Risk factors for intracerebral hemorrhage differ according to hemorrhage location

Abstract

Objectives: Risk factors have been described for spontaneous intracerebral hemorrhage (ICH); their relative contribution to lobar vs nonlobar hemorrhage location is less clear. Our purpose here was to investigate risk factors by hemorrhage location.Methods: This case-control study prospectively enrolled subjects with first-ever spontaneous ICH and matched each with up to 3 controls by age, race, and gender. Conditional stepwise logistic regression modeling was used to determine significant independent risk factors for lobar and nonlobar ICH.Results: From December 1997 through December 2006, 597 cases and 1,548 controls qualified for the analysis. Hypertension, warfarin use, first-degree relative with ICH, personal history of ischemic stroke, less than a high school education, and APOE e2 or e4 genotype were more common in ICH cases. Hypercholesterolemia and moderate alcohol consumption (#2 drinks per day) were less common in ICH cases. The associations of hypertension and hypercholesterolemia were specific for nonlobar ICH. Conversely, the association of APOE e2 or e4 genotype was specific for lobar ICH.Conclusions: APOE e2 or e4 genotype was associated specifically with lobar ICH. Hypertension was associated specifically with nonlobar ICH. A protective association was seen between hypercholesterolemia and nonlobar ICH; no such association was identified for lobar ICH. Intracerebral hemorrhage (ICH) accounts for approximately 20% of strokes worldwide, with 30-day mortality estimates of 32%-50%. [1][2][3][4] Of patients who survive, only 28%-35% are independent at 3 months. 5,6 Prior reports from our group and others support the hypothesis that risk factors for ICH vary according to hemorrhage location.7-10 The Genetic and Environmental Risk Factors in Hemorrhagic Stroke (GERFHS) Study is designed to examine the genetic and environmental variables associated with hemorrhagic stroke in the biracial population of the Greater Cincinnati/Northern Kentucky (GCNK) region (population 1.3 million, 16% black). In 2002, our preplanned interim analysis examined the hypothesis that risk factors for ICH varied according to hemorrhage location. Hypertension had the highest attributable risk for nonlobar ICH (e.g., basal ganglia, thalamus, brainstem, cerebellum, or periventricular white matter), whereas APOE alleles e2 and e4 had the highest attributable risk for lobar ICH 7 -findings that have been replicated in other studies. [8][9][10] That report had a limited sample size and therefore limited ability to differentiate risk factors by subgroup. The current report, with over 3 times the sample size of our interim report, re-examines the hypothesis that risk factors for ICH vary in prevalence and attributable risk for lobar vs nonlobar ICH.METHODS Study design. GERFHS is a case-control study of hemorrhagic stroke that used population-based case ascertainment.

Influence of Intracerebral Hemorrhage Location on Incidence, Characteristics, and Outcome

“…21 Determining whether risk factors and outcome differ according to ICH location has been further complicated by studies' varied definitions of ICH location. Of 41 observational studies comparing lobar and nonlobar ICH, 20 did not define lobar location, 18,[22][23][24][25][26][27][28][29][30][31][32][33][34][35][36][37][38][39][40] and 21 used different definitions of lobar location (including ICH which was cortical, subcortical, or cortical and subcortical, [41][42][43][44][45][46] cerebellar, 47 predominantly cortical and involving underlying white matter, [48][49][50] subcortical or in a hemisphere excluding the basal ganglia or thalamus, [51][52][53] or in any lobe(s) of the brain). [54][55][56][57][58][59][60][61] Of 28 studies that defined nonlobar ICH, 20 defined nonlobar as involving the basal ganglia or infratentorial regions, 18,25,27,<...>…”

Imaging of Nontraumatic Neuroradiology Emergencies

“…Hemorrhage in these locations, particularly in a patient with a history of hypertension, should favor this diagnosis. 19 The presence of microbleeds isolated to the deep structures is a helpful confirmatory finding (Fig. 4).…”

“…13 Lobar intraparenchymal hemorrhage Lobar hemorrhage refers to bleeding involving the cortex and adjacent white matter of a hemisphere and is also called cortical-subcortical hemorrhage. Lobar hemorrhage is often associated with CAA in older patients, 19 but may be due to a variety of causes.…”

Clinical Profiles of Spontaneous Intracerebral Haemorrhage Patients: Experience of 100 Cases in Dhaka City

“…Hypertension is the most important risk factor for spontaneous ICH and the contribution of hypertension is greater for deep ICH than for lobar ICH 10 . Current smoking and heavy alcohol consumption are associated with increased risk of ICH.…”

“…The neurologic symptoms usually aggravate over minutes or a few hours. The most common site of ICH is the putamen, and clinical presentations vary by the size and location of ICH 10 . Common ICH symptoms are headache, nausea, and vomiting.…”