Genetic and environmental risk factors for intracerebral hemorrhage: preliminary results of a population-based study

A functional variant in promoter region of platelet-derived growth factor-D is probably associated with intracerebral hemorrhage

Background

Platelet-derived growth factor D (PDGF-D) plays an important role in angiogenesis, vessel remodeling, inflammation and repair in response to injury. We hypothesized that genetic variation in PDGFD gene might alter the susceptibility to stroke.

Findings

We determined the genotypes of a single nucleotide polymorphism (SNP) (-858A/C, rs3809021) in 1484 patients with stroke (654 cerebral thrombosis, 419 lacunar infarction, 411 intracerebral hemorrhage [ICH]) and 1528 control subjects from an unrelated Chinese Han population and followed the stroke patients up for a median of 4.5 years.

The -858AA genotype showed significantly increased risk of ICH (dominant model: odds ratio [OR] 1.29, 95% confidence interval [CI] 1.00-1.68, P = 0.05; additive model: OR 1.24, 95% CI 1.01-1.52, P = 0.04) than wild-type genotype. Further analyses showed that -858AA genotype conferred about 2-fold increase in risk of non-hypertensive ICH (dominant model: OR 2.1, 95%CI 1.34-3.29, P = 0.001; additive model: OR 1.75, 95% CI 1.24-2.46, P = 0.001). After a median follow-up of 4.5 years, -858AA genotype was associated with a reduced risk of ICH recurrence (dominant model: adjusted hazard ratio [HR] 0.09, 95%CI 0.01-0.74, P = 0.025; additive model: HR 0.21, 95% CI 0.04-1.16, P = 0.073) in non-hypertensive patients.

Conclusions

The -858AA genotype is probably associated with risk for non-hypertensive ICH. Further studies should be conducted to reveal the role of PDGF-D at various stages of ICH development--beneficial, or deleterious.

Therapeutic strategies in acute intracerebral hemorrhage

Intracerebral hemorrhage is a devastating disease, and no specific therapy has been proven to reduce mortality in a randomized controlled trial. However, management in a neuroscience intensive care unit does appear to improve outcomes, suggesting that many available therapies do in fact provide benefit. In the acute phase of intracerebral hemorrhage care, strategies aimed at minimizing ongoing bleeding include reversal of anticoagulation and modest blood pressure reduction. In addition, the monitoring and regulation of glucose levels, temperature, and, in selected cases, intracranial pressure are recommended by many groups. Selected patients may benefit from hematoma evacuation or external ventricular drainage. Ongoing clinical trials are examining aggressive blood pressure management, hemostatic therapy, platelet transfusion, stereotactic hematoma evacuation, and intraventricular thrombolysis. Finally, preventing recurrence of intracerebral hemorrhage is of pivotal importance, and tight blood pressure management is paramount.

The collagen-binding protein of Streptococcus mutans is involved in haemorrhagic stroke

Although several risk factors for stroke have been identified, one-third remain unexplained. Here we show that infection with Streptococcus mutans expressing collagen-binding protein (CBP) is a potential risk factor for haemorrhagic stroke. Infection with serotype k S. mutans, but not a standard strain, aggravates cerebral haemorrhage in mice. Serotype k S. mutans accumulates in the damaged, but not the contralateral hemisphere, indicating an interaction of bacteria with injured blood vessels. The most important factor for high-virulence is expression of CBP, which is a common property of most serotype k strains. The detection frequency of CBP-expressing S. mutans in haemorrhagic stroke patients is significantly higher than in control subjects. Strains isolated from haemorrhagic stroke patients aggravate haemorrhage in a mouse model, indicating that they are haemorrhagic stroke-associated. Administration of recombinant CBP causes aggravation of haemorrhage. Our data suggest that CBP of S. mutans is directly involved in haemorrhagic stroke.

The risk factors associated with both ischemic and haemorrhagic stroke are not fully understood. Here a certain strain of the bacteria, Streptococcus mutans, which expresses a collagen-binding protein, is shown to be associated with haemorrhagic stroke in both animal models and human patients.

Carotid intima-media thickness, electrocardiographic left ventricular hypertrophy, and incidence of intracerebral hemorrhage

BACKGROUND AND PURPOSE

Carotid intima-media thickness and electrocardiographic left ventricular hypertrophy are 2 subclinical cardiovascular disease measures associated with increased risk of total and ischemic strokes. Increased intima-media thickness and electrocardiographic left ventricular hypertrophy also may reflect end-organ hypertensive effects. Information is scant on the associations of these subclinical measures with intracerebral hemorrhage (ICH). We hypothesized that greater carotid intima-media thickness and the presence of electrocardiographic left ventricular hypertrophy would be independently associated with increased ICH incidence.

METHODS

Among 18,155 participants initially free of stroke in the Atherosclerosis Risk in Communities Study (ARIC) and the Cardiovascular Health Study (CHS), we assessed carotid intima-media thickness, carotid plaque, and electrocardiographic left ventricular hypertrophy. Over a median of 18 years of follow-up, 162 incident ICH events occurred.

RESULTS

After adjustment for other ICH risk factors, carotid intima-media thickness was associated positively with incidence of ICH in both ARIC and CHS. The risk was lowest in study-specific Quartile 1, elevated 1.6- to 2.6-fold in Quartiles 2 to 3, and elevated 2.5 to 3.7-fold in Quartile 4 (P<0.05 for both studies). In CHS, having a carotid plaque was associated with a 2-fold (95% CI, 1.1-3.4) greater ICH risk than having no plaque, but only 1.2-fold (95% CI, 0.76-2.0) greater ICH risk in ARIC. Electrocardiographic left ventricular hypertrophy carried a hazard ratio of ICH of 1.7 (95% CI, 0.77-3.7) in CHS and 2.8 (95% CI, 1.2-6.4) in ARIC.

CONCLUSIONS

Our data suggest that people with carotid atherosclerosis and possibly left ventricular hypertrophy are at increased risk not only of ischemic stroke, but also of ICH.

Stroke Genetics Update: 2011

Although stroke remains a leading cause of disability and mortality worldwide, recently there have been significant advances related to our understanding of the genetic basis of stroke. Ongoing research efforts put us on the cusp for major breakthroughs in the field. In this review, we present the substantial evidence for the contribution of genetic variation to the development of stroke, and the difficulties posed in the study of stroke given the numerous genetically driven risk factors and stroke subtypes. We emphasize recent findings implementing candidate gene and genome-wide association approaches. We then discuss how emerging knowledge is informing and reshaping our understanding of stroke biology and how, in the near term, genetics may be used clinically to identify individuals who are at risk of disease or who may derive benefit from specific treatment modalities. Lastly, we address ongoing and future approaches that will continue to improve our understanding of stroke genetics.

