Diagnostic Accuracy of MRI in Spontaneous Intracerebral Hemorrhage (DASH)

Intracerebral hemorrhage (ICH) is a devastating type of stroke caused due to bleeding within the brain tissue. It affects about a million patients worldwide every year and has the highest mortality and morbidity of any type of stroke. Of all patients who present with a stroke 10-20% will have suffered a spontaneous (non-traumatic) ICH rather than an ischemic stroke. This percentage is higher among Black, Asian, and Hispanic populations, and expected to rise in the United States over the next few decades, due to increasing age and continuing changes in racial demographics.

ICH occurs due to a variety of causes including hypertension, cerebral amyloid angiopathy, excessive anticoagulation, vascular malformations, cerebral venous thrombosis or brain tumors. The acute treatment, prognosis and prevention of recurrent ICH depend on the reason for the brain hemorrhage. For example, a patient who has an ICH due to cerebral amyloid angiopathy will need to avoid blood thinners to decrease the probability of a recurrent ICH. On the other hand, a patient with ICH due to cerebral venous thrombosis will require blood thinners for treatment.

ICH is readily diagnosed by CT, which is typically the first imaging test performed during the initial diagnostic evaluation. CT provides information on the size and the location of the hematoma. However, although CT is very sensitive for the detecting of acute blood in the brain, it often does not provide information that allows determination of the cause of the hemorrhage. While magnetic resonance imaging (MRI) has substantially improved our diagnostic capabilities, the appropriate use of MRI and its effectiveness has not been studied systematically in these patients. Furthermore, it is unclear whether routine MRI in ICH yields clinically relevant data and if this data will change management decisions regarding further diagnostic testing and therapeutic options above and beyond that which can be achieved by CT and cerebral angiography. These questions have major ramifications for the care of patients with ICH or IVH. If MRI truly can categorize patients into specific diagnostic categories better than CT, this would represent a major paradigm shift in the way that these patients are typically evaluated. On the other hand, because of the added expense of MRI, its general use could result in a substantial increase in the cost of neurological care. These added costs must result in improvements in patient management in order to justify the added financial resources involved.

DASH (Diagnostic accuracy of MRI in Spontaneous Intracerebral Hemorrhage) is a prospective study funded by the National Institute of Health (NIH). The overall aim of this project is to prospectively determine whether MRI can improve the conventional neuroradiological evaluation of patients with a spontaneous ICH or IVH. The study design will also allow us to identify the added benefit of specific MR sequences (including novel state-of-the-art sequences) and repeat MRI in the chronic stage, thereby allowing us to prospectively determine their value in a consecutive series of patients. This information should have a major impact on the management of these patients by providing data on the diagnostic yield of routine MRI in patients presenting with a wide variety of causes for ICH or IVH. These data will help guide the diagnostic evaluation and the management of brain hemorrhage patients in the future. In addition, the data derived from this study will make a substantial contribution to future patient management by facilitation of the development of evidence based practice guidelines for the use of MRI in the workup of patients presenting with spontaneous ICH or IVH.