Etiology, 3-Month Functional Outcome and Recurrent Events in Non-Traumatic Intracerebral Hemorrhage

Abstract

Background and Purpose Knowledge about different etiologies of non-traumatic intracerebral hemorrhage (ICH) and their outcomes is scarce.Methods We assessed prevalence of pre-specified ICH etiologies and their association with outcomes in consecutive ICH patients enrolled in the prospective Swiss Stroke Registry (2014 to 2019). Results We included 2,650 patients (mean±standard deviation age 72±14 years, 46.5% female, median National Institutes of Health Stroke Scale 8 [interquartile range, 3 to 15]). Etiology was as follows: hypertension, 1,238 (46.7%); unknown, 566 (21.4%); antithrombotic therapy, 227 (8.6%); cerebral amyloid angiopathy (CAA), 217 (8.2%); macrovascular cause, 128 (4.8%); other determined etiology, 274 patients (10.3%). At 3 months, 880 patients (33.2%) were functionally independent and 664 had died (25.1%). ICH due to hypertension had a higher odds of functional independence (adjusted odds ratio [aOR], 1.33; 95% confidence interval [CI], 1.00 to 1.77; <i>P</i>=0.05) and lower mortality (aOR, 0.64; 95% CI, 0.47 to 0.86; <i>P</i>=0.003). ICH due to antithrombotic therapy had higher mortality (aOR, 1.62; 95% CI, 1.01 to 2.61; <i>P</i>=0.045). Within 3 months, 4.2% of patients had cerebrovascular events. The rate of ischemic stroke was higher than that of recurrent ICH in all etiologies but CAA and unknown etiology. CAA had high odds of recurrent ICH (aOR, 3.38; 95% CI, 1.48 to 7.69; <i>P</i>=0.004) while the odds was lower in ICH due to hypertension (aOR, 0.42; 95% CI, 0.19 to 0.93; <i>P</i>=0.031).Conclusions Although hypertension is the leading etiology of ICH, other etiologies are frequent. One-third of ICH patients are functionally independent at 3 months. Except for patients with presumed CAA, the risk of ischemic stroke within 3 months of ICH was higher than the risk of recurrent hemorrhage.

External validation of the diagnostic value of perihematomal edema characteristics in neoplastic and non‐neoplastic intracerebral hemorrhage

“…Data from several case reports indicate similar findings and report that glioblastoma multiforme in primary brain tumors exhibits the highest tendency to bleed [4–10]. Further support is given by recently published clinical imaging and neuropathology studies that suggest a considerably underestimated incidence of hemorrhage‐associated brain neoplasia beyond 15%–20%, especially in cases that are clinically inapparent [4, 16]. A growing body of scientific evidence even points to the need to incorporate aspects of vascularization into the brain tumor classification scheme [4].…”

“…ICH etiology was determined according to seven prespecified categories based on an adapted version of the mechanistic H-ATOMIC classification [15]. For the purpose of this study, we did not mandate a strict hierarchy as in the original H-ATOMIC classification but used the etiology which was most likely causal based on evidence from the follow-up MRI examination [16]. Patients with non-neoplastic ICH had underlying (i) hypertensive ICH, (ii) cerebral amyloid angiopathy-associated ICH, (iii) oral anticoagulant-associated ICH, or (iv) vascular malformation-associated ICH.…”

Association of the Presence and Pattern of MRI Markers of Cerebral Small Vessel Disease With Recurrent Intracerebral Hemorrhage

“…7,8 Nevertheless, a relevant proportion of ICH (10%–20%) remains unexplained (i.e., cryptogenic) after diagnostic workup, although this proportion is not well established and will depend on the extent of investigation including the type(s), frequency, and timing of brain and vascular imaging used. 6,8…”

“…Most (65%-80%) 6,7 of ICH is caused by small vessel disease (SVD), namely either arteriolosclerosis (deep perforator arteriopathy) or cerebral amyloid angiopathy (CAA), while 10%-20% are attributed to secondary etiologies, such as macrovascular or structural causes. 7,8 Nevertheless, a relevant proportion of ICH (10%-20%) remains unexplained (i.e., cryptogenic) after diagnostic workup, although this proportion is not well established and will depend on the extent of investigation including the type(s), frequency, and timing of brain and vascular imaging used. 6,8 MRI is a very sensitive method to visualize several markers of SVD, including cerebral microbleeds (CMBs), cortical superficial siderosis (cSS), lacunes, white matter hyperintensities (WMH), and enlarged perivascular spaces (ePVS).…”

“…7,8 Nevertheless, a relevant proportion of ICH (10%-20%) remains unexplained (i.e., cryptogenic) after diagnostic workup, although this proportion is not well established and will depend on the extent of investigation including the type(s), frequency, and timing of brain and vascular imaging used. 6,8 MRI is a very sensitive method to visualize several markers of SVD, including cerebral microbleeds (CMBs), cortical superficial siderosis (cSS), lacunes, white matter hyperintensities (WMH), and enlarged perivascular spaces (ePVS). 9 These markers allow the assessment of the presence, type, and severity of underlying SVD including CAA, with potential relevance for ICH recurrence risk.…”