMI greater than 30 were significantly associated with an increased risk for deep ICH in both univariate and multivariate analyses. Some traditional risk factors for deep ICH – hypertension and consumption of more than 3 ounces of alcohol per day – also were associated with significantly increased risk in the two analyses. Diabetes mellitus was a risk factor only in univariate analysis.

The risk for deep ICH was 34% higher in males, nearly twice as high in patients with either a BMI of less than 18.5 or greater than 30, four times higher in patients with hypertension, and nearly three times higher in patients consuming more than 3 ounces of alcohol per day, compared with patients without those characteristics, in a multivariate analysis.

A subsequent sex-stratified analysis found a 75% higher risk for deep ICH in females with a BMI greater than 30, compared with females with a BMI of 19-24. The risk for deep ICH was 81% higher in males with BMI greater than 30 and nearly three times higher in males with a BMI less than 18.5, compared with males with a BMI of 19-24.

"There does appear to be, at least in these data, a difference in the effect of BMI on risk of deep ICH in men compared with women," Dr. Rosand said at the conference, sponsored by the American Heart Association.

Risk for lobar ICH did not vary significantly based on BMI in either a univariate or multivariate analysis.

The association of deep ICH with of hypertension, BMI, and possibly diabetes raises the possibility that deep ICH is linked to the metabolic syndrome, but this hypothesis requires further study, he said.

The current study was limited by its size and by the fact that it did not match controls to patients by sex.

Dr. Rosand said he had no relevant conflicts of interest.

LOS ANGELES - A body mass index of less than 18.5 or greater than 30 kg/m² was associated with increased risk for deep intracerebral hemorrhage in a case-control study of 772 adults.

The findings differed by sex, with increased risk seen in males with BMI of less than 18.5 or greater than 30 kg/m² but only in females with BMI greater than 30 kg/m², Dr. Jonathan Rosand said at the International Stroke Conference.

There appeared to be no association between BMI and risk for lobar intracerebral hemorrhage (ICH), said Dr. Rosand, director of the neuroscience intensive care unit and of the division of neurocritical care and emergency neurology at Harvard Medical School, Boston.

ICHs routinely get categorized based on whether they occur in the cortical or subcortical regions (lobar ICH) or in the deep brain structures or brain stem (deep ICH). Extremes of BMI have been associated with increased incidence of ICH in previous studies. Dr. Rosand and his associates studied the effect of BMI on the risk of the subtypes of ICH by comparing consecutive patients with either lobar (188) or deep ICH (196) who were admitted to Massachusetts General Hospital, Boston, with a control group of 388 individuals matched for age and ethnicity.

All patients were older than 18 years. CT imaging at the time of admission determined the ICH location. Investigators calculated BMI based on subjects’ height and weight at enrollment and divided subjects into four BMI quartiles: less than 18.5, 19-24, 25-30, and greater than 30.

Male sex, BMI less than 18.5, and BMI greater than 30 were significantly associated with an increased risk for deep ICH in both univariate and multivariate analyses. Some traditional risk factors for deep ICH – hypertension and consumption of more than 3 ounces of alcohol per day – also were associated with significantly increased risk in the two analyses. Diabetes mellitus was a risk factor only in univariate analysis.

The risk for deep ICH was 34% higher in males, nearly twice as high in patients with either a BMI of less than 18.5 or greater than 30, four times higher in patients with hypertension, and nearly three times higher in patients consuming more than 3 ounces of alcohol per day, compared with patients without those characteristics, in a multivariate analysis.

A subsequent sex-stratified analysis found a 75% higher risk for deep ICH in females with a BMI greater than 30, compared with females with a BMI of 19-24. The risk for deep ICH was 81% higher in males with BMI greater than 30 and nearly three times higher in males with a BMI less than 18.5, compared with males with a BMI of 19-24.

"There does appear to be, at least in these data, a difference in the effect of BMI on risk of deep ICH in men compared with women," Dr. Rosand said at the conference, sponsored by the American Heart Association.

Risk for lobar ICH did not vary significantly based on BMI in either a univariate or multivariate analysis.

The association of deep ICH with of hypertension, BMI, and possibly diabetes raises the possibility that deep ICH is linked to the metabolic syndrome, but this hypothesis requires further study, he said.

The current study was limited by its size and by the fact that it did not match controls to patients by sex.

Dr. Rosand said he had no relevant conflicts of interest.

