Clinical findings in patients with recurrent intracerebral hemorrhage

Predictors for recurrent primary intracerebral hemorrhage: a retrospective population-based study

BACKGROUND AND PURPOSE

Underlying comorbidities, previous strokes, and medication may increase the risk for primary intracerebral hemorrhage (PICH) and its recurrence. The aim of this study was to determine the independent predictors for recurrent PICH.

METHODS

We identified 961 subjects with first-ever PICH from 1993 to 2008 among the population of Northern Ostrobothnia, Finland. Hospital and death records were reviewed and data on drug use were obtained from the national register of prescribed medicines. Kaplan-Meier survival curves and Cox proportional hazards models were used to demonstrate predictors for recurrence of PICH.

RESULTS

Total follow-up time of the 961 patients was 3481 person-years. During the follow-up time, 58 subjects had altogether 68 recurrent PICHs. The annual average incidence of first recurrence was 1.67%. Cumulative 5- and 10-year incidence rates were 9.6% and 14.2%, respectively. In univariable analysis, history of ischemic stroke, diabetes mellitus, and aspirin use were associated with a higher recurrence rate. In multivariable analysis, only previous ischemic stroke (adjusted hazard ratio, 2.22; 95% confidence interval, 1.22-4.05; P=0.009) independently predicted PICH recurrence. Diabetes mellitus tended to increase (adjusted hazard ratio, 2.38; 95% confidence interval, 0.98-5.80; P=0.056), whereas treated hypertension tended to decrease (0.45, 0.20-1.01; P=0.054) the risk for fatal recurrent PICH.

CONCLUSIONS

Previous ischemic stroke independent of confounding factors may increase the risk for PICH recurrence.

Prevention of intracerebral hemorrhage recurrence

PURPOSE OF REVIEW

: Limited data are available on the prevention of intracerebral hemorrhage (ICH) recurrence, which is substantial, especially in the case of lobar ICH related to cerebral amyloid angiopathy. In view of the relative paucity of prospectively generated data, current strategies for the secondary prevention of ICH involve the extrapolation of data on primary prevention of ICH to its secondary prevention and the avoidance of certain agents that have been shown in clinical series to be associated with increased risk of ICH recurrence. This review analyzes ways to approach the secondary prevention of ICH in the setting of a paucity of adequate prospectively generated data on the subject.

RECENT FINDINGS

: Risk factors for ICH recurrence identified through data extrapolation include hypertension, diabetes, excessive alcohol consumption, cigarette smoking, and probably migraine with aura. Agents associated with increased risk of ICH recurrence include warfarin, antiplatelet agents, statins, and vitamin E.

SUMMARY

: This article reviews the prevention of ICH recurrence based on extrapolating data from primary prevention of ICH along with the clinically appropriate strategy of avoiding the use of agents that have been shown to carry an increased risk of ICH recurrence.

Comparisons of 30-day mortalities and 90-day functional recoveries after first and recurrent primary intracerebral hemorrhage attacks: a multiple-institute retrospective study

BACKGROUND

The aim of this study was to determine and compare 30-day mortalities and 90-day functional recoveries after first and recurrent primary intracerebral hemorrhage (PICH) attacks. The investigators sought to identify factors predisposing 30-day mortality and functional recovery and to compare patients after first and recurrent PICH attacks.

METHODS

The medical records of 1856 PICH patients treated in Samsung Changwon Hospital and Dong-A University Medical Center from January 2000 to December 2010 were retrospectively evaluated.

RESULTS

Of these 1856 patients, 1499 were included. Mean patient age was 66.4 ± 16.3 years, and there were 742 male patients (49.5%). Recurrent PICH occurred in 142 (9.5%) patients. Thirty-day mortality was 13.6% for first PICH patients and 14.1% for recurrent PICH patients (P = 0.824). Good functional recovery at 90 days after ictus was achieved by 52.2% of first PICH patients and by 31.0% of recurrent patients (P = 0.003). In both groups, multivariate analysis showed that unconsciousness, pupillary abnormality, surgery, and underlying disease were associated with high mortality, and that consciousness, a lobal location, a small hemorrhagic volume, and conservative treatment were associated with good functional recovery. After excluding recurrent patients with a previous moderate to severe disability due to the sequelae of PICH, no difference was found between the first (25.1%) and recurrent groups (19.0%) in terms of functional recovery (P = 0.083).

