Incidence and case-fatality from spontaneous intracerebral hemorrhage in a southern region of Portugal

Epidemiology of intracerebral hemorrhage: A systematic review and meta-analysis

Background

Intracerebral hemorrhage (ICH) is associated with high mortality and disability rates. This study aimed to investigate the relationship between sex, age, study year, risk factors, bleeding site, median year of study, and the incidence of ICH.

Method

Literature on the incidence of ICH published on 1 January 1980 and 1 January 2020, was systematically retrieved from PubMed and Embase databases. The random-effects model and subgroup analysis were used to explore the relationship between the incidence of ICH and different ages, sex, bleeding sites, and risk factors.

Results

We summarized the epidemiological changes in ICH in the past 40 years according to 52 studies and found that the total incidence of ICH is 29.9 per 100,000 person-years (95% CI: 26.5–33.3), which has not decreased worldwide. The incidence of ICH in the Asian population is much higher than in other continents. In addition, the incidence of ICH increases with age and differs at the 85-year-old boundary. Men are more likely to develop ICH than women, and the basal ganglia region is the most common area for ICH. Of the 10 risk factors examined in this study, those with hypertension had the highest incidence of ICH, followed by those with excessive alcohol consumption and heart disease.

Conclusion

The prevention and treatment of ICH still need to be improved continuously according to age, sex, risk factors, and other factors, and targeted and normative strategies should be gradually developed in the future.

Impact of process of care in the short-term mortality in non-severe intracerebral hemorrhage in southern Portugal

INTRODUCTION

Patients with spontaneous intracerebral hemorrhage (SICH) face the worse functional and vital prognosis among all stroke subtypes. In cases of severe SICH, therapeutic inertia or nihilism complicates meaningful identification of outcome predictors. Therefore, we sought to investigate clinic-radiological and process of care predictors of short-term mortality in patients with mild to moderate SICH.

PATIENTS AND METHODS

Observational retrospective community representative consecutive case series of patients from Algarve, southern Portugal. Logistic regression was used to identify predictors of short-term (30-day) death.

RESULTS

Mortality was 23.9% (111/464). Most important predictors of death were unconsciousness at admission (OR = 12.392, 95% CI = 3.816-40.241, p < 0.001), hospital arrival ≥ 6 h after stroke onset (OR = 2.842, 95% CI = 1.380-5.852, p =.005), hematoma volume > 30 cc/cm3 (OR = 3.295, 95% CI 0 1.561-6.953, p =.002), intraventricular extension (OR = 2.885, 95% CI = 1.457-5.712, p =.002) and ≥ 24 h in the Emergency Department (OR = 19.675, 95% CI = 3.682-34.125, p =.009). Stroke Unit (SU) admission reduced the likelihood of death (OR = 0.293, 95% CI = 0.137-0.682, p =.002).

CONCLUSION

The observed mortality is high. Apart from the traditional clinic-radiological factors, in mild to moderate SICH, process of care related factors have strong impact on mortality. These results highlight the need of continuous improvement of SICH care to improve the prognosis.

Incidence and Long-Term Survival of Spontaneous Intracerebral Hemorrhage Over Time: A Systematic Review and Meta-Analysis

Background and Purpose

Recent epidemiological data indicate that the absolute number of hemorrhagic stroke cases increased by 47% between 1990 and 2010 and continued to cause high rates of death and disability. The last systematic review and meta-analysis of incidence and long-term survival of intracerebral hemorrhage (ICH) were published 11 and 7 years ago, respectively, and lacked comparison between different income groups, therefore, a more up to date analysis is needed. We aim to investigate the ICH incidence and long-term survival data in countries of different income groups.

Materials Methods

We systematically searched Ovid Medline for population-based longitudinal studies of first-ever spontaneous ICH published from January 2000 to December 2020. We performed meta-analyses on the incidence and survival rate in countries of 4 different income groups with random-effects models (severe inconsistency). The I² was used to measure the heterogeneity. Heterogeneity was further investigated by conducting the meta-regression on the study mid-year. Time trends of the survival rate were assessed by weighted linear regression.

