The H-ATOMIC Criteria for the Etiologic Classification of Patients with Intracerebral Hemorrhage

Abstract

Background and PurposeThere are no generally accepted criteria for the etiologic classification of intracerebral hemorrhage (ICH). For this reason, we have developed a set of etiologic criteria and have applied them to a large number of patients to determine their utility.MethodsThe H-ATOMIC classification includes 7 etiologic categories: Hypertension, cerebral Amyloid angiopathy, Tumour, Oral anticoagulants, vascular Malformation, Infrequent causes and Cryptogenic. For each category, the etiology is scored with three degrees of certainty: Possible(3), Probable(2) and Definite(1). Our aim was to perform a basic study consisting of neuroimaging, blood tests, and CT-angio when a numerical score (SICH) suggested an underlying structural abnormality. Combinations of >1 etiologic category for an individual patient were acceptable. The criteria were evaluated in a multicenter and prospective study of consecutive patients with spontaneous ICH.ResultsOur study included 439 patients (age 70.8 ± 14.5 years; 61.3% were men). A definite etiology was achieved in 176 (40.1% of the patients: Hypertension 28.2%, cerebral Amyloid angiopathy 0.2%, Tumour 0.2%, Oral anticoagulants 2.2%, vascular Malformation 4.5%, Infrequent causes 4.5%). A total of 7 patients (1.6%) were cryptogenic. In the remaining 58.3% of the patients, ICH was attributable to a single (n = 56, 12.7%) or the combination of ≥2 (n = 200, 45.5%) possible/probable etiologies. The most frequent combinations of etiologies involved possible hypertension with possible CAA (H3A3, n = 38) or with probable CAA (H3A2, n = 29), and probable hypertension with probable OA (H2O2, n = 27). The most frequent category with any degree of certainty was hypertension (H1+2+3 = 80.6%) followed by cerebral amyloid angiopathy (A1+2+3 = 30.9%).ConclusionsAccording to our etiologic criteria, only about 40% patients received a definite diagnosis, while in the remaining patients ICH was attributable to a single possible/probable etiology or to more than one possible/probable etiology. The use of these criteria would likely help in the management of patients with ICH.

Hypertension and Hemorrhagic Stroke

“…In a recent study, possible etiologies of ICH were prospectively investigated in 439 patients. 4 Hypertension was found as an etiology (definite, probable, or possible) in about 80% of the patients. The next most common etiology was cerebral amyloid angiopathy (in only 30% of patients).…”

Hypertension prevalence and control in Ulaanbaatar, Mongolia

“…1,2 Hypertension is the major risk factor for stroke and precedes hemorrhagic stroke in as many as 80% of all hemorrhagic stroke cases. 3 This makes hypertension a particularly important public health issue in Mongolia which has one of the highest mortality rates from hemorrhagic stroke in the world. 2,4 Hypertension prevalence in low-and middle-income countries (LMICs) is increasing faster than in high-income countries (HICs), yet hypertension awareness, treatment, and control in are much lower and increasing at a slower rate.…”

Current approaches to diagnosing in intracerebral hemorrhage

“…В клинической практике удобно применение этиологической классификации ВМК SMASH-U (structural vascular lesions -S, medication -M, amyloid angiopathy -A, systemic disease -S, hypertension -H, or undetermined -U) [8]. Более детальный подход к установлению причины ВМК отражен в классификации H-ATOMIC (Hypertension, cerebral Amyloid angiopathy, Tumour, Oral anticoagulants, vascular Malformation, Infrequent causes and Cryptogenic), в которой каждая из семи категорий представлена тремя степенями значимости -возможная, вероятная и достоверная [9].…”

“…Расширенный диагностический алгоритм предполагает выполнение повторных ангиографий, МРТ головного мозга с возможностью оценки церебральных микрокровоизлияний (ЦМК) и коркового поверхностного сидероза (КПС; необходима МР-последовательность SWI), контрастным усилением и анализом сосудистой стенки, а также люмбальной пункции, биопсии и онкопоиска. [9]. Также гипертензионная ангиопатия лежит в основе большинства случаев мозжечкового ВМК [11].…”

“…Установление достоверного диагноза гипокоагуляторного ВМК требует приема варфарина в анамнезе и международного нормализованного отношения (МНО) ≥2 при отсутствии других причин, тогда как при наличии альтернативной этиологии или МНО <2 диагноз носит вероятный характер. Прием ПОАК может рассматриваться в качестве достоверной причины ВМК при отклонении результатов коагуляторных тестов и в качестве возможной причины при наличии альтернативных объяснений или нормальных показателей свертывания [9]. Рутинные коагуляторные тесты недостаточно информативны для оценки антикоагулянтного эффекта ПОАК.…”