Intracerebral Hemorrhage with Intraventricular Extension—Getting the Prognosis Right Early

Primary Intracranial Hemorrhage: Characteristics, Distribution, Risk Factors, and Outcomes-A Comparative Study between Jewish and Arab Ethnic Groups in Northern Israel

Background and purpose: This study aimed to investigate the differences in intracerebral hemorrhage (ICH) between Jews and Arabs residing in northern Israel, focusing on risk factors, hemorrhage volume, and functional outcome. Methods: A retrospective analysis was conducted utilizing a population-based registry to investigate intracerebral hemorrhage (ICH) characteristics, risk factors, and outcomes. The registry consisted of inpatients diagnosed with hemorrhagic stroke. Due to the wide variation in data on ICH characteristics and the limited availability of population-based data on predictors of ICH survival and functional outcomes, we collected retrospective data on all adult patients admitted to the Galilee Medical Center with a diagnosis of ICH. Data were obtained from the registry covering the period from 2013 to 2019. Ethnic differences and risk factors associated with intracranial hemorrhage (ICH) were examined within a diverse population of 241 patients, comprising 52.70% Jews (n = 127) and 47.30% Arabs (n = 114). Results: The results of this study revealed significant differences in age, obesity rates, and intracerebral hemorrhage (ICH) location between the two ethnic groups. Hypertension emerged as the most prevalent condition among ICH patients in both ethnic groups (76.70%), followed primarily by anticoagulant use (63.60%), dyslipidemia (60.70%), diabetes (44.60%), obesity (30.60%), smoking (24.60%), and a history of cardiovascular disease (21.80%). Furthermore, 20.90% of the patients had a history of previous cerebrovascular accidents (CVA). Arab patients with ICH were generally younger (62.90 ± 16.00 years) and exhibited higher rates of obesity (38.70%) compared to Jewish patients with ICH (70.17 ± 15.24 years, 23% obesity; p = 0.001, p = 0.013, respectively). Hemorrhage volume was identified as a crucial determinant of patient outcomes, with larger volumes associated with poorer Modified Rankin Scale (mRS) scores at discharge and higher mortality rates. Interestingly, patients without hypertension had higher hemorrhage volumes compared to those with hypertension. The extent of hemorrhage into the ventricles did not significantly correlate with mRS at discharge in our dataset. Conclusions: This study highlights significant differences in the characteristics and outcomes of intracranial hemorrhage (ICH) between Jews and Arabs in northern Israel. The findings reveal variations in age, obesity rates, and ICH location between the two groups. While hypertension was the most prevalent risk factor for both populations, other risk factors differed. Notably, hemorrhage volume emerged as a crucial prognostic factor, aligning with previously published data. These findings underscore the necessity for tailored approaches that consider ethnic-specific factors in the risk assessment, prevention, and management of ICH. Further research is warranted to elucidate the underlying mechanisms and develop interventions aimed at improving outcomes and enhancing healthcare practices in ICH management.

Radioimaging and Demographic Profiles of Patients with Spontaneous Intracerebral Hemorrhage: A Need for the Pragmatic Referral System

Referring patients with severe medical conditions, like brain stroke, from small or rural hospitals to tertiary care centers is often overexploited leading to a kind of defensive medicine. The issue of a patient referral system remains unaddressed in Nepal. In this article, we investigated the legitimacy of referring patients with spontaneous intracranial hemorrhage (ICH) from country peripheral hospitals to the leading tertiary neurological center in Nepal. We found that 81 out of the 130 ICH patients reviewed in the study were referred. We further show that the classifiers to be considered most in the decision-making on the patient referral are as follows: hematoma volume, midline shift found in radioimaging, ventricular extension of bleeding, and appearance of hydrocephalus. An improper referral of the patient to the tertiary care center decreases limited resources of healthcare services in low-income countries. We believe the study reflects a prevailing belief among healthcare professionals that the current referral system could be improved with the inception of the "hub and spoke" model of healthcare. In this model, a network of secondary health institutions, capable of offering limited treatment, would refer ICH patients to an anchor tertiary institution, respecting the proper dichotomization of patients based on the clinical classifiers. We conclude that the use of the "hub and spoke" model, legitimizing the patient referral system, is posed to offer medical benefits for patients hit by a stroke and would be economically viable for both patients and healthcare services.

CT Guided Catheter Aspiration & Thrombolysis of Hypertensive Basal Ganglionic Hematomas: Technique and Short-Term Outcome Comparison CT guided catheter thrombolysis of ICH

BACKGROUND

Minimally invasive techniques of hematoma evacuation with or without the use of thrombolytic agents to lyse the clots have shown promising outcomes against open surgical evacuation. However, there is a dearth of literature in developing nations.

OBJECTIVE

To evacuate spontaneous hypertensive basal ganglionic haemorrhages using CT guided catheter insertion, hematoma aspiration and lysis with thrombolytic agents and analyse the efficacy and outcomes.

METHODOLOGY

Ten patients with spontaneous basal ganglionic haemorrhage underwent CT guided clot catheter insertion, followed by aspiration of hematoma and clot lysis using 25000 IU urokinase instilled every 12 hours. Details including symptoms, clinical and radiological findings, efficacy of the technique, functional outcomes during follow-up, length of stay and cost were recorded. Relevant details for 12 age and sex-matched conservatively treated patients were compared.

RESULTS

Functional outcome in the catheter group at six months was better than the medically managed group, with improved mean Glasgow outcome scale (+0.4 vs +0.08), reduced modified Rankin score (-0.8 vs -0.25), and reduced National Institute of Health Stroke Scale scores (-6.8 vs -1.5 points). However, it was not statistically significant. Average hematoma volume reduction in catheter group was 83.14%. In the medically managed group, 2 of 12 patients(16.6%) had hematoma expansion, 6 patients(50%) developed hydrocephalus, and 2 patients(16.6%) died. In the catheter group, 4 patients of 10(40%) developed mild pneumocephalus that resolved.

CONCLUSION

The evacuation of hypertensive basal ganglionic hematomas is feasible with basic neurosurgical instruments and existing resources such as CT scan with improved functional outcome compared to conservative treatment alone.