Results

We identified 84 eligible papers, including 68 publications reporting incidence and 24 publications on the survival rate. The pooled incidence of ICH per 100,000 per person-years was 26.47 (95% CI: 21.84–32.07) worldwide, 25.9 (95% CI: 22.63–29.63) in high-income countries (HIC), 28.45 (95% CI: 15.90–50.88) in upper-middle-income countries, and 31.73 (95% CI: 18.41–54.7) in lower-middle-income countries. The 1-year pooled survival rate was from 50% (95% CI: 47–54%; n = 4,380) worldwide to 50% (95% CI: 47–54%) in HIC, and 46% (95% CI: 38–55%) in upper-middle income countries. The 5-year pooled survival rate was 41% (95% CI: 35–48%; n = 864) worldwide, 41% (95% CI: 32–50%) in high-income and upper-middle countries. No publications were found reporting the long-term survival in lower-middle-income and low-income countries. No time trends in incidence or survival were found by meta-regression.

Conclusion

The pooled ICH incidence was highest in lower-middle-income countries. About half of ICH patients survived 1 year, and about two-fifths survived 5 years. Reliable population-based studies estimating the ICH incidence and long-term survival in low-income and low-middle-income countries are needed to help prevention of ICH.

Systematic Review Registration

https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=170140, PROSPERO CRD42020170140.

Stroke due to Percheron Artery Occlusion: Description of a Consecutive Case Series from Southern Portugal

The artery of Percheron (AOP) is an abnormal variant of the arterial supply of the thalamus. Stroke caused by AOP occlusion is seldom reported. AOP leads to bilateral thalamic and rostral midbrain infarct presenting with unspecific manifestations. There are few descriptions of case series of stroke caused by AOP. We sought to review the clinicoradiological characteristics of AOP infarction from Algarve, Southern Portugal. Eight consecutive cases were retrospectively identified by searching the electronic clinical charts, as well as the stroke Unit database (2015–2020). Sociodemographic (age and gender) and clinicoradiological characteristics (etiological classification, admission severity, manifestations, and short- and long-term prognoses) were retrieved. The corresponding frequency of AOP infarction was 0.17% (95% confidence interval: 0.05–0.28). The mean age was 67.1 (range: 60–80) years. The range of stroke severity evaluated assessed by the National Institute of Health Stroke Scale ranged from 5 to 23 (median = 7.5). None of the patients receive acute ischemic stroke reperfusion treatment. AOP patterns were isolated bilateral paramedian thalamic ( n  = 2), bilateral paramedian and anterior thalamic ( n  = 2), and bilateral paramedian thalamic with rostral midbrain ( n  = 4). Two patients (20%) died on the short term (30 days). At hospital discharge, six patients had functional disability of ≤2 on the modified Rankin scale. In the follow-up at 6 months, half ( n  = 3) of the survivors had persistent hypersomnia and two had vascular dementia. Stroke from AOP presents with variable clinical and radiological presentations and patients do not receive alteplase. The short-term survivor and the long-term functional independency can be compromised after AOS infarct.

Gender differences in long-term mortality after spontaneous intracerebral hemorrhage in southern Portugal

Introduction:

the prognosis of spontaneous intracerebral hemorrhage (SICH) remains poor. Understanding gender differences can clarify the clinico-epidemiological and process of care related factors that influence SICH prognosis. We analyzed the long-term gender differences of mortality after SICH in Algarve, southern Portugal.

Patients and Methods:

analysis of consecutive community representative of SICH survivors (2009–2015). Logistic regression analysis and Kaplan–Meier method was used to assess gender differences on 1-year mortality and survival. We further analyzed if differences exist between 4 age and gender based subgroups (women <75 years, women ≥75 years, men <75 years, men ≥75 years).

