Intracerebral hemorrhage more than twice as common as subarachnoid hemorrhage

Intracerebral hemorrhage

There is a significant variation in the management of ICH by neurologists, neurosurgeons, and emergency physicians. Most of the randomized clinical therapeutic trials have focused on subarachnoid hemorrhage (SAH) and acute ischemic stroke (AIS). Well-organized practice guidelines are now available for the management of ICH. Exciting research areas are being aggressively explored. Medical and surgical interventions for SAH, AIS, and ICH are always time-dependent, which places additional responsibility on the EP to correctly and promptly recognize these conditions to prevent further injury. The time-dependent care of these patients places the EP on the front lines of future stroke care. Special thanks to Dr. Daniel Woo and Dr. Stewart Wright for their assistance in reviewing the manuscript and Amy Hess for preparation of the manuscript.

Spontaneous intracerebral hemorrhage: epidemiology and clinical presentation

The advent of widespread CT availability has dramatically changed our understanding of the incidence and risk factors regarding intracerebral hemorrhage (ICH). In the pre-CT era, many patients with a small ICH were misclassified having had ischemic strokes and patients with massive ICH or subarachnoid hemorrhage (SAH) were often difficult to classify correctly. The fact that the precise mechanism of spontaneous ICH is often difficult to ascertain without pathologic evidence continues to hamper epidemiologic studies. This article reviews the incidence rates, natural history, epidemiology, and clinical presentations of nontraumatic ICH.

Spontaneous intracerebral hemorrhage: epidemiology, pathophysiology, and medical management

This article introduces the basic epidemiology of intracerebral hemorrhage (ICH) and discusses the current available literature on the pathophysiology of primary ICH, hematoma enlargement, and cerebral edema. The article also includes a brief presentation of the basic steps regarding initial ICH management is presented as a framework for patient care.

Hemoglobin-induced cytotoxicity in rat cerebral cortical neurons: caspase activation and oxidative stress

BACKGROUND AND PURPOSE

Apoptotic-like pathways may contribute to brain cell death after intracerebral hemorrhage. In this study, we used a simplified in vitro model of hemoglobin neurotoxicity to map the caspase cascades involved and to document the role of oxidative stress.

METHODS

Primary neuronal cultures were obtained from rat cerebral cortex and exposed to hemoglobin to induce cell death. Cytotoxicity was assessed via measurements of mitochondrial viability (MTT assay) and lactate dehydrogenase (LDH assay). Activation of caspase-3, -8, and -9 was measured by Western blot and enzyme activity assays. Various caspase inhibitors (zVADfmk, zDEVDfmk, zIETDfmk, and zLEHDfmk) were tested for neuroprotective efficacy. The role of oxidative stress was assessed with the use of U83836E as a potent scavenger of free radicals.

RESULTS

Exposure of primary cortical neurons to hemoglobin induced a dose- and time-dependent cytotoxicity. Western blots showed upregulation of cleaved caspase-3. Enzyme assays showed an increase in caspase-9-like and caspase-3-like activity. However, caspase inhibition did not result in neuroprotection. In contrast, the free radical scavenger U83836E significantly reduced hemoglobin-induced neuronal death. Combination treatment with both U83836E and the broad spectrum caspase inhibitor zVADfmk did not yield additional protection.

CONCLUSIONS

Upstream and downstream caspases were upregulated after hemoglobin-induced neurotoxicity in vitro, but only an antioxidant approach with a potent free radical scavenger significantly improved neuronal survival. These data suggest that in addition to the activation of caspase cascades, parallel pathways of oxidative stress may predominate in this model of hemoglobin neurotoxicity.

Diagnostic imaging for intracerebral hemorrhage

Magnetic resonance imaging (MRI) is an excellent tool for the diagnosis and evaluation of intracerebral hemorrhage with its unique specificity to hemoglobin degradation products in different stages. Computed tomography (CT) remains the diagnostic test of choice in the setting of acute intracerebral hemorrhage because of its exquisite sensitivity and specificity for small amounts of intracerebral hemorrhage (although there is emerging evidence that MRI may be as sensitive as CT). The effects of the biochemical evolution of intracerebral hemorrhage on the temporal MRI signal changes are described. This article discusses imaging features of the common causes of intracerebral hemorrhage.

Intracerebral hemorrhage secondary to vascular lesions

The article reviews intracerebral hemorrhage caused by vascular malformations. The article also reviews incidence, prevalence, and distribution of parenchymal hemorrhage caused by aneurysms, arteriovenous malformations, and cavernous malformations are defined, and less common vascular lesions. There is a discussion of the role of cerebral vascular malformations in producing cerebral hemorrhage in young adults abusing illicit drugs.

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

BACKGROUND AND PURPOSE

Intracerebral hemorrhage (ICH) has a 30-day mortality rate of 40% to 50% and lacks a proven treatment. We report a preplanned, midpoint analysis of the first population-based, case-control study that examines both genetic and environmental risk factors of ICH.

METHODS

We prospectively identified cases of hemorrhagic stroke at all 16 hospitals in the Greater Cincinnati/Northern Kentucky region. All cases underwent medical record and neuroimaging review. Cases enrolled in the direct interview and genetic sampling arm of the study were matched to population-based control subjects by age, race, and sex. Multivariable logistic regression was performed to identify significant independent risk factors.

RESULTS

We enrolled 188 cases of ICH (67 lobar, 121 nonlobar) and 366 control subjects in the direct interview arm of the study. Significant independent risk factors for lobar ICH included the presence of an apolipoprotein E2 or E4 allele, frequent alcohol use, prior stroke, and first-degree relative with ICH. Significant independent risk factors for nonlobar ICH were hypertension, prior stroke, and first-degree relative with ICH. An increasing level of education was associated with a decreased risk of nonlobar ICH. The attributable risk of apolipoprotein E2 or E4 for lobar ICH was 29%, and the attributable risk of hypertension for nonlobar ICH was 54%.

CONCLUSIONS

There is significant epidemiological evidence that the pathophysiology of ICH varies by location. We estimate that a third of all cases of lobar ICH are attributable to possession of an apolipoprotein E4 or E2 allele and that half of all cases of nonlobar ICH are attributable to hypertension.

Sex differences in US mortality rates for stroke and stroke subtypes by race/ethnicity and age, 1995-1998

BACKGROUND AND PURPOSE

Ischemic stroke accounts for 70% to 80% of all strokes, but intracerebral and subarachnoid hemorrhagic strokes have greater fatality. Age-standardized death rates from overall stroke are higher among men than women, but little is known about sex differences in stroke subtype mortality by race/ethnicity.

METHODS

We analyzed 1995 to 1998 national death certificate data to compare sex-specific age-standardized death rates (per 100 000) for ischemic stroke (n=507 256), intracerebral hemorrhagic stroke (n=98 709), and subarachnoid hemorrhagic stroke (n=27 334) among whites, blacks, American Indians/Alaska Natives, Asians/Pacific Islanders, and Hispanics. We calculated rate ratios and 95% CIs comparing women with men within age and racial/ethnic groups.

RESULTS

Age-specific rates of ischemic and intracerebral hemorrhagic stroke deaths were lower for women than for men aged 25 to 44 and 45 to 64 years but were higher for ischemic stroke among older women, aged > or =65 years. Only among whites did women have higher age-standardized rates of ischemic stroke. Age-standardized death rates for intracerebral hemorrhagic stroke among women were lower than or similar to those among men in all racial/ethnic groups. Women had higher risk of death from subarachnoid hemorrhagic; this sex differential increased with age.

