Intracerebral hemorrhage in young patients from a tertiary neurology center in North India

Etiology, Risk Factors and Outcome of Spontaneous Intracerebral Hemorrhage in Young Adults Admitted to Tertiary Care Hospital in Mogadishu, Somalia

Introduction

Spontaneous Intracerebral hemorrhage (ICH) in young patients is less common and not well studied compared to ICH in older patients. The etiology, risk factors and outcome of ICH in young patients may have regional and ethnic differences. The study aims to investigate the clinical characteristics, risk factors, etiology and outcome of spontaneous intracerebral hemorrhage in young adults in Somalia.

Methods

The study enrolled 168 young patients with ICH (16-50 years) admitted to the neurology department of a tertiary hospital from 2019 to 2022. The information about the demographic details, documented ICH risk factors, etiology and patients' clinical status were retrieved. The etiology of ICH was determined based on clinical, laboratory and radiological findings. Intra-hospital survival status and associated factors were assessed.

Results

The mean age of the patients was 35±8.6 years. 99 (59%) of patients were male while 69 (41%) were females. Hypertension 48 (29%) was the most common risk factor, followed by substance abuse. Hypertensive hemorrhage was the most common etiology of ICH 60 (35.7%), followed by cerebral venous thrombosis (CVT) 5(15%), substance abuse 23 (13.7%) and arteriovenous malformation (AVM) in 10 (6%). AVM, CVT, cavernoma, eclampsia, substance abuse and cryptogenic etiology were more common in the 2nd and 3rd decades whereas hypertension was more common in the 4th and 5th decade. Intrahospital mortality was 28% in this study. Factors predicting intrahospital mortality were hematoma volume of greater than 30mL, thrombolytic etiology, brainstem ICH location, substance abuse related etiology, presence of associated mass effect, low GCS score on admission, high systolic blood pressure on admission, and the presence of chronic renal failure.

Conclusion

In this study, hypertension, substance abuse, CVT and vascular malformation are the leading causes of ICH in young adults. Intracerebral hemorrhage in the young has different spectrum of etiologies and factors associated with short-term mortality compared to older patients.

Spontaneous Intracerebral Hemorrhage in the Young: An Institutional Registry Analysis

Background

Spontaneous intracerebral hemorrhage (SICH) accounts for about 10-15% of all strokes. Generally, it is a disease of the elderly; worldwide, the incidence of SICH in the young is showing an increasing trend, especially in India and the Asian continent. An attempt is also made to analyze the presence of factors, which may predict the risk of SICH among young hypertensives.

Methods

A six-year retrospective review of patients aged below 50 years who presented with SICH was included in the study. Patients with bleeds secondary to an identifiable cause such as tumor, trauma, vascular malformations, and coagulopathy-induced bleeds were excluded from the study. The outcome was measured at 90 days using the modified ranking scale, and predictors of outcome (good outcome modified ranking score (mRS): 0-3; poor outcome mRS: 4-6) were analyzed.

Results

SICH in the young accounted for 28.4% of all intracerebral hemorrhage (ICH) patients admitted during the study period (344/1210). The mean age of our male-dominant (78.5%) cohort was 42.9 ± 6.24 years, and the median Glasgow coma score (GCS) on presentation was 11 (IQR: 8-14). A prior history of hypertension (HTN) was obtained in 51.2% (176), and left ventricular hypertrophy (LVH) was documented in 237 (68.9%) patients. The basal ganglia was the most common location of the bleed (62.2%). At 90 days, 200 patients (58.1%) had good outcome and 144 (41.9%) had poor outcome with an overall mortality of 75 (21.8%). Independent predictors of poor outcome were poor GCS, larger volume, and high serum creatinine values.

Conclusion

The incidence of SICH among the young accounts for nearly 30% of admitted ICH. Poor outcome and mortality are high with HTN being the single most important modifiable risk factor in the cohort.

