Recurrent intracerebral hemorrhage

In Search of the Optimal Antithrombotic Regimen for Intracerebral Hemorrhage Survivors with Atrial Fibrillation

Spontaneous intracerebral hemorrhage (ICH) constitutes 10-15% of all strokes, and is a significant cause of mortality and morbidity. Survivors of ICH, especially those with atrial fibrillation (AF), are at risk for both recurrent hemorrhagic and ischemic cerebrovascular events. A conundrum in the field of vascular neurology, neurosurgery, and cardiology has been the decision to initiate or resume versus withhold anticoagulation in survivors of ICH with AF. To initiate anticoagulation would decrease the risk of ischemic stroke but may increase the risk of hemorrhage. To withhold anticoagulation maintains a lower risk of hemorrhage but does not decrease the risk of ischemic stroke. In this narrative review, we discuss the evidence for and against the use of antithrombotics in ICH survivors with AF, focusing on recently completed and ongoing clinical trials.

The Prevalence and Characterization of Cerebral Microbleeds in Young People Having Intracerebral Hemorrhage

Objective

Cerebral microbleeds (CMBs) are known as the neuroimaging markers of risk in stroke and dementia. Many studies on CMBs in elderly patients with hemorrhagic or ischemic stroke have been reported; however, reports on CMBs in young populations with intracerebral hemorrhage (ICH) are lacking.

Materials and Methods

A total of 272 patients aged 18–54 years presented to our hospital with ICH between December 2009 and August 2017. Among these, CMB presence, count, and topography with respect to ICH were evaluated on magnetic resonance imaging (MRI) gradient echo images (GREs). We also evaluated the prevalence and risk factors of CMBs.

Results

Among 272 patients, only 66 underwent GRE T2-weighted MRI. CMBs were detected in 40 patients (61%), with 29 (73%) being of the multifocal type. Among the 219 CMBs, 150 (68.5%) were of the deep type and 69 (31.5%) of the lobar type. CMB prevalence was higher in men. In multivariate logistic regression analysis, history of hypertension (adjusted odds ratio [aOR], 4.048; 95% confidence interval [CI], 1.14–14.32; p = 0.030), and male sex (aOR, 4.233; 95% CI, 1.09–16.48; p = 0.037) were independently associated with CMBs.

Conclusion

In young patients who presented with spontaneous ICH, CMBs were highly prevalent in 61% of patients and strongly associated with history of hypertension and male sex.

Long-term neurological, vascular, and mortality outcomes after stroke

Background

Despite improved survival and short-term (90-day) outcomes of ischemic stroke patients, only sparse data exist describing the sustained benefits of acute stroke care interventions and long-term prognosis of stroke survivors.

Aim

We review the contemporary literature assessing long-term (5 years or more) outcomes after stroke and acute stroke treatment.

Summary of review

Acute stroke unit care and intravenous thrombolysis have sustained benefits over longer follow-up, but few data exist on the long-term outcome after endovascular thrombectomy (EVT). A large proportion of stroke survivors face challenges of residual disability and neuropsychiatric sequelae (especially affective disorders and epilepsy) which affects their quality of life and is associated with poorer prognosis due to increase in stroke recurrences/mortality. Nearly, a quarter of stroke survivors have a recurrent stroke at 5 years, and nearly double that at 10 years. Mortality after recurrent stroke is high, and half of the stroke survivors are deceased at 5 years after stroke and three fourth at 10 years. Long-term all-cause mortality is largely due to conditions other than stroke. Both stroke recurrence and long-term mortality are affected by several modifiable risk factors, and thus amenable to secondary prevention strategies.

Conclusions

There is a need for studies reporting longer term effects of acute interventions, especially EVT. Better preventive strategies are warranted to reduce the vascular and non-vascular mortality long after stroke.

Recurrent Intracerebral Hemorrhage: Associations with Comorbidities and Medicine with Antithrombotic Effects

Background

Intracerebral hemorrhage (ICH) is a disease with high mortality and a substantial risk of recurrence. However, the recurrence risk is poorly documented and the knowledge of potential predictors for recurrence among co-morbidities and medicine with antithrombotic effect is limited.

Objectives

1) To estimate the short- and long-term cumulative risks of recurrent intracerebral hemorrhage (ICH). 2) To investigate associations between typical comorbid diseases, surgical treatment, use of medicine with antithrombotic effects, including antithrombotic treatment (ATT), selective serotonin reuptake inhibitors (SSRI’s), and nonsteroidal anti-inflammatory drugs (NSAID’s) with recurrent ICH.