CONCLUSIONS

The female-to-male mortality ratio differs for stroke subtypes by race/ethnicity and age. A primary public health effort should focus on increasing the awareness of stroke symptoms, particularly among people at high risk, to decrease delay in early detection and effective stroke treatment.

Subarachnoid hemorrhage: a preventable disease with a heritable component

BACKGROUND AND PURPOSE

Subarachnoid hemorrhage (SAH) caused by ruptured intracranial aneurysm affects approximately 16 000 Americans annually, and almost 40% of affected patients die within 30 days despite the best current therapy. Prevention of SAH is therefore of paramount importance. We present a preliminary analysis of risk factors for SAH from our population-based, case-control study.

METHODS

Cases were prospectively collected and matched 2:1 by age, race, and gender to controls using random digit dialing. Personal risk factor history, family history, neuroimaging data, and genetic samples were obtained. Univariate and bivariate analyses were performed and population-attributable risks estimated. Multivariable analysis was performed using conditional logistic regression.

RESULTS

Between June 1997 and February 2000, 107 cases and 197 controls were enrolled. In bivariate analyses, a large proportion of population-attributable risk for SAH could be explained by modifiable risk factors: smoking, hypertension, and heavy alcohol use. In multivariable analysis, current cigarette smoking, history of hypertension, frequent alcohol use, lower body mass index, and a family history of a relative with SAH or intracranial aneurysm were found to be significant, independent risk factors for SAH.

CONCLUSION

Our data confirm previous reports that SAH clusters within some families independent of environmental risk factors, suggesting that SAH has a significant genetic component. Yet, even among families at increased risk of SAH, smoking cessation, treatment of hypertension, and reduced alcohol intake may substantially decrease SAH risk. The independent associations with heavy alcohol use and low body mass index with SAH may be confounded by smoking and require further study.

Outcome prediction with serum intercellular adhesion molecule-1 levels after aneurysmal subarachnoid hemorrhage

OBJECT

Although upregulated adhesion molecule expression has been demonstrated in experimental models of subarachnoid hemorrhage (SAH) and in the cerebrospinal fluid of patients with aneurysmal SAH, the clinical significance of these proinflammatory findings remains unclear. The authors hypothesize that 1) serum levels of soluble intercellular adhesion molecule-l (ICAM-1) are increased in all patients with aneurysmal SAH shortly after the hemorrhagic event, and 2) elevated soluble ICAM-1 values are associated with poor patient outcome, even when controlling for the severity of the initial hemorrhagic insult.

METHODS

One hundred one patients were prospectively enrolled and stratified according to their admission Hunt and Hess grade and functional status at discharge (modified Rankin Scale [mRS] score). Soluble ICAM-1 levels were determined every other day for 12 days post-SAH by using the enzyme-linked immunosorbent assay. Early soluble ICAM-1 levels (post-SAH Days 2-4) were increased compared with levels in control patients without SAH (p < 0.05). Patients with aneurysmal SAH who had a poor outcome (mRS Grades 4-6) had significantly higher soluble ICAM-1 levels over the first 2 weeks post-SAH compared with patients who had a good outcome (mRS Grades 0-3, p < 0.01). This association with outcome was predicted by late increases (Day 6, p = 0.07; Days 8-12, p < 0.05) rather than early increases (p = not significant) and was best seen in patients with Hunt and Hess Grades I and II. in whom only those with poor outcomes demonstrated delayed ICAM-1 elevations (p < 0.05).

CONCLUSIONS

These data demonstrate a correlation between soluble ICAM-1 levels and functional outcome following aneurysmal SAH that appears to be, at least in part, independent of the initial hemorrhage.

Critical care of intracerebral and subarachnoid hemorrhage

The acute management of primary intracerebral or aneurysmal subarachnoid hemorrhage requires a comprehensive approach involving stabilization of the patient, surgical intervention, and continued intensive care treatment of medical and neurologic complications. The are several causes of intracerebral hemorrhage (ICH), including hypertension, cerebral amyloid angiopathy, sympathomimetic drugs, and coagulopathies. More recently, use of thrombolytic agents in the treatment of acute ischemic stroke has increased the risk of ICH. Treatment of intracerebral hemorrhage is based on blood pressure control, and, in selected cases, surgical evacuation of clot. Patients with aneurysmal subarachnoid hemorrhage may experience rebleeding, symptomatic vasospasm, or hydrocephalus. Medical management in the intensive care unit with careful attention to fluid and electrolyte balance, nutrition, cardiopulmonary monitoring, and close observation for changes in the neurologic exam is vital. This review examines the diagnosis and intensive care management of patients with intracerebral or subarachnoid hemorrhage, and reviews some of the newer therapies for treatment of these disorders.

Comparing stroke rehabilitation outcomes between acute inpatient and nonintense home settings

OBJECTIVE

To compare outcomes in stroke survivors who received rehabilitation services in an acute inpatient rehabilitation setting (multidisciplinary rehabilitation team) with outcomes in survivors in a home-based setting (family caregivers, limited team supervision).

DESIGN

Randomized clinical trial, with mean follow-up after 60 days.

SETTING

Inpatient rehabilitation setting and home-based settings.

PATIENTS

Sixty patients (age range, 43-80yr) who had a stroke between 1996 and 1999 and had been referred after medical stabilization, randomly divided into 2 groups: group 1, inpatient rehabilitation; group 2, home-based rehabilitation.

INTERVENTIONS

Group 1: therapeutical and neuromuscular exercises with occupational therapy with professional supervision; group 2: conventional exercises with family caregiver and limited professional supervision.

MAIN OUTCOME MEASURES

Spasticity was evaluated with the Ashworth Scale, motor status with Brunnstrom's stages, functional status with the FIM instrument, and cognitive status with the Mini-Mental State Examination before and after rehabilitation.

RESULTS

Patients rehabilitated in acute inpatient settings had better motor, functional, and cognitive outcomes (p < .05). Spasticity changes did not differ between the groups.

CONCLUSION

Intense inpatient rehabilitation services for stroke survivors provide significantly more favorable functional and cognitive outcomes with relatively low complications than did nonintense rehabilitation efforts in home settings.

Blood clot resolution in human cerebrospinal fluid: evidence of first-order kinetics

OBJECTIVE

To determine the kinetics of blood clot resolution in human cerebrospinal fluid.

METHODS

Computed tomographic scans of 17 adult patients with intraventricular hemorrhages were analyzed. Intraventricular clot volume was determined and analyzed over time to determine both a standardized percentage rate and an absolute rate of clot resolution. Results were analyzed by use of regression for cross sectional time-series data. To determine the kinetics of intraventricular clot resolution, the effect of the clot volume on the percentage rate of clot resolution, clot half-life, and absolute rate of clot resolution was analyzed. The potential effect of age, sex, type of hemorrhage, and treatment with external ventricular drainage on the percentage rate of clot resolution was assessed.

RESULTS

The percentage rate of clot resolution was 10.8% per day (95% confidence interval, 9.05-12.61 %), and it was independent of initial clot volume, age, sex, type of underlying hemorrhage, and use of external ventricular drainage. The absolute rate of clot resolution varied directly with the maximal clot volume (R2 = 0.88; P < 0.001). The percentage clot resolution data are consistent with events during the first 24 to 48 hours that antagonize clot resolution.

CONCLUSION

These findings demonstrate that intraventricular blood clot resolution in patients with intraventricular hemorrhage follows first-order kinetics. The thrombolytic enzyme system responsible for intraventricular clot resolution seems to be saturated at 24 to 48 hours after the initial hemorrhage.