A 6-month prognostic nomogram incorporating hemoglobin level for intracerebral hemorrhage in younger adults

OBJECTIVE

Intracerebral hemorrhage (ICH) is the second most common subtype of stroke, with high mortality and morbidity. At present, there are no effective 6-month prognostic markers, particularly for younger patients. The aim of this research was to construct a new valuable prognostic nomogram model incorporating haemoglobin levels for adult patients with ICH.

METHODS

Patients aged between 18 and 50 presenting with intracerebral haemorrhage at the Tongji Hospital, Tongji Medical College of Huazhong University of Science and Technology between January 1st 2012 and December 31st 2018 were included in this retrospective study. Independent factors of prognosis were identified by univariate and multivariate logistic regression analyses, and a new nomogram model was constructed and validated. The clinical value of the nomogram model was subsequently explored utilizing decision curve analysis and clinical impact curves.

RESULTS

In total, 565 patients were enrolled in this study, 117 (20.7%) of whom developed an unfavourable prognosis. Infratentorial lesion (adjusted odds ratio [aOR] = 3.708, 95% confidence interval [CI], 1.490-9.227; P = 0.005) was the most significant unfavourable outcome. Age ([aOR] = 1.054; 95% CI, 1.014-1.096; P = 0.008), hematoma volume (aOR = 1.014, 95% CI, 1.002-1.027; P = 0.024), haemoglobin (aOR = 0.981, 95% CI, 0.969-0.993; P = 0.002), blood glucose (aOR = 1.135, 95% CI, 1.037-1.241; P = 0.005) and NIHSS (aOR = 1.105, 95% CI, 1.069-1.141; P < 0.001) were independent risk factors. Based on these 6 factors, the nomogram can be employed to predict early functional prognosis with high accuracy (AUC 0.791). Decision curve analysis and clinical impact curves showed an increased net benefit for utilizing the nomogram.

CONCLUSION

The haemoglobin level at admission may be an easily overlooked factor in clinical work. This new nomogram model could be a promising and convenient tool to predict the early functional prognosis of adults with ICH. More prospective multicentre studies are needed to validate these findings.

Prevalence and characterization of cerebral small vessel disease in young adults with intracerebral hemorrhage

BACKGROUND AND AIMS

Cerebral small vessel disease (CSVD) is the main cause of intracerebral hemorrhage (ICH) in older individuals but has not been systematically studied in younger people. We aimed to evaluate the prevalence and characteristics of CSVD in young adults with symptomatic ICH.

METHODS

We conducted a cohort study of consecutive adults aged 18-50 years with non-traumatic ICH. All patients were evaluated with brain and vascular imaging. Using validated imaging markers (cerebral microbleeds (CMBs), white matter hyperintensities and/or lacunes), patients were categorized as having CSVD-related ICH or non-CSVD-related ICH. Factors associated with CSVD were evaluated using multivariable analyses. CSVD subtypes were characterized using pre-specified criteria.

RESULTS

Of 146 young adults with ICH (mean age = 37.7), CSVD was present in 41 patients (28.1%; 95% confidence interval (CI) = 21.0-36.1). In multivariable analysis, older age, male sex, and hypertension were independently associated with the presence of CSVD. Deep perforator arteriopathy (48.8%) and mixed CSVD (31.7%) were the most common CSVD subtypes.

CONCLUSION

Our results suggest that CSVD is a frequent cause of ICH in young adults and provide new insights into the characterization of the disease. These findings may have important implications since the treatment and management differ from other causes of ICH.

Does gender difference matter in cerebral venous thrombosis?

