Primary intracerebral and aneurysmal subarachnoid hemorrhage in Izumo City, Japan. Part II: management and surgical outcome

Seasonal Variation of Drug Prescription Rate for Overactive Bladder in Men Based on National Health Insurance Claims Data, 2012-2016

Purpose

Overactive bladder (OAB) symptoms might be affected by weather, but only a few clinical studies have investigated this issue. We investigated seasonal variations in OAB-drug prescription rate (DPR) in men using nationwide claims data in Korea.

Methods

A total of 2,824,140 men aged over 18 years were included from the Health Insurance Review and Assessment service – National Patient Sample data between 2012 and 2016. Depending on the monthly average temperature, the seasons were divided into 3 groups, namely, hot (June, July, August, and September), intermediate (April, May, October, and November), and cold (January, February, March, and December) seasons. OAB-DPR was estimated using the claims data, and differences in its rate were examined among the 3 seasonal groups.

Results

The overall OAB-DPR was 1.97% (55,574 of 2,824,140). The OAB-DPR were 0.38%, 0.63%, 0.92%, 1.74%, 4.18%, 7.55%, and 9.69% in the age groups of under 30, 30s, 40s, 50s, 60s, 70s, and over 80 years, respectively; thus, the prescription rate increased with age (P<0.001), with a steeper increase after 60 years of age. OAB-DPR was 1.02% in the hot season, 1.19% in the intermediate season, and 1.27% in the cold season, with significant differences among the 3 seasonal groups (P<0.001). These seasonal variations persisted in the subgroup analysis in each age decade (P<0.001).

Conclusions

OAB-DPR varied with seasons and was significantly higher in the cold season than in the hot season, suggesting that cold weather may affect development and aggravation of OAB symptoms in men.

Acute Stroke Care in Korea in 2013-2014: National Averages and Disparities

BACKGROUND

This study aimed to describe the current status of acute stroke care in Korea and explore disparities among hospitals and regions.

METHODS

The 2013 and 2014 national stroke audit data and the national health insurance claims data were linked and used for this study. Stroke patients hospitalized via emergency rooms within 7 days of stroke onset were selected.

RESULTS

A total of 19,608 patients treated in 216 hospitals were analyzed. Among them 76% had ischemic stroke; 15%, intracerebral hemorrhage (ICH); and 9%, subarachnoid hemorrhage (SAH). Of the hospitals, 31% provided inpatient stroke unit care. Ambulances were used in 56% of cases, and the median interval from onset to arrival was 4.5 hours. One-quarter of patients were referred from other hospitals. Intravenous thrombolysis (IVT) and endovascular treatment (EVT) rates were 11% and 4%, respectively. Three-quarters of the analyzed hospitals provided IVT and/or EVT, whereas 47% of hospitals providing IVT and 67% of hospitals providing EVT had less than one case per month. Decompressive surgery was performed on 28% of ICH patients, and clipping and coiling were performed in 17.2% and 14.3% of SAH patients, respectively. There were noticeable regional disparities between the various interventions, ambulance use, arrival time, and stroke unit availability.

CONCLUSION

This study describes the current status of acute stroke care in Korea. Despite quite acceptable quality of stroke care, it suggests regional and hospital disparities. Expansion of stroke units, stroke center certification or accreditation, and connections between stroke centers and emergency medical services are highly recommended.

Prognosis and futility in neurosurgical emergencies: A review

A patient with a life-threatening intracranial insult presents a difficult situation to the neurosurgeon. In a few short minutes the neurosurgeon must assess the patient's neurologic status, imaging, and medical condition then confer with the patient's proxy regarding treatment. This assessment ideally includes recognition of situations where aggressive care is futile and therefore such treatments should not be offered. The proxy discussion must involve surgical and nonsurgical management options and the impact of these options on survival and residual disability. Surgical decision-making is frequently difficult, even for designated proxies armed with advance directives, as these documents are usually vague with regard to acceptable functional outcomes. To complicate things further, when emergencies are off-hours, housestaff or physician extenders may need to represent the medical team in these discussions so that surgical treatment, if desired, can be arranged expeditiously. These difficulties sometimes lead to the performance of emergent surgical procedures in situations where poor outcome is certain, with deleterious effects to the patient, family, and healthcare system. It is clear then that neurosurgeons as well as their housestaff and extenders should have working knowledge of prognostic information relating to intracranial insults and familiarity with the complex ethical concept of medical futility. In this paper we review the relevant literature and our goal is to juxtapose these topics so as to provide a framework for decision making in that critical time.

Spontaneous Intracerebral Hemorrhage

Background and Purpose- We compared clinical and radiological predictors of long-term mortality in patients with spontaneous intracerebral hemorrhage (ICH) needing intensive care. Methods- A retrospective multicenter study of adult ICH patients treated in Finnish tertiary hospital's intensive care units during 2003 to 2013. We created 3 multivariable models (clinical, radiological, and combined clinical-radiological) for 12-month mortality prediction and compared their areas under receiver operating characteristic curves (AUCs). We analyzed supratentorial and infratentorial ICHs separately. Results- Of 972 patients (796 supratentorial ICH, 176 infratentorial ICH) included, 43% died within 12 months (42% supratentorial ICH, 49% infratentorial ICH). For all patients, the clinical model (AUC, 0.83; 95% CI, 0.81-0.86) outperformed the radiological model (AUC, 0.73; 95% CI, 0.70-0.77; P<0.001), yet the combined model (AUC, 0.85; 95% CI, 0.83-0.88) outperformed both condensed models (P<0.001). For supratentorial ICH, the combined model outperformed both the clinical and radiological models (AUC, 0.84; 95% CI, 0.81-0.87 versus AUC, 0.82; 95% CI, 0.79-0.85 and AUC, 0.73; 95% CI, 0.69-0.77; P<0.001 for all). For infratentorial ICH patients, the combined model significantly outperformed the radiological model but not the clinical model (AUC, 0.92; 95% CI, 0.88-0.96 versus AUC, 0.76; 95% CI, 0.69-0.83 versus AUC, 0.91; 95% CI, 0.87-0.95; P<0.001 and P=0.433, respectively). Conclusions- Clinical factors were more important than objective radiological factors for 12-month mortality prediction in intensive care unit-treated ICH patients. The effect of clinical and radiological factors on outcome was different for supratentorial and infratentorial ICHs stressing that these should not be treated as one entity.

Seasonal Changes in Lower Urinary Tract Symptoms in Japanese Men With Benign Prostatic Hyperplasia Treated With α1-Blockers

PURPOSE

To investigate whether seasonal changes occurred in lower urinary tract symptoms (LUTS) in patients with benign prostatic hyperplasia (BPH).

