Incidence of Recurrent Intracerebral Hemorrhages in a Multiethnic South Asian Population

Short-term functional outcomes of patients with acute intracerebral hemorrhage in the native and expatriate population

Objectives

Functional outcomes in patients with intracerebral hemorrhage (ICH) have not been well characterized in the Middle East and North Africa Region. We report the 30 and 90-day clinical outcomes in the native and expatriate of Qatar with ICH.

Methods

We evaluated the Glasgow Coma Scale (GCS), NIHSS, and imaging in the Qatar Stroke Registry (2013-22). The outcome measures were a modified Rankin Scale (mRS) at 90 days and mortality at 30 and 90 days. Unfavorable outcome was defined as mRS of 4-6. We performed non-parametric ROC analyses to measure the concordance index (C-index) to assess the goodness-of-fit of ICH score for predicting 30 day and 90-day mortality and functional outcome.

Results

1,660 patients (median age of 49 (41.5-58) years; male 83.1%, expatriates 77.5%) with ICH, including supratentorial deep in 65.2%, cortical in 16.2%, infratentorial 16% and primary intraventricular in 2.5% were studied. The median baseline ICH volume was 7.5 (3.2-15.8) ml. An unfavorable outcome was seen in 673 (40.5%) patients at 90 days. The unfavorable 90-day outcome (mRS 4-6) was 49.2% in the native population vs. 44.4% in Africans, 39.0% in South Asian, 35.3% in Far Eastern, and 7.7% in Caucasians, p < 0.001. Mortality at 30 days and 90 days was 10.4 and 15.1%. Increasing age [OR (95% CI), 1.02 (1.00-1.03)], lower GCS [0.77 (0.73-0.80)], prior use of antiplatelet medications [1.82 (1.19-2.08)], higher ICH volume [1.03 (1.02-1.04)], and presence of any intraventricular hemorrhage [1.57(1.19-2.08)], were associated with unfavorable outcome.

Conclusion

In this relatively younger ICH cohort more than 75% were expatriates. The ICH volume, 90-day unfavorable outcome and mortality was lower in the expatriates compared to the local Arab population, likely related to the younger age and smaller size of the hemorrhages. Prognostic scoring systems may have to be modified in this population to avoid early withdrawal of care.

Cardiovascular Events After Intracerebral Hemorrhage

Cardiovascular events after primary intracerebral hemorrhage (ICH) have emerged as a leading cause of poor functional outcomes and mortality during the long-term recovery after an ICH. These events encompass arterial ischemic events such as ischemic stroke and myocardial infarction, arterial hemorrhagic events that include recurrent ICH, and venous thrombotic events such as venous thromboembolism. The purpose of this review is to summarize the cardiovascular complications after ICH, epidemiology and associated risk factors, and their impact on ICH outcomes. Additionally, we will highlight possible pathophysiological mechanisms to explain the short- and long-term increased risks of ischemic and hemorrhagic events after ICH. Finally, we will highlight potential secondary stroke and venous thrombotic prevention strategies often not considered after ICH, balanced against the risk of ICH recurrence.

Repeated intracerebral hemorrhage after craniotomy for a distal middle cerebral artery aneurysm: A case report

RATIONALE

Distal middle cerebral artery aneurysms are very rare in the clinic, and craniotomy clipping is the better treatment after diagnosis. However, patients can also have repeated acute intracerebral hemorrhage after craniotomy for aneurysm, which has not been previously reported.

PATIENT CONCERNS

A 24-year-old male patient was admitted to our hospital with headache, nausea, and vomiting. He was well before, had no family history of cerebrovascular disease or hypertension, and had no history of trauma.

DIAGNOSES

Computer tomography and digital subtraction angiography of the brain revealed intracranial hematoma and an aneurysm located at the M4 segment of the left middle cerebral artery.

INTERVENTIONS

The patient underwent 2 surgeries to treat the aneurysm, followed by 2 operations for acute cerebral hemorrhage.

OUTCOMES

Despite repeated surgical treatments, the patient had a poor prognosis and eventually died of respiratory and circulatory failure after repeated brain bleeding.

LESSONS

Briefly, it is of great importance to consider the risk factors of cerebral hemorrhage, and provide individualized treatment and psychological counseling for patients with intracerebral hemorrhage.