Serum lipid levels and the risk of intracerebral hemorrhage: the Rotterdam Study

OBJECTIVE

Low serum total cholesterol levels are associated with an increased risk of symptomatic intracerebral hemorrhage and with presence of asymptomatic cerebral microbleeds. The relative contribution of lipid fractions to these associations is unclear and requires investigation. We determined whether serum HDL-cholesterol, LDL-cholesterol, and triglycerides are associated with risk of intracerebral hemorrhage and presence of cerebral microbleeds.

METHODS AND RESULTS

Nine thousand sixty-eight stroke-free community-dwelling persons aged ≥55 were followed from baseline (1990-2001) up to January 1, 2009, of whom 85 suffered from intracerebral hemorrhage during follow-up. Brain MRI was carried out in 789 healthy participants, of whom 162 had cerebral microbleeds. Triglycerides were strongly and inversely associated with intracerebral hemorrhage, independently of HDL-cholesterol, LDL-cholesterol, and potential confounders [hazard ratio for highest versus lowest quartile: 0.20 (0.06-0.69)]. Triglycerides were also associated with deep or infratentorial microbleeds [odds ratio for highest versus lowest quartile: 0.37 (0.14-0.96)], but not with strictly lobar microbleeds. No associations were found for HDL-cholesterol or LDL-cholesterol.

CONCLUSIONS

Low serum triglyceride levels were associated with an increased risk of intracerebral hemorrhage and with the presence of deep or infratentorial cerebral microbleeds. This provides novel insights into the role of lipid fractions, particularly triglycerides, in the etiology of intracerebral hemorrhage.

Apolipoprotein E gene polymorphism and the risk of intracerebral hemorrhage in the Chinese population

Prior studies investigating the association between apolipoprotein E (APOE) gene polymorphism and the risk of intracerebral hemorrhage (ICH) have been inconsistent and limited to small sample sizes. The aim of this study was to test the hypothesis that APOE gene polymorphisms are associated with the risk of ICH in Chinese Han patients. We enrolled 180 ICH patients and 180 controls. APOE genotype was determined by using a polymerase chain reaction-restriction fragment length polymorphism assay. ICH patients had a significantly lower frequency ɛ3/ɛ3 [odds ratio (OR)=0.45, 95% confidence interval (CI)=0.28, 0.71; p=0.001] and ɛ3 allele (OR=0.51, 95% CI=0.35, 0.76; p=0.001) than healthy controls. ICH patients also had a significantly higher frequency ɛ3/ɛ4 (OR=3.61, 95% CI=1.89, 6.88; p<0.001) and ɛ4 allele (OR=3.00, 95% CI=1.76, 5.13; p<0.001) than healthy controls. This study suggests that the APOE genotype is associated with the risk of ICH in Chinese Han patients.

Reported Antiplatelet Use Influences Long-Term Outcome Independently in Deep Intracerebral Hemorrhage

BACKGROUND:

Recent studies have focused on antiplatelet (AP) use in intracerebral hemorrhage (ICH) patients. Several outcome predictors have been debated, but influences on mortality and outcome still remain controversial, especially for different ICH locations.

OBJECTIVE:

To investigate the characteristics and functional outcome of ICH patients with reported regular AP use according to hemorrhage locations.

METHODS:

This retrospective analysis included 210 consecutive spontaneous ICH patients. Clinical data including the preadmission status, initial presentation, neuroradiological data, treatment, and outcome were evaluated. Analyses were calculated for AP use vs non-AP use according to hematoma locations, and multivariate models were calculated for hematoma expansion and unfavorable (modified Rankin Scale = 4–6) long-term functional outcome (at 1 year).

RESULTS:

For all AP users ICH volume was significantly larger, 27.7 mL (interquartile range 7.4-66.1) vs 16.8 mL (interquartile range 4.2-44.7); (P = .032). Analyses showed an increased mortality for AP users at 90 days and 1 year (P = .036; P = .008). Multivariately, for all ICH patients, prior AP use was independently associated with hematoma expansion (odds ratio [OR] 3.61; P = .026) and poorer functional outcome at 1 year (OR 3.82, P = .035). In deep ICH patients, AP use was an independent predictor of an unfavorable functional outcome at 1 year (OR 4.75, P = .048).

CONCLUSION:

Hematoma expansion and more frequent unfavorable long-term functional outcome were independently associated with prior AP use for all patients, and in deep ICH patients AP use was an independent predictor of an unfavorable long-term functional outcome.

Circulating microRNA-26a: potential predictors and therapeutic targets for non-hypertensive intracerebral hemorrhage

The mechanisms of non-hypertensive intracerebral hemorrhages (ICH), which may have different pathologies, mechanisms and genetic background from hypertensive ICH, are not clear. MicroRNAs are a new class of endogenous small RNAs that negatively regulate gene expression at the posttranscriptional level. Previous studies indicate that vascular smooth muscle cell (VSMC) function places important role in non-hypertensive ICH. MiRNA-26a, a pivotal regulator of VSMC function, is one of the cell-free miRNAs that could be detected in healthy humans. Therefore, we get the hypotheses that circulating miR-26a is a potential predictors and therapeutic targets for non-hypertensive ICH.

Critical care management of acute intracerebral hemorrhage

OPINION STATEMENT

Intracerebral hemorrhage is a medical emergency. It is the most deadly and disabling form of stroke, and no individual therapy has been demonstrated to improve outcome. However, it appears that aggressive medical care in general, and management by neuroscience specialists in particular, offers substantial benefit. Therefore, providing the best supportive care based on currently available evidence may well improve outcomes. Airway management and management of blood pressure aimed at maximizing cerebral perfusion while minimizing ongoing bleeding, as well as rapid reversal of anticoagulation, are likely to be important in the early phase. Additionally, efforts should be undertaken to provide careful glucose management and temperature management and to maximize cerebral perfusion pressure. Selected patients are likely to benefit from external ventricular drainage or even hematoma evacuation. Except in rare circumstances, most patients should be managed in a neuroscience intensive care unit during the acute phase. Some patients appear to have no reasonable likelihood of recovery and can be considered for limitations of care such as Do Not Resuscitate orders or Comfort Measures Only orders. However, it can be difficult to accurately predict long-term outcome in the acute phase; formal prognostic tools should be used to offer information to patients and their families. After the hemorrhage has stabilized, efforts to minimize complications include thromboembolism prophylaxis, physical therapy, and acute rehabilitation.

APOE genotype and extent of bleeding and outcome in lobar intracerebral haemorrhage: a genetic association study

BACKGROUND

Carriers of APOE ε2 and ε4 have an increased risk of intracerebral haemorrhage (ICH) in lobar regions, presumably because of the effects of these gene variants on risk of cerebral amyloid angiopathy. We aimed to assess whether these variants also associate with severity of ICH, in terms of haematoma volume at presentation and subsequent outcome.