CONCLUSIONS

The factors found to predispose clinical outcome were similar in the two groups. This study shows that given optimal treatment, recurrent PICH patients can achieve the same clinical outcomes as first PICH patients.

The risk of recurrent stroke after intracerebral haemorrhage

BACKGROUND AND AIM

The risks of recurrent intracerebral haemorrhage (ICH) vary widely (0-24%). Patients with ICH also have risk factors for ischaemic stroke (IS) and a proportion of ICH survivors re-present with an IS. This dilemma has implications for prophylactic treatment. This study aims to determine the risk of recurrent stroke events (both ICH and IS) following an index bleed and whether ICH recurrence risk varies according to location of index bleed.

PATIENTS AND METHODS

All patients diagnosed with an acute ICH presenting over an 8.5 year period were identified. Each ICH was confirmed by reviewing all of the radiology results and, where necessary, the clinical case notes or post-mortem data. Recurrent stroke events (ICH and IS) were identified by reappearance of these patients in our stroke database. Coronal post-mortem results for the same period were also reviewed. Each recurrent event was reviewed to confirm the diagnosis and location of the stroke.

RESULTS

Of the 7686 stroke events recorded, 768 (10%) were ICH. In the follow-up period, there were 19 recurrent ICH and 17 new IS in the 464 patients who survived beyond the index hospital stay. Recurrence rate for ICH was 2.1/100 in the first year but 1.2/100/year overall. This compares with 1.3/100/year overall for IS. Most recurrences were "lobar-lobar" type.

CONCLUSION

The cumulative risk of recurrent ICH in this population is similar to that of IS after the first year.

Going High with Preexisting Neurological Conditions

This review presents the potential impact of high altitude exposure on preexisting neurological conditions in patients usually living at low altitude. The neurological conditions include permanent and transient ischemia of the brain, occlusive cerebral artery disease, cerebral venous thrombosis, intracranial hemorrhage and vascular malformations, multiple sclerosis, intracranial space-occupying lesions, dementia, extrapyramidal disorders, migraine and other headaches, and epileptic seizures. New developments in diagnostic work-up and treatment of preexisting neurological conditions are also mentioned where applicable. For each neurological disorder, the authors developed absolute and relative contraindications for a trip to high altitude. These recommendations are not based on the results of controlled randomized trials, but mainly on case reports, pathophysiological considerations, and extrapolations from the low altitude situation.

Recurrence and extension of lobar hemorrhage related to cerebral amyloid angiopathy: multivariate analysis of clinical risk factors

BACKGROUND

Many recent studies have analyzed clinical risk factors for the recurrence and extension of intracerebral hemorrhage. However, they have not been investigated in patients with lobar hemorrhage related to cerebral amyloid angiopathy (CAA).

METHODS

We studied 40 surgically treated patients with lobar hemorrhage diagnosed histologically as being related to CAA. To determine clinical factors influencing the recurrence and hematoma size their clinical data (demographics, medical history, and radiographic and laboratory data) were examined retrospectively and subjected to multivariate analysis.

RESULTS

Twelve patients (30%) had recurrent lobar hemorrhage. Twenty-one patients had a small hematoma and 19 had a large hematoma. Hypertension was the only significant clinical factor influencing the recurrence of CAA-related lobar hemorrhage. There was no significant clinical factor influencing the hematoma size of CAA-related lobar hemorrhage.

CONCLUSIONS

The history of hypertension is associated with an increase in the recurrence of CAA-related lobar hemorrhage.

Recurrent primary intracerebral hemorrhage in Izumo City, Japan

BACKGROUND

Recurrent intracerebral hemorrhage (ICH) is a devastating illness among stroke survivors. We investigated the rate and characteristics of ICH recurrence in Izumo City, Japan.