Risk factors for subarachnoid hemorrhage

OBJECTIVE

Cigarette smoking has been demonstrated to increase the risk of subarachnoid hemorrhage (SAH). Whether cessation of smoking decreases this risk remains unclear. We performed a case-control study to examine the effect of smoking and other known risk factors for cerebrovascular disease on the risk of SAH.

METHODS

We reviewed the medical records of all patients with a diagnosis of SAH (n = 323) admitted to Johns Hopkins Hospital between January 1990 and June 1997. Controls matched for age, sex, and ethnicity (n = 969) were selected from a nationally representative sample of the Third National Health and Nutrition Examination Survey. We determined the independent association between smoking (current and previous) and various cerebrovascular risk factors and SAH by use of multivariate logistic regression analysis. A separate analysis was performed to determine associated risk factors for aneurysmal SAH.

RESULTS

Of 323 patients admitted with SAH (mean age, 52.7+/-14 yr; 93 were men), 173 (54%) were hypertensive, 149 (46%) were currently smoking, and 125 (39%) were previous smokers. In the multivariate analysis, both previous smoking (odds ratio [OR], 4.5; 95% confidence interval [CI], 3.1-6.5) and current smoking (OR, 5.2; 95% CI, 3.6-7.5) were significantly associated with SAH. Hypertension was also significantly associated with SAH (OR, 2.4; 95% CI, 1.8-3.1). The risk factors for 290 patients with aneurysmal SAH were similar and included hypertension (OR, 2.4; 95% CI, 1.8-3.2), previous smoking (OR, 4.1; 95% CI, 2.7-6.0), and current smoking (OR, 5.4; 95% CI, 3.7-7.8).

CONCLUSION

Hypertension and cigarette smoking increase the risk for development of SAH, as found in previous studies. However, the increased risk persists even after cessation of cigarette smoking, which suggests the importance of early abstinence from smoking.

Acute care in neurosurgery: quantity, quality, and challenges

OBJECTIVE

Part of the daily routine in neurosurgery is the treatment of emergency room admissions, and acute cases from other departments or from outside hospitals. This acute care is not normally included in performance figures or budget management, nor analysed scientifically in respect of quantity and quality of care provided by neurosurgeons.

METHOD

Over a 1 year period, all acute care cases managed by two neurosurgical on call teams in a large northern German city, were recorded prospectively on a day by day basis. A large database of 1819 entries was created and analysed using descriptive statistics.

RESULTS

The minimum incidence of patients requiring neurosurgical acute care was estimated to be 75-115/100 000 inhabitants/year. This corresponds to a mean of about 6/day. Only 30% of patients came directly via the emergency room. The fate of 70% of patients depended initially on the "neurosurgical qualification" of primary care doctors and here deficits existed. Although most intracerebral and subarachnoid haemorrhages were managed with the participation of neurosurgeons, they were not involved in the management of most mild and moderate traumatic brain injuries. Within 1 year the additional workload from acute care amounted to 1000 unplanned admissions, 900 acute imaging procedures, and almost 400 emergency operations.

CONCLUSION

The current policy in public health, which includes cuts in resources, transport facilities, and manpower, is not compatible with the demonstrated extent of acute neurosurgical care. In addition to routine elective work, many extra admissions, evening or night time surgery, and imaging procedures have to be accomplished. An education programme for generalists is required to improve overall patient outcome. These conclusions hold special importance if health authorities wish to not only maintain present standards but aim to improve existing deficits.

Trends in incidence and case fatality rates of aneurysmal subarachnoid hemorrhage in Izumo City, Japan, between 1980-1989 and 1990-1998

BACKGROUND AND PURPOSE

With aging of the population, the profile of subarachnoid hemorrhage (SAH) is likely to change; however, evaluation of long-term trends for incidence and case fatality rates of SAH is still limited.

METHODS

We compared the incidence and case fatality rates of aneurysmal SAH during the 9-year period 1990-1998 with those during the 10-year period 1980-1989 in Izumo City, Japan.

RESULTS

During 1980-1989 and 1990-1998, we diagnosed 170 and 188 patients as having aneurysmal SAH, respectively. The percentage of very elderly patients aged >/=80 years increased from 5% (8 patients) during 1980-1989 to 18% (33 patients) during 1990-1998 (P<0.001). The age-specific incidence rate of SAH has a tendency to increase with increasing age. The crude and the age- and sex-adjusted incidence rates using the 1995 population statistics for Japan were 21 and 23 per 100 000/y for all ages during 1980-1989 and 25 and 23 per 100 000/y during 1990-1998, respectively. The 3-month case fatality rate of patients aged </=79 years decreased from 38% during 1980-1989 to 26% during 1990-1998 (P=0.021), whereas the case fatality rates in patients aged >/=80 years were very high (63% and 79%, respectively) regardless of study periods. Consequently, the overall case fatality rates for patients with SAH were similar for the 2 study periods (39% and 36%).

CONCLUSIONS

The age- and sex-adjusted incidence rates of aneurysmal SAH were stable over the 19-year period since 1980 and, despite improvement of outcome in patients aged </=79 years, the overall case fatality rate was not lower because the improvements were counterbalanced by increasing numbers of very elderly patients

Admission to a neurologic/neurosurgical intensive care unit is associated with reduced mortality rate after intracerebral hemorrhage

OBJECTIVE

To determine whether mortality rate after intracerebral hemorrhage (ICH) is lower in patients admitted to a neurologic or neurosurgical (neuro) intensive care unit (ICU) compared to those admitted to general ICUs.

BACKGROUND

The utility of specialty ICUs is debated. From a cost perspective, having fewer larger ICUs is preferred. Alternatively, the impact of specialty ICUs on patient outcome is unknown. Patients with ICH are admitted routinely to both general and neuro ICUs and provide an opportunity to address this question.

SETTING

Forty-two neuro, medical, surgical, and medical-surgical ICUs.

MEASUREMENTS AND MAIN RESULTS

The study was an analysis of data prospectively collected by Project Impact over 3 yrs from 42 participating ICUs (including one neuro ICU) across the country. The records of 36,986 patients were merged with records of 3,298 patients from a second neuro ICU that collected the same data over the same period. The impact of clinical (age, race, gender, Glasgow Coma Scale score, reason for admission, insurance), ICU (size, number of ICH patients, full-time intensivist, clinical service, American College for Graduate Medical Education or Critical Care Medicine fellowship), and institutional (size, location, medical school affiliation) characteristics on hospital mortality rate of ICH patients was assessed by using a forward-enter multivariate analysis. Data from 1,038 patients were included. The 13 ICUs that admitted >20 patients accounted for 83% of the admissions with a mortality rate that ranged from 25% to 64%. Multivariate analysis adjusted for patient demographics, severity of ICH, and ICU and institutional characteristics indicated that not being in a neuro ICU was associated with an increase in hospital mortality rate (odds ratio [OR], 3.4; 95% confidence interval [CI], 1.65-7.6). Other factors associated with higher mortality rate were greater age (OR, 1.03/year; 95% CI, 1.01-1.04), lower Glasgow Coma Scale score (OR, 0.6/point; 95% CI, 0.58-0.65), fewer ICH patients (OR, 1.01/patient; 95% CI, 1.00-1.01), and smaller ICU (OR, 1.1/bed; 95% CI, 1.02-1.13). Having a full time intensivist was associated with lower mortality rate (OR, 0.388; 95% CI, 0.22-0.67).

CONCLUSIONS

For patients with acute ICH, admission to a neuro vs. general ICU is associated with reduced mortality rate.