Female specific risk factors (FSRFs) in cerebral venous thrombosis (CVT) may have difference in clinical, imaging and outcome parameters compared to those females with additional risk factors and males. We compare the clinical, MRI and outcome between male and female patients with CVT. We also compare female patients with and without female specific risk factors. 172 patients were included from a prospectively maintained CVT registry. The diagnosis was confirmed on magnetic resonance venography (MRV). Clinical details, risk factors, MRI and MRV findings were noted. The risk factors in the females were categorized as 1) Isolated FSRF (oral contraceptive, pregnancy, puerperium), 2) FSRF in addition to other risk factor, 3) non FSRF only, and 4) no risk factor groups. Outcome at 6 months was assessed using modified Rankin Scale (mRS) as death, poor (mRS 3-5) and good (mRS ≤ 2). There were 80 (46.5%) females; 24 (30%) had FSRFs and 18 (75%) of whom also had other risk factors leaving only 6(25%) females with isolated FSRF. The frequency of other prothrombotic risk factors, and clinical and imaging findings were similar in males and females except more frequent hyperhomocysteinemia in males (59% vs 41%; P = 0.036) and altered sensorium in females (66% vs 40%; P = 0.001). 17(9.9%) patients died, 12(7%) had poor and 143(83.1%) had good outcome, which were similar in both the gender, and in the females with and without FSRF. Isolated FSRF is rare in CVT, and there is no gender difference in terms of non FSRFs, clinico-radiological severity and outcome.

The Intracerebral Hemorrhage Score Overestimates Mortality in Young Adults

OBJECTIVE

To determine whether the intracerebral hemorrhage (ICH) score is accurate in predicting 30-day mortality in young adults, we calculated the ICH score for 156 young adults (aged 18-45) with primary spontaneous ICH and compared predicted to observed 30-day mortality rates.

METHODS

We retrospectively reviewed all patients aged 18-45 consecutively presenting to the University of Iowa from 2009 to 2019 with ICH. We calculated the ICH score and recorded its individual subcomponents for each patient. Poisson regression was used to test the association of ICH score components with 30-day mortality.

RESULTS

We identified 156 patients who met the inclusion criteria; mean± standard deviation (SD) age was 35±8 years. The 30-day mortality rate was 15% (n=24). The ICH score was predictive of 30-day mortality for each unit increase (p= 0.04 for trend), but the observed mortality rates for each ICH score varied considerably from the original ICH score predictions. Most notably, the 30-day mortality rates for ICH scores of 1, 2, and 3 are predicted to be 13%, 26%, and 72% respectively, but were observed in our population to be 0%, 3%, and 41%. An ICH volume of >30cc [relative risk (RR) 28, 95% confidence intervals (CI) 3-315, p=0.01] and a GCS score of <5 (RR 13, 95% CI 0.1-1176, p=0.01) were independently associated with 30-day mortality.

CONCLUSIONS

The ICH score tends to overestimate mortality in young adults. ICH volume and GCS score are the most relevant items in predicting mortality at 30 days in young adults.

MRI Characterization of Non-traumatic Intracerebral Hemorrhage in Young Adults

Background and Purpose: Non-traumatic intracerebral hemorrhage (ICH) in younger population is a relatively rare event but is associated with considerable mortality and poor functional outcome. Imaging plays a crucial role in determining the underlying cause and guide treatment of ICH. In up to 41% of patients in prior studies, the underlying cause remained elusive. However, the usage of MRI as part of diagnostic work-up was scanty. We aimed to analyze MRI findings of ICH in younger patients and assess specificity and sensitivity of MRI in detecting structural or local underlying causes of ICH.

Methods: We included patients aged 15–49 years with first-ever ICH identified from a prospective hospital discharge registry, 2000–2010. All study patients underwent MRI within 3 months of ICH. Imaging data was analyzed by a senior neuroradiologist blinded to final clinical diagnosis. We calculated the diagnostic accuracy of MRI in detecting structural/local underlying causes.

Results: Of our 116 patients (median age, 39; 67% males), structural/local causes were the leading causes of ICH (50.0%), and of these, bleeding cavernomas (23.3%) were the most frequent followed by arteriovenous malformations (12.9%), cerebral venous thrombosis (CVT) (7.8%), brain tumors (5.2%), and moyamoya disease (0.9%). Lobar location of ICH was more prevalent in younger patients. MRI was highly sensitive (90.0%; 95% confidence interval, 79.5–96.2%) for detection of structural/local causes compared with angiographic imaging (55.6%; 95% CI, 40.0–70.4%), while MRI was less specific (87.3%; 95% CI, 75.5–94.7%) for structural/local causes, compared with angiographic imaging (97.4%; 95% CI, 86.5–99.9%).