METHODS

We investigated the association of APOE ε2 and ε4 with ICH volume and outcomes in patients with primary ICH in three phases: a discovery phase of 865 individuals of European ancestry from the Genetics of Cerebral Hemorrhage on Anticoagulation study, and replication phases of 946 Europeans (replication 1) and 214 African-Americans (replication 2) from an additional six studies. We also assessed the association of APOE variants with ICH volume and outcomes in meta-analyses of results from all three phases, and the association of APOE ε4 with mortality in a further meta-analysis including data from previous reports. Admission ICH volume was quantified on CT scan. We assessed functional outcome (modified Rankin scale score 3-6) and mortality at 90 days. We used linear regression to establish the effect of genotype on haematoma volume and logistic regression to assess the effect on outcome from ICH.

FINDINGS

For patients with lobar ICH, carriers of the APOE ε2 allele had larger ICH volumes than did non-carriers in the discovery phase (p=2·5×10(-5)), in both replication phases (p=0·008 in Europeans and p=0·016 in African-Americans), and in the meta-analysis (p=3·2×10(-8)). In the meta-analysis, each copy of APOE ε2 increased haematoma size by a mean of 5·3 mL (95% CI 4·7-5·9; p=0·004). Carriers of APOE ε2 had increased mortality (odds ratio [OR] 1·50, 95% CI 1·23-1·82; p=2·45×10(-5)) and poorer functional outcomes (modified Rankin scale score 3-6; 1·52, 1·25-1·85; p=1·74×10(-5)) compared with non-carriers after lobar ICH. APOE ε4 was not associated with lobar ICH volume, functional outcome, or mortality in the discovery phase, replication phases, or meta-analysis of these three phases; in our further meta-analysis of 2194 patients, this variant did not increase risk of mortality (1·08, 0·86-1·36; p=0·52). APOE allele variants were not associated with deep ICH volume, functional outcome, or mortality.

INTERPRETATION

Vasculopathic changes associated with the APOE ε2 allele might have a role in the severity and clinical course of lobar ICH. Screening of patients who have ICH to identify the ε2 variant might allow identification of those at increased risk of mortality and poor functional outcomes.

FUNDING

US National Institutes of Health-National Institute of Neurological Disorders and Stroke, Keane Stroke Genetics Research Fund, Edward and Maybeth Sonn Research Fund, and US National Center for Research Resources.

Correlations between left ventricular mass index and cerebrovascular lesion

Left ventricular (LV) mass and LV geometry are well-established measures of hypertension chronicity and severity, have a prognostic value on cardiovascular morbidity and mortality, and are related to asymptomatic cerebral small-artery disease (SAD) and largeartery disease (LAD). The aim of the present study was to clarify the different effects of LV mass and LV geometry on underlying SAD compared with its effects on underlying LAD in ischemic stroke patients. Four hundred three ischemic stroke patients underwent echocardiography to determine LV mass index and relative wall thickness. Brain magnetic resonance imaging, angiography, and carotid magnetic resonance angiography were preformed to detect LAD (≥50% stenosis) and SAD (leukoaraiosis, microbleeds, and old lacunar infarction) in the brain. Multivariate analyses showed that the LV mass index was highly associated with underlying SAD but not with underlying LAD. Among the various subtypes of SAD, only cerebral microbleeds were closely related to the LV mass index. Concentric LV hypertrophy was not related to the presence of either SAD or LAD. Subgroup analyses revealed that, among the various subtypes of SAD, only cerebral microbleeds were associated with concentric LV hypertrophy. In conclusion, cerebral microbleeds may imply more advanced target organ damage than underlying LAD and ischemic subtypes of SAD.

State of the art in managing nontraumatic intracerebral hemorrhage

Nontraumatic intracerebral hemorrhage constitutes a major public health problem worldwide. Intracerebral hemorrhage leads to a high rate of morbidity and mortality. To date, no medical or surgical trials have clearly attested to the benefit of a particular therapy. The aim of this review was to summarize the best evidence for management decision-making in intracerebral hemorrhage.

Is ED disposition associated with intracerebral hemorrhage mortality?

BACKGROUND

Early deterioration is common in intracerebral hemorrhage (ICH). Treatment at tertiary care centers has been associated with lower ICH mortality. Guidelines recommend aggressive care for 24 hours irrespective of the initial outlook. We examined the frequency of and factors associated with transfer to tertiary centers in ICH patients who initially presented at nontertiary emergency departments (EDs). We also compared observed with expected mortality in transferred and nontransferred patients using published short-term mortality predictors for ICH.

METHODS

Adult patients who resided in a 5-county region and presented to nontertiary EDs with nontraumatic ICH in 2005 were identified. Intracerebral hemorrhage score and ICH Grading Scale (ICH-GS) were determined. Of 16 local hospitals, 2 were designated tertiary care centers. Logistic regression was used to assess factors associated with transfer.

RESULTS

Of 205 ICH patients who presented to nontertiary EDs, 80 (39.0%) were transferred to a tertiary center. In multivariate regression, better baseline function (modified Rankin scale 0-2 versus 3-5; odds ratio, 0.42, 95% confidence interval, 0.21-0.85, P = .016) and black race (odds ratio, 2.28, 95% confidence interval 1.01-5.12, P = .046) were associated with transfer. A trend toward higher 30-day mortality was observed in nontransferred patients (32.5% versus 45.6%, P = .06). The ICH-GS overestimated mortality for all patients, while the ICH Score adequately predicted mortality.

CONCLUSIONS

We found no significant difference in mortality between transferred and nontransferred patients, but the trend toward higher mortality in nontransferred patients suggests that further evaluation of ED disposition decisions for ICH patients is warranted. Expected ICH mortality may be overestimated by published tools.

Variants at APOE influence risk of deep and lobar intracerebral hemorrhage

OBJECTIVE

Prior studies investigating the association between APOE alleles ε2/ε4 and risk of intracerebral hemorrhage (ICH) have been inconsistent and limited to small sample sizes, and did not account for confounding by population stratification or determine which genetic risk model was best applied.

METHODS

We performed a large-scale genetic association study of 2189 ICH cases and 4041 controls from 7 cohorts, which were analyzed using additive models for ε2 and ε4. Results were subsequently meta-analyzed using a random effects model. A proportion of the individuals (322 cases, 357 controls) had available genome-wide data to adjust for population stratification.

RESULTS

Alleles ε2 and ε4 were associated with lobar ICH at genome-wide significance levels (odds ratio [OR] = 1.82, 95% confidence interval [CI] = 1.50-2.23, p = 6.6 × 10(-10); and OR = 2.20, 95%CI = 1.85-2.63, p = 2.4 × 10(-11), respectively). Restriction of analysis to definite/probable cerebral amyloid angiopathy ICH uncovered a stronger effect. Allele ε4 was also associated with increased risk for deep ICH (OR = 1.21, 95% CI = 1.08-1.36, p = 2.6 × 10(-4)). Risk prediction evaluation identified the additive model as best for describing the effect of APOE genotypes.

