Active bleeding in hypertensive intracranial hemorrhage

Computed tomography findings of ongoing subgaleal hemorrhage

Neonatal subgaleal hemorrhage (SGH) is a serious adverse event that is often underestimated and sometimes goes unrecognized. It can cause bleeding complications and jeopardize the patient's life. Early diagnosis and prompt treatment are important in optimizing the outcome in neonates with SGH. Herein we describe the case of a newborn who developed severe SGH and died. We report unenhanced computed tomography (CT) of ongoing SGH, which showed a low-density region in the surrounding area of the head. The density could be explained by unclotted active bleeding and low hematocrit. Even if a patient with clinically suspected SGH has a low-density region on CT, the presence of SGH should not be excluded.

Progressive expansion of hypertensive intracerebral hemorrhage by coagulopathy

To test the hypothesis that an impaired coagulation system facilitates rapid expansion of hypertensive intracerebral hemorrhage (HICH), coagulation markers were assayed in plasma and their relations to both the hemorrhage size and its progressive expansion were analyzed. Ninety patients with HICH were studied. On admission, plasma samples were taken for the coagulation assay. Hematoma volume was calculated from a computed tomography (CT) scan and its enlargement was estimated by comparison to the volume of the hematoma calculated from a second CT scan taken later within 24 hr. Nine out of 90 patients showed enlargement in their hematoma size (enlarged hematoma group). Four of the enlarged hematoma group fell into acute fatal deterioration and died. Plasma levels of both fibrino peptide A (17.2+/-7.8 vs. 4.0+/-0.6 ng/ml, P < 0.05) and thrombin-antithrombin complex (21.9+/-3.1 vs. 7.4+/-2.8 ng/ml, not significant) were higher in the unchanged group than those in the enlarged hematoma group. In the hematoma-enlarged group fibrino-peptide A level did not exceed 10 ng/ml. In the hematoma unchanged group thrombin-AT-III complex values were positively correlated to hematoma volume. Thus, the coagulation system seemed to be highly activated depending on the hemorrhage volume within three hr after ictus in hypertensive intracerebral hemorrhage patients. When thrombin generation was not sufficient after bleeding, the hematoma seemed to be progressively enlarged. In conclusion, plasma levels of the coagulation markers on admission could be useful predictors of the possible enlargement of hematoma which leads to a poor outcome.

Multivariate analysis of predictors of hematoma enlargement in spontaneous intracerebral hemorrhage

BACKGROUND AND PURPOSE

We conducted this study to determine, through use of multivariate analyses, the independent predictors of hematoma enlargement occurring after hospital admission in patients with spontaneous intracerebral hemorrhage (i.c.h.).

METHODS

We reviewed 627 patients with ICH admitted within 24 hours of onset. The first CT was performed at admission and the second within 24 hours of admission, and a blood sample was taken for laboratory examinations. Univariate and multivariate analyses were performed to assess the relationships between hematoma enlargement and time from onset, consciousness level, CT findings, amount of alcohol consumption, systolic blood pressure at and after admission, clinical outcome, and hematologic parameters.

RESULTS

Eighty-eight patients (14.0%) showed enlarged hematomas after admission. Multivariate analyses revealed that the following five factors were independently associated with hematoma enlargement: the time from onset (odds ratio [OR], 0.26 for a 1-SD change; 4.9 hours; P < 0.001); the amount of alcohol consumption (OR, 1.50 for 1 SD; 46.3 g/d; P = 0.002); the sharp of hematoma (OR, 1.40 for 1 SD; 0.45 round; P = 0.006); the presence of consciousness disturbance (OR, 1.38 for 1 SD; 0.50 coma; P = 0.026); and the level of fibrinogen (OR, 0.74 for 1 SD; 87.1 mg/dL; P = 0.042). Hematoma enlargement was an independent factor increasing the mortality rate in the ICH patients (OR, 1.57; P < 0.001).

CONCLUSIONS

A particularly high likelihood of hematoma enlargement was observed in patients who (in order of importance) were admitted shortly after onset, who were heavy drinkers; who had an irregularly shaped hematoma, whose consciousness was disturbed, and who had a low level of fibrinogen.

Hematoma enlargement in spontaneous intracerebral hemorrhage

In order to evaluate the incidence and risk factors of hematoma enlargement in spontaneous intracerebral hemorrhage (ICH), 419 cases of ICH were reviewed. The first computerized tomography (CT) scan was performed within 24 hours of onset and the second within 24 hours of admission; a blood sample was taken for laboratory examination within 1 hour of admission. In 60 patients (14.3%) the second CT scan showed an enlarged hematoma. The incidence of enlargement significantly decreased with time (p < 0.05) and significantly increased with the severity of liver dysfunction and the volume of the hematoma on the first CT scan. Patients with an irregularly shaped hematoma had a higher risk of hematoma growth than those with a round hematoma. In addition, patients with hematoma enlargement were more likely to have coagulation abnormalities (low platelet counts and low levels of fibrinogen, alpha 2-antiplasmin activity and platelet aggregation). Moreover, hematoma growth was associated with a poor clinical outcome. It is concluded that patients admitted to a hospital within 6 hours of onset of ICH, especially those admitted within 2 hours, and patients with liver dysfunction or irregularly shaped large hematomas should be closely observed for at least 6 hours after onset in preparation for emergency surgery, since the risk of hematoma growth in these circumstances is high.