METHODS

Patients aged 50 years and older with BPH treated with α₁-blockers were enrolled. The International Prostate Symptom Score (IPSS), quality of life (QoL) score, maximum and average flow rate, voided volume, and postvoid residual volume were measured in summer and winter.

RESULTS

A total of 164 patients were enrolled. The total IPSS and QoL index did not show a significant difference between the 2 seasons. When the IPSS was divided into storage symptoms and voiding symptoms, storage symptoms in winter were substantially but nonsignificantly higher than those in summer (P=0.056). Of the 7 individual symptoms in the IPSS, a significant seasonal difference was observed only for nocturia, with a higher score in winter. Moreover, none of the uroflowmetric parameters showed a seasonal change. Voided volume had significant correlations with each symptom (urgency and nocturia) and overall subjective scores (storage, total IPSS, and QoL) exclusively in summer, while this correlation remained only for nocturia in winter.

CONCLUSIONS

As it has generally been assumed that LUTS deteriorate in winter, the present study corroborated that the severity of storage symptoms was higher in winter than in summer, even in patients treated with α₁-blockers. In contrast, a seasonal difference was not observed in the uroflowmetric parameters, which may be partly due to the loss of the correlation between subjective and objective measurements of storage symptoms in winter.

Life-Threatening Cerebral Hematoma Owing to Aneurysm Rupture

OBJECTIVE

To refine the surgical indications of surgery for life-threatening cerebral hematomas caused by aneurysm rupture, through the analysis of possible outcome predictors.

METHODS

Forty-nine consecutive patients requiring prompt clot evacuation were retrospectively reviewed. In all cases, the hematoma was equal to or greater than 60 mL. The bleeding aneurysm was located on the middle cerebral artery in 26 cases, on the internal carotid artery in 10 cases, and on the anterior cerebral artery in 13 cases; four aneurysms were giant. Six patients underwent aneurysm coiling followed by clot removal, whereas 43 patients were managed by concomitant clot evacuation and aneurysm clipping. The main clinical and radiologic features, the management paths and the treatment modalities were correlated with the outcomes. A statistical analysis was conducted.

RESULTS

Overall mortality was 32.6%, severe morbidity was 22.4% and 22 patients (44.8%) achieved favorable results. The short-term results were more significantly influenced by the radiological parameters than by the initial clinical conditions. The prognostic weight of the radiologic findings was partially lost for six-month results, whereby management factors gained in importance.

CONCLUSIONS

The bleeding severity was strongly determinant for early mortality. However, if patients can survive the initial crucial phase, their chances of a favorable outcome are not negligible. Further improvement may be possible through better patient selection and the identification of nonsalvageable subjects.

The Predictor of Mortality within Six-Months in Patients with Spontaneous Cerebellar Hemorrhage: A Retrospective Study

Background and Purpose

The mortality rate of cerebellar hemorrhage (CH) is generally higher than other types of intracranial hemorrhage. Recently, the increased survey rate of CH has come from improved clinical imaging and earlier surgical intervention. Hence, the predictors of intermittent- (1 to 6 months) and long-term (> 6months) mortality are clinically practical use for educational and therapeutic decisions. Unfortunately, the factors predictive mortality within six-month had not yet been systematically investigated.

Methods

Seventy-two patients with acute spontaneous CH were retrospectively analyzed. The patients were divided into the six-month mortality group (n = 21, died within 6 months after CH onset) and survival group (n = 51, survived beyond 6 months). The independent predictors of six-month mortality were investigated by multivariate Cox proportional hazards regression.

Results

The radiological brainstem compression (hazard ratios = 23.5; p < 0.001) was independent predictor of mortality within six-month after CH onset. The median onset time of six-month mortality was 5 days in patients with brainstem compression (p < 0.001) and the hazard ratios for the onset time was 13.1 compared with those without brainstem compression (95% CI, 4.7 to 36.3, p < 0.001).

Conclusions

We report the first study that radiological brainstem compression predicted the mortality within six-month after onset of CH. Patients with radiological brainstem compression were about 23 times more likely to die within 6 months after CH than those without radiological brainstem compression.

Falling temperature and colder weather are associated with an increased risk of aneurysmal subarachnoid hemorrhage

OBJECTIVE

To use weather data to predict increased incidence of aneurysmal subarachnoid hemorrhage (aSAH) at a large institution with an extensive referral network in response to falling temperatures.

METHODS

In a retrospective study, 1175 prospectively collected aSAH cases accrued over 18 years from one hospital were reviewed to determine if season, maximum ambient temperature (MAT), average relative humidity, and atmospheric pressure were related to incidence of aSAH at that institution on a given day. A Poisson regression model was used to assess daily risk of incident aSAH based on daily MAT and 1-day change in MAT.

RESULTS

A MAT decrease of 1°F from one day to the next was associated with a 0.6% increase in risk of aSAH (relative risk [RR]=1.006, P=0.016). The increased risk associated with MAT decrease from the previous day was especially strong for female patients (RR=1.008/°F, P=0.007) and drove the overall model, representing 72% of cases. In addition, warmer temperatures were associated with a decreased risk of aSAH; each 1°F increase in temperature compared with the previous day was associated with a 0.3% decrease in risk of aSAH (RR=0.997; P<0.001).

CONCLUSIONS

A 1-day decrease in temperature and colder daily temperatures were associated with an increased risk of incident aSAH at a single institution with a large referral network. These variables appeared to act synergistically and independently of season. These relationships were particularly predominant in the fall when the transition from warmer to colder temperatures occurred.

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.

Factors associated with severity on admission and in-hospital mortality after primary intracerebral hemorrhage in China

BACKGROUND AND PURPOSE

Of the stroke types, intracerebral hemorrhage is the most debilitating and fatal. The aim of the current study was to determine factors that influence the severity and in-hospital mortality after primary intracerebral hemorrhage.

METHODS

Data were collected retrospectively on 1268 patients with primary intracerebral hemorrhage admitted to stroke units at participating hospitals in Guangzhou between January 2005 and August 2008. Logistic regression analysis was used to determine factors associated with severity on admission and in-hospital mortality.

