Intracerebral hemorrhage more than twice as common as subarachnoid hemorrhage

Thrombolytic therapy in neurointensive care

Thrombolytic therapy has been studied in acute ischemic stroke, intracranial hemorrhage, intraventricular hemorrhage, subarachnoid hemorrhage, and sagittal sinus thrombosis. This form of therapy has an evolving role in contemporary neurologic practice, and increased investigational fervor will ensure more exacting therapeutic alternatives for stroke victims in the future.

Lifetime cost of stroke in the United States

BACKGROUND AND PURPOSE

Stroke imposes a substantial economic burden on individuals and society. This study estimates the lifetime direct and indirect costs associated with the three major types of stroke: subarachnoid hemorrhage (SAH), intracerebral hemorrhage (ICH), and ischemic stroke (ISC).

METHODS

We developed a model of the lifetime cost of incident strokes occurring in 1990. An epidemiological model of stroke incidence, survival, and recurrence was developed based on a review of the literature. Data on direct cost of treating stroke were obtained from Medicare claims data, the 1987 National Medical Expenditure Survey (NMES), and insurance claims data representing a group of large, self-insured employers. Indirect costs (the value of foregone market and nonmarket production) associated with premature morbidity and mortality were estimated based on data from the US Bureau of Economic Analysis and the 1987 NMES.

RESULTS

The lifetime cost per person of first strokes occurring in 1990 is estimated to be $228,030 for SAH, $123,565 for ICH, $90,981 for ISC, and $103,576 averaged across all stroke sub-types. Indirect costs accounted for 58.0% of lifetime costs. Aggregate lifetime cost associated with an estimated 392,344 first strokes in 1990 was $40.6 billion: $5.6 billion for SAH, $6.0 billion for ICH, and $29.0 billion for ISC. Acute-care costs incurred in the 2 years following a first stroke accounted for 45.0%, long-term ambulatory care accounted for 35.0%, and nursing home costs accounted for 17.5% of aggregate lifetime costs of stroke.

CONCLUSIONS

The lifetime cost of stroke varies considerably by type of stroke and entails considerable costs beyond the first 2 years after a stroke.

Validation of family history in subarachnoid hemorrhage

BACKGROUND AND PURPOSE

In 6% to 9% of patients with subarachnoid hemorrhage (SAH), familial aggregation occurs; truly familial cases carry a worse prognosis than sporadic cases and raise the question of screening. If relatives have died from SAH, the family history is often the only available clue to the diagnosis, but the sensitivity and predictive value of such a history for SAH are unknown.

METHODS

We contacted a next of kin for a consecutive series of patients who had died in the hospital of subarachnoid hemorrhage (n=20), intracerebral hemorrhage (n=22), or ischemic stroke (n=23) between 3 and 5 years previously, and we compared the diagnosis based on the history from this next of kin with the medical diagnosis confirmed by a CT scan.

RESULTS

The positive predictive value of the diagnosis of "probable SAH" from the history in our study sample was 0.7; when adjusted for incidence rates in the general population it was 0.6 (95% confidence interval, 0.3 to 0.8). The sensitivity of the diagnosis based on the history was 0.5 (95% confidence interval. 0.3 to 0.7); 10 of the 20 cases of SAH were not identified.

CONCLUSIONS

The family history of SAH, without confirmation from medical documents, is an insufficiently accurate tool to prove or disprove the diagnosis of familial SAH.

Risk factors for subarachnoid hemorrhage: a systematic review

BACKGROUND AND PURPOSE

Knowledge of modifiable risk factors for subarachnoid hemorrhage (SAH) is important in terms of prevention. We therefore conducted a systematic review of studies on risk factors for SAH, with emphasis on sufficiently precise criteria for the diagnosis of SAH.

METHODS

To identify studies we performed a Medline search from 1966 to 1994 and searched the reference lists of all relevant publications. Studies were included only if they fulfilled predefined methodological criteria. Case-control studies were included if the diagnosis of SAH was proved by CT, angiography, or autopsy in at least 70% of patients. Longitudinal studies were included if the criteria for SAH were based on a review of the medical records.

RESULTS

Nine longitudinal studies and 11 case-control studies were included. Significant risk factors were as follows: (1) smoking (relative risk [RR] for longitudinal studies, 1.9; 95% confidence interval [CI], 1.5 to 2.3; odds ratio [OR] for case-control studies, 3.5; 95% CI, 2.9 to 4.3); (2) hypertension (RR, 2.8; 95% CI, 2.1 to 3.6; OR, 2.9; 95% CI, 2.4 to 3.7) and (3) drinking 150 g or more of alcohol per week (RR, 4.7; 95% CI, 2.1 to 10.5; OR, 1.5; 95% CI, 1.1 to 1.9). Use of oral contraceptives, hormone replacement therapy, hypercholesterolemia, and physical activity were not significantly related to the risk of SAH.