LOS ANGELES - A body mass index of less than 18.5 or greater than 30 kg/m² was associated with increased risk for deep intracerebral hemorrhage in a case-control study of 772 adults.

The findings differed by sex, with increased risk seen in males with BMI of less than 18.5 or greater than 30 kg/m² but only in females with BMI greater than 30 kg/m², Dr. Jonathan Rosand said at the International Stroke Conference.

There appeared to be no association between BMI and risk for lobar intracerebral hemorrhage (ICH), said Dr. Rosand, director of the neuroscience intensive care unit and of the division of neurocritical care and emergency neurology at Harvard Medical School, Boston.

ICHs routinely get categorized based on whether they occur in the cortical or subcortical regions (lobar ICH) or in the deep brain structures or brain stem (deep ICH). Extremes of BMI have been associated with increased incidence of ICH in previous studies. Dr. Rosand and his associates studied the effect of BMI on the risk of the subtypes of ICH by comparing consecutive patients with either lobar (188) or deep ICH (196) who were admitted to Massachusetts General Hospital, Boston, with a control group of 388 individuals matched for age and ethnicity.

All patients were older than 18 years. CT imaging at the time of admission determined the ICH location. Investigators calculated BMI based on subjects’ height and weight at enrollment and divided subjects into four BMI quartiles: less than 18.5, 19-24, 25-30, and greater than 30.

Male sex, BMI less than 18.5, and BMI greater than 30 were significantly associated with an increased risk for deep ICH in both univariate and multivariate analyses. Some traditional risk factors for deep ICH – hypertension and consumption of more than 3 ounces of alcohol per day – also were associated with significantly increased risk in the two analyses. Diabetes mellitus was a risk factor only in univariate analysis.

The risk for deep ICH was 34% higher in males, nearly twice as high in patients with either a BMI of less than 18.5 or greater than 30, four times higher in patients with hypertension, and nearly three times higher in patients consuming more than 3 ounces of alcohol per day, compared with patients without those characteristics, in a multivariate analysis.

A subsequent sex-stratified analysis found a 75% higher risk for deep ICH in females with a BMI greater than 30, compared with females with a BMI of 19-24. The risk for deep ICH was 81% higher in males with BMI greater than 30 and nearly three times higher in males with a BMI less than 18.5, compared with males with a BMI of 19-24.

"There does appear to be, at least in these data, a difference in the effect of BMI on risk of deep ICH in men compared with women," Dr. Rosand said at the conference, sponsored by the American Heart Association.

Risk for lobar ICH did not vary significantly based on BMI in either a univariate or multivariate analysis.

The association of deep ICH with of hypertension, BMI, and possibly diabetes raises the possibility that deep ICH is linked to the metabolic syndrome, but this hypothesis requires further study, he said.

The current study was limited by its size and by the fact that it did not match controls to patients by sex.

Dr. Rosand said he had no relevant conflicts of interest.

Major Finding: A BMI of less than 18.5 kg/m

Data Source: Case-control study of 384 consecutive patients with ICH (188 lobar ICH and 196 deep ICH) and 388 controls matched for age and ethnicity.

Disclosures: Dr. Rosand said he had no relevant financial disclosures.

LOS ANGELES – A body mass index of less than 18.5 or greater than 30 kg/m

The findings differed by sex, with an increased risk seen in males with a BMI of less than 18.5 or greater than 30 kg/m

There appeared to be no association between BMI and risk for lobar intracerebral hemorrhage (ICH), said Dr. Rosand, director of the neuroscience intensive care unit and of the division of neurocritical care and emergency neurology at Harvard Medical School, Boston.

Intracerebral hemorrhages routinely get categorized based on whether they occur in the cortical or subcortical regions (lobar ICH) or in the deep brain structures or brain stem (deep ICH). Extremes of BMI have been associated with an increased incidence of ICH in previous studies.

Dr. Rosand and his associates studied the effect of BMI on the risk of the subtypes of ICH by comparing consecutive patients with either lobar (188) or deep ICH (196) who were admitted to Massachusetts General Hospital, Boston, with a control group of 388 individuals matched for age and ethnicity.

All patients were older than 18 years. CT imaging at the time of admission determined the ICH location. Investigators calculated the BMI based on subjects' height and weight at enrollment and divided subjects into four BMI quartiles: less than 18.5, 19–24, 25–30, and greater than 30.