Results:

a total of 285 survivors were analyzed; majority men (66.3%). Women were 2 years older on average. Overall case fatality was 11.6% [CI: 8.3–15.8]. A non-statistically significant (P = .094) higher case-fatality rate was observed in women; men were more frequently admitted to stroke unit; women had more often poor functional outcome or modified Rankin scale (mRS) ≥3. Predictors of death were: being women with ≥ 75 years, in-hospital pneumonia and hospital discharge mRS ≥3. The likelihood of death was higher in women ≥75 years (OR = 2.91 [1.23–8.1], P = .035) in comparison to women <75 years and men ≥75 years. Women <75 years had the longest survivor time, whereas women ≥75 years the shortest survivor time (P < .001).

Conclusion:

gender and age interact to influence long-term mortality after SICH. Women ≥75 years are at increased risk of death and have reduced survival after SICH in southern Portugal. Further studies are needed to clarify the biological or social factors contributing for the poor prognosis in the very old women in the region.

Prediction of short-term prognosis in elderly patients with spontaneous intracerebral hemorrhage

AIM

The incidence of spontaneous intracerebral hemorrhage (SICH) increases with age. Data on SICH mortality in the very old are sparse. We aimed to describe the predictors of 30-day SICH mortality in the very elderly in southern Portugal.

METHODS

A total of 256 community representative SICH patients aged ≥ 75 years (2009-2016) were included. Multiple logistic regression was used to identify predictors of 30-day mortality.

RESULTS

Mean age was 82.1 years; 57.4% males. The 30-day case fatality was 38.7%. The frequency of patients taking anticoagulants (29.3% vs. 11.5%); comatose (46.9% vs. 2.5%); with hematoma volume ≥ 30 mL (64.6% vs. 13.4%); intraventricular dissection (78.8% vs. 27.4%) was higher in deceased patients (p < 0.05). Survivors were more often admitted to stroke unit (SU) (68.2 vs. 31.3%) and had lower mean admission glycaemia values (p < 0.05). The likelihood of death was increased in patients with higher admission hematoma volume (≥ 30 mL) (OR: 8.817, CI 1.753-44.340, p = 0.008) and with prior to SICH history of ≥ 2 hospitalizations OR = 1.022, CI 1.009-1.069, p = 0.031). Having higher Glasgow coma scale score, OR: 0.522, CI 0.394-0.692, p < 0.001, per unit was associated with reduced risk of death. Age was not an independent risk factor of short-term death.

CONCLUSIONS

The short-term mortality is high in very elderly SICH. Prior to SICH history of hospitalization, an indirect and gross marker of coexistent functional reserve, not age per se, increases the risk of short-term death. Other predictors of short-term death are potentially manageable reinforcing the message against any defeatist attitude toward elderly patients with SICH.

Epidemiological characteristics of 561 cases of intracerebral hemorrhage in Chengdu, China