INTERPRETATION

APOE ε2 and ε4 are independent risk factors for lobar ICH, consistent with their known associations with amyloid biology. In addition, we present preliminary findings on a novel association between APOE ε4 and deep ICH. Finally, we demonstrate that an additive model for these APOE variants is superior to other forms of genetic risk modeling previously applied.

[Apolipoprotein E (APOE) gene polymorphism and risk and prognosis in cerebral amyloid angiopathy-related haemorrhage]

The authors present current opinions about the role of APOE (apolipoprotein E gene) genotype as a factor modifying risk, course and prognosis in haemorrhagic stroke of cerebral amyloid origin. The search for the role of genetics in haemorrhagic stroke has been ongoing for more than 15 years. One of the most frequently investigated genotypes in the context of intracerebral haemorrhages is the APOE genotype. Alleles APOE e2 and e4 have been established as risk factors for cerebral amyloid angiopathy (CAA), as well as for cerebral amyloid angiopathy-related haemorrhage (CAAH). Moreover, APOE genotype seems to determine prognosis in CAAH in terms of early mortality, as well as risk of recurrence. Current findings related to the association between different isoforms of apoE and haemorrhagic stroke due to CAA do not allow us to formulate any clinical recommendations yet.

Statin use following intracerebral hemorrhage: a decision analysis

CONTEXT

Statins are widely prescribed for primary and secondary prevention of ischemic cardiac and cerebrovascular disease. Although serious adverse effects are uncommon, results from a recent clinical trial suggested increased risk of intracerebral hemorrhage (ICH) associated with statin use. For patients with baseline elevated risk of ICH, it is not known whether this potential adverse effect offsets the cardiovascular and cerebrovascular benefits.

OBJECTIVE

To address the following clinical question: Given a history of prior ICH, should statin therapy be avoided?

DESIGN

A Markov decision model was used to evaluate the risks and benefits of statin therapy in patients with prior ICH.

MAIN OUTCOME MEASURE

Life expectancy, measured as quality-adjusted life-years. We investigated how statin use affects this outcome measure while varying a range of clinical parameters, including hemorrhage location (deep vs lobar), ischemic cardiac and cerebrovascular risks, and magnitude of ICH risk associated with statins.

RESULTS

Avoiding statins was favored over a wide range of values for many clinical parameters, particularly in survivors of lobar ICH who are at highest risk of ICH recurrence. In survivors of lobar ICH without prior cardiovascular events, avoiding statins yielded a life expectancy gain of 2.2 quality-adjusted life-years compared with statin use. This net benefit persisted even at the lower 95% confidence interval of the relative risk of statin-associated ICH. In patients with lobar ICH who had prior cardiovascular events, the annual recurrence risk of myocardial infarction would have to exceed 90% to favor statin therapy. Avoiding statin therapy was also favored, although by a smaller margin, in both primary and secondary prevention settings for survivors of deep ICH.

CONCLUSIONS

Avoiding statins should be considered for patients with a history of ICH, particularly those cases with a lobar location.

Moving the tipping point: the decision to anticoagulate patients with atrial fibrillation

BACKGROUND

The rate of ischemic stroke associated with traditional risk factors for patients with atrial fibrillation has declined over the past 2 decades. Furthermore, new and potentially safer anticoagulants are on the horizon. Thus, the balance between risk factors for stroke and benefit of anticoagulation may be shifting.

METHODS AND RESULTS

The Markov state transition decision model was used to analyze the CHADS(2) score, above which anticoagulation is preferred, first using the stroke rate predicted for the CHADS(2) derivation cohort, and then using the stroke rate from the more contemporary AnTicoagulation and Risk Factors In Atrial Fibrillation cohort for any CHADS(2) score. The base case was a 69-year-old man with atrial fibrillation. Interventions included oral anticoagulant therapy with warfarin or a hypothetical "new and safer" anticoagulant (based on dabigatran), no antithrombotic therapy, or aspirin. Warfarin is preferred above a stroke rate of 1.7% per year, whereas aspirin is preferred at lower rates of stroke. Anticoagulation with warfarin is preferred even for a score of 0 using the higher rates of the older CHADS(2) derivation cohort. Using more contemporary and lower estimates of stroke risk raises the threshold for use of warfarin to a CHADS(2) score ≥2. However, anticoagulation with a "new, safer" agent, modeled on the results of the Randomized Evaluation of Long-Term Anticoagulation Therapy trial of dabigatran, leads to a lowering of the threshold for anticoagulation to a stroke rate of 0.9% per year.

CONCLUSIONS

Use of a more contemporary estimate of stroke risk shifts the "tipping point," such that anticoagulation is preferred at a higher CHADS(2) score, reducing the number of patients for whom anticoagulation is recommended. The introduction of "new, safer" agents, however, would shift the tipping point in the opposite direction.

Screening for familial APP mutations in sporadic cerebral amyloid angiopathy

BACKGROUND

Advances in genetic technology have revealed that variation in the same gene can cause both rare familial and common sporadic forms of the same disease. Cerebral amyloid angiopathy (CAA), a common cause of symptomatic intracerebral hemorrhage (ICH) in the elderly, can also occur in families in an autosomal dominant pattern. The majority of affected families harbor mutations in the Beta amyloid Peptide (Aβ) coding region of the gene for amyloid precursor protein (APP) or have duplications of chromosomal segments containing APP.

METHODOLOGY/PRINCIPAL FINDINGS

A total of 58 subjects with a diagnosis of probable or definite CAA according to validated criteria were included in the present study. We sequenced the Aβ coding region of APP in 58 individuals and performed multiplex ligation-dependent probe amplification to determine APP gene dosage in 60. No patient harbored a known or novel APP mutation or gene duplication. The frequency of mutations investigated in the present study is estimated to range from 0% to 8% in individuals with probable CAA in the general population, based on the ascertained sample size.

CONCLUSIONS/SIGNIFICANCE

We found no evidence that variants at loci associated with familial CAA play a role in sporadic CAA. Based on our findings, these rare highly-penetrant mutations are unlikely to be seen in sporadic CAA patients. Therefore, our results do not support systematic genetic screening of CAA patients who lack a strong family history of hemorrhage or dementia.

Aspirin and recurrent intracerebral hemorrhage in cerebral amyloid angiopathy

OBJECTIVE

To identify and compare clinical and neuroimaging predictors of primary lobar intracerebral hemorrhage (ICH) recurrence, assessing their relative contributions to recurrent ICH.

METHODS

Subjects were consecutive survivors of primary ICH drawn from a single-center prospective cohort study. Baseline clinical, imaging, and laboratory data were collected. Survivors were followed prospectively for recurrent ICH and intercurrent aspirin and warfarin use, including duration of exposure. Cox proportional hazards models were used to identify predictors of recurrence stratified by ICH location, with aspirin and warfarin exposures as time-dependent variables adjusting for potential confounders.