METHODS

The recurrence rate of ICH was calculated for 279 patients who suffered their first-ever ICH between 1991 and 1998 and were followed up during a mean period of 3.0 years (range, 1 month to 11 years). The characteristics of recurrent ICH were evaluated for 42 patients who were treated for it between 1991 and 1998.

RESULTS

Of the 279 patients with ICH, 19 (7%) had rebleeding; the recurrence rate was 2.3% per year. Analysis of the 42 patients with recurrent ICH showed that the most common pattern of recurrence was ganglionic-ganglionic (n = 25). The crude and the age- and sex-adjusted annual incidence rates for recurrent ICH were both 6 per 100,000 population. Of the 42 patients with recurrent ICH, 16 (38%) had a favorable outcome at discharge and 10 (24%) died. The overall 1-year survival rate for recurrent ICH was 72%. Intraventricular hemorrhage on computed tomography scans was the only significant predictor of not only ICH recurrence but also the 1-year case-fatality rate in patients with recurrent ICH.

CONCLUSIONS

Recurrence after an initial ICH is not rare, and the most common pattern of recurrence is ganglionic-ganglionic. Whereas the functional outcome of recurrent ICH is unsatisfactory, the 1-year survival rate is not necessarily low. Intraventricular hemorrhage on computed tomography scans is an important predictor of both ICH recurrence and the 1-year case-fatality rate in patients with recurrent ICH.

Long-term prognosis after recovery from primary intracerebral hemorrhage

BACKGROUND

Little is known about the long-term outcome for patients who recover from a primary intracerebral hemorrhage. The authors examined the rate of recurrence, vascular events, and death in survivors of a primary intracerebral hemorrhage and the factors related to the long-term prognosis.

METHODS

All 243 patients admitted to one of three hospitals with a primary intracerebral hemorrhage who regained independence were interviewed about vascular events after the index hemorrhage. The authors used the Kaplan-Meier method to estimate the event-free survival and Cox proportional hazards regression analysis to identify predictors of recurrence, any vascular event, or death.

RESULTS

During a mean follow-up of 5.5 years, the annual rates of recurrent primary intracerebral hemorrhage, vascular events, and vascular death were 2.1% (95% CI, 1.4 to 3.3%), 5.9% (95% CI, 4.5 to 7.7%), and 3.2% (95% CI, 2.2 to 4.5%). Age of 65 years or older was the only predictor of a recurrence (hazard ratio [HR], 2.8; 95% CI, 1.3 to 6.1) and vascular death (HR, 3.7; 95% CI, 2.0 to 7.0). In addition to age, male sex predicted the occurrence of vascular events (HR, 1.8; 95% CI, 1.1 to 3.0). Use of anticoagulation after the index bleeding tripled the risk of hemorrhagic events (HR, 3.0; 95% CI, 1.3 to 7.2).

CONCLUSION

Patients who recovered from a primary intracerebral hemorrhage had a 2.1% to 5.9% annual rate of recurrence, vascular death, or vascular events. Age of 65 years or older more than doubled the risk of recurrence, vascular event, or death. The risk of vascular events in men was increased twofold.

Repeated thalamic haemorrhage: case report and review of the literature

Recurrence of thalamic haemorrhage has rarely been reported. A 70-year-old woman had recurrent thalamic haemorrhage five-times during a period of 6 years. The first, second and fifth haemorrhages were located in the right thalamic region, and the third and fourth haemorrhages in the left thalamic region. Cranial computed tomography and magnetic resonance imaging revealed no abnormal lesion. After the first, second, and third haemorrhage with medical treatments, the patient recovered her functional ability or was at least capable of self-care at home. However, after the fourth and fifth haemorrhage, with medical therapy the patient's prognosis was severe disability. In this case, systemic blood pressure was normalized without antihypertensive agents after the first attack. However, there was an episode of sudden hypertension at each attack. Although the mechanism of rebleeding has not been clarified, rebleeding might be associated with changes of cerebral circulation following the previous haemorrhage.

