The risk of subarachnoid and intracerebral hemorrhages in blacks as compared with whites

Initial and recurrent bleeding are the major causes of death following subarachnoid hemorrhage

BACKGROUND AND PURPOSE

The goal of this study was to determine the causes of mortality and morbidity after subarachnoid hemorrhage.

METHODS

We identified all first-ever spontaneous subarachnoid hemorrhages that occurred in the nearly 1.3 million population of greater Cincinnati during 1988.

RESULTS

Thirty-day mortality for subarachnoid hemorrhage was 45% (36 of 80 cases). Of the 36 deaths, 22 (61%) died within 2 days of onset; 21 of these deaths were due to the initial hemorrhage, and one death was due to rebleeding documented by computer tomography. Nine of the remaining 14 deaths after day 2 were caused by the initial hemorrhage (2 cases) or rebleeding (7 cases). Volume of subarachnoid hemorrhage was a powerful predictor of 30-day morality (P = .0001). Only 3 of the 29 patients with a volume of subarachnoid hemorrhage of 15 cm3 or less died before 30 days. Two of these 3 patients died from documented rebleeding; the third had 87 cm3 of additional intraventricular hemorrhage. Delayed arterial vasospasm contributed to only 2 of all 36 deaths.

CONCLUSIONS

Most deaths after subarachnoid hemorrhage occur very rapidly and are due to the initial hemorrhage. Rebleeding is the most important preventable cause of death in hospitalized patients. In a large representative metropolitan population, delayed arterial vasospasm plays a very minor role in mortality caused by subarachnoid hemorrhage.

Management of intracerebral hemorrhage in a large metropolitan population

The management of all patients with spontaneous, nonaneurysmal intracerebral hemorrhages that occurred in the 1.26 million population of Greater Cincinnati during 1988 was reviewed. Of the 188 patients with intracerebral hemorrhage, 26 had operative removal of their intracerebral hemorrhage, and 8 had removal of their intracerebral hemorrhage and an arteriovenous malformation. In 15 of the 34 patients, the operation was performed within 12 hours of onset. The operative removal of parenchymal hemorrhages was performed in 29% of cerebellar, 24% of lobar, 13% of deep, and 10% of pontine hemorrhages. Admission Glasgow Coma Scale scores were similar for operated and nonoperated patients (11 +/- 3 versus 11 +/- 3), but operated patients were significantly younger (58 +/- 17 versus 72 +/- 15 yr), were more likely to have a lobar hemorrhage (64 versus 43%) or a cerebellar hemorrhage (29 versus 7%), and had larger parenchymal hemorrhages (50 +/- 31 versus 37 +/- 38 ml). Operated patients had a borderline lower 30-day mortality (25%) than nonoperated patients (46%), but the overall morbidity and mortality for the two groups did not differ significantly. Patients undergoing an early operation were more critically ill preoperatively and had a greater 30-day mortality (45%) than did those patients undergoing a late operation (12%). Half of the 43% mortality for all hospitalized cases occurred during the first 2 days after onset, and two-thirds occurred during the first 4 days. Only 12% of all patients had a minor handicap or better at 30 days. Neurosurgeons in our community performed operative removal of parenchymal hemorrhage in nearly one fifth of all patients with intracerebral hemorrhage.(ABSTRACT TRUNCATED AT 250 WORDS)

Stroke in children within a major metropolitan area: the surprising importance of intracerebral hemorrhage

Our objective was to determine the incidence rate of stroke and stroke subtypes in children. We reviewed the medical records, autopsy records, and brain imaging studies of all children with a possible stroke within the Greater Cincinnati metropolitan area population of nearly 1.3 million during 1988 and 1989. Traumatic brain hemorrhages and germinal matrix hemorrhages were excluded. Of the 295,577 children in Greater Cincinnati, medical records of 178 children were screened. Sixteen cases (13 whites and three blacks) less than age 15 years fit strictly defined criteria for first-ever stroke. The incidence rate for cerebral infarction was 1.2 cases per 100,000 (95% confidence interval, 0.3 to 2.0). The combined incidence rate for intracerebral hemorrhage and subarachnoid hemorrhage was 1.5 cases per 100,000 children (95% confidence interval, 0.4 to 2.3). The incidence rate of all stroke in white children was 2.6 cases per 100,000 (95% confidence interval, 1.2 to 4.1), compared to 3.1 per 100,000 in black children (95% confidence interval, 0 to 6.6). The combined 30-day mortality for intracerebral hemorrhage and subarachnoid hemorrhage was 22% (two of nine) compared to 14% (one of seven) for cerebral infarction. We conclude that in contrast to the picture in adults, hemorrhagic stroke among infants and children is at least as common as ischemic infarction.