RESULTS

Of the 1268 patients, 20·4% were reported to have a severe stroke on admission, and the in-hospital mortality rate was 12·5%. Severity on admission was strongly associated with Glasgow Coma Scale score on admission (odds ratio = 0·89, 95% confidence interval 0·85-0·94) and hematoma location. Notably, basal ganglia hemorrhages were associated with increased severity (odds ratio = 1·40, 95% confidence interval 1·03-1·90), and cerebellar hemorrhages were associated with reduced severity (odds ratio = 0·29, 95% confidence interval 0·10-0·84). In-hospital mortality was not only correlated with Glasgow Coma Scale score on admission (odds ratio = 0·79, 95% confidence interval 0·74-0·84) and basal ganglia location (odds ratio = 0·47, 95% confidence interval 0·26-0·83), but also with dysnatremia (odds ratio = 1·91, 95% confidence interval 1·08-3·40) and comorbidities such as upper gastrointestinal hemorrhage (odds ratio = 2·28, 95% confidence interval 1·33-3·91), pneumonia (odds ratio = 3·50, 95% confidence interval 2·17-5·63), urinary incontinence (odds ratio = 2·22, 95% confidence interval 1·40-3·51), and renal dysfunction (odds ratio = 2·28, 95% confidence interval 1·42-3·65).

CONCLUSION

Glasgow Coma Scale score and hematoma locations were independently associated with severity on admission and in-hospital mortality after primary intracerebral hemorrhage. The study also highlights the deleterious effect of comorbidities on in-hospital mortality following primary intracerebral hemorrhage in China.

Risk factors for the formation and rupture of intracranial saccular aneurysms in Shimane, Japan

BACKGROUND

Prevention of aneurysmal subarachnoid hemorrhage (SAH) can be achieved by reducing risk factors, which include those for aneurysm formation and aneurysm rupture. However, neither of these 2 factors has been discussed separately so far. A case control study was undertaken in Shimane, Japan, to identify modifiable risk factors for the formation and rupture of aneurysms.

METHODS

This study included 858 patients with ruptured aneurysms, 285 patients with unruptured aneurysms without a history of SAH, and 798 control subjects. Hypertension, diabetes mellitus, heart disease, hypercholesterolemia, cigarette smoking, and alcohol consumption were assessed as risk factors by using conditional logistic regression.

RESULTS

After adjustment for other risk factors, hypertension was the most powerful risk factor for aneurysm formation, regardless of age and sex, followed by hypercholesterolemia, heart disease, and cigarette smoking, whereas diabetes mellitus and daily drinking were insignificant for aneurysm formation. Hypertension and daily drinking were not related to the risk of aneurysm rupture, regardless of age and sex, whereas cigarette smoking was associated with an increased risk of aneurysm rupture in patients 60 years or older and in men. In contrast, hypercholesterolemia was strongly associated with a decreased risk of rupture, regardless of age and sex, and in patients with small aneurysms (<5 mm). Diabetes mellitus and heart disease were also related to a decreased risk of rupture in patients 60 years or older and in women.

CONCLUSION

Identification of risk factors for aneurysm formation and rupture separately seems to be pivotal for reducing the incidence of SAH.

Predictors of 30-day mortality and 90-day functional recovery after primary intracerebral hemorrhage : hospital based multivariate analysis in 585 patients

OBJECTIVE

The purpose of this study was to identify independent predictors of mortality and functional recovery in patients with primary intracerebral hemorrhage (PICH) and to improve functional outcome in these patients.

METHODS

Data were collected retrospectively on 585 patients with supratentorial PICH admitted to the Stroke Unit at our hospital between 1st January 2004 and the 31st July 2008. Using multivariate logistic regression analysis, the associations between all selected variables and 30-day mortality and 90-day functional recoveries after PICH was evaluated.

RESULTS

Ninety-day functional recovery was achieved in 29.1% of the 585 patients and 30-day mortality in 15.9%. Age (OR=7.384, p=0.000), limb weakness (OR=6.927, p=0.000), and hematoma volume (OR=5.293, p=0.000) were found to be powerful predictors of 90-day functional recovery. Furthermore, initial consciousness (OR=3.013, p=0.014) hematoma location (lobar, OR=2.653, p=0.003), ventricular extension of blood (OR=2.077, p=0.013), leukocytosis (OR=2.048, p=0.008), alcohol intake (drinker, OR=1.927, p=0.023), and increased serum aminotransferase (OR=1.892, p=0.035) were found to be independent predictors of 90-day functional recovery after PICH. On the other hand, a pupillary abnormality (OR=4.532, p=0.000) and initial unconsciousness (OR=3.362, p=0.000) were found to be independent predictors of 30-day mortality after PICH.

CONCLUSION

The predictors of mortality and functional recovery after PICH identified during this analysis may assist during clinical decision-making, when advising patients or family members about the prognosis of PICH and when planning intervention trials.

Admission microalbuminuria and neurologic outcomes in intensive care unit patients with spontaneous intracerebral hemorrhage

This study was performed to determine the prevalence and the prognostic significance of microalbuminuria in patients admitted to intensive care unit (ICU) after spontaneous intracerebral hemorrhage (ICH). From May 2004 to April 2006, we studied 59 consecutive ICH patients verified using computed tomography and admitted to our ICU within a day after stroke. General clinical, neurologic data, and Glasgow Coma Scale (GCS) were recorded at admission to ICU. Urine was collected at admission to ICU for measuring the urinary microalbumin/creatinine ratio. At hospital discharge, neurologic outcome was assessed using Glasgow Outcome Scale. Among 59 patients, 37 (63%) had unfavorable neurologic outcomes (death, persistent vegetative state, and severe disability). The prevalence rate of microalbuminuria was 85% [95% confidence interval (CI), 76-94]. The areas under the receiver operator characteristic curves showed that the urinary microalbumin/creatinine ratio [0.81 (95% CI, 0.70-0.92)] and the GCS score [0.78 (95% CI, 0.66-0.90)] at admission were significant predictors of unfavorable neurologic outcome at hospital discharge. The threshold value, sensitivity, specificity, and likelihood ratio for the urinary microalbumin/creatinine ratio were 200 mg/g, 51% (95% CI, 39-64), 96% (95% CI, 90-100), and 11.3 (95% CI, 7.9-16.0); and those for the GCS score were 11, 46% (95% CI, 36-61), 96% (95% CI, 90-100), and 10.1 (95% CI, 7.2-14.1), respectively. This study confirmed a high prevalence of microalbuminuria in ICH patients in ICU, and suggested that the urinary microalbumin/creatinine ratio >200 mg/g was comparable to the GCS score <11 at admission to the ICU with regard to its prognostic characteristics after ICH.

Open Surgical Evacuation of Spontaneous Putaminal Hematomas: Prognostic Factors and Comparison of Outcomes between Transsylvian and Transcortical Approaches

OBJECTIVE

The purpose of this study was to investigate the factors affecting the surgical outcome and to compare the surgical results between transsylvian and transcortical approaches in patients with putaminal hematomas.

