Lobar hemorrhage in the elderly. The undiminishing importance of hypertension

Intracerebral Hemorrhage

INTRODUCTION

Intracerebral hemorrhage (ICH) occurs from the rupture of small vessels into the brain parenchyma and accounts for approximately 10% of all strokes in the United States, and carries with it a significantly high morbidity and mortality.

SUMMARY

This article reviews the course and management of ICH. The most common chronic vascular diseases that lead to ICH are chronic hypertension and cerebral amyloid angiopathy. Additional factors that predispose to ICH include vascular malformations, chronic alcohol use, hypocholesterolemia, and use of anticoagulant medications. The understanding of mechanisms leading to ICH has advanced significantly, but questions regarding site predilection and timing of spontaneous hemorrhage still remain. Management in the acute setting is first focused on reducing hematoma expansion. Although no specific therapy has yet been proven effective, promising agents, particularly recombinant Factor VIIa, are on the horizon. Subsequent care is focused on controlling hemostasis, hemodynamics, and intracranial pressure in efforts to minimize secondary brain injury.

CONCLUSION

The morbidity and mortality associated with ICH remain high despite recent advances in our understanding of the clinical course of ICH. Novel preventive and acute treatment therapies are needed and may be on the horizon.

The incidence of deep and lobar intracerebral hemorrhage in whites, blacks, and Hispanics

BACKGROUND

Black and Hispanic Americans have a greater risk of primary intracerebral hemorrhage (ICH) than whites. Deep ICH is most often associated with hypertension, while lobar ICH is associated with cerebral amyloid angiopathy. The authors conducted a population-based incidence study to directly compare the incidence of deep vs lobar ICH in all three race-ethnic groups.

METHODS

The authors used an active hospital and community surveillance program and autopsy reports to identify incident ICH cases among white, black, and Caribbean Hispanic adults in Northern Manhattan between July 1993 and June 1997. Incidence rates were adjusted for age and sex to the 1990 US Census. CIs for risk ratios (RR) were calculated with Byar's chi2 approximation of the Poisson distribution.

RESULTS

The authors identified 155 cases of ICH for an annual incidence of 30.9/100,000 (26.7 to 35.0). Men had a higher risk of ICH than women (RR 1.5, 95% CI 1.2 to 1.8), driven entirely by the incidence of deep ICH (RR 1.8) rather than lobar ICH (RR 1.0). Compared with whites, RR for blacks was all ICH 3.8 (2.2 to 8.9), deep 4.8 (2.3 to 21.1), lobar 2.8 (1.2 to 14.4); RR for Hispanics was all 2.6 (1.4 to 6.1), deep 3.7 (1.7 to 16.5), lobar 1.4 (0.4 to 7.4).

CONCLUSIONS

ICH is a heterogeneous disease with deep and lobar subtypes distinguishable on an epidemiologic basis. The different patterns of these two subtypes in our race-ethnically diverse population lend credence to the notion that ICH should no longer be treated as a single entity.

Hemorragias en lóbulos cerebrales: estudio de 97 pacientes

BACKGROUND AND OBJECTIVE

We aimed to characterize the clinical features,etiology and prognosis in lobar hemorrhages (LH).

PATIENTS AND METHOD

Descriptive study of 97 patients with LH included in the Sagrat Cor Hospital of Barcelona Stroke Registry over a 12 year period. The vascular risk factors and clinical profiles in a LH group and a subcortical hemorrhage group (n = 92) were compared.

RESULTS

LH accounted for 3.9% of all acute strokes (n = 2,500) and 35.9% of all intracerebral hemorrhages. The parietal lobe was the most frequent cerebral topography (45.4%). LH were caused by arterial hypertension in 41% of patients, vascular malformations in 8.5%, bleeding diathesis in 5.5% and anticoagulation in 3%. The overall in-hospital mortality rate was 26.8%. Early seizures (odds ratio [OR] = 5.41; confidence interval [CI] 95%, 1.06-27.69), headache (OR = 2.19; CI 95%, 1.13-4.26), female sex (OR = 1.97; CI 95%, 1.04-3.75), sensory deficit (OR = 0.41; CI 95%, 0.22-0.77) and hypertension (OR = 0.34; CI 95%, 0.18-0.65) were independent predictors of LH.