CONCLUSIONS

We conclude that smoking, hypertension, and alcohol abuse are important risk factors for SAH. Reduction of exposure to these risk factors might result in a decreased incidence of SAH.

Edema from intracerebral hemorrhage: the role of thrombin

The mechanism by which intracerebral hemorrhage leads to the formation of brain edema is unknown. This study assesses the components of blood to determine if any are toxic to surrounding brain. Various solutions were infused stereotactically into the right basal ganglia of rats. The animals were sacrificed 24 hours later; brain edema and ion contents were measured. Whole blood caused an increase in brain water content and ion changes consistent with brain edema. Concentrated blood cells, serum from clotted blood, and plasma from unclotted blood all failed to provoke edema formation when infused directly into the brain. On the other hand, activation of the coagulation cascade by adding prothrombinase to plasma did produce brain edema. The edema response to whole blood could be prevented by adding a specific thrombin inhibitor, hirudin, to the injected blood. This study indicates that thrombin plays an important role in edema formation from an intracerebral blood clot.

Familial subarachnoid hemorrhage: distinctive features and patterns of inheritance

To delineate the distinctive features of familial subarachnoid hemorrhage, we compared gender and age at the time of subarachnoid hemorrhage, as well as site and number of aneurysms, in patients with familial subarachnoid hemorrhage (at least 1 first-degree relative with subarachnoid hemorrhage) and patients with sporadic subarachnoid hemorrhage (no subarachnoid hemorrhage in first- or second-degree relatives), in a prospective, hospital-based series of patients. In addition we studied the pattern of inheritance in 17 families with familial subarachnoid hemorrhage. Mean age at the time of hemorrhage in patients with the familial form was 6.8 years lower than that in those with the sporadic form, and middle cerebral artery aneurysms occurred more often in patients with familial disease. Sex distribution and number of aneurysms were similar in the two groups. Inheritance was compatible with autosomal dominant transmission in some families, and with autosomal recessive or multifactorial transmission in others. In our 5 families as well as in all 18 previously reported families with two affected generations, the age at the time of subarachnoid hemorrhage was invariably lower in later generations, which is suggestive of anticipation. We conclude that familial subarachnoid hemorrhage is a separate entity with occurrence at a young age, predilection for aneurysms of the middle cerebral artery, and variable modes of inheritance, including autosomal dominant inheritance with possible anticipation.

Stroke in young black patients. Risk factors, subtypes, and prognosis

BACKGROUND AND PURPOSE

Stroke subtypes and prognosis differ among older black patients compared with whites; however, few data are available regarding stroke among young black patients.

METHODS

To determine the risk factors for stroke, stroke subtype, and prognosis among young black patients, we retrospectively reviewed the medical records of all 15- to 44-year-old patients admitted with stroke to a university-affiliated public hospital from January 1990 through June 1994.

RESULTS

Of the 248 eligible patients admitted with stroke, 219 were blacks. Hypertension was more frequently associated with stroke in young black than in non-black patients (55% versus 24%, P = .003). Cocaine abuse was frequent among both black and non-black patients (27% versus 38%, P = NS). Hypertensive intracerebral hemorrhage (64%) was the most common subtype of intracerebral hemorrhage (n = 67), and lacunar infarction (21%) was the most common subtype of cerebral infarction (n = 112) in young black patients. Outcome in black patients with stroke at discharge was 69% independent, 8% dependent, and 23% dead.

CONCLUSIONS

The high frequency of hypertension, hypertensive intracerebral hemorrhage, and lacunar infarction among young black patients with stroke suggests accelerated hypertensive arteriolar damage, possibly due to poor control of hypertension.

Predictors of early deterioration and mortality in black Americans with spontaneous intracerebral hemorrhage

BACKGROUND AND PURPOSE

Black Americans with spontaneous intracerebral hemorrhage (SICH) may have unique clinical characteristics that affect outcome. The aim of this study was to determine the prognostic value of clinical characteristics and initial CT scan for outcome in black Americans with SICH.

METHODS

Clinical and demographic data were extracted from the charts of 182 consecutive black Americans admitted for SICH diagnosed by clinical criteria and initial CT scan. Hemorrhage volumes were calculated from admission CT scans by a computerized method. Univariate and multiple logistic regression analyses were performed to determine independent predictors of early deterioration (defined as a decrease from an initial Glasgow Coma Scale score > 12 by > or = 4 points within 24 hours from presentation) and mortality.