The benefit of an acute stroke unit in patients with intracranial haemorrhage: a controlled trial

OBJECTIVES

Patients with stroke receiving organised inpatient (stroke unit) care after stroke are more likely to be alive and independent compared with patients offered conventional care. The objective was to determine the effect of an acute stroke unit on patients with primary intracranial haemorrhage.

METHODS

In a prospective controlled study, the effect of an acute stroke unit was examined on 30 day and 1 year mortality in patients with primary intracranial haemorrhage. Patients treated in general medical wards served as controls.

RESULTS

Of 121 patients included, 56 were allocated to an acute stroke unit and 65 to a general medical ward. The 30 day mortality rate was 39% in the acute stroke unit compared with 63% in the general medical wards, and the 1 year mortality rates were 52% and 69%, respectively. There was a difference between the 30 day and 1 year survival curves between the groups (p=0.007 and 0.013, respectively); however, there was no difference in survival between 30 and 365 days. There was no difference in risks of being discharged home or to long term care between the groups.

CONCLUSIONS

In this study admission to an acute stroke unit reduced mortality 30 days and 1 year after primary intracranial haemorrhage, which could be attributed to a large difference in survival during the first 30 days.

The ICH score: a simple, reliable grading scale for intracerebral hemorrhage

BACKGROUND AND PURPOSE

Intracerebral hemorrhage (ICH) constitutes 10% to 15% of all strokes and remains without a treatment of proven benefit. Despite several existing outcome prediction models for ICH, there is no standard clinical grading scale for ICH analogous to those for traumatic brain injury, subarachnoid hemorrhage, or ischemic stroke.

METHODS

Records of all patients with acute ICH presenting to the University of California, San Francisco during 1997-1998 were reviewed. Independent predictors of 30-day mortality were identified by logistic regression. A risk stratification scale (the ICH Score) was developed with weighting of independent predictors based on strength of association.

RESULTS

Factors independently associated with 30-day mortality were Glasgow Coma Scale score (P<0.001), age >/=80 years (P=0.001), infratentorial origin of ICH (P=0.03), ICH volume (P=0.047), and presence of intraventricular hemorrhage (P=0.052). The ICH Score was the sum of individual points assigned as follows: GCS score 3 to 4 (=2 points), 5 to 12 (=1), 13 to 15 (=0); age >/=80 years yes (=1), no (=0); infratentorial origin yes (=1), no (=0); ICH volume >/=30 cm(3) (=1), <30 cm(3) (=0); and intraventricular hemorrhage yes (=1), no (=0). All 26 patients with an ICH Score of 0 survived, and all 6 patients with an ICH Score of 5 died. Thirty-day mortality increased steadily with ICH Score (P<0.005).

CONCLUSIONS

The ICH Score is a simple clinical grading scale that allows risk stratification on presentation with ICH. The use of a scale such as the ICH Score could improve standardization of clinical treatment protocols and clinical research studies in ICH.

Primary intracerebral and aneurysmal subarachnoid hemorrhage in Izumo City, Japan. Part II: management and surgical outcome

OBJECT

The purpose of this study was to assess the overall management and surgical outcome of primary intracerebral hemorrhage (ICH) and aneurysmal subarachnoid hemorrhage (SAH) among the 85,000 residents of Izumo City, Japan.

METHODS

During 1991 through 1996, 267 patients with ICH and 123 with SAH were treated in Izumo. Of the 267 patients with ICH, 25 underwent hematoma removal by open craniotomy or suboccipital craniectomy and 34 underwent stereotactic evacuation of the hematoma, whereas aneurysm clipping was performed in 71 of the 123 patients with SAH; operability rates were thus 22% for ICH and 58% for SAH (p < 0.0001). The overall 30-day survival rates were 86% for ICH and 66% for SAH (p < 0.0001) and the 2-year survival rates were 73% and 62% (p = 0.0207), respectively. In patients who underwent surgery, 30-day and 2-year survival rates were 93% for ICH and 100% for SAH (p = 0.0262), and 75% for ICH and 97% for SAH (p = 0.0002), respectively. In patients with ICH, the most important predictors of 30-day case-fatality rates were the volume of the hematoma, the Glasgow Coma Scale (GCS) score, rebleeding, and midline shifting, whereas those for 2-year survival were the GCS score, age, rebleeding, and hematoma volume. In patients with SAH, the most important determinants of 30-day case-fatality rates were the GCS score and age, whereas only the GCS score had a significant impact on 2-year survival.

CONCLUSIONS

The overall survival rates for patients with ICH or SAH in Izumo were more favorable than those in previously published epidemiological studies. However, despite improved surgical results, the overall management of ICH and SAH still produced an unsatisfactory outcome, mainly because of primary brain damage.

Primary intracerebral and aneurysmal subarachnoid hemorrhage in Izumo City, Japan. Part I: incidence and seasonal and diurnal variations

OBJECT

The purpose of this community-based study was first to estimate the incidence rates of primary intracerebral hemorrhage (ICH) and aneurysmal subarachnoid hemorrhage (SAH) in Izumo City, Japan, and second to investigate whether there were seasonal and diurnal periodicities in their onset.

METHODS

During 1991 through 1996, 267 patients with primary ICH and 123 with aneurysmal SAH were treated in Izumo City. The crude and the age- and sex-adjusted annual incidence rates per 100,000 population for all ages were 52 and 48 for ICH and 24 and 23 for SAH, respectively. These incidence rates were higher than those previously published for any other geographical region. The incidence rates of both ICH and SAH increased almost linearly with age. For ICH, a significant seasonal pattern was observed in men and in patients younger than 65 years, with a peak in winter and a trough in summer. However, no significant seasonal fluctuation was found in women or in individuals aged 65 years or older. There was no significant seasonal periodicity for SAH, even when patients were analyzed according to sex and age. Diurnal variations in the onset of both ICH and SAH were significant (except in men with SAH), with a nadir between midnight and 6:00 a.m.

CONCLUSIONS

The actual incidence rates of both primary ICH and aneurysmal SAH seem to be much higher than have been reported so far. In addition, the data indicate the existence of seasonal periodicity for men and younger patients with ICH, and that the risk of both ICH and SAH is lower during nighttime.

Estimate of the maximum time interval between formation of cerebral aneurysm and rupture

The recent publication of the results of the international study on unruptured intracranial aneurysms highlighted a paradox: there do not seem to be enough unruptured aneurysms in the population to account for the observed incidence of subarachnoid haemorrhage. Some authors have suggested that the answer to this paradox is that most aneurysms that bleed do so shortly after formation. This would mean that the bulk of subarachnoid haemorrhages come from recently formed rather than long standing aneurysms. This paradox and proposed answer are examined. The available statistics on the incidence of subarachnoid haemorrhage, the prevalence of unruptured aneurysms, and the risk of bleeding from unruptured aneurysms are used to place a maximum on the time interval between aneurysm formation and rupture. For aneurysms less than 10 mm in diameter in persons with no history of subarachnoid haemorrhage, an estimate of less than 42 weeks was made. The null hypothesis that such aneurysms pose a constant risk with time is rejected with p <10(-9). In larger aneurysms the risk seems to be constant with time.

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.

Natural history of unruptured intracranial aneurysms: probability of and risk factors for aneurysm rupture

OBJECT

The authors conducted a study to investigate the long-term natural history of unruptured intracranial aneurysms and the predictive risk factors determining subsequent rupture in a patient population in which surgical selection of cases was not performed.