Conclusion: MRI was highly sensitive for the detection of structural and local causes underlying ICH in young adults. Thus, MRI should be considered in the diagnostic work-up of all young ICH patients to enable targeted secondary prevention.

Non-Traumatic Intracerebral Hematoma in the Young: Findings from a Tertiary Hospital in the Philippines

BACKGROUND

There is geographic variability in the clinical profile and outcomes of non-traumatic intracerebral hematoma (ICH) in the young, and data for the Philippines is lacking. We aimed to describe this in a cohort from the Philippines, and identify predictors of mortality.

METHODS

We performed a retrospective study of all patients aged 19-49 years with radiographic evidence of non-traumatic ICH admitted in our institution over five years. Data on demographics, risk factors, imaging, etiologies, surgical management, in-hospital mortality, and discharge functional outcomes were collected. Multivariate logistic regression analysis was done to determine factors predictive of mortality.

RESULTS

A total of 185 patients were included, which had a mean age of 40.98 years and a male predilection (71.9%). The most common hematoma location was subcortical, but it was lobar for the subgroup of patients aged 19-29 years. Overall, the most common etiology was hypertension (73.0%), especially in patients aged 40-49. Conversely, the incidence of vascular lesions and thrombocytopenia was higher in patients aged 19-29. Surgery was done in 7.0% of patients. The rates of mortality and favorable functional outcome at discharge were 8.7% and 35.1%, respectively. Younger age (p = 0.004), higher NIHSS score on admission (p=0.01), higher capillary blood glucose on admission (p=0.02), and intraventricular extension of hematoma (p = 0.01) predicted mortality.

CONCLUSIONS

In the Philippines, the most common etiology of ICH in young patients was hypertension, while aneurysms and AVM's were the most common etiology in the subgroup aged 19 - 29 years. Independent predictors of mortality were identified.

Significance of recanalization of sinuses and resolution of parenchymal lesion in cerebral venous sinus thrombosis

In cerebral venous sinus thrombosis (CVST), the degree of recanalization may determine resolution of parenchymal lesion and clinical outcome. The aim of our study was to evaluate the relationship of recanalization with resolution of MRI lesion and clinical outcome. The patients with CVST diagnosed on the basis of magnetic resonance venography (MRV) were included prospectively. Risk factors, clinical features, and MRI and MRV findings were noted. MRI and MRV were repeated at 6 months and the change in parenchymal lesion and grade of recanalization (I, II, III) were noted. Patients were evaluated clinically at three and six months. Complete recovery was considered if modified Rankin Scale (mRS) score was 0. Thirty-three CVST patients were included, 12 (36.4%) of whom were females. Recanalization occurred in 29 (87.9%), which was complete (grade III) in 6 (21%). Sigmoid sinus (52%) recanalized more frequently. Resolution of parenchymal lesion on repeat MRI occurred in 13.3% (4/30) patients, and they had no sequelae. Degree of recanalization was not related to resolution of neurological sequelae, MRI lesion at follow up and burden of thrombosis at baseline. Varying degree of recanalization occurred in 87.9% patients with CVST, and resolution of parenchymal lesion occurred in 13.3%. Clinical outcome however was not related to recanalization.

Hypertension is a Leading Cause of Nontraumatic Intracerebral Hemorrhage in Young Adults

OBJECTIVE

To evaluate the etiology and discharge outcome of nontraumatic intracerebral hemorrhage (ICH) in young adults admitted to a comprehensive stroke center.

METHODS

A retrospective chart review was performed on patients with a discharge diagnosis of nontraumatic ICH admitted from 7/1/2011 to 6/30/2016. Data was collected on demographics, clinical history, ICH score, hemorrhage location, do-not-resuscitate (DNR) orders, likely etiology, and discharge disposition. Categorical data was reported as percentage. Chi-squared test was performed to evaluate association of location of ICH, etiology of ICH, and ICH score with the discharge outcome.