RESULTS

A total of 104 primary lobar ICH survivors were enrolled. Recurrence of lobar ICH was associated with previous ICH before index event (hazard ratio [HR] 7.7, 95% confidence interval [CI] 1.4-15.7), number of lobar microbleeds (HR 2.93 with 2-4 microbleeds present, 95% CI 1.3-4.0; HR = 4.12 when >or=5 microbleeds present, 95% CI 1.6-9.3), and presence of CT-defined white matter hypodensity in the posterior region (HR 4.11, 95% CI 1.01-12.2). Although aspirin after ICH was not associated with lobar ICH recurrence in univariate analyses, in multivariate analyses adjusting for baseline clinical predictors, it independently increased the risk of ICH recurrence (HR 3.95, 95% CI 1.6-8.3, p = 0.021).

CONCLUSIONS

Recurrence of lobar ICH is associated with previous microbleeds or macrobleeds and posterior CT white matter hypodensity, which may be markers of severity for underlying cerebral amyloid angiopathy. Use of an antiplatelet agent following lobar ICH may also increase recurrence risk.

Prevalence and risk factors of cerebral microbleeds: an update of the Rotterdam scan study

BACKGROUND AND PURPOSE

We previously reported on the high prevalence of cerebral microbleeds (CMBs) in community-dwelling people aged 60 years and older. Moreover, we found that their spatial distribution likely reflects differences in underlying etiology. We have since almost quadrupled the number of participants in our study and expanded it to include persons of 45 years and older. We examined the prevalence and determinants of microbleeds in this larger and younger cohort from the general population.

METHODS

In 3979 persons (mean age, 60.3 years), we performed brain MRI at 1.5T, including a sequence optimized for visualization of CMBs. Associations between APOE genotype, cardiovascular risk factors, and markers of cerebrovascular disease with the presence and location of CMBs were assessed by multiple logistic regression adjusted for age, sex, and relevant confounders.

RESULTS

Microbleed prevalence gradually increased with age, from 6.5% in persons aged 45 to 50 years to 35.7% in participants of 80 years and older. Overall, 15.3% of all subjects had at least 1 CMB. Cardiovascular risk factors and presence of lacunar infarcts and white matter lesions were associated with microbleeds in a deep or infratentorial region, whereas APOE ε4 and diastolic blood pressure were related to microbleeds in a strictly lobar location.

CONCLUSIONS

Findings in this larger population are in line with our previous results and, more importantly, extend these to a younger age group. CMBs are already present at middle age, and prevalence rises strongly with increasing age. We confirmed that determinants of the presence of cerebral microbleeds differ according to their location in the brain.

Genetics and genomics of stroke: novel approaches

Evidence for a genetic basis for stroke comes from twin and family studies and from the occurrence of a number of uncommon monogenic disorders, but the contribution of genetic factors identified for stroke so far is small. Advances in genetics and genomics may permit new insights. In recent genome-wide association studies, a number of single-nucleotide polymorphisms have been associated with specific stroke subtypes and major stroke risk factors such as diabetes and atrial fibrillation. These await replication. Studies of messenger ribonucleic acid expression have also shown promise for the development of genomic signatures for stroke classification. Stroke and coronary heart disease share some features of pathophysiology, risk, and treatment, and their genetic and genomic bases also appear to overlap.

Management of spontaneous nontraumatic intracranial hemorrhage

Intracerebral hemorrhage (ICH) is one of the most devastating subtypes of stroke and is characterized by spontaneous extravasation into the parenchymal tissue of the brain. Although advances in critical care have improved, there is no intervention currently available that has shown to alter the outcome of patients who have suffered acute ICH. Therefore, management is largely supportive. Treatment strategies are aimed at limiting hematoma enlargement, seizures, and cerebral edema, as well as other ICU-related complications such as deep venous thrombosis, hyperglycemia, and fever. This review will outline the key pharmacological management strategies in patients with ICH and highlight the most current American Heart Association/American Stroke Association (AHA/ASA) guidelines for management published in 2007.

Guidelines for the management of spontaneous intracerebral hemorrhage: a guideline for healthcare professionals from the American Heart Association/American Stroke Association

PURPOSE

The aim of this guideline is to present current and comprehensive recommendations for the diagnosis and treatment of acute spontaneous intracerebral hemorrhage.

METHODS

A formal literature search of MEDLINE was performed. Data were synthesized with the use of evidence tables. Writing committee members met by teleconference to discuss data-derived recommendations. The American Heart Association Stroke Council's Levels of Evidence grading algorithm was used to grade each recommendation. Prerelease review of the draft guideline was performed by 6 expert peer reviewers and by the members of the Stroke Council Scientific Statements Oversight Committee and Stroke Council Leadership Committee. It is intended that this guideline be fully updated in 3 years' time.

RESULTS

Evidence-based guidelines are presented for the care of patients presenting with intracerebral hemorrhage. The focus was subdivided into diagnosis, hemostasis, blood pressure management, inpatient and nursing management, preventing medical comorbidities, surgical treatment, outcome prediction, rehabilitation, prevention of recurrence, and future considerations.

CONCLUSIONS

Intracerebral hemorrhage is a serious medical condition for which outcome can be impacted by early, aggressive care. The guidelines offer a framework for goal-directed treatment of the patient with intracerebral hemorrhage.

Stroke in women

AIMS

The aim of this article is to provide an overview of stroke in women and describe modifiable and non-modifiable risk factors for stroke.

DATA SYNTHESIS

Data supporting this article come from the National Center for Health Statistics, from American Heart Association publications, and from some of the large, multicenter trials and observational studies that inform guidelines for prevention of stroke. These data indicate that stroke is the third leading cause of death in women, that risk for stroke rises rapidly with age, and that the strongest risk factors for stroke are high blood pressure and atrial fibrillation, as well as diabetes and smoking. Risk rises rapidly when two or more risk factors are present. Hormone therapy in postmenopausal women increases risk of ischemic, but not hemorrhagic stroke, by 40-50%. Biomarkers of inflammation are associated with stroke risk. Other risk factors include certain lipids, physical inactivity, and low potassium diets. Although there has been improvement in the past decade, control of hypertension is inadequate in older women and many strokes could be prevented by better treatment of hypertension.

CONCLUSION

Death and disability from stroke can be reduced with modification, treatment, and better control of risk factors like hypertension, diabetes and atrial fibrillation.