METHODS

One hundred forty-two patients with 181 unruptured aneurysms were followed from the 1950s until death or the occurrence of subarachnoid hemorrhage or until the years 1997 to 1998. The annual and cumulative incidence of aneurysm rupture as well as several potential risk factors predictive of rupture were studied using lifetable analyses and Cox's proportional hazards regression models including time-dependent covariates. The median follow-up time was 19.7 years (range 0.8-38.9 years). During 2575 person-years of follow up, there were 33 first-time episodes of hemorrhage from previously unruptured aneurysms, for an average annual incidence of 1.3%. In 17 patients, hemorrhage led to death. The cumulative rate of bleeding was 10.5% at 10 years, 23% at 20 years, and 30.3% at 30 years after diagnosis. The diameter of the unruptured aneurysm (relative risk [RR] 1.11 per mm in diameter, 95% confidence interval [CI] 1-1.23, p = 0.05) and patient age at diagnosis inversely (RR 0.97 per year, 95% CI 0.93-1, p = 0.05) were significant independent predictors for a subsequent aneurysm rupture after adjustment for sex, hypertension, and aneurysm group. Active smoking status at the time of diagnosis was a significant risk factor for aneurysm rupture (RR 1.46, 95% CI 1.04-2.06, p = 0.033) after adjustment for size of the aneurysm, patient age, sex, presence of hypertension, and aneurysm group. Active smoking status as a time-dependent covariate was an even more significant risk factor for aneurysm rupture (adjusted RR 3.04, 95% CI 1.21-7.66, p = 0.02).

CONCLUSIONS

Cigarette smoking, size of the unruptured intracranial aneurysm, and age, inversely, are important factors determining risk for subsequent aneurysm rupture. The authors conclude that such unruptured aneurysms should be surgically treated regardless of their size and of a patient's smoking status, especially in young and middle-aged adults, if this is technically possible and if the patient's concurrent diseases are not contraindications. Cessation of smoking may also be a good alternative to surgery in older patients with small-sized aneurysms.

Epidemiology of aneurysmal subarachnoid hemorrhage in Australia and New Zealand: incidence and case fatality from the Australasian Cooperative Research on Subarachnoid Hemorrhage Study (ACROSS)

BACKGROUND AND PURPOSE

More data on the epidemiology of subarachnoid hemorrhage (SAH) are required to increase our understanding of etiology and prevention. This study sought to determine the incidence and case fatality of SAH from 4 prospective, population-based registers in Australia and New Zealand.

METHODS

We identified all cases of "aneurysmal" SAH from November 1995 to June 1998 in Adelaide, Hobart, Perth (Australia), and Auckland (New Zealand), a total population of approximately 2.8 million, using standard diagnostic criteria and uniform community-wide surveillance and data extraction procedures.

RESULTS

A total of 436 cases of SAH were registered, including 432 first-ever events and 4 recurrent events. The mean age of cases was 57 years (range, 16 to 94 years), and 62% were female. From the 400 first-ever events registered over whole years, the crude annual incidence for the total population was 8.1 per 100 000 (95% CI, 7.4, 9.0), with rates higher for females (9. 7; 95% CI, 8.6, 11.0) than for males (6.5; 95% CI, 5.5, 7.6). Age-specific rates showed a continuous upward trend with age, although the shape and strength of this association differed between the sexes. Standardized annual incidence of SAH varied across centers, being highest in Auckland largely because of the high rate in Maori and Pacific people. The 28-day case fatality rate for the total population was 39% (95% CI, 34%, 44%), with little variation in ratios across centers.

CONCLUSIONS

There is variation in the incidence of SAH in Australia and New Zealand, but the rates are consistently higher for females. A monotonic increase in incidence with age suggests that exposures with cumulative effects and long induction times may be less relevant in the etiology of SAH.

Stroke in African Americans

There is an excess burden of cerebrovascular disease in African Americans. This article will define possible reasons for excess stroke risk, review racial differences in stroke subtype and stroke prevention programs in the African American Community, and delineate sequelae of stroke. The authors provide insights about stroke prevention in African Americans and highlight challenges to reduce the burden of cerebrovascular disease in this high-risk group.

Intracerebral hemorrhage

Intracerebral hemorrhage (ICH) represents a significant fraction of all strokes and causes a disproportionate amount of stroke related morbidity and mortality, especially in young blacks. While diagnosis of this disorder has greatly improved in the CT era, morbidity and mortality remain essentially unchanged. Not one currently utilized therapeutic modality has been clearly associated with a beneficial effect on long term outcome in small prospective randomized treatment trials for ICH. In spite of the lack of scientific data regarding therapy, patients often require aggressive medical and surgical intervention because of the life-threatening presentation of many patients. Recent clinical and experimental ICH research has identified a number of potentially effective new therapeutic strategies, and time to treatment is likely to be very important as it is for ischemic stroke. Large prospective, randomized, placebo controlled trials to examine the judicious application of current therapeutic modalities, and to investigate the potential benefit of proposed new treatment modalities, are long overdue.

Decreased perihematomal edema in thrombolysis-related intracerebral hemorrhage compared with spontaneous intracerebral hemorrhage

BACKGROUND AND PURPOSE

Intracerebral hemorrhage (ICH) is a highly morbid disease process. Perihematomal edema is reported to contribute to clinical deterioration and death. Recent experimental observations indicate that clotting of the intrahematomal blood is the essential prerequisite for hyperacute perihematomal edema formation rather than blood-brain barrier disruption.

METHODS

We compared a series of patients with spontaneous ICH (SICH) to a series of patients with thrombolysis-related ICH (TICH). All patients were imaged within 3 hours of clinical onset. We reviewed relevant neuroimaging features, emphasizing and quantifying perihematomal edema. We then analyzed clinical and radiological differences between the 2 ICH types and determined whether these factors were associated with perihematomal edema.

RESULTS

TICHs contained visible perihematomal edema less than half as often as SICHs (31% versus 69%, P<0.001) and had both lower absolute edema volumes (0 cc [25th, 75th percentiles: 0, 6] versus 6 cc [0, 13], P<0.0001) and relative edema volumes (0.16 [0.10, 0.33] versus 0.55 [0.40, 0.83], P<0.0001). Compared with SICHs, TICHs were 3 times larger in volume (median [25th, 75th percentiles] volume 69 cc [30, 106] versus 21 cc [8, 45], P<0.0001), 4 times more frequently lobar in location (62% versus 15%, P<0.001), 80 times more frequently contained blood-fluid level(s) (86% versus 1%, P<0.001), and were more frequently multifocal (22% versus 0%, P<0.001).

CONCLUSIONS

The striking qualitative and quantitative lack of perihematomal edema observed in the thrombolysis-related ICHs compared with the SICHs provides the first substantial, although indirect, human evidence that intrahematomal blood clotting is a plausible pathogenetic factor in hyperacute perihematomal edema formation.

Diffusion-weighted MRI and proton MR spectroscopic imaging in the study of secondary neuronal injury after intracerebral hemorrhage

BACKGROUND AND PURPOSE

Cerebral ischemia has been proposed as contributing mechanism to secondary neuronal injury after intracerebral hemorrhage (ICH). Possible tools for investigating this hypothesis are diffusion-weighted (DWI) and proton magnetic resonance spectroscopic imaging ((1)H-MRSI). However, magnetic field inhomogeneity induced by paramagnetic blood products may prohibit the application of such techniques on perihematoma tissue. We report on the feasibility of DWI and (1)H-MRSI in the study of human ICH and present preliminary data on their contribution to understanding perihematoma tissue functional and metabolic profiles.

METHODS

Patients with acute supratentorial ICH were prospectively evaluated using DWI and (1)H-MRSI. Obscuration of perihematoma tissue with both sequences was assessed. Obtainable apparent diffusion coefficient (Dav) and lactate spectra in perihematoma brain tissue were recorded and analyzed.