Involvement of fluctuating high blood pressure in the enlargement of spontaneous intracerebral hematoma

The correlations between changes in blood pressure after admission and hematoma expansion were investigated in 118 patients with spontaneous intracerebral hematoma admitted within 24 hours of onset who underwent serial computed tomography. Multiple logistic regression was performed to assess correlations between hematoma enlargement and clinical characteristics on admission. Hematoma enlargement was predominantly correlated with time of onset (p = 0.01567), and not well correlated with blood pressure at admission (p = 0.07908). Serial changes in blood pressure were investigated in 57 patients admitted within 6 hours of ictus whose blood pressures were monitored every hour from admission. Wilcoxon signed-rank analysis was used to determine the relationships between hematoma enlargement and blood pressure. Patients with hematoma enlargement was significantly correlated with increased blood pressure (p = 0.0004). Increases in blood pressure after admission may be a factor in hematoma enlargement.

Recurrent intracerebral hemorrhages in cerebral amyloid angiopathy: a case report

Cerebral amyloid angiopathy frequently causes recurrent intracerebral hemorrhages in elderly patients who do not have systemic hypertension. Surgery should be reserved for conditions which cannot be controlled by medical treatment. When surgery is needed, potential complications (such as bleeding near the operation site or remote area) should be kept in mind. A case study of a 66-year-old woman with cerebral amyloid angiopathy and recurrent intracerebral hemorrhages is presented.

Rate of stroke recurrence in patients with primary intracerebral hemorrhage

BACKGROUND AND PURPOSE

Primary intracerebral hemorrhage (PICH) is a devastating illness with high early mortality. Hypertension is a major risk factor both for ischemic cerebrovascular disease and for intracranial hemorrhage. Survivors of PICH are at risk for both recurrent hemorrhage and ischemic cerebrovascular disease. We sought to determine the rate of recurrence of ICH or cerebral ischemia in a cohort of PICH patients at the Toronto Hospital, Toronto, Canada.

METHODS

A retrospective search of computerized hospital records from 1986 to 1996 for patients with a discharge diagnosis of intracerebral hemorrhage (International Classification of Diseases, Ninth Revision-Clinical Modification [ICD-9-CM] code 431) was conducted to identify the index cases. Charts were abstracted for demographic and clinical characteristics. CT scans, MR scans, or radiologist reports were reviewed. To determine recurrence, the database was linked to the Ontario Provincial Government Vital Statistics Registry and to the Canadian Institute for Health Information database of hospital discharge abstracts. Logistic regression analysis was used to identify predictive factors for mortality after PICH. A Cox proportional hazards model was fitted to identify predictive factors for recurrent ICH or stroke.

RESULTS

A total of 746 charts were identified by computer search. After abstraction, 423 index patients with PICH were identified. Of these, 27.4% died in the first 30 days of their admission. Predictors of death were age, intraventricular rupture of hemorrhage, and trilobar hemorrhage. The recurrence rate for PICH was 2.4% (95% CI 1.4% to 3. 9%) per year, whereas the recurrence rate for ischemic cerebrovascular disease was 3.0% (95% CI 1.8% to 4.7%) per year. The only significant predictor of readmission for ICH was lobar location of the index hemorrhage, with a hazard ratio of 3.8 (95% CI 1.2 to 12.0).

CONCLUSIONS

PICH has a high 30-day mortality rate. Survival from the initial insult portends a moderate risk of recurrence of 2. 4% per year for PICH and 3.0% per year for ischemic cerebrovascular disease. Patients with PICH are at risk for both ischemic stroke or TIA and recurrent hemorrhage; thus, PICH may be a marker for ischemic stroke. Patients with lobar hemorrhage have a 3.8-fold increased risk of recurrent ICH.

Intracerebral hemorrhage in young people: analysis of risk factors, location, causes, and prognosis

BACKGROUND AND PURPOSE

The frequency of intracerebral hemorrhages (ICHs) in people aged </=40 years has been poorly studied. We investigated the incidence, causes, locations, and prognosis of ICH in young patients.