Male sex, a BMI less than 18.5, and a BMI greater than 30 were significantly associated with an increased risk for deep ICH in both univariate and multivariate analyses. Some traditional risk factors for deep ICH – hypertension and consumption of more than 3 ounces of alcohol per day – also were associated with a significantly increased risk in the two analyses. Diabetes mellitus was a risk factor in only univariate analysis.

The risk for deep ICH was 34% higher in males, nearly twice as high in patients with either a BMI of less than 18.5 or greater than 30, four times higher in patients with hypertension, and nearly three times higher in patients consuming more than 3 ounces of alcohol per day, compared with patients without those characteristics, in a multivariate analysis.

A subsequent sex-stratified analysis found a 75% higher risk for deep ICH in females with a BMI greater than 30, compared with females with a BMI of 19–24.

The risk for deep ICH was 81% higher in males with a BMI greater than 30 and nearly three times higher in males with a BMI less than 18.5, compared with males with a BMI of 19–24.

“There does appear to be, at least in these data, a difference in the effect of BMI on risk of deep ICH in men compared with women,” Dr. Rosand said at the conference, which was sponsored by the American Heart Association.

Risk for lobar ICH did not vary significantly based on BMI in either a univariate or multivariate analysis.

The association of deep intracerebral hemorrhage with hypertension, BMI, and possibly diabetes raises the possibility that deep ICH is linked to the metabolic syndrome, but this hypothesis requires further study, he said, adding that the study was limited by its size and by the fact that it did not match controls to patients by sex.

Major Finding: A BMI of less than 18.5 kg/m

Data Source: Case-control study of 384 consecutive patients with ICH (188 lobar ICH and 196 deep ICH) and 388 controls matched for age and ethnicity.

Disclosures: Dr. Rosand said he had no relevant financial disclosures.

LOS ANGELES – A body mass index of less than 18.5 or greater than 30 kg/m

The findings differed by sex, with an increased risk seen in males with a BMI of less than 18.5 or greater than 30 kg/m

There appeared to be no association between BMI and risk for lobar intracerebral hemorrhage (ICH), said Dr. Rosand, director of the neuroscience intensive care unit and of the division of neurocritical care and emergency neurology at Harvard Medical School, Boston.

Intracerebral hemorrhages routinely get categorized based on whether they occur in the cortical or subcortical regions (lobar ICH) or in the deep brain structures or brain stem (deep ICH). Extremes of BMI have been associated with an increased incidence of ICH in previous studies.

Dr. Rosand and his associates studied the effect of BMI on the risk of the subtypes of ICH by comparing consecutive patients with either lobar (188) or deep ICH (196) who were admitted to Massachusetts General Hospital, Boston, with a control group of 388 individuals matched for age and ethnicity.

All patients were older than 18 years. CT imaging at the time of admission determined the ICH location. Investigators calculated the BMI based on subjects' height and weight at enrollment and divided subjects into four BMI quartiles: less than 18.5, 19–24, 25–30, and greater than 30.

Male sex, a BMI less than 18.5, and a BMI greater than 30 were significantly associated with an increased risk for deep ICH in both univariate and multivariate analyses. Some traditional risk factors for deep ICH – hypertension and consumption of more than 3 ounces of alcohol per day – also were associated with a significantly increased risk in the two analyses. Diabetes mellitus was a risk factor in only univariate analysis.

The risk for deep ICH was 34% higher in males, nearly twice as high in patients with either a BMI of less than 18.5 or greater than 30, four times higher in patients with hypertension, and nearly three times higher in patients consuming more than 3 ounces of alcohol per day, compared with patients without those characteristics, in a multivariate analysis.

A subsequent sex-stratified analysis found a 75% higher risk for deep ICH in females with a BMI greater than 30, compared with females with a BMI of 19–24.

The risk for deep ICH was 81% higher in males with a BMI greater than 30 and nearly three times higher in males with a BMI less than 18.5, compared with males with a BMI of 19–24.

“There does appear to be, at least in these data, a difference in the effect of BMI on risk of deep ICH in men compared with women,” Dr. Rosand said at the conference, which was sponsored by the American Heart Association.

Risk for lobar ICH did not vary significantly based on BMI in either a univariate or multivariate analysis.

The association of deep intracerebral hemorrhage with hypertension, BMI, and possibly diabetes raises the possibility that deep ICH is linked to the metabolic syndrome, but this hypothesis requires further study, he said, adding that the study was limited by its size and by the fact that it did not match controls to patients by sex.