RESULTS

Nine patients with mean age of 63.4 (36 to 87) years were enrolled. Mean time from symptom onset to initial MRI was 3.4 (1 to 9) days; mean hematoma volume was 35.4 (5 to 80) cm(3). Perihematoma diffusion values were attainable in 9 of 9 patients, and (1)H-MRSI measures were obtainable in 5 of 9 cases. Dav in perihematoma regions was 172.5 (120.0 to 302.5)x10(-5) mm(2)/s and 87.6 (76.5 to 102.1)x10(-5) mm(2)/s in contralateral corresponding regions of interest (P=0.002). One patient showed an additional area of reduced Dav with normal T(2) intensity, which suggests ischemia. (1)H-MRSI revealed lactate surrounding the hematoma in 2 patients.

CONCLUSIONS

DWI and (1)H-MRSI can be used in the study of ICH patients. Our preliminary data are inconsistent with ischemia as the primary mechanism for perihematoma tissue injury. Further investigation with advanced MRI techniques will give a clearer understanding of the role that ischemia plays in tissue injury after ICH.

Plasma endothelin concentrations after aneurysmal subarachnoid hemorrhage

OBJECT

The pathogenesis of cerebral vasospasm and delayed ischemia after subarachnoid hemorrhage (SAH) seems to be complex. An important mediator of chronic vasospasm may be endothelin (ET), with its powerful and long-lasting vasoconstricting activity. In this study the author investigated the correlation between serial plasma concentrations of ET and ischemic symptoms, angiographically demonstrated evidence of vasospasm, and computerized tomography (CT) findings after aneurysmal SAH.

METHODS

Endothelin-1 immunoreactivity in plasma was studied in 70 patients with aneurysmal SAH and in 25 healthy volunteers by using a double-antibody sandwich-enzyme immunoassay (immunometric) technique. On the whole, mean plasma ET concentrations in patients with SAH (mean +/- standard error of mean, 2.1 +/- 0.1 pg/ml) did not differ from those of healthy volunteers (1.9 +/- 0.2 pg/ml). Endothelin concentrations were significantly higher (p < 0.05) in patients who experienced delayed cerebral ischemia with fixed neurological deficits compared with those in other patients (post-SAH Days 0-5, 3.1 +/- 0.8 pg/ml compared with 2.1 +/- 0.2 pg/ml; post-SAH Days 6-14, 2.5 +/- 0.4 pg/ml compared with 1.9 +/- 0.2 pg/ml). Patients with angiographic evidence of severe vasospasm also had significantly (p < 0.05) elevated ET concentrations (post-SAH Days 0-5, 3.2 +/- 0.8 pg/ml; post-SAH Days 6-14, 2.7 +/- 0.5 pg/ml) as did those with a cerebral infarction larger than a lacuna on the follow-up CT scan (post-SAH Days 0-5, 3.1 +/- 0.8 pg/ml; post-SAH Days 6-14, 2.5 +/- 0.4 pg/ml) compared with other patients. Patients in whom angiography revealed diffuse moderate-to-severe vasospasm had significantly (p < 0.05) higher ET levels than other patients within 24 hours before or after angiography (2.6 +/- 0.3 compared with 1.9 +/- 0.2 pg/ml). In addition, patients with a history of hypertension or cigarette smoking experienced cerebral infarctions significantly more often than other patients, although angiography did not demonstrate severe or diffuse vasospasm more often in these patients than in others.

CONCLUSIONS

Endothelin concentrations seem to correlate with delayed cerebral ischemia and vasospasm after SAH. The highest levels of ET are predictive of the symptoms of cerebral ischemia and vasospasm, and ET may also worsen ischemia in patients with a history of hypertension. Thus, ET may be an important causal or contributing factor to vasospasm, but its significance in the pathogenesis of vasospasm remains unknown.

Results in 95 hemorrhagic stroke patients included in CLASS, a controlled trial of clomethiazole versus placebo in acute stroke patients

BACKGROUND AND PURPOSE

Clomethiazole is a neuroprotective drug that enhances gamma-aminobutyrate type A (GABA(A)) receptor activity. Its efficacy and safety were tested in the CLomethiazole Acute Stroke Study (CLASS). The protocol allowed a CT scan to be done after randomization but within 7 days of stroke onset to minimize delays before start of treatment. Ninety-five of the 1360 patients randomized were diagnosed as having intracranial hemorrhage rather than ischemic stroke. Safety results for clomethiazole compared with placebo in this group are reported.

METHODS

The study included patients with a clinical diagnosis of acute hemispheric cerebral infarction. Treatment was a 24-hour intravenous infusion of 75 mg/kg clomethiazole or placebo. Patients with intracranial hemorrhage discovered on a postrandomization CT were withdrawn from study treatment if treatment was ongoing, and all patients were followed up to 90 days.

RESULTS

Ninety-four patients received treatment, 47 in each group. The hemorrhage was classified as intracerebral in 89 patients (94%). Mortality at 90 days was 19.1% in the clomethiazole group and 23.4% in the placebo group. Sedation was the most common adverse event, occurring at a higher incidence in clomethiazole-treated patients (clomethiazole 53%, placebo 17%), followed by rhinitis and coughing. The incidence and pattern of serious adverse events was similar between the treatment groups. The percentage of patients reaching relative functional independence on the Barthel Index (score >/=60) at 90 days was 59.6% in the clomethiazole group and 53.2% in the placebo group.

CONCLUSIONS

Clomethiazole appears safe to administer to hemorrhagic stroke patients compared with placebo. These results would obviate the need for a CT scan before therapy is initiated in acute stroke. The safety of clomethiazole in hemorrhagic stroke patients will be further evaluated in a prospective study that is under way in North America.

Early surgical treatment for supratentorial intracerebral hemorrhage: a randomized feasibility study

BACKGROUND AND PURPOSE

The safety and the effectiveness of the surgical treatment of spontaneous intracerebral hemorrhage (ICH) remain controversial. To investigate the feasibility of urgent surgical evacuation of ICH, we conducted a small, randomized feasibility study of early surgical treatment versus current nonoperative management in patients with spontaneous supratentorial ICH.

METHODS

Patients with spontaneous supratentorial ICH who presented to 1 university and 2 community hospitals were randomized to surgical treatment or best medical treatment. Principal eligibility criteria were ICH volume >10 cm(3) on baseline CT scan with a focal neurological deficit, Glasgow Coma Scale score >4 at the time of enrollment, randomization and therapy within 24 hours of symptom onset, surgery within 3 hours of randomization, and no evidence for ruptured aneurysm or arteriovenous malformation. The primary end point was the 3-month Glasgow Outcome Scale (GOS). A good outcome was defined as a 3-month GOS score >3.

RESULTS

Twenty patients were randomized over 24 months, 9 to surgical intervention and 11 to medical treatment. The median time from onset of symptoms to presentation at the treating hospitals was 3 hours and 17 minutes, the time from randomization to surgery was 1 hour and 20 minutes, and the time from onset of symptoms to surgery was 8 hours and 35 minutes. The likelihood of a good outcome (primary outcome measure: GOS score >3) for the surgical treatment group (56%) did not differ significantly from the medical treatment group (36%). There was no significant difference in mortality at 3 months. Analysis of the secondary 3-month outcome measures showed a nonsignificant trend toward a better outcome in the surgical treatment group versus the medical treatment group for the median GOS, Barthel Index, and Rankin Scale and a significant difference in the National Institutes of Health Stroke Scale score (4 versus 14; P=0.04).