CONCLUSIONS

One in every 3 intracerebral hemorrhages is a LH. Different potentially modifiable vascular risk factors and clinical profiles were identified in LH versus subcortical hemorrhages.

Study of clinical features of amyloid angiopathy hemorrhage and hypertensive intracerebral hemorrhage

OBJECTIVE

The purpose of this study was to differentiate between cerebral amyloid angiopathy (CAA) and hypertension (HTN) based on hemorrhage pattern interpretation.

METHODS

From June 1994 to Oct., 2000, 83 patients admitted to our service with acute intracerebral hemorrhage (ICH) were investigated retrospectively; 41 patients with histologically proven diagnosis of cerebral amyloid angiography and 42 patients with clear history of hypertension were investigated.

RESULTS

Patients with a CAA-related ICH were significantly older than patients with a HTN-related ICH (74.0 years vs 66.5 years, P < 0.05). There was a significantly higher number of hematomas > or = 30 ml in CAA (85.3%) when compared with HTN (59.5%). No basal ganglional hemorrhage was seen in CAA, but in 40.5% in HTN. In CAA-related ICH, subarachnoid hemorrhage (SAH) was seen in 26 patients (63.4%) compared to only 11 patients (26.2%) in HTN-related ICH. Intraventricular hemorrhage was seen in 24.4% in CAA, and in 26.2% in HTN. Typical features of CAA-related ICH included lobar distribution affecting mainly the lobar superficial areas, lobulated appearance, rupture into the subarachnoid space, and secondary IVH from the lobar hemorrhage. More specifically, multiplicity of hemorrhage, bilaterality, and repeated episodes also strongly suggest the diagnosis of CAA. Multiple hemorrhages, defined as 2 or more separate hematomas in multiple lobes, accounted for 17.1% in CAA-related ICH.

CONCLUSION

There are certain features in CAA on CT and MRI and in clinical settings. To some extent, these features may contribute to distinguishing CAA from HTN related ICH.

Hemorragia intraparenquimatosa encefálica espontânea: achados à tomografia computadorizada

Foram analisados os exames de tomografia computadorizada de crânio de 250 pacientes com hematoma intraparenquimatoso encefálico espontâneo em três diferentes hospitais na cidade do Rio de Janeiro, com o objetivo de se levantar os aspectos mais freqüentes desta doença. O hematoma intraparenquimatoso cerebral profundo foi o de maior incidência, seguido do lobar. Mais raramente foi observado sangramento cerebelar e do tronco cerebral. A faixa etária de acometimento mais freqüente foi entre 61 e 70 anos de idade. Não houve diferença expressiva quanto ao sexo predominante ou ao lado mais acometido, porém verificou-se que os homens são mais acometidos em uma faixa etária mais precoce do que as mulheres. A cefaléia foi o sintoma de maior freqüência e a hipertensão arterial esteve presente na maioria dos casos. A drenagem da hemorragia para o sistema ventricular ocorreu mais comumente nos hematomas profundos.

Primary intracerebral haemorrhage--clinical and radiologic predictors of survival and functional outcome

PURPOSE

Primary intracerebral haemorrhage (ICH) is a common and devastating disorder that often results in long-term disability. This review examines the literature on predictors of survival and long-term functional outcome after ICH.

METHOD

Medical literature review.

RESULTS

Numerous clinical and radiologic variables have been shown to be associated with survival and functional recovery following ICH. These include patient age and gender, lesion size and location, initial level of consciousness, presence of intraventricular haemorrhage, hydrocephalus, and mass effect. Studies have employed a variety of outcome measures including survival and functional recovery.

CONCLUSIONS

Clinical and radiologic findings following ICH may assist rehabilitation specialists as they develop treatment goals, anticipate long-term patient care needs, and educate and train caregivers.