Longitudinal assessment of blood pressures in black and white children

The prevalence of hypertension is greater for blacks than whites. Whether black children have higher blood pressure than white children is less clear. We investigated this issue through a prospective longitudinal assessment of blood pressure in 345 white children and 164 black children. Each child had his or her blood pressure measured every 6 months for 2 to 5.5 years. The means for systolic and diastolic blood pressures for each individual were calculated, and the rate of change in blood pressure over time for each subject was estimated. The mean blood pressure and the mean rate were compared between gender-specific black and white groups. For both boys and girls, the mean systolic blood pressure was 2 mm Hg higher in black children than white children (P = .0008). Boys had a higher systolic blood pressure than girls (P = .0048). The mean diastolic blood pressure was 1.5 mm Hg higher in black children than in white children (P = .0270); no significant gender difference in diastolic blood pressure was observed. Age, weight, height, and body mass index were highly correlated with blood pressure. When accounting for these variables, for girls the racial difference in systolic blood pressure remained significant, whereas the difference in diastolic blood pressure in boys and girls was no longer significant. The rate of increase in blood pressure over time was significantly greater in blacks than whites: for systolic blood pressure, P = .0002, and for diastolic blood pressure, P = .009.(ABSTRACT TRUNCATED AT 250 WORDS)

Volume of intracerebral hemorrhage. A powerful and easy-to-use predictor of 30-day mortality

BACKGROUND AND PURPOSE

The aim of this study was to determine the 30-day mortality and morbidity of intracerebral hemorrhage in a large metropolitan population and to determine the most important predictors of 30-day outcome.

METHODS

We reviewed the medical records and computed tomographic films for all cases of spontaneous intracerebral hemorrhage in Greater Cincinnati during 1988. Independent predictors of 30-day mortality were determined using univariate and multivariate statistical analyses.

RESULTS

The 30-day mortality for the 188 cases of intracerebral hemorrhage was 44%, with half of deaths occurring within the first 2 days of onset. Volume of intracerebral hemorrhage was the strongest predictor of 30-day mortality for all locations of intracerebral hemorrhage. Using three categories of parenchymal hemorrhage volume (0 to 29 cm3, 30 to 60 cm3, and 61 cm3 or more), calculated by a quick and easy-to-use ellipsoid method, and two categories of the Glasgow Coma Scale (9 or more and 8 or less), 30-day mortality was predicted correctly with a sensitivity of 96% and a specificity of 98%. Patients with a parenchymal hemorrhage volume of 60 cm3 or more on their initial computed tomogram and a Glasgow Coma Scale score of 8 or less had a predicted 30-day mortality of 91%. Patients with a volume of less than 30 cm3 and a Glasgow Coma Scale score of 9 or more had a predicted 30-day mortality of 19%. Only one of the 71 patients with a volume of parenchymal hemorrhage of 30 cm3 or more could function independently at 30 days.

CONCLUSIONS

Volume of intracerebral hemorrhage, in combination with the initial Glasgow Coma Scale score, is a powerful and easy-to-use predictor of 30-day mortality and morbidity in patients with spontaneous intracerebral hemorrhage.

Intracerebral hemorrhage more than twice as common as subarachnoid hemorrhage

The authors report a study of all instances of spontaneous intracerebral hemorrhage (ICH) (188 cases) and subarachnoid hemorrhage (SAH) (80 cases) that occurred in the Greater Cincinnati area during 1988. Adjusted for age, sex, and race, the annual incidence of ICH was 15 per 100,000 population (95% confidence interval 13 to 17) versus six per 100,000 for SAH (95% confidence interval 5 to 8). The incidence of ICH was at least double that of SAH for women, men, and whites and approximately 1 1/2 times that for blacks. The 30-day mortality rate of 44% for ICH was not significantly different from the 46% mortality rate for SAH. Despite the evidence that ICH is more than twice as common and the disorder just as deadly as SAH, clinical and laboratory research continues to focus primarily on SAH.

Lobar hemorrhage in the elderly. The undiminishing importance of hypertension

BACKGROUND AND PURPOSE

We sought to determine whether hypertension is less common in primary lobar hemorrhage than intracerebral hemorrhage in other locations and whether the frequency of hypertension in lobar hemorrhage diminishes with advancing age.

METHODS

We identified all cases of intracerebral hemorrhage in Greater Cincinnati during 1988 by review of hospital and autopsy records as well as computed tomographic and magnetic resonance scans.

RESULTS

During 1988, 66 primary lobar hemorrhages occurred, constituting 46% of all intracerebral hemorrhages in those under 75 years of age and 34% in those age 75 and older. A history of hypertension was present in 67% of patients with lobar, 73% of those with deep, 73% of those with cerebellar, and 78% of those with pontine hemorrhages. Left ventricular hypertrophy was present in 21% of patients with lobar, 27% of those with deep, and 47% of those with pontine/cerebellar hemorrhages. The frequency of hypertension in patients with lobar hemorrhage did not decrease with advancing age.

CONCLUSIONS

The proportion of all intracerebral hemorrhages that are lobar does not increase with advancing age. Hypertension is nearly as common in primary lobar hemorrhage as in deep, cerebellar, and pontine hemorrhages, and its importance as an associated condition for lobar hemorrhage does not diminish with advancing age.