CONCLUSIONS

Very early surgical treatment for acute ICH is difficult to achieve but feasible at academic medical centers and community hospitals. The trend toward less 3-month morbidity with surgical intervention in patients with spontaneous supratentorial ICH warrants further investigation of very early clot removal in larger randomized clinical trials.

Intraventricular Hemorrhage in Adults

Intraventricular hemorrhage (IVH) in adults usually occurs in the setting of aneurysmal subarachnoid hemorrhage or hypertension-related intracerebral hemorrhage. Thus, the underlying cause of IVH is apparent from history and radiographic findings. If the underlying cause of IVH is not apparent, additional studies, including cerebral angiography, magnetic resonance imaging, and toxicology screening, should be performed to identify etiologic agents that may alter management of IVH. Management of IVH is thus done amidst (and must be tempered by) the multiple pharmacologic, surgical, and critical care interventions directed toward the diagnosis and treatment of the underlying cause of IVH. The most immediate threat to life posed by IVH is the development of acute obstructive hydrocephalus. If the hydrocephalus is contributing to a neurologic decline, it must be treated emergently with external ventricular drainage (EVD) through an intraventricular catheter (IVC). The patient with IVH should be evaluated and treated for deficient clotting function before an IVC is inserted. For this purpose, clotting function can be adequately assessed by prothrombin and partial thromboplastin times. Insertion of an IVC may significantly lower intracranial pressure, increasing the transmural pressure difference across the wall of a ruptured cerebral aneurysm and precipitating rerupture of the aneurysm. Therefore, with IVH secondary to a ruptured cerebral aneurysm, it is advisable to delay treatment of hydrocephalus that is not contributing to a neurologic decline until the aneurysm is repaired. Hydrocephalus contributing to significant neurologic decline in the setting of a ruptured aneurysm must be treated immediately despite the unprotected status of the aneurysm. Extreme diligence must be used to allow for the slow, controlled release of cerebrospinal fluid after IVC insertion. This will mitigate the effects of increasing the transmural pressure gradient across the wall of the ruptured aneurysm. In the patient with a neurologic deficit who has IVH-related hydrocephalus and an associated intracerebral hemorrhage, it is best to assume that the hydrocephalus is a significant contributor to the deficit and that it should be treated with EVD. An IVH that is not causing hydrocephalus but is apparently occluding one or both foramina of Monro or the third ventricle should be treated with EVD because obstructive hydrocephalus may develop precipitously and, if unrecognized, may cause irreversible brain damage or death. An IVH that is not likely to cause hydrocephalus because of small volume relative to its location can be followed expectantly. Intraventricular injections of thrombolytic agents through an IVC is a treatment option that may be considered in all patients with IVH that is causing or threatening to cause obstructive hydrocephalus. Unrepaired cerebral aneurysms, untreated cerebral arteriovenous malformations, and clotting disorders are contraindications for this intervention. The surgical evacuation of IVH has a role only in very rare cases in which the IVH is causing a significant mass effect independent of hydrocephalus and associated intraparenchymal brain hemorrhage.

Determinants of 30-day mortality of spontaneous intracerebral hemorrhage in Pakistan

BACKGROUND

The present study was undertaken to evaluate the determinants of acute (30-day) mortality after spontaneous intracerebral hemorrhage (ICH) in a developing country setting, and to compare these findings with those available from studies conducted in the West.

METHODS

Medical records of 146 patients admitted to a major tertiary hospital in Karachi, Pakistan between 1990 and 1991 with a diagnosis of spontaneous ICH were reviewed. The level and intensity of care provided to these patients was similar to that available at modern neurosurgical centers. The salient prognostic indicators that were studied included hypertension, pulse pressure, GCS score, neurologic deficits, and CT-scan predictors including site, size, and intraventricular spread of hemorrhage. These data were used to determine independent predictors of 30-day mortality by univariate and multivariate analysis. Additionally, 30-day survival probabilities for these outcome predictors were also computed.

RESULTS

The 30-day mortality after spontaneous ICH was 39.7%. Two-thirds of the patients had a history of hypertension. The important clinical predictors at the multivariate level included GCS score < or =8 and progressive increase in pulse pressure. The CT scan predictors included intraventricular spread of hemorrhage, ventricular enlargement, and size of the bleed. Location of the lesion did not appear to significantly influence mortality. Survival analysis showed a large clustering of deaths within the first 72 hours of hospitalization.

CONCLUSIONS

The 30-day mortality rate and prognostic predictors for spontaneous intracerebral hemorrhage were found to be similar to those reported in the Western hemisphere. However, the correlation of incremental increase in pulse pressure with deteriorating prognosis was a new and significant finding.

Cerebral aneurysms in the elderly in Yamaguchi, Japan. Analysis of the Yamaguchi Data Bank of Cerebral Aneurysm from 1985 to 1995

BACKGROUND AND PURPOSE

The number of elderly people is markedly increasing in Japan. We have investigated the epidemiology and management outcome of cerebral aneurysms in elderly patients aged > or = 70 years.

METHODS

A total of 3100 patients were enrolled in the Yamaguchi Data Bank of Cerebral Aneurysm between 1985 and 1995. Of these, 598 with ruptured cerebral aneurysms and 120 with unruptured cerebral aneurysms were elderly (ie, aged > or = 70 years).

RESULTS

The number of elderly patients with cerebral aneurysms has markedly increased since 1991, and in 1995 approximately 30% of all patients with cerebral aneurysms were elderly. In cases of ruptured cerebral aneurysms, the proportion of patients with severe neurological grade did not change and that with an unfavourable outcome did not decrease throughout the 11 years. The proportion of patients with severe neurological grade in the elderly group was higher than in the younger group (< 70 years), and the management outcome of elderly patients for each neurological grade on admission was worse than that of younger patients (P < .01). However, the incidence rate of symptomatic cerebral vasospasm and rebleeding was the same for the two age groups. Eventually, 60.4% of all elderly patients with ruptured cerebral aneurysms had an unfavorable outcome. In cases of unruptured cerebral aneurysms, 63.3% of the selected elderly patients were surgically treated, and the surgical morbidity and mortality rates were 26.3% and 4.0%, respectively. These rates were nonsignificantly higher than those for younger patients.

CONCLUSIONS

The number of elderly patients with cerebral aneurysms has markedly increased in Yamaguchi. Because of the unsatisfactory management outcome of ruptured cerebral aneurysms and surgical outcome of unruptured cerebral aneurysms in elderly patients during the 11-year period, we propose the treatment of unruptured cerebral aneurysms at a younger age and the use of a screening system to detect these subjects.

Relationship between age and mortality due to intracerebral versus subarachnoid hemorrhage

This cross-sectional study compares trends in mortality by age for intracerebral and subarachnoid hemorrhage. United States mortality data from the Centers for Disease Control from the years 1991 to 1992 are examined with the program CDC Wonder, and mortality rates for 10-year age groups for each disease are compared. As expected, the crude mortality rate attributable to intracerebral hemorrhage, at 7.1 per 100,000, is much greater than that of subarachnoid hemorrhage, at 2.7 per 100,000. However, the age distribution of this mortality is found to be very different in the two conditions (chi(2), P<.0001), with a younger population affected by subarachnoid hemorrhage. This difference is even more pronounced in earlier United States mortality data from 1979 to 1980. This has important implications for epidemiological studies of hemorrhagic stroke as a whole.