Current intracerebral haemorrhage management

Primary intracerebral haemorrhage (ICH) refers to spontaneous bleeding from intraparenchymal vessels. It accounts for 10-20% of all strokes, with higher incidence rates amongst African and Asian populations. The major risk factors are hypertension and age. In addition to focal neurological findings, patients may present with symptoms of elevated intracranial pressure. The diagnosis of ICH can only be made through neuro-imaging. A CT scan is presently standard, although MRI is increasingly important in the evaluation of acute cerebrovascular disease. A significant proportion of intracerebral haematomas expand in the first hours post-ictus and this is often associated with clinical worsening. There is evidence that the peri-haematomal region is compromised in ICH. This tissue is oedematous, although the precise pathogenesis is controversial. An association between elevated arterial pressure and haematoma expansion has been reported. Although current guidelines recommend conservative management of arterial pressure in ICH, an acute blood pressure lowering trial is overdue. ICH is associated with a high early mortality rate, although a significant number of survivors make a functional recovery. Current medical management is primarily aimed at prevention of complications including pneumonia and peripheral venous thromboembolism. Elevated intracranial pressure may be treated medically or surgically. Although the latter definitively lowers elevated intracranial pressure, the optimal patient selection criteria are not clear. Aggressive treatment of hypertension is essential in the primary and secondary prevention of ICH.

Spontaneous intraparenchymal hemorrhage in full-term neonates

OBJECTIVE

Spontaneous intraparenchymal hemorrhage is extremely rare in full-term newborns. Reports to date have been limited to descriptions of individual cases, small groups within larger studies of intracranial hemorrhage, and one series of four patients. Structural lesions are rarely identified, and the majority of patients described have been managed without surgical intervention.

METHODS

Analysis of a computerized database of pediatric neurosurgical patients from January 1960 to February 2000 identified full-term newborns younger than 3 months of age with nontraumatic intraparenchymal hemorrhages. Prenatal histories, labor and delivery histories, clinical presentations, imaging studies, management, and outcomes were reviewed.

RESULTS

Eleven full-term newborns with spontaneous intraparenchymal hemorrhages were identified. The majority had normal prenatal courses. Most presented within the first 2 days of life (6 of 11 patients), and the most common presenting sign was seizure (7 of 11 patients). No cause was identified in 6 of 11 patients; the remainder were attributed to coagulopathy (n = 3), ruptured intracranial aneurysm (n = 1), or hemorrhagic infarction (n = 1). Eight patients underwent surgical hematoma evacuation on the basis of radiographic evidence of significant mass effect, evidence of signs of elevated intracranial pressure, or both. Three patients did not receive surgical intervention. There were no subsequent hemorrhages or deaths during a mean follow-up period of 4.5 years (range, 1-16 yr). Four patients had normal neurological outcomes, four had motor deficits (one of whom additionally demonstrated cognitive delay), and three had delayed speech.

CONCLUSION

No cause is identified in most newborns with spontaneous intraparenchymal hemorrhage. Radiographic evidence of mass effect or signs of elevated intracranial pressure may necessitate surgical hematoma evacuation. Outcome varies widely and may be normal, even in patients with sizeable intraparenchymal hemorrhages.

Incidence of intracerebral and subarachnoid haemorrhage in southern Sweden

OBJECTIVES

Spontaneous intracranial haemorrhage-that is, mainly subarachnoid haemorrhage (SAH) and primary intracerebral haemorrhage (PICH)-constitutes an important part of all strokes. As previous epidemiological studies have demonstrated highly variable incidence rates, we conducted a large prospective investigation of all haemorrhagic strokes during a 1 year period.

METHODS

Twelve hospitals serving a defined population of 1.14 million in southern Sweden registered all cases with spontaneous intracranial haemorrhage, including those found dead outside hospitals, during 1996. All patients were examined with CT of the brain or underwent necropsy. Incidence rates adjusted to the Swedish population for age and sex, as well as location of haematoma and prevalence of risk factors were calculated.