Cardiovascular and cerebrovascular events in patients with intracerebral hemorrhage: Clinical characteristics and long-term predictors

Few studies have examined the long-term prognosis of Chinese patients with intracerebral hemorrhage (ICH). This study assessed the clinical characteristics and predictors of vascular events occurring within 5 years after ICH. We included consecutive patients diagnosed with first-ever ICH between June 2013 and December 2014. Based on follow-up data (collected until December 2019), we used multivariable logistic regression to examine the clinical characteristics and long-term predictors of vascular events (including recurrent ICH, ischemic stroke, and acute coronary syndrome) in patients who survived more than 30 days after ICH. Across the 307 patients in our analysis, the 5-year mortality rate was 28.01%. Within 5 years after ICH, major vascular events were observed in 62 patients (17.82%, 95% CI 13.78-21.82%). We observed high incidence of recurrent ICH (8.91%) and ischemic stroke (10.06%), but low incidence of acute coronary syndrome (1.15%). Most cases of recurrent ICH (80.65%) occurred within 3 years after ICH. Age ≥56 years and history of ischemic stroke or transient ischemic attack (TIA) were identified as predictors of cardiovascular and cerebrovascular events. ICH survivors are at high risk of both cardiovascular and cerebrovascular events, especially older patients (≥56 years) and those who experienced ischemic stroke or TIA prior to their first ICH. Recurrent ICH is more likely to occur within the first three years after first ICH than at later times. Clinicians should monitor patients closely for adverse events, particularly during the first three years after initial ICH.

The prevalence, mortality rate and functional outcome of intracerebral hemorrhage according to age sex and ethnic group in the state of Qatar

OBJECTIVE

To investigate the prevalence of intracerebral hemorrhage (ICH) using stroke database from the main tertiary hospital in Qatar (Hamad General Hospital) over the period of Dec 2013 to Oct 2017.

METHODS

The prevalence of ICH was calculated based on age groups and ethnicity (Qatari nationals, non-Qatari Arab, South east Indian (SI) and Far East Asians (FE)). Thirty-day case fatality rate, poor clinical outcome at discharge (modified Rankin scale (mRS):3-6) and poor long-term outcome (mRS at 90 days: 3-6) were calculated per each age group sex and ethnicity.

RESULT

There were 653/4039 (16 %) with ICH. The median age was 53 (IQ range: 45-64) with a male/female ratio: 557/96 (85.3/14.7 %). The 30-day mortality rate was 14.7 % (96/653), poor outcome at discharge (mRS 3-6): 66.8 % (436/653) and poor long-term outcome (mRS 90 days:3-6) 50.1 % (199/397). The prevalence of ICH in Qatar was 24.9 per 100 000. The highest mortality rate was seen in the elderly (≥ 70 years old) (16/67 (23.9 %)) and young group (48/291 (16.5 %)). The most common ethnic group among our ICH population are the following: FE (40.59 per 100 000), Qatari (25.26 per 100 000) and SI ethnic group (24.97 per 100 000). In multiple logistic regression analysis only, old age (≥ 70 years old) was associated with 30 days mortality (adj OR: 2.51, 95 % CI: 1.14-5.54, P = 0.023). Similar regression analysis was also observed that age ≥ 70 years old (adj. OR: 4.18, 95 % CI: 1.27-13.77, P = 0.019), sex (male) (adj. OR: 0.21, 95 % CI: 0.08-0.56, P = 0.002), and ethnicity (SI vs Qatari: adj. OR: 4.08, 95 % CI: 1.28-12.92, P = 0.017); (FE vs Qatari: adj. OR: 2.22, 95 % CI: 0.65-7.67, P = 0.203) are statistically associated with poor outcome.

CONCLUSION

The prevalence of ICH was high in the elderly and in the FE, Qatari, and SI ethnic group. Further studies are needed to better understand the differences in ICH prognosis in multiethnic groups.

Long-term prognosis after intracerebral haemorrhage

Introduction

The aim of this study was to determine the risk of recurrent intracerebral haemorrhage (ICH), ischaemic stroke, all stroke, any vascular event and all-cause mortality in 30-day survivors of ICH, according to age and sex.

Patients and methods

We linked national hospital discharge, population and cause of death registers to obtain a cohort of Dutch 30-day survivors of ICH from 1998 to 2010. We calculated cumulative incidences of recurrent ICH, ischaemic stroke, all stroke and composite vascular outcome, adjusted for competing risk of death and all-cause mortality. Additionally, we compared survival with the general population.

Results

We included 19,444 ICH-survivors (52% male; median age 72 years, interquartile range 61–79; 78,654 patient-years of follow-up). First-year cumulative incidence of recurrent ICH ranged from 1.5% (95% confidence interval 0.9–2.3; men 35–54 years) to 2.4% (2.0–2.9; women 75–94 years). Depending on age and sex, 10-year risk of recurrent ICH ranged from 3.7% (2.6–5.1; men 35–54 years) to 8.1% (6.9–9.4; women 55–74 years); ischaemic stroke 2.6% to 7.0%, of all stroke 9.9% to 26.2% and of any vascular event 15.0% to 40.4%. Ten-year mortality ranged from 16.7% (35–54 years) to 90.0% (75–94 years). Relative survival was lower in all age-groups of both sexes, ranging from 0.83 (0.80–0.87) in 35- to 54-year-old men to 0.28 (0.24–0.32) in 75- to 94-year-old women.

Discussion

ICH-survivors are at high risk of recurrent ICH, of ischaemic stroke and other vascular events, and have a sustained reduced survival rate compared to the general population.

Conclusion

The high risk of recurrent ICH, other vascular events and prolonged reduced survival-rates warrant clinical trials to determine optimal secondary prevention treatment after ICH.