RESULTS

Sixty-three patients met the study criteria, with mean age 35.4 ± 6.4 years including 26 (41%) women and 40 (64%) whites. Headache (65%) and change in mental status (48%) were the most common presenting symptoms. Hemorrhage was most commonly seen in the deep structures in 29 (46%) patients followed by lobar ICH in 14 (22%) patients. The most common etiology of ICH was hypertension in 23 (37%) patients, followed by vascular abnormalities in 18 (29%) patients. Forty-two (67%) had good outcome defined as discharge to home (n = 25) or acute inpatient rehabilitation (n = 17). Twenty-one (33%) patients had bad outcome with discharge to skilled nursing facility (n = 6), hospice (n = 1) or died in the hospital (n = 14). Hospital DNR orders were noted in 11 (18%) patients. Higher ICH score (P < .0001) and use of DNR orders (P < .0001) were associated with bad outcome. All 11 patients with DNR orders died in the hospital. Location or etiology of hemorrhage were not associated with discharge outcome.

CONCLUSIONS

Hypertension, a modifiable risk factor, is a major cause of nontraumatic ICH in young adults. Aggressive management of hypertension is essential to halt the recent increased trends of ICH due to hypertension. Early DNR orders may need to be cautiously used in the hospital.

In-Hospital and Long-Term Prognosis after Spontaneous Intracerebral Hemorrhage among Young Adults Aged 18-65 Years

BACKGROUND

Spontaneous intracerebral hemorrhage (ICH) accounts for 10%-15% of all strokes and has an estimated annual incidence of 5/100,000 in young adults. Limited data on prognosis after ICH in young adults are available. We aimed to identify prognostic predictors after ICH among adults aged 18-65 years.

METHODS

We retrospectively selected all patients with ICH from a prospective single-center registry of adults with first stroke before 65 years between 1997 and 2002. We recorded in-hospital mortality as well as mortality and recurrent stroke after discharge until December 1, 2018. For in-hospital analysis, we compared patients that died in-hospital versus patients discharged alive. For long-term analysis, we compared patients that died in follow-up versus patients still alive. Independent prognostic predictors were identified using multivariate analyses.

RESULTS

Among 161 patients included, 24 (14.9%) died in-hospital. Among in-hospital survivors, 5-year survival was 92.0%, 10-year survival 78.1%, and 15-year survival 62.0%. After median follow-up of 17 years, 47.4% of patients died, 18 patients had ischemic stroke, and 6 recurrent ICH. Regarding in-hospital prognosis, coma at admission (OR .02 [.00-.11]) was independent predictor for mortality whereas alcoholic habits (OR 12.32 [1.82-83.30]) was independent predictor for survival. An increasing age (OR 1.08 [1.03-1.12]), higher blood glucose levels (OR 1.01 [1.00-1.01]), and hypertension (OR 2.21 [1.22-4.00]) were independent predictors of long-term mortality after ICH.

CONCLUSIONS

Alcoholic habits may influence in-hospital survival after ICH in young adults. Long-term mortality in young adults seems to be lower than in elderly and was predicted by higher blood glucose levels and hypertension.

Is nontraumatic intracerebral hemorrhage different between young and elderly patients?

Only a few studies have reported nontraumatic intracerebral hemorrhage in young patients notwithstanding its fatal and devastating characteristics. This study investigated the clinical characteristics and outcome of nontraumatic intracerebral hemorrhage in young patients in comparison to those of the elderly. A retrospective review of consecutive patients admitted at the department of neurosurgery of two tertiary care medical centers presenting with first-ever nontraumatic intracerebral hemorrhage was performed. We identified and compared the demographics, etiologies, risk factors, and laboratory, radiological, and clinical findings between elderly and young patients. Additionally, logistic regression analyses of independent prognostic factors associated with 1-month mortality and favorable functional outcome were performed. Altogether, 247 patients including 69 young patients and 178 elderly patients were enrolled. On multivariate analysis, young patients exhibited significantly more often an infratentorial hematoma location, excessive alcohol consumption, and high body mass index (BMI), but less frequent systemic hypertension. There was no statistical difference between the two groups in 1-month mortality (17.46% and 18.01% for young and elderly patients, respectively), but the favorable functional outcome based on modified Rankin scale score of 0 or 1 was significantly different between the two groups (favorable outcome in 51.79% and 29.93% of patients, respectively). Predictors of 1-month mortality was the presence of herniation in the young group, and lower Glasgow Coma Scale score, renal or heart disease, and leukocytosis (WBC > 10,000) in the elderly group. Lower National Institutes Health Stroke Scale score was associated with favorable functional outcome in both groups. Nontraumatic intracerebral hemorrhage in younger patients appears to be associated with excessive alcohol consumption and high BMI. Younger patients had similar short-term mortality but more favorable functional outcome than the elderly.