RESULTS

A total of 106 patients with SAH and 341 patients with PICH were identified. The annual incidence/100 000 was 10.0 (6.4 for men and 13.5 for women) for SAH and 28.4 (32.2 for men and 24.7 for women) for PICH when adjusted to the Swedish population. Subarachnoid haemorrhage affected twice as many women as men. The incidence of both types of haemorrhage increased with advancing age, but in particular, this was the case for supratentorial PICH. Lobar haematomas were the most common (51.6%) type of PICH. Among patients with PICH, 37% had hypertension, 41% other vascular disease, and 12% were on oral anticoagulation. Among patients with SAH, 28% had hypertension and 18% vascular disease before the haemorrhage but no one was on treatment with oral anticoagulation.

CONCLUSIONS

The incidence of PICH was high, especially for the older age groups. PICH was, on average, three times as common as SAH. The study underscores the importance of PICH and SAH as significant stroke subgroups.

Utility of magnetic resonance imaging in acute intracerebral hemorrhage

The authors determine whether magnetic resonance imaging (MRI) during acute hospitalization for spontaneous intracerebral hemorrhage (ICH) provides new diagnostic information. ICD-9 codes were used to identify consecutive patients with spontaneous ICH at Hermann Hospital, Houston, Texas, between January 1995 and August, 1997. Two investigators employed rigorous criteria to determine whether the MRI findings led to a specific new diagnosis. Two hundred ninety-one patients met inclusion and exclusion criteria. Sixty-seven (23%) patients underwent brain MRI during the acute hospitalization. MRI provided a new diagnosis in 15 of these 67 patients (22%). Amyloid angiopathy and vascular malformation (four each) were the most frequently identified etiologies. The yield of MRI was low in basal ganglia and thalamic hemorrhage. Two of 23 (9%) patients with deep ICH and 13 of 44 (30%) patients with lobar and infratentorial hemorrhage had etiology determined by MRI. Timing of MRI did not affect yield.

Apolipoprotein E genotype and the risk of recurrent lobar intracerebral hemorrhage

BACKGROUND

Recurrent lobar intracerebral hemorrhage is the hallmark of cerebral amyloid angiopathy. The factors that predispose patients to early recurrence of lobar hemorrhage are unknown. One candidate is the apolipoprotein E gene, since both the epsilon2 and the epsilon4 alleles of apolipoprotein E appear to be associated with the severity of amyloid angiopathy.

METHODS

We performed a prospective, longitudinal study of consecutive elderly patients who survived a lobar intracerebral hemorrhage. The patients were followed for recurrent hemorrhagic stroke by interviews at six-month intervals and reviews of medical records and computed tomographic scans.

RESULTS

Nineteen of 71 enrolled patients had recurrent hemorrhages during a mean follow-up period of 23.9+/-14.8 months, yielding a 2-year cumulative rate of recurrence of 21 percent. The apolipoprotein E genotype was significantly associated with the risk of recurrence. Carriers of the epsilon2 or epsilon4 allele had a two-year rate of recurrence of 28 percent, as compared with only 10 percent for patients with the common apolipoprotein E epsilon3/epsilon3 genotype (risk ratio, 3.8; 95 percent confidence interval, 1.2 to 11.6; P=0.01). Early recurrence occurred in eight patients, four of whom had the uncommon epsilon2/epsilon4 genotype. Also at increased risk for recurrence were patients with a history of hemorrhagic stroke before entry into the study (two-year recurrence, 61 percent; risk ratio, 6.4; 95 percent confidence interval, 2.2 to 18.5; P<0.001).

CONCLUSIONS

The apolipoprotein E genotype can identify patients with lobar intracerebral hemorrhage who are at highest risk for early recurrence. This finding makes possible both the provision of prognostic information to patients with lobar hemorrhage and a method of targeting and assessing potential strategies for prevention.

Aging and cerebrovascular disease

Aging influences cerebrovascular disease expression by a variety of mechanisms. Age-related changes in cerebral autoregulation, cellular metabolism, the blood-brain barrier, and autonomic function may leave the cerebrovascular system vulnerable to injury. Certain cerebrovascular disease, such as atrial fibrillation, watershed infarctions, carotid artery atherosclerosis, cerebral hemorrhages, subdural hematomas, and transient global amnesia manifest in the elderly. Vascular dementia and white matter disease are better understood with newer neuroimaging studies, careful neuropsychological and histopathologic examinations. Atherosclerosis and cerebral amyloid angiopathy may have larger roles than previously understood in Alzheimer's disease.