Protective effect of melatonin upon neuropathology, striatal function, and memory ability after intracerebral hemorrhage in rats

Since free radicals play a role in the mechanisms of brain injury after hemorrhagic stroke, the effect of melatonin (a potent antioxidant and free-radical scavenger) on outcomes was investigated after intracerebral hemorrhage (ICH) in rats. ICH was induced by clostridial collagenase infusion into the right caudate putamen, and several time points and doses of melatonin were studied. Brain edema and neurological function at 24 h were unchanged in comparison with vehicle-treated groups, in spite of oxidative stress reductions. Repeated treatment with the lower dose of melatonin (5 mg/kg) given at 1 h and every 24 h thereafter for 3 days after ICH, led to normalization of striatal function and memory ability over the course of 8 weeks, and less brain atrophy 2 weeks later. These results suggest that melatonin is safe for use after ICH, reduces oxidative stress, provides brain protection, and could be used for future investigations of free radical mechanisms after cerebral hemorrhage.

Association of TNF-alpha gene with spontaneous deep intracerebral hemorrhage in the Taiwan population: a case control study

Background

Genetic factors may play a role in susceptibility to spontaneous deep intracerebral hemorrhage (SDICH). Previous studies have shown that TNF-α gene variation was associated with risks of subarachnoid hemorrhage in multiple ethnicities. The present case-control study tested the hypothesis that genetic variations of the TNF-α gene may affect the risk of Taiwanese SDICH. We examined the association of SDICH risks with four single nucleotide polymorphisms (SNPs) within the TNF-α gene promoter, namely T-1031C, C-863A, C-857T, and G-308A.

Methods

Genotyping was determined by PCR-based restriction and electrophoresis assay for 260 SDICH patients and 368 controls. Associations were tested by logistic regression or general linear models with adjusting for multiple covariables in each gender group, and then in combined. Multiplicative terms of gender and each of the four SNPs were applied to detect the interaction effects on SDICH risks. To account for the multiple testing, permutation testing of 1,000 replicates was performed for empirical estimates.

Results

In an additive model, SDICH risks were positively associated with the minor alleles -1031C and -308A in men (OR = 1.9, 95% CI 1.1 to 3.4, p = 0.03 and OR = 2.6, 95% CI 1.3 to 5.3, p = 0.005, respectively) but inversely associated with -863A in females (OR = 0.5, 95% CI 0.2 to 0.9, p = 0.03). There were significant interaction effects between gender and SNP on SDICH risks regarding SNPs T-1031C, C-863A, and G-308A (p = 0.005, 0.005, and 0.007, respectively). Hemorrhage size was inversely associated with -857T in males (p = 0.04).

Conclusions

In the Taiwan population, the associations of genetic variations in the TNF-α gene promoter with SDICH risks are gender-dependent.

The relationship between smoking and replicated sequence variants on chromosomes 8 and 9 with familial intracranial aneurysm

BACKGROUND AND PURPOSE

The purpose of this study was to replicate the previous association of single nucleotide polymorphisms (SNPs) with risk of intracranial aneurysm (IA) and to examine the relationship of smoking with these variants and the risk of IA.

METHODS

White probands with an IA from families with multiple affected members were identified by 26 clinical centers located throughout North America, New Zealand, and Australia. White control subjects free of stroke and IA were selected by random digit dialing from the Greater Cincinnati population. SNPs previously associated with IA on chromosomes 2, 8, and 9 were genotyped using a TaqMan assay or were included in the Affymetrix 6.0 array that was part of a genomewide association study of 406 IA cases and 392 control subjects. Logistic regression modeling tested whether the association of replicated SNPs with IA was modulated by smoking.

RESULTS

The strongest evidence of association with IA was found with the 8q SNP rs10958409 (genotypic P=9.2x10(-5); allelic P=1.3x10(-5); OR=1.86, 95% CI: 1.40 to 2.47). We also replicated the association with both SNPs on chromosome 9p, rs1333040 and rs10757278, but were not able to replicate the previously reported association of the 2 SNPs on chromosome 2q. Statistical testing showed a multiplicative relationship between the risk alleles and smoking with regard to the risk of IA.

CONCLUSIONS

Our data provide complementary evidence that the variants on chromosomes 8q and 9p are associated with IA and that the risk of IA in patients with these variants is greatly increased with cigarette smoking.

Stroke pharmacogenomics

Circulatory disease accounts for fifteen million deaths each year, of which stroke accounts for four and a half million- with an estimated nine million stroke survivors annually. The overall incidence rate of stroke is 2 to 2.5 per thousand adults with an approximate prevalence of 5 per thousand and an estimated 5-year risk of stroke recurrence of 15 to 40 percent. Conventional risk factors for stroke include: increasing age, hypertension, diabetes mellitus, smoking, increased body mass index, ischemic heart disease, heart failure, atrial fibrillation and lack of physical activity. Age is the strongest risk factor for both ischemic and haemorrhagic stroke with its incidence doubling for each successive decade after the age of fifty-five years. However, there is a substantial portion of patients with significant cerebrovascular disease who do not have any of these stroke risk-factors, leading to the speculation that there are other factors that have not been identified yet So as to improve diagnosis and treatment strategies, as well as to reduce the related public health burden, it could be helpful to successfully identify its extremely complex genetic determinants (polygenic, multiple genes play a role). Pharmacogenetics is the field of pharmacology that deals with the influence of genetic variation on drug response by correlating gene expression and gene variants with the efficacy or toxicity of drugs. The principle drugs in stroke medicine are antithrombotics. The aim of this paper was to review the most commonly used drugs for stroke such as rtPA in the acute phase as well as antiplatelets and wafarin for secondary prophylaxis.

Neuroprotective role of haptoglobin after intracerebral hemorrhage

After intracerebral hemorrhage (ICH), the brain parenchyma is exposed to blood containing red blood cells (RBCs) and consequently to its lysis products. Iron-rich hemoglobin (Hb) is the most abundant protein in RBCs. When released into the brain parenchyma during hemolysis, Hb becomes a central mediator of cytotoxicity. Our study indicates that haptoglobin (Hp), an acute-phase response protein primarily synthesized in the liver and known to bind and neutralize Hb in the bloodstream, is also expressed in brain in which it plays an important role in defending neurons from damage induced by hemolytic products after ICH. We demonstrate that the Hb-induced hypohaptoglobinemia aggravates ICH-induced brain damage while pharmacologic intervention with sulforaphane to induce brain Hp is linked to a reduction in brain damage. In agreement with these findings, Hp deficiency worsens whereas Hp overexpression alleviates ICH-mediated brain injury. We also identified that oligodendroglia are the primary source of brain-derived Hp among brain cells and that oligodendroglia-released Hp plays protective roles against Hb-mediated toxicity to neurons and oligodendrocytes. We conclude that Hp, particularly the brain-derived Hp, plays cytoprotective roles and represents a potential therapeutic target for ICH treatment.

Analyses of interaction effect between apolipoprotein E polymorphism and alcohol use as well as cholesterol concentrations on spontaneous deep intracerebral hemorrhage in the Taiwan population

BACKGROUND

To determine the interaction effect between APOE polymorphism and lipid concentrations and alcohol use on spontaneous deep intracerebral hemorrhage (SDICH) risks.

