Clinical and Radiological Profile in Non Hypertensive Intracerebral Haemorrhage- A Prospective Observational Study
Correspondence Address :
Dr. Siddaganga,
Hallikeri Farm Vinayak Nagar, Kelgeri Raod, Dharwad-58000, Karnataka, India.
E-mail: drsiddaganga@gmail.com
Introduction: Intracerebral Haemorrhage (ICH) is less frequent than ischemic stroke, but has higher mortality and morbidity, it being one of the first causes of severe disability. Hypertension is the most common cause of ICH but Non Hypertensive Intracerebral Haemorrhages (NHICH) are not rare. Hence, the importance of recognizing these conditions and need for urgent specific therapy which may play a vital role in therapeutic planning and prevention of ICH. Hence this study was performed to study.
Aim: To study the clinical and radiological profile in NHICH, to identify risk factors, and to determine whether clinical/neuronradiological parameters would predict the prognosis of ICH.
Materials and Methods: The present prospective observational study was conducted in the Department of General Medicine Mahadevappa Rampure Medical College Gulbarga, Karnataka, India, from January 2016-January 2017. It involved 50 subjects with NHICH. Demographic details, clinical and radiological data were collected in patients presenting with signs and symptoms of stroke and confirmed by Computed Tomography (CT) scan/Magnetic Resonance Imaging (MRI) brain as ICH, who were non hypertensive and with age more than 18 years. Clinical outcome of the patients was measured based on Glasgow Coma Scale (GCS), site and volume of haemorrhage. Descriptive statistics of the explanatory and outcome variables were calculated by mean, Standard Deviation (SD) and Chi-square test was applied for qualitative variables.
Results: In the present study 31 (62%) were males, and 19 (38%) were females. The age of patients ranged from 18-85 years. The most common risk factor associated with intracerebral haemorrhage was alcohol consumption 16 (32.0%), followed by smoking 13 (26%), and anticoagulant intake 13 (26%). Most common clinical presentation were hemiplegia/hemiparesis, speech defect, vomiting, convulsion, pupillary defect and cranial nerve involvement, in decreasing frequency. High ICH score and low GCS were poor prognostic factors for outcome of intracerebral haemorrhage patient in the present study. In hospital mortality rate was 28%. During 30 days follow-up, there was 22.2% mortality among the discharged patient.
Conclusion: Although hypertension remains as a most common risk factor for intracerebral bleed, other risk factors such as significant alcohol consumption, coagulopathy should also be kept in mind especially in young. Non hypertensive haemorrhage usually occurs at sites not typical for hypertensive bleed. All efforts should be directed to establish the aetiological factors for intracerebral bleed, so that appropriate timely therapy can be provided to prevent further morbidity and mortality.
Aetiology, Glasgow coma scale, Mortality, Outcome
Intracerebral haemorrhage accounts for 10-15% of total cerebral vascular accident. ICH is less frequent than ischemic stroke, but has higher mortality and morbidity, it being one of the first causes of severe disability (1). Non traumatic intracerebral haemorrhage results from rupture of blood vessels in the brain parenchyma. It accounts as a major public health problem with an annual incidence of 10-30 per 100 000 population, accounting for 2 million (10-15%) of about 15 million strokes worldwide each year (2),(3),(4). There are many non hypertensive causes of ICH including Cerebral Amyloid Antipathy (CAA), vacuities, vascular malformations, and the use of anticoagulants, fibrinolysis, antiplatelet agents, underlying co-morbidities like diabetes mellitus, alcohol intake, smoking, drug abuse like cocaine, and finally genetic and ethnicity also play an important role in causation of intracerebral bleed (5),(6),(7),(8),(9). Primary and secondary (anticoagulant induced) intracerebral haemorrhages have similar underlying pathological changes (10). Hence, the importance of recognising these conditions and need for urgent specific therapy which may play a vital role in therapeutic planning and prevention of ICH (11).
Spontaneous ICH has still remained a serious disease despite attempts at improving outcome by medical and neurosurgical treatment. There are many clinical/neuro-radiological parameters like GCS, severity of neurological deficit, site, size, volume of haemorrhage, presence of intraventricular extension, hydrocephalous and others that would predict the outcome of ICH (12),(13). Hence this study was performed to study clinical and radiological findings in non hypertensive intracerebral haemorrhage with an aim to find out the other non hypertensive risk factors and causes for intracerebral haemorrhage, and to determine whether clinical/neuron-radiological parameters would predict the outcome of ICH.