METHODS

Retrospective review of charts and CT scan images was conducted in 45 patients (20 transsylvian and 25 transcortical approaches) who underwent open surgical evacuation of putaminal hematomas. Mean Glasgow coma scale (GCS) score and hematoma volume were 7.5+/-3.2 and 78.1+/-29.3 cc, respectively. The factors affecting the functional mortality were investigated using a multivariate logistic regression analysis. In addition, surgical results between transsylvian and transcortical approaches were compared.

RESULTS

None of the patients had a good recovery after the surgery. Overall functional survival rate and mortality were 37.7% and 31%, respectively. The only risk factor for functional mortality was GCS motor score after controlling age, history of hypertension, side of hematoma, hematoma amount, midline shift, presence of intraventricular hemorrhage and surgical approach (p=0.005). Even though a transcortical approach was shorter in operative time (4.4 versus 5.1 hour) and showed a higher mortality rate (40% versus 20%) and lower functional survival (45% versus 35%) compared to the transsylvian approach, the differences were not statistically significant between the two groups.

CONCLUSION

In patients who have large amounts of hematoma and require open surgical evacuation, the only significant risk factor for functional survival is the preoperative GCS score. Cortical incision methods such as transsylvian and transcortical approaches have no influence on the surgical outcome. To decompress the swollen brain rapidly, transcortical approach seems to be more suitable than transsylvian approach.

A polymorphic variant of the endoglin gene is associated with increased risk for intracranial aneurysms in a Korean population

BACKGROUND

Endoglin is a component of the transforming growth factor-beta receptor complex and is predominantly expressed on the cell surface of endothelial cells. It plays an important role in vascular growth and development. There have been conflicting reports on whether a polymorphic variant, in the endoglin gene, is associated with risk for IAs. In this study, we investigated whether polymorphisms of the endoglin gene are associated with the development of cerebral aneurysms in a Korean population.

METHODS

This was a hospital-based, case-control study conducted at the Chonnam University Hospital, Gwangju, Korea. The study population consisted of 342 patients who had been treated for intracranial aneurysm and 253 healthy, hospital-based controls. Two polymorphic loci were amplified by polymerase chain reaction. The well-known in/del in intron 7 of the endoglin gene and the rs1800956 coding nonsynonymous SNP were amplified by PCR and analyzed by MADGE or the pyrosequencing system.

RESULTS

The endoglin insertion polymorphism was not associated with IAs in comparisons between cases and controls (OR, 0.11 [95% CI, 0.79-1.57] vs OR, 0.88 [95% CI, 0.50-1.56]). An association was found with rs1800956 in the heterozygous type (OR, 1.71); however, the association was not evident for the homozygous type. These differences were statistically significant. In addition, the C allele was significantly associated with an increased risk for IAs (OR, 1.73).

CONCLUSION

The rs1800956 (G/C transversion with D366H substitution, National Center for Biotechnology Information SNP database) of endoglin may play an important role in the pathogenesis of IAs in the Korean population. However, the in/del of intron 7 was not associated with an increased risk for IAs, which is consistent with the findings of previous reports.

Risk factors for primary intracerebral hemorrhage in patients in Izumo City, Japan

The annual incidence rate of primary intracerebral hemorrhage (ICH) in Izumo City, Japan, appears to be the highest rate among those reported. Despite improvement of management and surgical therapy, the overall morbidity and mortality after ICH are still high. The author investigated the risk factors for ICH in patients in Izumo. A case-control study of 242 patients (137 men and 105 women with ages ranging from 34 to 97 years) with primary ICH was conducted in Izumo between 1991 and 1998. Hypertension, diabetes mellitus, heart disease, liver disease, alcohol consumption, cigarette smoking, and serum levels of total cholesterol, aspartate aminotransferase, and alanine aminotransferase were assessed as possible risk factors for ICH by using conditional logistic regression. The prevalence of hypertension among ICH patients was 77% and the odds ratio (OR) for hypertension was 17.07 (95% CI: 8.30-35.09), which are much higher than figures reported from Western countries. The OR for hypertension was higher in individuals < or = 69 years of age than in those > or = 70 years of age and lower for lobar hemorrhage than for hemorrhages at other sites. High serum total cholesterol (> or = 220 mg/dl) was the second most important risk factor for ICH (OR: 2.52; 95% CI: 1.23-5.14), and low total cholesterol (< 160 mg/dl) decreased the risk of ICH (OR: 0.47; 95% CI: 0.27-0.82). In contrast, heart disease decreased the risk of ICH, and there was no observed association between alcohol consumption, cigarette smoking, or diabetes mellitus and ICH. This study conducted in Izumo suggests that hypertension is the most important risk factor for ICH and contrary to most previous studies indicates that serum total cholesterol concentration is also positively associated with the risk of ICH. In contrast, heart disease may decrease the risk of ICH.

Early surgical treatment vs conservative management for spontaneous supratentorial intracerebral hematomas: A prospective randomized study

BACKGROUND

Treatment of primary SICH is still controversial. The aim of this study was to investigate the effectiveness of craniotomy and early hematoma evacuation vs nonoperative management in patients with SICH.

METHODS

A prospective randomized study of craniotomy and early hematoma removal vs best medical management was performed in 108 patients with primary SICH. Surgical or medical treatment was initiated within 8 hours post ictus. Principal eligibility criterium was the presence of neurologic impairment associated with a spontaneous subcortical or putaminal hemorrhage bigger than 30 mL. Outcomes were assessed at 1 year post ictus.

RESULTS

Analysis of outcome revealed a significantly higher percentage of GOS scores higher than 3 for the surgical patients, compared with those of the conservative group (33% and 9%, respectively; P < .05). By contrast, the mortality rates between operated and conservatively managed patients did not differ significantly. The main prognostic variables were the initial neurologic status, hematoma volume, and location. Stratifications of these parameters and analysis showed that the positive effect of surgery on the quality of survival was statistically not valid for patients with GCS scores lower than 8 or ICH volumes 80 mL or higher at the time of enrollment.

CONCLUSIONS

The study demonstrates that surgical patients with subcortical or putaminal hematomas showed better functional results than their conservatively treated counterparts. However, early ICH evacuation failed to improve the survival rates, as compared with best medical management.