Hemostasis and fibrinolysis activation after subarachnoid hemorrhage

The authors assessed hemostasis and fibrinolysis serially: on admission and on the 1st and 7th days after surgery for subarachnoid hemorrhage (SAH), examining the complications of aneurysm rupture and its surgical repair. Of 32 patients, 25 with SAH were compared with seven control patients who underwent surgery for an unruptured intracranial aneurysm. On admission, patients with SAH had higher thrombin-antithrombin III complex (TAT) levels (13.3 +/- 3.8 vs. 3.8 +/- 0.6 ng/ml, p = 0.01), fibrin degradation product, D-dimer levels (1310 +/- 220 vs. 556 +/- 89 ng/ml, p = 0.0001), and leukocyte counts (14.6 +/- 0.7 vs. 10.6 +/- 1.8 x 10(9) cells/L, p < 0.05) than did control patients. Postoperative D-dimer values (p = 0.007) remained higher in the SAH group. Furthermore, admission D-dimer levels were higher in the patients in poor clinical condition than in those in good condition (2017 +/- 377 vs. 934 +/- 208 ng/ml, p = 0.007), and D-dimer levels were associated with the outcome at 3 months after admission. Additionally, thrombin generation and fibrinolytic markers measured on admission were related to clinical grade, amount of subarachnoid blood seen on computerized tomography (CT) scanning, and patient fatality. Patients with hypodense lesions verified on follow-up CT scanning or with persistent neurological deficits at 3 months had higher prothrombin fragments 1 and 2, TAT, D-dimer, and plasminogen activator inhibitor-1 values on the 1st day postoperatively than did patients without such lesions. In short, in patients with SAH, activation of coagulation and fibrinolysis was strongly associated with clinical state, patient fatality, and outcome at 3 months, and postoperatively this activation correlated with the development of brain infarction.

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.

Intracerebral hemorrhage in blacks. Risk factors, subtypes, and outcome

BACKGROUND AND PURPOSE

Blacks are at a higher risk for intracerebral hemorrhage (ICH) than whites; however, few data are available regarding the demographic and clinical characteristics of ICH among blacks.

METHODS

We determined the frequency of risk factors, etiologic subtypes, and outcome among consecutive black patients admitted with nontraumatic ICH to a university-affiliated public hospital.

RESULTS

The most common risk factors in the 403 black patients with ICH were preexisting hypertension (77%), alcohol use (40%), and smoking (30%). Among the 91 nonhypertensive patients, 21 (23%) were diagnosed with hypertension after onset. Compared with women, men had a younger age of onset (54 versus 60 years; P < .001) and higher frequency of alcohol use (54% versus 22%; P < .001) and smoking (39% versus 17%; P < .001). ICH secondary to hypertension (n = 311) and of undetermined etiology (n = 73) were the most common subtypes in blacks. Patients aged 65 years and older (compared with those aged 15 to 44 years; P = .001) and women (compared with men; P = .02) were more likely to be dependent at discharge.

CONCLUSIONS

Primary preventive strategies are required to reduce the high frequency of modifiable risk factors predisposing to ICH in blacks.

Hospitalization and case-fatality rates for subarachnoid hemorrhage in Canada from 1982 through 1991. The Canadian Collaborative Study Group of Stroke Hospitalizations

BACKGROUND AND PURPOSE

Subarachnoid hemorrhage (SAH) has a different epidemiological profile from other types of stroke and a different etiology. Although there has been a general decline in overall stroke incidence since the 1950s, secular trends for SAH have been modest. In contrast to other stroke types, changes in incidence over the last few decades have been less clear. The purpose of this study was to estimate hospitalization and case-fatality rates of SAH according to age, sex, calendar year, and season.

METHODS

Data were obtained for each of Canada's 10 provinces for the 10 fiscal years 1982 through 1991. All hospitalizations of persons 15 years of age or older with a primary diagnosis at discharge coded 430 according to the International Classification of Diseases, 9th Revision, were included. Rates of SAH per 100,000 population were calculated for men and women for 5-year age groups, by calendar year, and by season. Annual age- and sex-specific (hospital) case-fatality rates up to 30 days were also calculated. Additionally, hospital deaths from this study were related to national SAH mortality statistics.

RESULTS

A total of 14145 women and 8995 men were discharged with a primary diagnosis of SAH during the 10-year period. In contrast to other types of stroke, the rates of SAH were higher for women than for men at all ages. The age-standardized rates of SAH in 1991-1992 were 11.2 per 100000 women and 8.0 per 100000 men. For women, there was a 6% (95% confidence interval [CI], -12% to 0%) decline in hospitalization rates over that period; for men, the decline was 15% (95% CI, -21% to -8%). The peak season for SAH among women was winter; for men the peaks were in the fall and spring. For both sexes, the lowest occurrence was in the summer. Over this period, 30-day case-fatality rates declined somewhat (statistically significant only in the age group of 35 to 44 years). The number of deaths enumerated from hospital discharges was 20% to 50% lower than the number recorded on national mortality statistics, indicating that a proportion of SAH deaths occurred before (or after) the hospital stay.

CONCLUSIONS

Although rates of hospitalization for SAH declined over this period, SAH remains an important neurological event affecting individuals at relatively young ages. The rates were higher for women than for men at all ages. Total (in-hospital) case-fatality rate remains high.

Early hemorrhage growth in patients with intracerebral hemorrhage

BACKGROUND AND PURPOSE

The goal of the present study was to prospectively determine how frequently early growth of intracerebral hemorrhage occurs and whether this early growth is related to early neurological deterioration.

METHODS

We performed a prospective observational study of patients with intracerebral hemorrhage within 3 hours of onset. Patients had a neurological evaluation and CT scan performed at baseline, 1 hour after baseline, and 20 hours after baseline.

RESULTS

Substantial growth in the volume of parenchymal hemorrhage occurred in 26% of the 103 study patients between the baseline and 1-hour CT scans. An additional 12% of patients had substantial growth between the 1- and 20-hour CT scans. Hemorrhage growth between the baseline and 1-hour CT scans was significantly associated with clinical deterioration, as measured by the change between the baseline and 1-hour Glasgow Coma Scale and National Institutes of Health Stroke Scale scores. No baseline clinical or CT prediction of hemorrhage growth was identified.

CONCLUSIONS

Substantial early hemorrhage growth in patients with intracerebral hemorrhage is common and is associated with neurological deterioration. Randomized treatment trials are needed to determine whether this early natural history of ongoing bleeding and frequent neurological deterioration can be improved.

What are the actual incidence and mortality rates of subarachnoid hemorrhage?

BACKGROUND

From 1987-92 in Izumo City, Japan, we diagnosed 123 patients as having subarachnoid hemorrhage (SAH) by computed tomography, autopsy, or surgery (proven SAH); the crude incidence rate was 25/100,000/year for all ages. However, to estimate the actual incidence and mortality rates, we should take into account the decedents who died without confirmation by these methods but were presumed to have died of SAH.

METHODS

From 1987-92, we reviewed all of 3562 death certificates for the city of Izumo (population 82,679), and calculated the incidence and mortality rates of SAH by combining proven and possible SAH.

RESULTS

We diagnosed 36 patients as having possible SAH on death certificates. When adding these 36 patients to the 123 with proven SAH, the crude and the age-adjusted and sex-adjusted incidence rates for all ages became 32/ 100,000/year and 29/100,000/year, respectively. Of these, 40% (64) died by day 3 (day 0 defined as the day of hemorrhage), 43% (69) within 1 week, and 53% (84) within 1-6 months, respectively.

CONCLUSIONS

When including the patients who may have died of SAH, the actual incidence rate of SAH is much higher than that which has been reported to date, and the actual mortality rate is still very high.

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.