The prospective observational cohort study in the Department of General Medicine, conducted at Mahadevappa Rampur Medical College Gulbarga, Karnataka, India; from January 2016-January 2017. The Institutional Ethical Committee (HKES/MRMCK/IEC/17/11/24) clearance was obtained. The study involved 50 subjects with non hypertensive intracerebral haemorrhage.
Inclusion criteria: Patients presenting with signs and symptoms of stroke and confirmed by CT scan/MRI brain as ICH, who were non hypertensive and were more than 18 years of age were included in the study.
Exclusion criteria: Known case of chronic hypertension on antihypertensive medication, patient with ischemic stroke and traumatic origin of intracerebral haemorrhage were excluded from the study.
Study Procedure
Demographic details, clinical and radiological data were collected. Clinical outcome of the patients was measured based GCS and site, and volume of haemorrhage.
Initial workup of patients included:
• CT scan head (plain)
• Complete haemogram
• Coagulation profile
• Random Blood Sugar (RBS), Blood urea, Serum creatinine
• Lipid profile
• Other investigations like chest radiograph, MRI brain with Magnetic Resonance Angiography (MRA), echocardiography, liver function tests, were done whenever needed. The following data were extracted by a radiologist from the patient’s CT scan, obtained at the time of admission:
• Site of haematoma-infratentorial.
• Volume of haematoma by ABC/2 formula. Haematoma volume were calculated by using ABC/2 formula of Kothari & coworkers by plan metric methods, and expressed either as >30 cm3 or <30cm3 (14).
Elements which comprise the ICH Score: age, Glasgow Coma Scale (GCS) score at the time of hospital admission , hematoma volume on the initial CT scan (as measured manually using the ABC/2 method by a single examiner , presence of intraventricular hemorrhage (IVH) on the initial CT scan, and hematoma origin (either infratentorial or supratentorial). The ICH Score was determined by creating a sumscore of points assigned for individual components: GCS (3–4=2, 5–12=1, 13–15=0), hematoma volume (≥30 mL=1, <30 mL=0), presence of IVH (yes=1, no=0), infratentorial origin (yes=1, no=0), and patient age ≥80 (yes=1, no=0). Patient ICH Scores ranged from 0 to 5. Increasing points on the ICH Score with increased risk of mortality or decreased likelihood of favorable functional outcome (15).
Statistical Analysis
Descriptive statistics of the explanatory and outcome variables were calculated by mean, Standard Deviation (SD), and Chi-square test was applied for qualitative variables. Data was entered in Microsoft excel and analysed using Statistical Package for the Social Sciences (SPSS) statistical software (SPSS, version 20.0,). A p-value <0.05 was considered statistically significant.
The study was conducted on 50 non hypertensive cases of CT scan/MRI brain proven intracerebral haemorrhage. The male to female ratio was 1.6:1. The mean age of study population was 51.51±17.9 years. Maximum number of cases 22 (44%) belonged to the age group of 51-70 years, followed by 31-50 years 14 (28%). Youngest age was 18 years and oldest was 85 years in the study. (Table/Fig 1). The most common presentation was hemiplegia/hemiparesis 39 (78%), followed by vomiting 29 (58%) and speech defect 29 (58%) (Table/Fig 2). Alcohol consumption 16 (32.0%) of about 30 to 40 gram for 10 to 15 years followed by smoking a pack year were >20 packs /day were associated with intracerebral bleed. Other factors like intake of anticoagulant were seven cases all were on warfarin (3-4 mg/day) for Cerebral Venous Thrombosis (CVT) and Atrial Fibrillation (AF), antiplatelet intake were six patient for Cerebrovascular Accident (CVA), clotting disorder like factor XIII deficiency was present in one case, other two cases had liver failure due to HbsAg positive and cirrhosis of liver, three patient had immune thrombocytopenic purpura all were female patient, four patients had aneurysmal bleed all were in anterior circulation confirmed by MRA, two had microbleed, one patient had Arteriovenous Malformation (AVM), (Table/Fig 3), (Table/Fig 4). Lower the GCS patients had a higher mortality (Table/Fig 5). RBS level was significantly higher among the patients who died (Table/Fig 6). The most common site for intracerebral haemorrhage was basal ganglia followed by lobar and least common was brain stem. A total of 100% mortality was seen in brain stem lesion, followed by thalamus (Table/Fig 7).