The role of endothelial nitric oxide synthase (eNOS) genetic variants in European patients with intracranial aneurysms

The endothelial nitric oxide synthase (eNOS) gene harbors three well-characterized genetic variants, which have been reported to be associated with various vascular diseases. Recently, conflicting results have been published relating to the role of these genetic variants in the pathogenesis of intracranial aneurysms (IA). Therefore, we analyzed these variants in a large European population of IA patients and controls. In all, 142 patients with IA and 190 controls were enrolled in our study. The -786T>C and 894G>T single-nucleotide polymorphisms (SNPs) were analyzed by direct sequencing of the corresponding sections in the genomic DNA. A variable number tandem repeat (VNTR) located in intron 4 of the gene and consisting of either four or five 27-base pair (bp) repeats was analyzed by polymerase chain reaction amplification and electrophoresis using ALF sequencertrade mark equipment. Genotype and allele frequencies were determined, and the frequencies in cases and controls were compared. In addition, haplotypes were constructed. There were no deviations from Hardy-Weinberg equilibrium. Genotype and allele frequencies did not differ significantly between cases and controls in any sample group or after stratification for multiple IA or aneurysm size. No single haplotype was significantly associated with the phenotype of an IA. The -786T>C, 894G>T, and 27-bp VNTR genetic variants of the eNOS gene are not associated with IA in the European population.

The Impact of Functional Status at Three Months on Long-Term Survival After Spontaneous Intracerebral Hemorrhage

BACKGROUND AND PURPOSE

Few studies have assessed long-term prognosis and risk factors for death after spontaneous intracerebral hemorrhage (ICH). Patients who survive the acute phase may run different prognoses, depending on their disability, treatment, and lifestyle. The present study was performed to find out the predictors for long-term mortality after ICH.

METHODS

We assessed 7-year prognosis in a population-based cohort of patients who had survived the first 3 months after ICH (n=140). Controls (n=206) living in the same geographical area were randomly drawn from the population register and followed up for the same time.

RESULTS

Seven-year mortality was significantly higher in ICH patients than in controls (32.9 and 19.4%, respectively; P=0.0034). The annual risk for death in ICH patients was 5.6%, and the annual risk for fatal recurrent ICH was 1.3%. The ICH patients with good recovery at 3 months showed similar risk for death as controls. Recurrent ICH and pneumonia were the most common causes of death in ICH patients. Cigarette smoking, age, and diabetes seemed to increase the risk for death in patients and controls.

CONCLUSIONS

Survivors of ICH run a higher long-term risk for death than age- and sex-matched controls. However, those who show good recovery at 3 months run a similar outcome as controls.

Regular aspirin-use preceding the onset of primary intracerebral hemorrhage is an independent predictor for death

BACKGROUND AND PURPOSE

Hematoma volume and impaired level of consciousness are the most potent predictors of outcome after spontaneous intracerebral hemorrhage (ICH). The effect of preceding aspirin-use on outcome after ICH is poorly investigated. We investigated short-term mortality and hematoma enlargement in subjects with ICH to find the predictors for these outcomes.

METHODS

This population-based study included all subjects with ICH during a period of 33 months in the population of Northern Ostrobothnia, Finland. The subjects were identified, and their clinical characteristics and outcomes were checked from hospital records or death records.

RESULTS

Three-month mortality of the 208 identified subjects with ICH was 33%. The independent risk factors for death were regular aspirin-use at the onset of ICH (relative risks [RR], 2.5; 95% CI, 1.3 to 4.6; P=0.004), warfarin-use at the onset of ICH (RR, 3.2; 95% CI, 1.6 to 6.1; P=0.001), and ICH score higher than 2 on admission (RR, 13.8; 95% CI, 6.0 to 31.4; P<0.001). Regular aspirin-use preceding the onset of ICH associated significantly with hematoma enlargement during the first week after ICH (P=0.006).

CONCLUSIONS

We observed poor short-term outcomes and increased mortality, probably attributable to rapid enlargement of hematomas, in the subjects with ICH who had been taking regularly moderate doses of aspirin (median 250 mg) immediately before the onset of the stroke.

Benefits of adapting minimal invasive techniques to selected patients with spontaneous supratentorial intracerebral hematomas

OBJECTIVES

This study assesses the benefits of adapting minimal invasive techniques (MIT) to selected patients with spontaneous supratentorial intracerebral hematomas (SSICHs).

METHODS

The study compares the post-operative residual clot volume and clinical outcome of 89 selected, MIT evacuated SSICH-patients to those of 138 unselected cases operated in our department. Selection criteria includes patient age, early admission and MIT treatment. MIT treatment included: 28 patients with deep SSICHs smaller than 30 cm3 associated with intraventricular bleeding who underwent neuronavigation-guided stereotactic catheter lysis, 37 patients with deep hematomas larger than 30 cm3 and 24 patients with a lobar hemorrhage compressing eloquent regions who underwent microsurgical (endoscopic or neuronavigation assisted) clot aspiration.

RESULTS

In eight (9%) of the patients in the MIT group, the CT scan control showed a residual clot smaller than 30% of the initial hemorrhage. The neurological condition 3 months later revealed 24 (26.9%) of these patients having a severe disability and 46 (51.6%) patients independent or slightly disabled. Nineteen patients (21.9%) died or remained vegetative. In the control group, 48 (34.7%) cases showed residual clots (<30%). Sixty-two (44.9%) patients of this group were severely disabled and only 40 (28.9%) were independent. Thirty-six (26%) patients died or were vegetative. There was a p<0.001 significant difference in volume of residual clots as well as p<0.01 for the outcome between the two groups.

CONCLUSIONS

Adapting minimally invasive techniques to case selection improves the effectiveness of clot removal and the outcome of the patients with SSICHs.

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.

Intubation without premedication may worsen outcome for unconsciousness patients with intracranial hemorrhage

To clarify the influence of an intubation maneuver with or without premedication for an intracranial hemorrhage in an unconsciousness patient, we retrospectively analyzed 70 patients who had received intubation for unconsciousness and in whom a nontraumatic intracranial hemorrhage was found by CT over a 6-year period. They were divided into 2 groups, consisting of a drug group (n=15), wherein drugs were used before intubation, and control group (n=55), wherein no drugs were used before were intubation. The physical findings on admission, CT findings, Glasgow Outcome Score (GOS) at 3 months from admission were analyzed between the groups. There were no significant differences in the backgrounds of the subjects between the groups. The GOS in the control group was significantly higher than in the drug group (P<.001). In cases of intubation for unconscious patients who may have intracranial hemorrhaging, premedication is considered associated with a more favorable outcome.

Predicting the overall management outcome in patients with a subarachnoid hemorrhage accompanied by a massive intracerebral or full-packed intraventricular hemorrhage: a 15-year retrospective study

BACKGROUND

Patients with a subarachnoid hemorrhage (SAH) accompanied by a massive intracerebral hemorrhage (ICH) or a full-packed intraventricular hemorrhage (IVH) have poor outcomes. We evaluated the clinical factors to predict the overall outcome in such patients.