RESULTS

Both hemorrhage volume and ventricular extension were significant, independent predictors of early deterioration (odds ratio [OR], 6.78; 95% confidence interval [CI], 1.89 to 24.35 and OR, 4.67; 95% CI, 1.30 to 16.72, respectively) and mortality (OR, 6.66; 95% CI, 2.85 to 15.58 and OR, 4.23; 95% CI, 1.82 to 9.82, respectively). A Glasgow Coma Scale score < or = 12 also predicted mortality (OR, 3.23; 95% CI, 1.46 to 7.14). Initial mean arterial pressure was not an independent predictor of early deterioration or mortality.

CONCLUSIONS

Hemorrhage volume and ventricular extension are the best predictors of early deterioration and mortality in black Americans with SICH.

Risk factors for spontaneous intracerebral hemorrhage

BACKGROUND AND PURPOSE

Spontaneous intracerebral hemorrhage has remained a serious disease despite recent improvements in medical treatment. This study was designed to identify modifiable risk factors for intracerebral hemorrhage.

METHODS

Health habits, previous diseases, and medication of 156 consecutive patients with intracerebral hemorrhage aged 16 to 60 years (96 men and 60 women) were compared with those of 332 hospitalized control patients (192 men and 140 women) who did not differ from case subjects in respect to age, day of onset of symptoms, or acuteness of disease onset.

RESULTS

After adjustment for sex, age, hypertension, body mass index, smoking status, and alcohol consumption during the last week, patients who had consumed 1 to 40, 41 to 120, or > 120 g of alcohol within the 24 hours preceding the onset of illness had a relative risk (95% confidence interval) of hemorrhage of 0.3 (0.2 to 0.7), 4.6 (2.2 to 9.4), and 11.3 (3.0 to 42.8), respectively, compared with those who had consumed 0 g. In addition, alcohol intake within 1 week before the onset of illness, excluding use within the last 24 hours, increased the risk of hemorrhage; adjusted risks were 2.0 (1.1 to 3.5) for 1 to 150 g, 4.3 (1.6 to 11.7) for 151 to 300 g, and 6.5 (2.4 to 17.7) for > 300 g compared with 0 g. The adjusted risk of hypertension for hemorrhage was 6.6 (3.9 to 11.3). Previous heavy alcohol consumption and current cigarette smoking were not independent risk factors for hemorrhage, but anticoagulant treatment was (P < .01). Erythrocyte mean corpuscular volume and gamma-glutamyl transferase values were also higher in patients with intracerebral hemorrhage than in control subjects.

CONCLUSIONS

Recent moderate and heavy alcohol intake as well as hypertension and likely also anticoagulant treatment seem to be independent risk factors for intracerebral hemorrhage.

Validation and comparison of models predicting survival following intracerebral hemorrhage

OBJECTIVE

To compare the performance of two previously reported logistic regression models using data independent from those data used to derive the models.

DESIGN

Prospective.

SETTING

Acute stroke unit of a tertiary care hospital.

PATIENTS

One hundred twenty-nine patients with supratentorial intracerebral hemorrhage.

MEASUREMENTS AND MAIN RESULTS

Model 1 contains the initial Glasgow Coma Scale score, hemorrhage size, and pulse pressure. The more complex model 2 includes, in addition to those three variables, the presence or absence of intraventricular hemorrhage and a term representing the interaction of intraventricular hemorrhage and Glasgow Coma Scale score. The areas under the receiver operating characteristic curves generated for each model were statistically indistinguishable.

CONCLUSIONS

Model 1 predicts 30-day patient status as well as the more complex model 2. Model 1 provides a valid, easy-to-use means of categorizing supratentorial intracerebral hemorrhage patients in terms of their probability of survival.

Study of aneurysmal subarachnoid hemorrhage in Izumo City, Japan

BACKGROUND AND PURPOSE

Estimation of the actual incidence rate of subarachnoid hemorrhage and evaluation of the treatment require the inclusion of all patients in a defined geographic area.

METHODS

During 1987 through 1992 in Izumo City, Japan, we estimated the incidence rate of subarachnoid hemorrhage by including dead-on-arrival patients and by further adding the results obtained after reviewing all death certificates registered in this city in the corresponding period. In addition, we compared the management and surgical outcomes in hospitalized patients from 1987 through 1992 with outcomes from 1980 through 1986.