Endoglin gene polymorphism as a risk factor for sporadic intracerebral hemorrhage

Intracerebral hemorrhage (ICH) is a common and serious type of stroke. Recent studies have shown that inherited factors that affect the development of the vessel wall can increase the risk of ICH. We studied endoglin as a candidate gene in patients with sporadic ICH, since mutations in this gene can cause telangiectasia formation. One hundred three patients with sporadic ICH and 202 controls were studied. The polymerase chain reaction and single-strand conformational polymorphism analysis were used to screen for mutations in exon 7 of the endoglin gene. No coding mutations in exon 7 were identified in the ICH patients or controls. A 6-base intronic insertion was found 26 bases beyond the 3' end of exon 7. The homozygous form of the insertion was present in 9 of 103 (8.7%) ICH patients compared with 4 of 202 (2.0%) controls, p = 0.012 (odds ratio 4.8 [95% confidence interval, 1.28, 21.60]). Analysis of the endoglin transcript around the insertion did not reveal any changes in the RNA sequence. There were no obvious clinical features that distinguished the ICH patients with the homozygous insertion from the other patients. The pathophysiologic mechanism underlying this association remains to be determined.

Management of hypertension in acute intracerebral hemorrhage

Hypertension commonly occurs in the acute period following spontaneous intracerebral hemorrhage. Management of this hypertension is controversial. Some advocate lowering blood pressure to reduce the risk of bleeding, edema formation, and systemic hypertensive complications, whereas others advocate allowing blood pressure to run its natural course as a protective measure against cerebral ischemia. This article reviews the pertinent clinical and experimental data regarding these issues and briefly discusses the use of antihypertensive agents commonly administered in this setting.

Lobar hemorrhages in full-term neonates

A chart analysis for a 5-year period through December 1992 identified four full-term neonates with lobar hemorrhage. Prenatal and obstetrical histories were uncomplicated; all infants presented with seizures within 48 h following birth. Perinatal asphyxia and isoimmune thrombocytopenia were associated with lobar hemorrhage in two children. Although computed tomography was sufficient for diagnosis, magnetic resonance evaluation provided assessment of specific cortical injury and the age of the hemorrhage. No infant underwent surgical intervention; three children reached developmental milestones at a mean follow-up of 3.3 years.

Spectrum of primary intracerebral haemorrhage in Perth, Western Australia, 1989-90: incidence and outcome

In a population based register of stroke (n = 536) compiled in Perth, Western Australia during an 18 month period in 1989-90, 60 cases (11%) of primary intracerebral haemorrhage were identified among 56 persons (52% men). The mean age of these patients was 68 (range 23-93) and 46 (77%) events were first ever strokes. The crude annual incidence was 35 per 100,000, with a peak in the eighth decade, and a male predominance. Deep and lobar haemorrhages each accounted for almost one third of all cases. The clinical presentations included sudden coma (12%), headache (8%), seizures (8%), and pure sensory-motor stroke (3%). Primary intracerebral haemorrhage was the first presentation of leukaemia in two cases (both fatal) and it followed an alcoholic binge in four cases. 55% had a history of hypertension. 16 (27%) patients, half of whom had a history of hypertension, were taking antiplatelet agents, and one patient was taking warfarin. There were only two confirmed cases of amyloid angiopathy. The overall 28 day case fatality was 35%, but this varied from 100% for haemorrhages in the brainstem to 22% for those in the basal ganglionic or thalamic region. Other predictors of early death were intraventricular extension of blood, volume of haematoma, mass effect, and coma and severe paresis at onset. Although based on small numbers, these data confirm the heterogeneous nature of primary intracerebral haemorrhage, but they also suggest a different clinical spectrum of this type of stroke in the community compared with the experience of specialist neurological units.