A total of 4 (8.0%) patients had aneurysmal bleed, and all were seen in anterior circulation - two patients underwent aneurysm clip procedure, 2 (4.0%) had microbleed and 1(2.0%) patient had AVM. All these patients survived (Table/Fig 8). Aroud 3 (6.0%) patients had low platelet count, and were diagnosed with immune thrombocytopenic purpura. They were on steroid and intermittent platelet transfusion, and all of them survived (Table/Fig 9). A total of 11 (22.0%) cases had intracerebral bleed because of increased Prothrombin Time/International Normalised Ratio (PT/INR) (INR was >3.5) due to warfarin overdose (Table/Fig 9). As the Intracerebral Haemorrhage (IHC) score increased the mortality also significantly increased. Mortality was seen in those with an ICH score of 3 and 4 (Table/Fig 10). Telephonic follow-up on 30 days revealed that six patients died-six patients were males and two patients were females. So, the 30 days mortality was 22.2% (all had more than 1 ICH score) (Table/Fig 11).
In the present study, ICH was highest in the age group 51-70 years (44% of the patients). There was significant gender difference also. The distribution was similar to several other studies (16),(17). The most common presentation was hemiplegia/hemiparesis, followed by vomiting and speech defect. The occurrence of headache (56%), vomiting (58%), and seizures (36%) were comparable with other similar studies (18),(19). Most common factors like alcohol intake, cigarette smoking, anticoagulant/antiplatelet, coagulation disorder, aneurysm, arteriovenous malformation and diabetic’s mellitus were associated with intracerebral bleed. This is comparable to other studies (20),(21),(23). It is proposed that high blood glucose at admission contributes to poor outcome, due to exacerbation of cerebral edema and cerebral damage. A recent meta-analysis by Zheng J et al., in 2018, concluded that hyperglycemia was associated with poor outcome in patients with ICH as seen present study (24). The most common site of haematoma was the basal ganglia (42%) followed by, cerebral lobes, thalamus,cerebellum and brain stem (28%, 8%,8% and 4%, respectively), which is in agreement with the pattern described for the non white races in the United States of America (USA) (25).
In present study, based on the GCS, 84.6% of the patients had poor outcome. Poor outcome was associated with lower baseline GCS larger baseline ICH volume, and the presence of IVH at baseline, conforming to a pattern described previously (26),(27),(28),(29),(30). A study from Cincinnati, USA, reported a high sensitivity (96%) and specificity (98%) for the combined ICH volume and baseline GCS score to predict the 30 day mortality (28).
The most important factors predicting the final outcome were the size of haematoma, intraventricular extension, midline shift, GCS score and ICH score. These results indicated that high ICH score, low GCS score at the time of admission, presence of IVH, and midline shift were significantly associated with poor clinical outcome. These results are similar to other studies (15),(31).
The ICH still remains a grave medical emergency with high mortality and morbidity. In spite of improvement in outcomes in ischemic stroke, outcomes in patients with ICH still remain poor with no specific medical treatment and poor consensus and controversial outcomes of surgical interventions (32),(33). The mortality rate in hospital and 30 days in the present study was 28.7% and 22.2% repectively. It was lesser than other studies, where the mortality ranged from 35 to 52%. Variations in mortality could be because of early intervension in the present study, and that it excluded hypertension patients which is an independent risk factor (34),(35),(36).
Limitation(s)
This hospital based study from a single center did not aim to provide true prevalence or burden of ICH in the community. The sample size was limited, and the follow-up period of one month allowed only short-term outcome assessment.
The ICH has remained a serious disease despite recent improvements in management. So, efforts must be directed towards better understanding and modification of risk factors. ICH had slight affinity towards male sex and mostly occurred after 5th decade of life hemiplegia/hemiparesis, speech disturbances and vomiting were frequent presenting features found in this study. All efforts should be directed to establish the etiological factors for intracerebral bleed, so that appropriate timely therapy can be provided to prevent further morbidity and mortality.
DOI: 10.7860/JCDR/2022/55362.16736
Date of Submission: Feb 02, 2022
Date of Peer Review: Apr 04, 2022
Date of Acceptance: May 31, 2022
Date of Publishing: Aug 01, 2022
AUTHOR DECLARATION:
• Financial or Other Competing Interests: None
• Was Ethics Committee Approval obtained for this study? Yes
• Was informed consent obtained from the subjects involved in the study? Yes
• For any images presented appropriate consent has been obtained from the subjects. NA
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