METHODS

Data on nontraumatic SAH patients were collected and classified into 3 groups: the pure SAH group (SAH accompanied with neither ICH nor IVH), the ICH group (SAH accompanied with a massive ICH; hematoma 30 mL), and the IVH group (SAH and all ventricles were full-packed with hematoma). One hundred seventy-nine patients were in the ICH group and 109 in the IVH group. We evaluated clinical factors, such as the Hunt & Hess (H&H) score on admission, age, sex, history, rebleeding ratio, and the computerized tomography findings (SAH score).

RESULTS

The result of multivariate logistic regression analysis of clinical variables in the ICH group, good and intermediate H&H grades, younger age (<70), no rebleeding, and lower SAH score were associated with a favorable outcome. In the result of the multivariate logistic regression analysis of clinical variables in the IVH group, only a higher SAH score was associated with an unfavorable outcome.

CONCLUSIONS

In the ICH group, factors that could be used to predict a favorable outcome included good and intermediate H&H scores (1, 2, and 3) on admission, younger age (<70), and a lower SAH score. In the IVH group, the main factor that could be used to predict a favorable outcome was a lower SAH score.

Systemic administration of argatroban reduces secondary brain damage in a rat model of intracerebral hemorrhage: histopathological assessment

This study investigated the effects of argatroban, a thrombin inhibitor, on brain edema and inflammation in a rat intracerebral hemorrhage (ICH) model. ICH was induced by injecting collagenase IV into the right caudate nucleus. Argatroban was administered intraperitoneally. Argatroban reduced brain edema from 44.6 to 14.3 microl at 72 h. Infiltration of polymorphonuclear leukocytes at 24 h and monocyte/macrophage at 24 and 72 h was significantly suppressed by argatroban. Argatroban did not increase the volume of hematoma. Systemic administration of argatroban reduced secondary brain damage including edema and inflammation in a rat ICH model.

Trends in Surgical and Management Outcomes in Patients with Aneurysmal Subarachnoid Hemorrhage in Izumo City, Japan, between 1980–1989 and 1990–1998

BACKGROUND AND PURPOSE

The purpose of this community-based study was to evaluate temporal changes in surgical and management outcomes in patients with aneurysmal subarachnoid hemorrhage (SAH).

METHODS

The subjects were 358 patients with aneurysmal SAH who were treated during the 19-year period from 1980 to 1998 in Izumo City, Japan. We compared data during the 9-year period 1990-1998 (period B; 188 patients) with those during the 10-year period 1980-1989 (period A; 170 patients).

RESULTS

The proportion of patients 80 years of age or older or those with World Federation of Neurosurgical Societies grade V increased significantly (period A, 5 and 25%; period B, 18 and 35%, respectively). The operability rate did not change for patients 69 years of age or younger, whereas it increased significantly for those 70-79 years of age (period A, 48%; period B, 72%). The 6-month and 2-year case fatality rates in surgically treated patients decreased significantly (period A, 12 and 20%; period B, 2 and 8%, respectively), whereas they were virtually unchanged for overall management (period A, 41 and 46%; period B, 38 and 42%, respectively). In patients who underwent surgery, the incidence of permanent symptomatic vasospasm decreased from 21% during period A to 11% during period B, and there was no death from vasospasm in the later period. However, no significant difference was found in the functional outcome between the two periods, regardless of whether surgery was performed. The most important determinants of 6-month and 2-year survival rates were grade on admission, rebleeding and the site of the ruptured aneurysms. Age was also a significant predictor of the 6-month case fatality rate.

CONCLUSIONS

For patients with SAH who underwent surgery, there were trends towards decreases in the case fatality rate and in the incidence of permanent symptomatic vasospasm. Nevertheless, the overall management outcome was still unsatisfactory, mainly because of increasing numbers of very elderly and/or high-risk patients. .

Spontaneous Intracerebral Hemorrhage Related to Methamphetamine Abuse

A healthy 31-year-old male abstinent from drug abuse during his recent incarceration developed slurred speech, a severe headache, and left-sided hemiparesis prior to his eventual death 9.5 hours after inhalation of methamphetamine. On postmortem examination, inspection of the brain revealed bilateral subarachnoid hemorrhage, with a prominent intralobar hemorrhage centered within the right frontal cerebral hemisphere. No evidence of vasculitis, infarction, intraventricular hemorrhage, or ruptured aneurysm could be observed. While this is not the first report of a methamphetamine-related stroke, this report describes the autopsy findings of an intracerebral hemorrhage secondary to methamphetamine abuse on autopsy and compares the findings and antemortem history to previously reported methamphetamine cerebral vascular deaths.

Matrix Metalloproteinase-9 Coding Sequence Single-nucleotide Polymorphisms in Caucasians with Intracranial Aneurysms

OBJECTIVE

There are several lines of evidence suggesting that matrix metalloproteinases (MMPs), particularly MMP-9, are involved in the pathogenesis of intracranial aneurysms. Some studies have demonstrated that genetic variants in the promoter region of the MMP-9 gene are associated with aneurysms. We performed a case-control study to investigate whether single-nucleotide polymorphisms (SNPs) within the coding region of the MMP-9 gene might affect the development of intracranial aneurysms.

METHODS

All 13 exons and the 3' untranslated region of the MMP-9 gene were analyzed by direct sequencing in a study group that comprised 40 Caucasian patients with at least one intracranial aneurysm and 44 Caucasian controls. Genotypes were determined, and those that were in Hardy-Weinberg disequilibrium were analyzed in another sample of 40 cases and 40 controls. Differences among the genotype frequencies of the identified polymorphisms were investigated.

RESULTS

Seven SNPs were identified in the coding region, two were identified in the adjacent intronic sequences, and two were identified in the 3' untranslated region. Genotype frequencies of four SNPs were demonstrated to be in Hardy-Weinberg disequilibrium in both analyzed study samples. Therefore, an accurate estimation of haplotype frequencies was not possible. No difference in genotype frequencies between cases and controls was detected at any of the 11 SNPs.

CONCLUSION

SNPs of the coding region and the 3' untranslated region of the MMP-9 gene are not associated with intracranial aneurysms in Caucasians.

Primary intracerebral hemorrhage in Izumo City, Japan: incidence rates and outcome in relation to the site of hemorrhage

OBJECTIVE

The aim of this community-based study was to investigate the incidence rates and outcome of primary intracerebral hemorrhage (ICH) in relation to the site of hemorrhage.

METHODS

The subjects were 350 patients with primary first-ever ICH who were treated during the 8-year period 1991 to 1998 in Izumo City, Japan.