METHODS

We enrolled 217 SDICH patients and 280 controls. Anthropometrics, personal history, and concentrations of total cholesterol (TC), high-density lipoprotein cholesterol, low-density lipoprotein cholesterol (LDL-c), and triglyceride were collected. Genotyping was determined by PCR-based restriction and electrophoresis assay. Associations were tested adjusting for multiple covariables.

RESULTS

Compared with the commonest genotype epsilon 3 epsilon 3, epsilon 2 epsilon 3 was inversely associated with TC (p=0.023) and LDL-c concentrations (p=0.005) in women. No APOE-alcohol interaction effect on lipids concentration was found. However, in men, there was a marginal effect of interaction between alcohol and APOE genotype epsilon 2 epsilon 3 vs. epsilon 3 epsilon 3 on SDICH risks (p=0.003), which is independent of TC concentration. In the male non-alcohol group, SDICH proportion was lower in the subjects carrying APOE epsilon 2 epsilon 3 (27.6%) than in those with epsilon 3 epsilon 3 (41.1%). In contrast, in the male alcohol consumption group, APOE epsilon 2 epsilon 3 was associated with a higher SDICH rate (77.8%) compared to epsilon 3 epsilon 3 (58.0%).

CONCLUSIONS

Male subjects carrying genotype epsilon 2 epsilon 3 tend to have a higher SDICH risk than those who have epsilon 3 epsilon 3 when they have alcohol exposure, but may have more benefit from alcohol abstinence.

Risk Factors and Stroke Subtypes: Results of Five Consecutive Years of the Perugia Stroke Registry

To understand the etiopathogenetic mechanisms of stroke and to target prevention, we need to know how risk factors differ among etiological subtypes. Our aims were to determine the different profile of risk factors for ischemic and hemorrhagic stroke subtypes in our cohort from the Perugia Hospital-Based Stroke Registry. We analyzed the characteristics and the different risk factors of 2,395 first-ever consecutive stroke patients admitted to the Perugia Hospitals in the period between January 1, 1998 and December 31, 2002. The prevalence of cerebrovascular risk factors in each stroke subtype was analyzed independently and compared with other subtypes of stroke pooled together by means of univariate analysis and logistic regression models. Hypertension occurred in 61% of patients; familial history of stroke in 41.6%; vascular disease in 27.2%; embolic heart disease in 22.3%; cigarette smoking in 21.6%. Different potentially modifiable risk factors profiles were identified for each ischemic subtype of stroke, while in hemorrhagic lobar stroke subtypes, only male gender was an independent risk factor.

Blood pressure management in acute intracerebral hemorrhage

Primary intracerebral hemorrhage (ICH) results from spontaneous rupture of an intracranial vessel and is associated with high rates of early mortality and long-term morbidity. No surgical or medical intervention has been demonstrated to improve outcome. Acute blood pressure elevation is seen in the majority of patients with ICH and is correlated with poor outcome. Potential, but unproven, mechanisms for this association include facilitation of hematoma expansion as well as perihematomal edema growth. Conversely, the perihematomal region has also been hypothesized to have ischemic properties. Therefore, management of blood pressure in the acute phase lends itself to two competing rationales and the optimal target blood pressure remains unknown. A number of parenchymal and blood-flow imaging techniques have been utilized to improve our understanding of blood flow and metabolism in acute ICH. These studies generally indicate that ischemia is not a major pathophysiological mechanism of secondary injury in ICH. Ultimately, randomized, controlled trials, which are underway, will be required to definitively determine the safety and efficacy of acute blood pressure reduction. It appears most likely that earlier and more aggressive treatment of acute blood pressure will be recommended in the future.

Apolipoprotein E genotype in patients with cerebrovascular diseases and its effect on the disease outcome

A total of 100 hospitalized stroke patients and 30 healthy controls were included in a study aiming to determine the predictive role of ApoE genotype polymorphism for stroke outcome in the Turkish population. The most frequent ApoE genotype was epsilon3/3 reflecting Asian population polymorphic distribution. ApoE polymorphism in the Eastern Turkish population was found to be independent of stroke type, OSCP subtypes of infarction, localization of hemorrhage, severity of carotid artery stenosis, and resultant stroke outcome. Distinct polymorphic results in populations from nearby regions suggest a multifactorial pathogenesis and presence of very complex genetic factors in the development of stroke and stroke outcome.

Should we test for CYP2C9 before initiating anticoagulant therapy in patients with atrial fibrillation?

BACKGROUND

Genetic variants of the warfarin sensitivity gene CYP2C9 have been associated with increased bleeding risk during warfarin initiation. Studies also suggest that such patients remain at risk throughout treatment.

OBJECTIVE

Would testing patients with non-valvular atrial fibrillation (AF) for CYP2C9 before initiating warfarin improve outcomes?

DESIGN

Markov state transition decision model.

SETTING

Ambulatory or inpatient settings necessitating new initiation of anticoagulation.

PATIENTS

The base case was a 69-year-old man with newly diagnosed non-valvular AF. Interventions included: (1) warfarin, (2) aspirin, or (3) no antithrombotic therapy without genetic testing; and genetic testing followed by (4) aspirin or (5) no antithrombotic therapy in those with culprit CYP2C9 alleles.

MEASURES

Quality-adjusted life years (QALYs).

RESULTS

In the base case, testing and treating patients with CYP2C9*2 and/or CYP2C9*3 with aspirin rather than warfarin was best (8.97 QALYs). However, warfarin without genetic testing was a close second (8.96 QALYs), a difference of roughly 5 days. Sensitivity analyses demonstrated that genetic testing followed by aspirin was best for patients at lower risk of embolic events. Warfarin without testing was preferred if the rate of embolic events was greater than 5% per year, or the risk of major bleeding while receiving warfarin was lower.

CONCLUSION

For patients at average risk for ischemic stroke due to AF and at average risk for major hemorrhage, treatment based on genetic testing offers no benefit compared to warfarin initiation without testing. The gain from testing may be larger in patients at lower risk of embolic events or at greater risk of bleeding.

Smoking and family history and risk of aneurysmal subarachnoid hemorrhage

OBJECTIVE

Smoking and family history of aneurysmal subarachnoid hemorrhage (aSAH) are independent risk factors for aSAH. Using a population-based case-control study of hemorrhagic stroke, we hypothesized that having both a first-degree relative with a brain aneurysm or SAH (+FH) and current smoking interact to increase the risk of aSAH.

METHODS

Cases of aneurysmal SAH were prospectively recruited from all 17 hospitals in the five-county region around the University of Cincinnati. Controls were identified by random digit dialing. Controls were matched to cases of aSAH by age (+/-5 years), race, and sex. Conditional multiple logistic regression was used to identify independent risk factors. For deviation from the additive model, the interaction constant ratio test was used.