Major Finding: A BMI of less than 18.5 kg/m

Data Source: Case-control study of 384 consecutive patients with ICH (188 lobar ICH and 196 deep ICH) and 388 controls matched for age and ethnicity.

Disclosures: Dr. Rosand said he had no relevant financial disclosures.

LOS ANGELES – A body mass index of less than 18.5 or greater than 30 kg/m

The findings differed by sex, with an increased risk seen in males with a BMI of less than 18.5 or greater than 30 kg/m

There appeared to be no association between BMI and risk for lobar intracerebral hemorrhage (ICH), said Dr. Rosand, director of the neuroscience intensive care unit and of the division of neurocritical care and emergency neurology at Harvard Medical School, Boston.

Intracerebral hemorrhages routinely get categorized based on whether they occur in the cortical or subcortical regions (lobar ICH) or in the deep brain structures or brain stem (deep ICH). Extremes of BMI have been associated with an increased incidence of ICH in previous studies.

Dr. Rosand and his associates studied the effect of BMI on the risk of the subtypes of ICH by comparing consecutive patients with either lobar (188) or deep ICH (196) who were admitted to Massachusetts General Hospital, Boston, with a control group of 388 individuals matched for age and ethnicity.

All patients were older than 18 years. CT imaging at the time of admission determined the ICH location. Investigators calculated the BMI based on subjects' height and weight at enrollment and divided subjects into four BMI quartiles: less than 18.5, 19–24, 25–30, and greater than 30.

Male sex, a BMI less than 18.5, and a BMI greater than 30 were significantly associated with an increased risk for deep ICH in both univariate and multivariate analyses. Some traditional risk factors for deep ICH – hypertension and consumption of more than 3 ounces of alcohol per day – also were associated with a significantly increased risk in the two analyses. Diabetes mellitus was a risk factor in only univariate analysis.

The risk for deep ICH was 34% higher in males, nearly twice as high in patients with either a BMI of less than 18.5 or greater than 30, four times higher in patients with hypertension, and nearly three times higher in patients consuming more than 3 ounces of alcohol per day, compared with patients without those characteristics, in a multivariate analysis.

A subsequent sex-stratified analysis found a 75% higher risk for deep ICH in females with a BMI greater than 30, compared with females with a BMI of 19–24.

The risk for deep ICH was 81% higher in males with a BMI greater than 30 and nearly three times higher in males with a BMI less than 18.5, compared with males with a BMI of 19–24.

“There does appear to be, at least in these data, a difference in the effect of BMI on risk of deep ICH in men compared with women,” Dr. Rosand said at the conference, which was sponsored by the American Heart Association.

Risk for lobar ICH did not vary significantly based on BMI in either a univariate or multivariate analysis.

The association of deep intracerebral hemorrhage with hypertension, BMI, and possibly diabetes raises the possibility that deep ICH is linked to the metabolic syndrome, but this hypothesis requires further study, he said, adding that the study was limited by its size and by the fact that it did not match controls to patients by sex.

The American Heart Association for the first time released guidelines for clinicians to help detect and treat cerebral venous thrombosis, a rare stroke that disproportionately affects young people, especially women who are pregnant or on oral contraceptives, or who just gave birth.

The guidelines include an algorithm for diagnosing and managing cerebral venous thromboembolism (CVT), which is caused by a clot in the dural venous sinuses, veins that drain blood from the brain toward the heart.

CVT is difficult to recognize because of its diverse risk factors and presentations. “The diagnosis and management of CVT requires a high level of suspicion,” Dr. Gustavo Saposnik said in an interview. Dr. Saposnik, codirector of the stroke program at the University of Toronto, chaired the guidelines writing committee of nine experts from five countries, which reviewed the literature on CVT and rated the evidence behind their recommendations (Stroke 2011 Feb. 3 [doi:10.1161/STR.0b013e31820a8364]).

The guidelines have been endorsed by the American Academy of Neurology, the American Association of Neurological Surgeons, the Congress of Neurological Surgeons, the Society of NeuroInterventional Surgery, and the Ibero-American Stroke Society.

Approximately five people per million develop CVT each year, accounting for 0.5%–1% of all strokes. In the largest cohort study of patients diagnosed with CVT, 54% were on oral contraceptives, 34% had an inherited or acquired prothrombotic condition, and 21% were pregnant or in the immediate postpartum period. Other predisposing conditions included infection in 12%, the presence of certain drugs in 8%, cancer in 7%, and other hematologic disorders in 12%. (Some patients had more than one predisposing condition.)