RESULTS

The crude and age- and sex-adjusted incidence rates for all types of ICH were 52 and 47 per 100,000 population, respectively, for all ages. The most common site of ICH was the putamen (120 patients, 34%), followed by the thalamus (115, 33%), lobar areas (53, 15%), brainstem (30, 9%), cerebellum (25, 7%), and caudate nucleus (7, 2%). The crude and age- and sex-adjusted annual incidence rates per 100,000 population were 18 and 16 for putaminal, 17 and 15 for thalamic, 8 and 7 for lobar, 4 and 3 for cerebellar, 4 and 4 for brainstem, and 1 and 1 for caudate hemorrhages, respectively. The Glasgow Coma Scale scores on admission were best in patients with cerebellar hemorrhage and worst in those with brainstem hemorrhage. Surgery was performed for 34% of putaminal, 9% of thalamic, 14% of caudate, 21% of lobar, and 32% of cerebellar hemorrhages but not for brainstem hemorrhages. The 30-day case fatality rate was 11% for putaminal, 9% for thalamic, 14% for caudate, 11% for lobar, 0% for cerebellar, and 53% for brainstem hemorrhages. When patients with ICH were analyzed as a whole, the overall survival rates at 30 days, 3 months, and 3 years were 87, 83, and 73%, respectively. Both the short-term and long-term outcomes after ICH were directly related to the site of hemorrhage and the severity of bleeding, which was assessed by the hematoma volume and Glasgow Coma Scale score. Overall, 190 (54%) of 350 patients had a favorable outcome, and 55 (16%) had died at discharge.

CONCLUSION

Marked differences were observed in the incidence rates and outcome of primary ICH in relation to the site of hemorrhage. The differences in outcome were primarily a result of differences in the severity of bleeding for each ICH subtype.

Long-term outcome in intensive care unit survivors after mechanical ventilation for intracerebral hemorrhage

OBJECTIVE

To evaluate long-term survival and functional outcome in intensive care unit survivors after mechanical ventilation for intracerebral hemorrhage.

DESIGN

Retrospective chart review and prospective follow-up study.

SETTING

Outpatient follow-up.

PATIENTS

Between 1997 and 2000, 120 patients were mechanically ventilated for an intracerebral hemorrhage at our intensive care unit. Sixty-two patients were discharged from hospital (in-hospital mortality = 48%). Sixty patients were evaluated for survival and functional outcome (two were lost to follow-up). Time between discharge and follow-up was > or =1 yr and was a mean of 27 +/- 14 months (range, 12-56).

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Patients' physicians were first asked about survival, and patients or proxies were interviewed by phone. Barthel Index and modified Rankin Scale scores were collected, and demographic information and general data were reviewed. The estimated life-table survival curve after discharge was 64.6% at 1 yr and 57% at 3 yrs. In the 24 patients who died, the mean time between discharge and death was 5 +/- 6 months. Probability of death after discharge significantly increased if age at admission was >65 yrs (p <.01; odds ratio, 3.5; 95% confidence interval, 1.4-9.1) and if Glasgow Coma Scale score at discharge was <15 (p <.01; odds ratio, 3.9; 95% confidence interval, 1.6-9.5). In the 36 long-term survivors, Barthel Index was 67.5 +/- 15 (median +/- median absolute dispersion) and modified Rankin Scale score was 2.6 +/- 0.5. Fifteen patients (42%) had a slight or no disability (Barthel Index > or =90 and modified Rankin Scale score < or =2), whereas 21 patients (58%) had moderate or severe disability (Barthel Index < or =85 and modified Rankin Scale score >2).

CONCLUSIONS

Probability of survival at 3 yrs after mechanical ventilation for an intracerebral hemorrhage was >50%. Age was an important determinant of long-term survival. Forty-two percent of long-term survivors were independent for activities of daily living. Only a few long-term survivors had a very high degree of disability.

International Variations in Surgical Practice for Spontaneous Intracerebral Hemorrhage

Background and Purpose— Spontaneous intracerebral hemorrhage is a major cause of death and disability, yet there is no convincing evidence of the benefit of any medical treatment and the role of surgery remains controversial. The international randomized Surgical Trial in Intracerebral Hemorrhage (STICH) provided an opportunity to assess the role of surgery within the centers taking part.

Methods— Screening logs were completed to record details of all patients assessed by the department, whether they were included in the trial, the reasons if they were not included, and whether they underwent surgery.

Results— Logs were returned by 42 centers and cover 704 months. They include details on 1578 patients with characteristics comparable to STICH inclusion criteria. Neurosurgeons were more likely to express clinical certainty about treatment for older patients, patients with a higher Glasgow Coma Score scale, and patients in whom the hematoma was located on the right or in the basal ganglia or thalamus. Patients for whom the neurosurgeon was certain about treatment were more likely to have the hematoma removed if they were younger (62 versus 68 years of age), had a lower Glasgow Coma Scale score (10 versus 13), and had a lobar hematoma (49% versus 40%). The operation rate varied between 74% in Lithuania and 2% in Hungary.

Conclusions— The difference in operation rates could not be explained by differences in patient characteristics alone. This finding demonstrates the need for further evidence to ensure that treatment for intracerebral hemorrhage is not governed by local custom.

Neurodegeneration of substantia nigra accompanied with macrophage/microglia infiltration after intrastriatal hemorrhage

Intrastriatal hemorrhage in rats causes neurodegenaration of the substantia nigra (SN) followed by the appearance of ED1(+) cells (macrophage/microglia). ED1(+) cells were observed for at least 8 weeks after hemorrhage. Phosphorylation of p38 mitogen-activated protein kinase (MAPK) was shown in ED1(+) cells with the expression of both brain-derived neurotrophic factor (BDNF) mRNA and BDNF, suggesting that activated-p38 MAPK(+)/ED1(+) cells would produce BDNF and may exhibit trophic effect on the degenerating neurons in the SN. However, in ELISA, BDNF protein decreased significantly in ipsilateral SN at 7 days after hemorrhage, which may be due to a dramatic decrease of BDNF immunoreactive neurons in pars compacta. Data suggest that activation of p38 MAPK in ED1(+) cells infiltrating in ipsilateral SN after hemorrhage may produce BDNF, but that the amount of BDNF produced from ED1(+) cells is insufficient for the rescue of degenerating neurons.

Intracerebral aneurysms: a review with special attention to geriatric aspects

Rupture of an intracranial aneurysm (ICA) remains a devastating complication associated with a high degree of morbidity and mortality. In the past 2 decades, older people were often excluded from active treatment on the unique basis of their chronological age. Recent developments of less-invasive techniques for the diagnosis and treatment of ruptured and unruptured ICAs suggest that this fatalistic attitude toward older patients should be reconsidered. Furthermore, taking into account the heterogeneity of the elderly population, the use of a comprehensive geriatric assessment approach, based on a multidisciplinary evaluation, appears particularly helpful in proposing the optimal treatment strategy for each older patient. This article reviews the geriatric features of epidemiological, physiopathological, as well as clinical and therapeutic aspects of ruptured and unruptured ICAs.

