ObjectiveTo investigate incidence of stroke and its subtypes in young adults, according to sex and age, and to study trends over time.MethodsWe established a nationwide cohort through linkage of national registries (hospital discharge, cause of death, and population register) with patients aged 18–50 years and those ≥50 years with first-ever ischemic stroke, intracerebral hemorrhage, or unspecified stroke, using ICD-9/ICD-10 codes between 1998 and 2010 in the Netherlands. Outcomes were yearly incidence of stroke stratified by age, sex, and stroke subtype, its changes over time, and comparison of incidence in patients 18–50 years to patients ≥50 years.ResultsWe identified 15,257 patients (53% women; mean age 41.8 years). Incidence increased exponentially with age (R2 = 0.99) and was higher for women than men, most prominently in the youngest patients (18–44 years). The relative proportion of ischemic stroke increased with age (18–24 years: 38.3%; 44–49 years: 56.5%), whereas the relative proportion of intracerebral hemorrhage decreased (18–24 years: 34.0%; 44–49 years: 18.3%). Incidence of any stroke in young adults increased (1998: 14.0/100,000 person-years: 2010: 17.2; +23%; p < 0.001), driven by an increase in those aged over 35 years and ischemic stroke incidence (46%), whereas incidence decreased in those ≥50 years (329.1%–292.2%; −11%; p = 0.009).ConclusionsIncidence of any stroke in the young increases with age in patients over 35, is higher in women than men aged 18–44 years, and has increased by 23% in one decade, through an increase in ischemic stroke. Incidence of intracerebral hemorrhage is comparable for women and men and remained stable over time.

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Study queStionWhat are the diagnostic yield and accuracy of early computed tomography (CT) angiography followed by magnetic resonance imaging/angiography (MRI/MRA) and digital subtraction angiography (DSA) in patients with non-traumatic intracerebral haemorrhage? MethodSThis prospective diagnostic study enrolled 298 adults (18-70 years) treated in 22 hospitals in the Netherlands over six years. CT angiography was performed within seven days of haemorrhage. If the result was negative, MRI/MRA was performed four to eight weeks later. DSA was performed when the CT angiography or MRI/MRA results were inconclusive or negative. The main outcome was a macrovascular cause, including arteriovenous malformation, aneurysm, dural arteriovenous fistula, and cavernoma. Three blinded neuroradiologists independently evaluated the images for macrovascular causes of haemorrhage. The reference standard was the best available evidence from all findings during one year's follow-up. Study anSwer and liMitationSA macrovascular cause was identified in 69 patients (23%). 291 patients (98%) underwent CT angiography; 214 with a negative result underwent additional MRI/MRA and 97 with a negative result for both CT angiography and MRI/MRA underwent DSA. Early CT angiography detected 51 macrovascular causes (yield 17%, 95% confidence interval 13% to 22%). CT angiography with MRI/MRA identified two additional macrovascular causes (18%, 14% to 23%) and these modalities combined with DSA another 15 (23%, 18% to 28%). This last extensive strategy failed to detect a cavernoma, which was identified on MRI during follow-up (reference strategy). The positive predictive value of CT angiography was 72% (60% to 82%), of additional MRI/MRA was 35% (14% to 62%), and of additional DSA was 100% (75% to 100%). None of the patients experienced complications with CT angiography or MRI/MRA; 0.6% of patients who underwent DSA experienced permanent sequelae. Not all patients with negative CT angiography and MRI/MRA results underwent DSA. Although the previous probability of finding a macrovascular cause was lower in patients who did not undergo DSA, some small arteriovenous malformations or dural arteriovenous fistulas may have been missed. what thiS Study addS CT angiography is an appropriate initial investigation to detect macrovascular causes of non-traumatic intracerebral haemorrhage, but accuracy is modest. Additional MRI/MRA may find cavernomas or alternative diagnoses, but DSA is needed to diagnose macrovascular causes undetected by CT angiography or MRI/MRA.

Objective: To determine whether the CT angiography (CTA) spot sign marks bleeding complications during and after surgery for spontaneous intracerebral hemorrhage (ICH). Methods:In a 2-center study of consecutive spontaneous ICH patients who underwent CTA followed by surgical hematoma evacuation, 2 experienced readers (blinded to clinical and surgical data) reviewed CTAs for spot sign presence. Blinded raters assessed active intraoperative and postoperative bleeding. The association between spot sign and active intraoperative bleeding, postoperative rebleeding, and residual ICH volumes was evaluated using univariable and multivariable logistic regression.Results: A total of 95 patients met inclusion criteria: 44 lobar, 17 deep, 33 cerebellar, and 1 brainstem ICH; $1 spot sign was identified in 32 patients (34%). The spot sign was the only independent marker of active bleeding during surgery (odds ratio [OR] 3.4; 95% confidence interval [CI] 1.3-9.0). Spot sign (OR 4.1; 95% CI 1.1-17), female sex (OR 6.9; 95% CI 1.7-37), and antiplatelet use (OR 4.6; 95% CI 1.2-21) were predictive of postoperative rebleeding. Larger residual hematomas and postoperative rebleeding were associated with higher discharge case fatality (OR 3.4; 95% CI 1.1-11) and a trend toward increased case fatality at 3 months (OR 2.9; 95% CI 0.9-8.8). Conclusions:The CTA spot sign is associated with more intraoperative bleeding, more postoperative rebleeding, and larger residual ICH volumes in patients undergoing hematoma evacuation for spontaneous ICH. The spot sign may therefore be useful to select patients for future surgical trials. Neurology ® 2014;83:883-889 GLOSSARY CI 5 confidence interval; CTA 5 CT angiography; ICH 5 intracerebral hemorrhage; MGH 5 Massachusetts General Hospital; OR 5 odds ratio; UMCU 5 Utrecht University Medical Center.Intracerebral hemorrhage (ICH) remains the most lethal form of stroke, with 1-month mortality rates of 40%.1 Clinical trials assessing surgical therapy for ICH have not shown an effect on functional outcome, although benefit has been shown for cerebellar hematomas larger than 3 cm in observational studies.2,3 Systematic reviews also suggest a beneficial effect for specific subgroups in supratentorial ICH. Thus, a tool to identify patients who may benefit from surgery is warranted. A robust marker of ongoing bleeding, studied extensively over the last 10 years, is the CT angiography (CTA) spot sign ( figure 1B). 7 The spot sign is commonly assumed to represent continued bleeding (e.g., contrast extravasation visualized on CTA after contrast bolus injection) from ruptured