Patients may present with slowly progressive symptoms, and delays in diagnosis are common. Studies have reported a mean lapse of 4 days from onset of symptoms to hospital admission, and 7 days from onset of symptoms to diagnosis. Headache, the most common symptom, occurs in about 90% of cases. Seizures also are common. About 30%–40% of patients with CVT present with intracranial hemorrhage.

Women outnumber men with CVT at ages younger than 61 years. The incidence of CVT during pregnancy and post partum in Western countries ranges from one to four cases per 10,000 deliveries, with the greatest risk during the third trimester and in the first 4 weeks after delivery.

CVT is not a contraindication for future pregnancy, Dr. Saposnik said.

If a clinician suspects CVT, either MRI or magnetic resonance venography (MRV) is recommended to make the diagnosis by showing a thrombus obstructing the venous sinuses or cerebral veins. In emergency departments, either a CT scan or CT venography can be used if MRI is not available. “This allows different clinicians to initiate the appropriate work-up in the acute setting,” Dr. Saposnik said.

Anticoagulation is the usual first-line therapy, with IV heparin or subcutaneous low-molecular-weight heparin in patients without contraindications. “There are several things that we still don't know. For example, the anticoagulation regimen and duration of IV anticoagulation therapy is not clear,” he said.

There is only limited, low-grade evidence for alternative treatments, such as endovascular therapy or decompressive hemicraniectomy. “These should be reserved for patients with progressive neurological deterioration despite anticoagulation therapy and the best medical treatment,” Dr. Saposnik said.

One coauthor reported a financial relationship with Boehringer Ingelheim, and another reported being an adviser or consultant for Servier and Tecnifar. Another coauthor received less than $10,000 as an expert witness in a legal case concerning CVT. Disclosures of funding for the American Heart Association can be read at www.heart.org/corporatefunding

Magnetic resonance venography shows thrombosis of the superior sagital sinus.

Source Courtesy Dr. Gustavo Saposnik

The American Heart Association for the first time released guidelines for clinicians to help detect and treat cerebral venous thrombosis, a rare stroke that disproportionately affects young people, especially women who are pregnant or on oral contraceptives, or who just gave birth.

The guidelines include an algorithm for diagnosing and managing cerebral venous thromboembolism (CVT), which is caused by a clot in the dural venous sinuses, veins that drain blood from the brain toward the heart.

CVT is difficult to recognize because of its diverse risk factors and presentations. “The diagnosis and management of CVT requires a high level of suspicion,” Dr. Gustavo Saposnik said in an interview. Dr. Saposnik, codirector of the stroke program at the University of Toronto, chaired the guidelines writing committee of nine experts from five countries, which reviewed the literature on CVT and rated the evidence behind their recommendations (Stroke 2011 Feb. 3 [doi:10.1161/STR.0b013e31820a8364]).

The guidelines have been endorsed by the American Academy of Neurology, the American Association of Neurological Surgeons, the Congress of Neurological Surgeons, the Society of NeuroInterventional Surgery, and the Ibero-American Stroke Society.

Approximately five people per million develop CVT each year, accounting for 0.5%–1% of all strokes. In the largest cohort study of patients diagnosed with CVT, 54% were on oral contraceptives, 34% had an inherited or acquired prothrombotic condition, and 21% were pregnant or in the immediate postpartum period. Other predisposing conditions included infection in 12%, the presence of certain drugs in 8%, cancer in 7%, and other hematologic disorders in 12%. (Some patients had more than one predisposing condition.)

Patients may present with slowly progressive symptoms, and delays in diagnosis are common. Studies have reported a mean lapse of 4 days from onset of symptoms to hospital admission, and 7 days from onset of symptoms to diagnosis. Headache, the most common symptom, occurs in about 90% of cases. Seizures also are common. About 30%–40% of patients with CVT present with intracranial hemorrhage.

Women outnumber men with CVT at ages younger than 61 years. The incidence of CVT during pregnancy and post partum in Western countries ranges from one to four cases per 10,000 deliveries, with the greatest risk during the third trimester and in the first 4 weeks after delivery.

CVT is not a contraindication for future pregnancy, Dr. Saposnik said.

If a clinician suspects CVT, either MRI or magnetic resonance venography (MRV) is recommended to make the diagnosis by showing a thrombus obstructing the venous sinuses or cerebral veins. In emergency departments, either a CT scan or CT venography can be used if MRI is not available. “This allows different clinicians to initiate the appropriate work-up in the acute setting,” Dr. Saposnik said.

