Nontraumatic hemorrhagic stroke in young adults in taiwan

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.

Etiology and risk factors of intracranial hemorrhage and ischemic stroke in young adults

BACKGROUND

Young stroke incidence has increased worldwide with lifestyle changes. Etiology and risk factors for both ischemic and hemorrhagic stroke in young Asians remain underexplored.

METHODS

We retrospectively reviewed consecutive acute stroke patients aged 16-45 years admitted to the Taipei Veterans General Hospital between 2009 and 2019 to analyze etiologic subtypes, risk factors, and serial modified Rankin Scale scores for 1 year and compare the age groups of 16-30 and 31-45 years.

RESULTS

Among 670 young Taiwanese patients (mean age at onset 37.5 ± 7.0 years; male 65.1%), there were 366 nontraumatic spontaneous hemorrhagic stroke (including 259 intracerebral hemorrhage [ICH] and 107 subarachnoid hemorrhage, SAH), 292 ischemic stroke and 12 cerebral venous thromboses. Notably, ICH was more prevalent in patients aged 16-30 than in those aged 31-45 (54.8% vs 36.8%). Specifically, structural vasculopathy (e.g., arteriovenous malformation, cavernoma) was the most common etiologic subtype in patients aged 16-30 (p < 0.001), whereas hypertensive ICH was the most common subtype in patients aged 31-45 (p < 0.001). On the other hand, the top ischemic subtype for both age groups was other determined diseases (e.g., arterial dissection, autoimmune diseases, moyamoya disease, etc.) rather than large artery atherosclerosis. Hyperlipidemia, diabetes, and cigarette smoking were more common risk factors for infarction than ICH. Familial stroke patients whose first- or second-degree relatives had a stroke by age 80 (n = 104, 15.5%) had more infarctions than those without a familial stroke history. In multivariate analyses, initial stroke severity, and infarction type were important predictors of favorable outcomes after 3 months. At the 1-year follow-up, patients with ICH and SAH had worse functional outcomes and survival rates than those with infarction.

CONCLUSION

An aggressive approach to elucidate the etiology of stroke is indicated because structural vasculopathy-induced ICH and other determined infarction are distinctively prevalent in young adults, particularly those aged 16-30.

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.

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.

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.

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.

Glioblastoma presenting as spontaneous intracranial haemorrhage: Case report and review of the literature

Glioblastoma (GB) classically presents with symptoms of raised intracranial pressure and gradual progressive neurological deficits. An acute presentation, with intracerebral haemorrhage (ICH) and rapid clinical deterioration, occurs infrequently. Contemporary imaging modalities do not reliably reflect underlying mass lesions in parenchymal brain haemorrhage at first presentation. We report a delayed diagnosis of GB in a 21-year-old patient presenting with spontaneous ICH and a negative initial neurovascular workup. A comprehensive literature review was performed to investigate the incidence of malignant aetiology for spontaneous ICH in young adults, and to underscore the importance of early utilisation of diagnostic magnetic resonance imaging (MRI) in such cases.

Intracerebral hemorrhage at young age: long-term prognosis

BACKGROUND AND PURPOSE

Intracerebral hemorrhage (ICH) is a devastating disorder associated with dismal outcomes. The long-term mortality and functional outcome of ICH in young patients was studied - areas so far poorly investigated.

METHODS

A follow-up study was performed on a cohort of patients. Clinical and imaging data on ICH patients aged 16-49 were retrospectively obtained and linked with a nationwide cause-of-death register. The modified Rankin Scale (mRS) was evaluated for 30-day survivors at a visit 9.7 (7.0-12.0) years after ICH onset. Independent factors associated with mortality and unfavorable functional outcome (mRS 2-5) were sought by multivariate analysis.

RESULTS

Amongst the 268 1-month survivors, 1-year survival was 98.1% [95% confidence interval (CI) 96.2%-100%], 5-year survival 93.2% (89.3%-97.1%) and 10-year survival 88.8% (84.9%-92.7%). After adjustment for age and intraventricular hematoma extension, male sex [odds ratio (OR) 3.36, 95% CI 1.28-8.80] and diabetes (OR 2.64, 1.01-6.89) were associated with increased mortality. Unfavorable functional outcome emerged in 49%. After adjustment for confounders, age (OR 1.09 per 1 year, 95% CI 1.03-1.15), initial stroke severity (1.17 per one National Institutes of Health Stroke Scale score point, 1.08-1.27) and intraventricular hemorrhage (3.26, 1.11-9.55) were associated with unfavorable functional outcome.

CONCLUSIONS

Of every 10 survivors of acute phase ICH at a young age, one died within 10 years after onset, male sex and diabetes being associated with increased mortality. Half the survivors did not achieve a favorable functional outcome, which was predicted by increasing age, initial stroke severity and intraventricular hemorrhage.

Medical acute complications of intracerebral hemorrhage in young adults

Background. Frequency and impact of medical complications on short-term mortality in young patients with intracerebral hemorrhage (ICH) have gone unstudied. Methods. We reviewed data of all first-ever nontraumatic ICH patients between 16 and 49 years of age treated in our hospital between January 2000 and March 2010 to identify medical complications suffered. Logistic regression adjusted for known ICH prognosticators was used to identify medical complications associated with mortality. Results. Among the 325 eligible patients (59% males, median age 42 [interquartile range 34–47] years), infections were discovered in 90 (28%), venous thrombotic events in 13 (4%), cardiac complications in 4 (1%), renal failure in 59 (18%), hypoglycemia in 15 (5%), hyperglycemia in 165 (51%), hyponatremia in 146 (45%), hypernatremia in 91 (28%), hypopotassemia in 104 (32%), and hyperpotassemia in 27 (8%). Adjusted for known ICH prognosticators and diabetes, the only independent complication associated with 3-month mortality was hyperglycemia (plasma glucose >8.0 mmol/L) (odds ratio: 5.90, 95% confidence interval: 2.25–15.48, P < 0.001). Three or more separate complications suffered also associated with increased mortality (7.76, 1.42–42.49, P = 0.018). Conclusions. Hyperglycemia is a frequent complication of ICH in young adults and is independently associated with increased mortality. However, multiple separate complications increase mortality even further.