Related Factors of Early Mortality in Young Adults with Cerebral Hemorrhage

Background

The main causes of intracerebral hemorrhage differ between young adults and older adults. Data regarding potential targets for early intervention in young adult patients with intracerebral hemorrhage are lacking.

Methods

We retrospectively analysed data for 196 young adult patients with intracerebral hemorrhage who were admitted to Tianjin Huanhu Hospital and died within 30 days of admission between June 2005 and June 2015. The Kaplan–Meier method was used to calculate survival rate, and the log-rank test was used to determine survival rate significance. A Cox proportional hazards regression model was used for univariate and multivariate analyses.

Results

Univariate analysis revealed a statistically significant association of age, disturbance of consciousness, National Institutes of Health Stroke Scale and Glasgow Coma Scale scores, seizure occurrence, infratentorial hemorrhage, intraventricular extension, hernia, glucose level, white blood cell count, albumin level, creatinine level, uric acid level, and surgical treatment with early mortality (P<0.05). However, multivariate regression analysis revealed that only infratentorial hemorrhage (P=0.003) and intraventricular extension (P=0.003) were significant risk factors for early mortality.

Conclusions

Our results suggest that young adult patients who exhibit infratentorial hemorrhage and intraventricular extension in the early stages of intracerebral hemorrhage onset exhibit an increased risk of early mortality.

Nontraumatic intracerebral haemorrhage in young adults

Nontraumatic intracerebral haemorrhage (ICH) is a common subtype of stroke with a poor prognosis, high mortality and long-term morbidity. The incidence of ICH increases with age. ICH has not been widely investigated in young adults (herein defined as aged ∼18-50 years) despite an annual incidence of ∼5 per 100,000 individuals. Furthermore, ICH characteristics differ between young and elderly patients. Risk factors for ICH are surprisingly common in young adults, in whom ICH is often caused by structural lesions or hypertension, and only rarely by anticoagulation therapy and cerebral amyloid angiopathy (which are common predisposing factors in elderly patients). High short-term mortality (17% at 3 months) and long-term mortality (>25% at 10 years) persist even in contemporary series from high-income countries, and long-term disability is very common. Thus, an aggressive approach to identifying treatable underlying conditions and preventing ICH recurrence is indicated in young patients, although treatment strategies have generally not been investigated specifically in this age group. This narrative Review summarizes existing knowledge on the epidemiology, risk factors, causes, diagnosis, treatment and outcomes of ICH in young adults. We provide comparisons with the population of elderly patients with ICH and discuss challenges for future research.

Cut stroke in half: Polypill for primary prevention in stroke

This review summarizes the potential for polypill therapies for stroke prevention. While a number of studies applying different approaches regarding polypill have been performed, none of them has had a focus on stroke as the main outcome. A combination pill containing drugs such as statins, diuretics, and other antihypertensives is currently available in various formats. Estimates focusing mostly on primary prevention show that using such a combination drug a reduction in the 5-year stroke incidence by 50% can be achieved - especially in low- and middle-income countries with a high prevalence of risk factors even among people at young ages. A combination of a large supporting population-wide program with a registry-based quality control is the most likely perspective and can be achieved within a reasonable time frame and potentially have significant influence in young stroke populations.

Fifty years of stroke researches in India

Currently, the stroke incidence in India is much higher than Western industrialized countries. Large vessel intracranial atherosclerosis is the commonest cause of ischemic stroke in India. The common risk factors, that is, hypertension, diabetes, smoking, and dyslipidemia are quite prevalent and inadequately controlled; mainly because of poor public awareness and inadequate infrastructure. Only a small number of ischemic stroke cases are able to have the benefit of thrombolytic therapy. Benefits from stem cell therapy in established stroke cases are under evaluation. Presently, prevention of stroke is the best option considering the Indian scenario through control and/or avoiding risk factors of stroke. Interventional studies are an important need for this scenario.