Anticoagulation is the usual first-line therapy, with IV heparin or subcutaneous low-molecular-weight heparin in patients without contraindications. “There are several things that we still don't know. For example, the anticoagulation regimen and duration of IV anticoagulation therapy is not clear,” he said.

There is only limited, low-grade evidence for alternative treatments, such as endovascular therapy or decompressive hemicraniectomy. “These should be reserved for patients with progressive neurological deterioration despite anticoagulation therapy and the best medical treatment,” Dr. Saposnik said.

One coauthor reported a financial relationship with Boehringer Ingelheim, and another reported being an adviser or consultant for Servier and Tecnifar. Another coauthor received less than $10,000 as an expert witness in a legal case concerning CVT. Disclosures of funding for the American Heart Association can be read at www.heart.org/corporatefunding

Magnetic resonance venography shows thrombosis of the superior sagital sinus.

Source Courtesy Dr. Gustavo Saposnik

The American Heart Association for the first time released guidelines for clinicians to help detect and treat cerebral venous thrombosis, a rare stroke that disproportionately affects young people, especially women who are pregnant or on oral contraceptives, or who just gave birth.

The guidelines include an algorithm for diagnosing and managing cerebral venous thromboembolism (CVT), which is caused by a clot in the dural venous sinuses, veins that drain blood from the brain toward the heart.

CVT is difficult to recognize because of its diverse risk factors and presentations. “The diagnosis and management of CVT requires a high level of suspicion,” Dr. Gustavo Saposnik said in an interview. Dr. Saposnik, codirector of the stroke program at the University of Toronto, chaired the guidelines writing committee of nine experts from five countries, which reviewed the literature on CVT and rated the evidence behind their recommendations (Stroke 2011 Feb. 3 [doi:10.1161/STR.0b013e31820a8364]).

The guidelines have been endorsed by the American Academy of Neurology, the American Association of Neurological Surgeons, the Congress of Neurological Surgeons, the Society of NeuroInterventional Surgery, and the Ibero-American Stroke Society.

Approximately five people per million develop CVT each year, accounting for 0.5%–1% of all strokes. In the largest cohort study of patients diagnosed with CVT, 54% were on oral contraceptives, 34% had an inherited or acquired prothrombotic condition, and 21% were pregnant or in the immediate postpartum period. Other predisposing conditions included infection in 12%, the presence of certain drugs in 8%, cancer in 7%, and other hematologic disorders in 12%. (Some patients had more than one predisposing condition.)

Patients may present with slowly progressive symptoms, and delays in diagnosis are common. Studies have reported a mean lapse of 4 days from onset of symptoms to hospital admission, and 7 days from onset of symptoms to diagnosis. Headache, the most common symptom, occurs in about 90% of cases. Seizures also are common. About 30%–40% of patients with CVT present with intracranial hemorrhage.

Women outnumber men with CVT at ages younger than 61 years. The incidence of CVT during pregnancy and post partum in Western countries ranges from one to four cases per 10,000 deliveries, with the greatest risk during the third trimester and in the first 4 weeks after delivery.

CVT is not a contraindication for future pregnancy, Dr. Saposnik said.

If a clinician suspects CVT, either MRI or magnetic resonance venography (MRV) is recommended to make the diagnosis by showing a thrombus obstructing the venous sinuses or cerebral veins. In emergency departments, either a CT scan or CT venography can be used if MRI is not available. “This allows different clinicians to initiate the appropriate work-up in the acute setting,” Dr. Saposnik said.

Anticoagulation is the usual first-line therapy, with IV heparin or subcutaneous low-molecular-weight heparin in patients without contraindications. “There are several things that we still don't know. For example, the anticoagulation regimen and duration of IV anticoagulation therapy is not clear,” he said.

There is only limited, low-grade evidence for alternative treatments, such as endovascular therapy or decompressive hemicraniectomy. “These should be reserved for patients with progressive neurological deterioration despite anticoagulation therapy and the best medical treatment,” Dr. Saposnik said.

One coauthor reported a financial relationship with Boehringer Ingelheim, and another reported being an adviser or consultant for Servier and Tecnifar. Another coauthor received less than $10,000 as an expert witness in a legal case concerning CVT. Disclosures of funding for the American Heart Association can be read at www.heart.org/corporatefunding

Magnetic resonance venography shows thrombosis of the superior sagital sinus.

Source Courtesy Dr. Gustavo Saposnik