Incidence, risk factors, etiology, severity and short-term outcome of non-traumatic intracerebral hemorrhage in young adults

BACKGROUND AND PURPOSE

Intracerebral hemorrhage (ICH) is a common and severe form of stroke but is scarcely studied in young adults. Our aim was to study risk factors, clinical presentation and early mortality of ICH in the young and compare these features with older patients.

METHODS

All consecutive patients aged between 16 and 49 diagnosed with a first-ever ICH at the Departments of Neurology or Neurosurgery of the Helsinki University Central Hospital between January 2000 and March 2010 (n = 336) were analyzed retrospectively. Comparisons were performed amongst demographic subgroups and with patients over 49 years of age enrolled between January 2005 and March 2010 (n = 921).

RESULTS

In the young patients, median age was 42 years (interquartile range 34-47), 59.5% were male, and annual incidence was 4.9 (95% confidence interval 4.5-5.3) per 100 000. The most prevalent risk factors were hypertension (29.8%) and smoking (22.3%). Compared with older patients hypertensive microangiopathy was less common (25.0% vs. 34.3%, P = 0.002) and structural lesions more common (25.0% vs. 4.9%, P < 0.001) assumed etiologies of ICH. The cause remained elusive in 32.1% of all young patients and in 22.5% of those who underwent magnetic resonance imaging and any angiography (n = 89, P = 0.023). Three-month mortality rate was lower in young patients compared with older ones (17.0% vs. 32.7%, P < 0.001). Hematoma volumes were similar across all ages (P = 0.324) and independently predicted mortality in older patients but not in the young.

CONCLUSIONS

Intracerebral hemorrhage (ICH) in the young appears less fatal and has a different spectrum of causes and factors associated with short-term mortality than for the elderly.

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

OBJECTIVE

There is paucity of information on the etiology and predictors of outcome of intracerebral hemorrhage (ICH) in young patients which may have regional and ethnic differences. In this study, we report the etiology and predictors of outcome of ICH in young patients from North India.

METHODS

404 young patients with ICH (16-50 years) were retrospectively reviewed who were admitted in neurology service of a tertiary care teaching hospital in North India. The data were retrieved from the computerized hospital information service. The information about the demography, risk factors, clinical status, laboratory findings, CT/MRI features and angiography (CT, MRI or digital substraction) were noted. The etiology of ICH was ascertained based on clinical, laboratory and radiological findings. Outcome at 1 month was assessed using Glasgow Outcome Scale (GOS).

RESULTS

The mean age of the patients was 41.6 years and 23.8% were females. Hypertension (57.2%), hypocholesterolemia (33.7%), alcohol (15.8%) and anticoagulant (3.5%) were the important risk factors. The etiology of ICH was hypertension in 320 (79.2%), vascular malformation in 17 (4.2%), coagulopathy in 16 (4%), cerebral venous sinus thrombosis (CVST) in 9 (2.2%), thrombocytopenia in 3 (0.7%), vasculitis in 2 (0.5%) and cryptogenic in 37 (9.2%) patients. The patients with cryptogenic ICH were younger, had better Glasgow coma scale (GCS) on admission and good outcome compared those with known etiology. The most common location of ICH was basal ganglion and thalamus (71.3%). 102 (25%) patients died, 161 (39.9%) had poor and 141 (34.9%) had good outcome. Hypertensive ICH patients had frequent death or disability (P<0.001). On multivariate analysis, low GCS score (P <0.001), large ICH (P=0.01) and high leukocyte count on admission (P=0.03) were significantly related to the 1 month mortality.

CONCLUSION

Hypertension is the commonest cause of ICH in young Indian adults and its outcome is related to volume of ICH, GCS score and admission leukocyte count.

Imaging in young adults with intracerebral hemorrhage

OBJECTIVE

Vascular malformations are a common yet treatable cause of intracerebral hemorrhage (ICH) in the young. The goal of this study was to review the implementation of appropriate secondary angiographic/venographic imaging to identify vascular malformations in young adults with ICH at our specialist neuroscience center.

METHODS

A retrospective analysis was undertaken of five years of prospectively recorded referral data to the on-call neurosurgery service at the Greater Manchester Neuroscience Centre.

RESULTS

The authors identified 111 ICH patients aged 18-40 over the five-year period, with a wide etiologic spectrum. When assessing the implementation of secondary imaging, they focused on 90 individuals, incorporating those without an identifiable precipitant for their ICH and those with recent recreational drug use and hypertension. Of these 90, 52 (58%) were admitted to the neuroscience center for further management; when excluding three with bilateral fixed and dilated pupils, the remaining 49 all underwent appropriate secondary imaging. Of the 38 subjects not accepted to the neuroscience center, 13 (34%) had bilateral fixed and dilated pupils, 10 (26%) underwent appropriate secondary imaging, and 15 did not - all but two of these 15 were referred outside of normal working hours. The positive yield from secondary imaging was 63%.

CONCLUSION

Young adults with ICH are more likely to get appropriate imaging to identify vascular malformations in a specialist neuroscience center compared to a non-specialist center. Out of hours care appears to be a significant contributor to this shortfall. This study suggests a need for service redevelopment and specialist neuroscience center input for all cases of young 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.