ABSTRACT

To explore the epidemiology of patients with spontaneous intracerebral hemorrhage (sICH) in Chengdu, China, we retrieved the data of patients with spontaneous cerebral hemorrhage admitted to the First Affiliated Hospital of Chengdu Medical College from January 2017 to December 2019. We performed a comprehensive analysis of the location of hemorrhage, demographics, factors of hemorrhage, condition of body, severity of disturbance of consciousness, treatment, length of stay (days), inpatient costs, prognosis, and mortality rate in patients with sICH. In total, data of 561 in patients with sICH were included. The hemorrhage site was primarily located in the basal ganglia and thalamus (64.71%). The mean patient age was 63.2 ± 12.4 years (64.17% men, 35.83% women). Male patients (mean age 62.3 ± 12.5 year) were younger than female patients (mean age 64.9 ± 12.1 year). The age of sICH onset in our sample was between 40 and 79 years; this occurred in 87.70% of the included cases. There were more males than females, which may be related to more daily smoking, longer drinking years, and overweight in males than in females. Cases occurred most frequently during the winter and spring months, and the relationship between sICH visits and hospitalizations appeared as a U-shape. The median time from illness onset to hospital admission was 3.0 hours. According to the Glasgow Coma Scale (GCS) score at admission, 20.50% of sICH cases were of mild intensity, 39.93% were moderate, and 39.57% were severe. Moderate disorder is the most common sICH severity. Factors influencing the disturbance of consciousness were blood glucose level at the time of admission as well as the number of years with hypertension. The lower the degree of disturbance of consciousness and the more they smoked per day indicated they had a higher likelihood of receiving surgical treatment while in hospital. The median hospital stay was 13.0 days, while the median inpatient cost was USD 3609. The 30-day mortality rate was 18.36%. sICH is an important public health problem in Chengdu, China. A governmental initiative is urgently needed to establish a sICH monitoring system that covers the Chengdu region to develop more effective and targeted measures for sICH prevention, treatment, and rehabilitation.

Intracerebral hemorrhage outcome: A comprehensive update

Non-traumatic intracerebral hemorrhage (ICH) is associated with a significant global burden of disease, and despite being proportionally less frequent than ischemic stroke, in 2010 it was associated with greater worldwide disability-adjusted life years lost. The focus of outcome assessment after ICH has been mortality in most studies, because of the high early case fatality which reaches 40% in some population-based studies. The most robust and consistent predictors of early mortality include age, severity of neurological impairment, hemorrhage volume and antithrombotic therapy at the time of the event. Long-term outcome assessment is multifaceted and includes not only mortality and functional outcome, but also patient self-assessment of the health-related quality of life, occurrence of cognitive impairment, psychiatric disorders, epileptic seizures, recurrent ICH and subsequent thromboembolic events. Several scores which predict mortality and functional outcome after ICH have been validated and are useful in the daily clinical practice, however they must be used in combination with the clinical judgment for individualized patients. Management of patients with ICH both in the acute and chronic phases, requires health care professionals to have a comprehensive and updated perspective on outcome, which informs decisions that are needed to be taken together with the patient and next of kin.

Frequent Emergency Department Visits After Spontaneous Intracerebral Hemorrhage: Who Is at Risk?

Background

The long-term prognosis of spontaneous intracerebral hemorrhage (SICH) is poor. Frequent emergency department (ED) visits can signal increased risk of hospitalization and death. There are no studies describing the risk of frequent ED visits after SICH.

Methods

Retrospective cohort study of a community representative consecutive SICH survivors (2009-2015) from southern Portugal. Logistic regression analysis was performed to identify sociodemographic and clinical factors associated with frequent ED visits (≥4 visits) within the first year after hospital discharge.

Results

A total of 360 SICH survivors were identified, 358 (98.6%) of whom were followed. The median age was 72; 64% were males. The majority of survivors (n = 194, 54.2%) had at least 1 ED visit. Reasons for ED visits included infections, falls with trauma, and isolated neurological symptoms. Forty-four (12.3%) SICH survivors became frequent ED visitors. Frequent ED visitors were older and had more hospitalizations (P < .001) and ED visits (P < .001) prior to the SICH, unhealthy alcohol use (P = .049), longer period of index SICH hospitalization (P = .032), pneumonia during hospitalization (P = .001), and severe neurological impairment at discharge (P = .001). Pneumonia during index hospitalization (odds ratio [OR]: 3.08; confidence interval [CI]: 1.39-6.76; P = .005) and history of ED visits prior to SICH (OR: 1.64; CI: 1.19-2.26, P = .003) increased the likelihood of becoming a frequent ED visitor.

Conclusions

Predictors of frequent ED visits are identifiable at hospital discharge and during any ED visit. Improvement of transitional care and identification of at-risk patients may help reduce multiple ED visits.