RESULTS

A total of 339 cases of aSAH were matched to 1,016 controls. Compared to current nonsmokers with no first-degree relatives with aSAH (-FH), the odds ratio (OR) for aSAH for current nonsmokers with +FH was 2.5 (95% confidence interval [CI] 0.9-6.9); for current smokers with -FH, OR = 3.1 (95% CI 2.2-4.4); and for current smokers with +FH, OR = 6.4 (95% CI 3.1-13. 2). The interaction constant ratio, which measured the deviation from the additive model, was significant: 2.19 (95% CI 0.80-5.99). The lower bound of the 95% CI >0.5 signifies a departure from the additive model.

CONCLUSION

Evidence of a gene-environment interaction with smoking exists for aneurysmal subarachnoid hemorrhage. This finding is important to counseling family members and for screening of intracranial aneurysm (IA) as well as the design and interpretation of genetic epidemiology of IA studies.

Diagnostic accuracy and yield of multidetector CT angiography in the evaluation of spontaneous intraparenchymal cerebral hemorrhage

BACKGROUND AND PURPOSE

Multidetector CT angiography (MDCTA) is emerging as the favored initial diagnostic examination in the evaluation of patients presenting with spontaneous intraparenchymal hemorrhage (IPH). This study aims to evaluate the diagnostic accuracy and yield of MDCTA for the detection of vascular etiologies in adult patients presenting to the emergency department with IPH.

MATERIALS AND METHODS

We conducted a retrospective study of 623 consecutive adult patients presenting to the emergency department with IPH, who were evaluated with MDCTA during a 9-year period. CT angiograms were reviewed by 2 neuroradiologists to determine the IPH site and the presence of a vascular etiology. Patients with associated subarachnoid hemorrhage in the basal cisterns were excluded from the study. Medical records were reviewed for risk factors and correlation with final diagnosis. The diagnostic accuracy of MDCTA compared with conventional angiography, intraoperative evaluation, and pathologic findings was determined, when available. Multiple-variable logistic regression analysis was performed to determine clinical and radiologic factors that predict a higher yield of MDCTA.

RESULTS

MDCTA demonstrated a vascular etiology in 91 patients (14.6%), with a sensitivity of 96%, specificity of 99%, and diagnostic accuracy of 98%. We found independent, statistically significant higher yields of MDCTA in patients with the following characteristics: 1) age younger than 46 years (47%); 2) lobar (20%) or infratentorial (16%) IPH, especially lobar IPH with associated intraventricular hemorrhage (25%); 3) female sex (18%); or 4) neither known hypertension nor impaired coagulation at presentation (33%).

CONCLUSIONS

MDCTA is an accurate diagnostic examination in the evaluation of adult patients presenting with spontaneous IPH and should be performed in all patients with the aforementioned clinical and radiologic characteristics.

Recent trends in the treatment of spontaneous intracerebral hemorrhage: analysis of a nationwide inpatient database

Object

Recently updated guidelines failed to reflect significant progress in the treatment of intracerebral hemorrhage (ICH). Using data from a nationwide hospital database, the authors identified recent trends in therapy and outcomes for ICH, as well as the effect of associated comorbidities and procedures, including surgery.

Methods

Data from the Nationwide Inpatient Sample hospital discharge database (Healthcare Cost and Utilization Project, Agency for Healthcare Research and Quality) for the period 1993–2005 was retrospectively reviewed. Multiple variables were categorized and subjected to statistical analysis for codes related to ICH from the International Classification of Diseases, 9th revision, Clinical Modification. Data linked by the Nationwide Inpatient Sample database to associated diagnoses and procedures were also retrieved and analyzed.

Results

The number of discharges remained constant for ICH. The mortality rate remained unchanged at an average of 31.6%, whereas routine discharges (home) steadily declined by 25%, and discharges other than home doubled (p < 0.01). By the end of the study, length of hospital stay decreased by 30% (p < 0.01), and mean hospital charges steadily increased to more than twice the original figures. Arterial hypertension was the most frequently associated comorbidity. Seizures were associated with longer hospital stays and higher mean hospital charges. Craniotomy was associated with decreased mortality rates but also with worse outcomes and lower rates of patients discharged home (p < 0.01). No geographic differences in treatment and outcomes were noted.

Conclusions

From 1993 to 2005, no significant progress in treatment and prevention of ICH was noted. There were no regional differences in the treatment and outcome of ICH. The role of surgery for ICH remains uncertain, and large-scale controlled studies are greatly needed to clarify this role.

Association of subdural hematoma with increased mortality in lobar intracerebral hemorrhage

OBJECTIVE

To determine the prevalence of subdural hematoma (SDH) in patients presenting with primary nontraumatic lobar intracerebral hemorrhage (ICH) and characteristics associated with the presence of SDH.

DESIGN

Retrospective analysis of data collected in a prospective cohort study.

SETTING

Hospital.

PATIENTS

Consecutive sample of 200 patients with primary lobar ICH and 75 patients with deep hemispheric ICH.

MAIN OUTCOME MEASURES

Presence of SDH and mortality.

RESULTS

Subdural hematoma was present in 40 of 200 patients (20%) with primary lobar ICH. By contrast, SDH was not present in any of 75 consecutive patients with deep hemispheric ICH (P < .001 for comparison with lobar ICH). Intracerebral hemorrhage volume higher than 60 cm3 was the only independent predictor of SDH (odds ratio [OR], 2.69; 95% confidence interval [CI], 1.14-6.34; P = .02). Subdural hematoma thickness more than 5 mm was an independent predictor of increased 30-day mortality (OR, 7.60; 95% CI, 1.86-30.99; P = .005) after controlling for other factors including ICH volume. Further analysis showed that the effect of SDH on mortality depended on ICH volume, with larger odds for mortality in those with low ICH volume (OR, 12.85; 95% CI, 2.42-68.23; P = .003 for those with ICH volume <30 cm3). Cerebral amyloid angiopathy was present in 8 of 9 patients with pathological specimens.

CONCLUSIONS

Nontraumatic SDH frequently accompanies primary lobar ICH and is associated with higher 30-day mortality, particularly when the ICH volume is relatively low. Rupture of an amyloid-laden leptomeningeal vessel, with extravasation into the brain parenchyma and subdural space, may be the pathogenic mechanism.

The diagnosis, management, and postnatal prevention of intraventricular hemorrhage in the preterm neonate

Intraventricular hemorrhage (IVH) occurs in 20% to 25% of very low birthweight preterm neonates and may be associated with significant sequelae. Infants who have IVH are at risk for posthemorrhagic hydrocephalus and periventricular leukomalacia; as many as 75% of those who have parenchymal involvement of hemorrhage suffer significant neurodevelopmental disability. Because of the prevalence of IVH and the medical and societal impact of this disease, many postnatal pharmacologic prevention strategies have been explored. Randomized clinical prevention trials should provide long-term neurodevelopmental follow-up to assess the impact of preterm birth, injury, and pharmacologic intervention on the developing brain.