Increased risk of intracerebral hemorrhage among patients with chronic osteomyelitis

OBJECT

Inflammation may provoke cerebral arteriolar ectasia, inducing microaneurysm formation and further promoting intracerebral hemorrhage (ICH). Chronic osteomyelitis (COM) is an inflammatory disorder for which study of its role in ICH is lacking. This study explored whether COM increases the risk of ICH.

METHODS

From Taiwan national insurance inpatient claims, 22,052 patients who were newly diagnosed with COM between 1997 and 2010 were identified; 88, 207 age and sex frequency-matched subjects without COM were selected at random for comparison. Risks of ICH associated with COM and comorbidities, including hypertension, diabetes, hyperlipidemia, chronic kidney disease, and drug abuse, were assessed by the end of 2010.

RESULTS

The incidence of ICH was 1.68 times higher in the COM cohort than in the comparison cohort, with an adjusted hazard ratio (HR) of 1.50 (95% CI 1.29–1.74) estimated in the multivariable Cox model. Age-specific analysis showed that the HR of ICH for COM patients decreased with age, with an adjusted HR of 3.28 (95% CI 1.88–5.75) in the < 40-year age group, which declined to 1.11 (95% CI 0.88–1.40) in the elderly. The incidence of ICH increased with the severity of COM; for those with severe COM the adjusted HR was 4.42 (95% CI 3.31–5.89). For subjects without comorbidities, the incidence of ICH was 1.20-fold (95% CI 1.00–1.45) higher in the COM cohort than in the comparison cohort.

CONCLUSIONS

This study suggests for the first time that COM is an inflammatory factor associated with increased risk of ICH, especially in younger patients.

Systemic Inflammatory Response Syndrome Predicts Severity of Stroke and Outcome

BACKGROUND

This study was undertaken to evaluate the frequency of systemic inflammatory response syndrome (SIRS) at admission and its correlation with clinical and radiological severity of stroke and outcome.

METHODS

Two hundred consecutive stroke patients within 48 hours of ictus were prospectively included, and their clinical details including Glasgow Coma Scale (GCS), National Institutes of Health Stroke Scale (NIHSS), and feature of raised intracranial tension were noted. Computed tomography/magnetic resonance imaging finding included stroke type, location, size, midline shift, herniation, and intraventricular hemorrhage score. SIRS was noted on days 1, 2, 7, and 15. Death and outcome at 3 months were based on modified Rankin Scale (mRS) score.

RESULTS

Seventy-five (37.5%) had infraction and 125(62.5%) intracranial hemorrhage (ICH). SIRS was present in 120 (60%) patients: all the features in 56 (28%), 3 in 48 (24%), and 2 in 16 (8%). The presence of SIRS decreased with time: on the second day in 57%, seventh day in 43%, and 15th day in 21% of patients. Admission SIRS correlated with the GCS score (P < .001), NIHSS score (P < .001), volume of ICH (P < .001), infarction size (P < .001), hypernatremia (P = .001), and respiratory paralysis (P < .001). Thirty-one (15.5%) patients died, and 30 (97%) of them had SIRS. At 3 months, 110 (55%) patients had poor outcome (mRS >2) and of them 90 (82%) had SIRS (P < .001). On multivariate regression analysis, the number of SIRS criteria (P = .16) was not significantly related to 3-month outcome and death but independently related to NIHSS score at admission (odds ratio [OR] = 1.39; 95% confidence interval [CI] = 1.22-1.56; P < .001), GCS score (OR = 1.32; 95% CI = 1.01-1.71; P = .04), and duration of hospitalization (OR = 1.07; 95% CI = 1.01-1.15; P = .03).

CONCLUSIONS

SIRS at presentation is a useful marker for clinicoradiological severity of stroke but not an independent marker of death and disability.