Outcome following intracerebral hemorrhage and subarachnoid hemorrhage

Intracerebral hemorrhage and subarachnoid hemorrhage account for almost 20% of all stroke cases. Both forms of stroke are associated with a high morbidity and mortality rate. The incidence of intracerebral hemorrhage increases with the age and certain ethnical groups are more affected. Subarachnoid hemorrhage tends to occur in a much younger population than other types of strokes. Outcome predictors for intracerebral and subarachnoid hemorrhage have been extensively discussed in the literature. Based on the current literature, we review the morbidity and mortality rates and predictors of outcome for these two life-threatening diseases. Initial Glasgow Coma Scale (GCS) score, hematoma volume, and presence of ventricular blood are the most prominent predictors of outcome following intracerebral hemorrhage. Age and initial severity of neurologic deficits on presentation, measured by GCS, Hunt and Hess Scale or the World Federation of Neurological Surgeons Scale, are the most important predictors of outcome following subarachnoid hemorrhage.

Aneurysmal subarachnoid hemorrhage in Baltic population: experience from Latvia (1996-2000)

Better knowledge of clinical epidemiology and course of aneurysmal subarachnoid hemorrhage (ASAH) is essential for dedicated planning of the need for services. The aim of the study was to obtain a picture of epidemiology and clinical course of ASAH in Riga City (the capital of Latvia). A retrospective population-based study included residents of Riga City who suffered their first ASAH during a 5-year period from the beginning of 1996 till the end of 2000. The total number of ASAH events in the population during the study period was 292, of which 56 (19%) were fatal before reaching the hospital. There was no significant difference between age-specific incidence rates in men and women. The mean ASAH rates per 100 000 per year were 10.3 for age-adjusted incidence (in the population aged 20-79 years) and 7.2 for crude incidence. The mean age-adjusted case fatality rates were 57% for all ASAH events and 45% for those who survived admission. Our data suggest that incidence of ASAH in Baltic population can be recognized as average compared with other European regions. However, the case fatality rate of ASAH in the study population was higher than those of SAH reported from MONICA Collaborating Centers.

Prediction of death in patients with primary intracerebral hemorrhage: a prospective study of a defined population

Object. Predictors of early (30-day) and long-term (1-year) mortality rates after primary intracerebral hemorrhage (ICH) were studied in a large population in southern Sweden.

Methods. All cases of primary ICH, verified using computerized tomography (CT) scanning or autopsy study, were prospectively registered at the 12 hospitals covering a defined population of 1.14 million during the calendar year 1996. Mortality was analyzed in relation to CT findings (hematoma location and volume and ventricular extension) and clinical parameters (patient age and sex, level of consciousness on admission, and history of preictal risk factors) by using univariate and multivariate statistical methods.

Three hundred forty-one cases of primary ICH were detected. The overall mortality rate was 36% at the 30-day and 47% at the 1-year follow up. Multivariate analysis revealed that initial level of consciousness, hematoma volume, and a history of heart disease were independent predictors of death at 30 days postictus. One year after bleeding, independent predictors of mortality were the initial level of consciousness, patient age, and hematoma location.

Conclusions. Primary ICH remains a stroke subtype associated with a high mortality rate and for which the level of consciousness on admission is the strongest predictor of fatal outcome both at 30 days and during the 1st year after bleeding. A preictal history of heart disease increased the 30-day mortality rate.

Unruptured intracranial aneurysms: a review

OBJECT

In this article, pathological, radiological, and clinical information regarding unruptured intracranial aneurysms is reviewed.

METHODS

Treatment decisions require that surgeons and interventionists take into account information obtained in pathological, radiological, and clinical studies of unruptured aneurysms. The author has performed a detailed review of the literature and has compared, contrasted, and summarized his findings. Unruptured aneurysms may be classified as truly incidental, part of a multiple aneurysm constellation, or symptomatic by virtue of their mass, irritative, or embolic effects. Unruptured aneurysms with clinical pathological profiles resembling those of ruptured lesions should be considered for treatment at a smaller size than unruptured lesions with profiles typical of intact aneurysms, as has been determined at autopsy in patients who have died of other causes. The track record of the surgeon or interventionist and the institution in which treatment is to be performed should be considered while debating treatment options. In cases in which treatment is not performed immediately, ongoing periodic radiological assessment may be wise. Radiological investigations to detect unruptured aneurysms in asymptomatic patients should be restricted to high-prevalence groups such as adults with a strong family history of aneurysms or patients with autosomal dominant polycystic kidney disease. All patients with intact lesions should be strongly advised to discontinue cigarette smoking if they are addicted.

CONCLUSIONS

The current state of knowledge about unruptured aneurysms does not support the use of the largest diameter of the lesion as the sole criterion on which to base treatment decisions, although it is of undoubted importance.

Trends in incidence and case fatality rates of aneurysmal subarachnoid hemorrhage in Izumo City, Japan, between 1980-1989 and 1990-1998

BACKGROUND AND PURPOSE

With aging of the population, the profile of subarachnoid hemorrhage (SAH) is likely to change; however, evaluation of long-term trends for incidence and case fatality rates of SAH is still limited.

METHODS

We compared the incidence and case fatality rates of aneurysmal SAH during the 9-year period 1990-1998 with those during the 10-year period 1980-1989 in Izumo City, Japan.

RESULTS

During 1980-1989 and 1990-1998, we diagnosed 170 and 188 patients as having aneurysmal SAH, respectively. The percentage of very elderly patients aged >/=80 years increased from 5% (8 patients) during 1980-1989 to 18% (33 patients) during 1990-1998 (P<0.001). The age-specific incidence rate of SAH has a tendency to increase with increasing age. The crude and the age- and sex-adjusted incidence rates using the 1995 population statistics for Japan were 21 and 23 per 100 000/y for all ages during 1980-1989 and 25 and 23 per 100 000/y during 1990-1998, respectively. The 3-month case fatality rate of patients aged </=79 years decreased from 38% during 1980-1989 to 26% during 1990-1998 (P=0.021), whereas the case fatality rates in patients aged >/=80 years were very high (63% and 79%, respectively) regardless of study periods. Consequently, the overall case fatality rates for patients with SAH were similar for the 2 study periods (39% and 36%).

CONCLUSIONS

The age- and sex-adjusted incidence rates of aneurysmal SAH were stable over the 19-year period since 1980 and, despite improvement of outcome in patients aged </=79 years, the overall case fatality rate was not lower because the improvements were counterbalanced by increasing numbers of very elderly patients