METHODS

We evaluated all consecutive patients with neuroimaging evidence or pathological confirmation of symptomatic ICH. We excluded patients with primary subarachnoid or traumatic hemorrhage, past evidence of vascular malformation, or brain tumor. We analyzed the risk factors, number, locations, and causes of ICH, and final outcome measured by the modified Glasgow Outcome Scale.

RESULTS

We retrospectively evaluated 200 patients (mean age, 27 years; range, 15 to 40 years). The most frequent risk factors were tobacco use (20%), hypocholesterolemia (35%), hypertension, (13%), and alcohol use (10%). The locations of ICH were lobar (55%), basal ganglia/internal capsule (22%), and others (24%). The most common causes of ICH were vascular malformations (49%), including cavernous angioma, and hypertension (11%). Cryptogenic ICH was considered in 15%. Other causes included cerebral venous thrombosis (5%) and sympathomimetic drug use (4%). The majority of patients with ICH that resulted from hypertension were aged >31 years (odds ratio, 3.48), and those with ICH that resulted from arteriovenous malformations were aged <20 years (odds ratio, 2.80). The final outcome was considered favorable in 60%.

CONCLUSIONS

ICHs in young people are mainly lobar in location and result from vascular malformation. Hypertension causes most cases in which the ICH is located in the basal ganglia. Mortality and morbidity in the acute phase are low and are related to hypertension as the cause of ICH.

Blood pressure control and recurrence of hypertensive brain hemorrhage

BACKGROUND AND PURPOSE

Recent studies have demonstrated that recurrence of hypertensive brain hemorrhage (HBH) is not uncommon. However, risk factors for the recurrence of HBH have not been evaluated systematically.

METHODS

We analyzed 74 patients with HBH who were admitted to our clinic and followed up as outpatients for a mean of 2.8 years. Blood pressure (BP) and other clinical features were compared between the groups of patients with and without rebleeding. We determined the recurrence rate of HBH in relation to BP.

RESULTS

Diastolic BP was significantly higher in the recurrence group than in the nonrecurrence group (88+/-8 versus 82+/-7 mm Hg; P=0.04). Systolic BP and other clinical variables were not different between the groups. The recurrence rate was 10.0% per patient-year in patients with diastolic BP >90 mm Hg and <1.5% in those with lower diastolic BP (P<0.001). No patients with diastolic BP <70 mm Hg experienced rebleeding.

CONCLUSIONS

Higher diastolic BP was related to an increased rate of rebleeding. Diastolic BP >90 mm Hg may be regarded as a factor predictive of the recurrence of HBH.

Recurrent primary cerebral hemorrhage: frequency, mechanisms, and prognosis

BACKGROUND AND PURPOSE

The frequency of recurrent primary cerebral hemorrhage (RPCH), mainly in cases related to hypertension, has been considered low. This study investigated the frequency, mechanisms, and prognosis of RPCH.

METHODS

We evaluated 359 patients with neuroimaging evidence of cerebral hemorrhage and selected 22 with RPCH.

RESULTS

Five patients (23%) were older than 70 years at the first cerebral hemorrhage. Mean ages at the first and second hemorrhages were 60 and 63 years, respectively. Risk factors included hypertension (86%), diabetes (27%), and tobacco and alcohol use (each 14%). Hypocholesterolemia was demonstrated in 35% of the patients. The most common pattern of recurrent bleeding was ganglionic-ganglionic, mainly related to hypertension. Overall mortality was 32%. Forty-one percent and 27% of patients, respectively, had incapacitating and nonincapacitating sequelae; 2 of the latter had RPCH with a lobar location. Ganglionic-ganglionic hemorrhage was associated with a poor prognosis; otherwise, this pattern was uncommon in patients with nonincapacitating sequelae. Analysis of the control of risk factors, primarily hypertension after the first cerebral hemorrhage, disclosed that 56% of patients did not gain subsequent control.

CONCLUSIONS

Rebleeding after a first primary intracerebral hemorrhage is not uncommon. The main topographic pattern of bleeding, ganglionic-ganglionic, is likely the result of hypertension; the less common lobar-lobar pattern probably results from amyloid angiopathy.