RESULTS

During 1987 through 1992, we diagnosed 123 patients as having subarachnoid hemorrhage. The crude and the age- and sex-adjusted incidence rates using the 1990 population statistics for Japan were 25 (95% confidence interval, 21 to 30) per 100,000/y and 23 (95% confidence interval, 19 to 28) per 100,000/y for all ages, respectively; these occurrences are the highest among those reported to date. Of these patients, 8% died before receiving medical attention, 27% in the first week, and 39% at 1 month. The survival curve for 2 years improved significantly from 1980-1986 to 1987-1992 in patients with admission grades 4 and 5 (P = .035) and in operated patients with preoperative grades 1 through 3 (P = .036). However, there was little improvement in the overall management results (P = .168), possibly because patients with high risk and/or old age were admitted and/or diagnosed more often in the latter period.

CONCLUSIONS

The incidence rate of subarachnoid hemorrhage is much higher than that reported so far in the literature, and despite improvement of management and surgical therapy, the actual case-fatality rate is still high, mainly because of the high mortality rate directly associated with the primary bleeding.

Stereotactic puncture and lysis of spontaneous intracerebral hemorrhage using recombinant tissue-plasminogen activator

We have tested a treatment protocol for intracerebral hemorrhage (ICH), consisting of stereotactic insertion of a catheter into the clot, hematoma lysis by the injection of a fibrinolytic agent, recombinant tissue-plasminogen activator (rt-PA), and closed system drainage of the liquefied clot. Fourteen patients underwent computed tomographically guided stereotactic hematoma puncture and silicone tube insertion within 72 hours of intracerebral hemorrhage. The majority (nine patients) suffered from ganglionic ICH, and the size of the hematoma ranged between 3 x 3 x 4 cm and 7 x 7 x 4 cm (mean, 5.2 x 4 x 3.6 cm). All patients had major neurological deficits with or without an impaired level of consciousness, but without signs of transtentorial herniation. The initial, then daily, dose (in milligrams) of rt-PA administered via the silicone tube equalled the maximal diameter (in centimeters) of the original and remaining clot as measured initially, then daily, by computed tomographic scan. The number of rt-PA injections was four in one patient, three in eight patients, two in four patients, and one in one patient, and the total dose of rt-PA required ranged from 5 to 16 mg (mean, 9.9 mg). After rt-PA injection, the tubing was clamped for 2 hours and then opened to drain spontaneously through a closed system against 0 cm of pressure. At follow-up 6.6 months (mean) after treatment (ranging from 3 to 13 months) and according to the Glasgow outcome score, one patient was Grade V, four were Grade IV, five were Grade III, two were Grade II, and two had died.(ABSTRACT TRUNCATED AT 250 WORDS)

Collagenase-induced intrastriatal hemorrhage in rats results in long-term locomotor deficits

BACKGROUND AND PURPOSE. Previous studies have shown that injection of the metalloproteinase collagenase directly into the caudate nucleus of rats causes an intracerebral hemorrhage. The purpose of the present study is to determine functional deficits associated with a collagenase-induced hemorrhagic lesion of the striatum.

METHODS

Twelve adult rats received a 2-microL infusion of bacterial collagenase (0.5 U in saline) into the right striatum. The rotational response to apomorphine (1 mg/kg SC) administration was then examined at 1, 4, 7, 21, 35, and 70 days after the surgery. In addition to the rotational asymmetry studies, the initiation of stepping movements in each forelimb was determined 8 weeks after the collagenase injections. In the assessment of rotational asymmetry and stepping ability, an additional six control animals received unilateral injections of saline alone. After behavioral testing, brains were processed for neuropathological evaluation.

RESULTS

A net ipsilateral rotation was noted at all posthemorrhage time periods. The average rotational asymmetries on these days were 14.57 +/- 2.9, 20.33 +/- 2.7, 19.99 +/- 4.4, 18.95 +/- 4.9, 17.03 +/- 4.9, and 14.4 +/- 4.7, respectively (data expressed as mean clockwise rotations per 5 minutes +/- SEM). The average number of steps initiated by the forelimb ipsilateral and contralateral to the lesion was 28.3 +/- 2.1 steps per minute and 13.6 +/- 1.5 steps per minute, respectively. This difference between left and right forelimb stepping was stable and reproducible for 3 consecutive days. Histological studies revealed a long-lasting hematoma cavity surrounded by dense reactive gliosis in the striatum.

CONCLUSIONS

We conclude that collagenase-induced intrastriatal hemorrhage results in long-term locomotor deficits and is therefore a useful model for developing and assessing therapeutic approaches for the restoration of neurological function after intracerebral hemorrhage.

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)

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.