Methods

The cohort consisted of all individuals diagnosed with a primary ICH in Denmark 1996–2011. Information on comorbidities, surgical treatment for the primary ICH, and the use of ATT, SSRI’s and NSAID’s was retrieved from the Danish national health registers. The cumulative recurrence risk of ICH was estimated using the Aalen-Johansen estimator, thus taking into account the competing risk of death. Associations with potential predictors of recurrent ICH were estimated as rate ratios (RR’s) using Poisson regression. Propensity score matching was used for the analyses of medicine with antithrombotic effects.

Results

Among 15,270 individuals diagnosed with a primary ICH, 2,053 recurrences were recorded, resulting in cumulative recurrence risk of 8.9% after one year and 13.7% after five years. Surgical treatment and renal insufficiency were associated with increased recurrence risks (RR 1.64, 95% CI 1.39–1.93 and RR 1.72, 95% CI 1.34–2.17, respectively), whereas anti-hypertensive treatment was associated with a reduced risk (RR 0.82, 95% CI 0.74–0.91). We observed non-significant associations between the use of any of the investigated medicines with antithrombotic effect (ATT, SSRI’s, NSAID’s) and recurrent ICH.

Conclusions

The substantial short-and long-term recurrence risks warrant aggressive management of hypertension following a primary ICH, particularly in patients treated surgically for the primary ICH, and patients with renal insufficiency.

Anticoagulation for Atrial Fibrillation in Patients with Cerebral Microbleeds

Intracranial haemorrhage (ICH) is the most feared and devastating complication of oral anticoagulation, with high mortality and disability in survivors. Oral anticoagulant-related ICH is increasing in incidence, most likely in part due to the increased use of anticoagulation for atrial fibrillation in the elderly populations with a high prevalence of bleeding-prone cerebral small vessel diseases. Risk scores have been developed to predict bleeding, including ICH, as well as the risk of ischaemic stroke. Recently, attention has turned to brain imaging, in particular, MRI detection of potential prognostic biomarkers, which may help better predict outcomes and individualize anticoagulant decisions. Cerebral microbleeds (CMBs)--small, round areas of signal loss on blood-sensitive MR sequences--have been hypothesized to be a marker for bleeding-prone small vessel pathology, and thus, future symptomatic ICH risk. In this review, we outline the prevalence and prognostic value of CMBs in populations affected by AF for whom anticoagulation decisions are relevant, including healthy older individuals and survivors of ischaemic stroke or ICH. We consider the limitations of currently available evidence, and discuss future research directions in relation to both prognostic markers and treatment options for atrial fibrillation.

Recurrent cerebral amyloid angiopathy-related hemorrhage

Cerebral amyloid angiopathy is an important cause of intracerebral hemorrhage in normotensive elder individuals. Surgical treatment for cerebral hematoma due to amyloid angiopathy remains controversial, and some authors emphasized the difficulty of hemostasis during surgery and the risk of recurrent hemorrhage after surgery. A case study of a 68-year-old man with cerebral amyloid angiopathy and recurrent intracerebral hemorrhages is presented.

Update in intracerebral hemorrhage

Spontaneous, nontraumatic intracerebral hemorrhage (ICH) is defined as bleeding within the brain parenchyma. Intracranial hemorrhage includes bleeding within the cranial vault and encompasses ICH, subdural hematoma, epidural bleeds, and subarachnoid hemorrhage (SAH). This review will focus only on ICH. This stroke subtype accounts for about 10% of all strokes. The hematoma locations are deep or ganglionic, lobar, cerebellar, and brain stem in descending order of frequency. Intracerebral hemorrhage occurs twice as common as SAH and is equally as deadly. Risk factors for ICH include hypertension, cerebral amyloid angiopathy, advanced age, antithrombotic therapy and history of cerebrovascular disease. The clinical presentation is "stroke like" with sudden onset of focal neurological deficits. Noncontrast head computerized tomography (CT) scan is the standard diagnostic tool. However, newer neuroimaging techniques have improved the diagnostic yield in terms of underlying pathophysiology and may aid in prognosis. Intracerebral hemorrhage is a neurological emergency. Medical care begins with stabilization of airway, breathing function, and circulation (ABCs), followed by specific measures aimed to decrease secondary neurological damage and to prevent both medical and neurological complications. Reversal of coagulopathy when present is of the essence. Blood pressure management can be key and continues as an area of debate and ongoing research. Surgical evacuation of ICH is of unproven benefit though a subset of well-selected patients may have improved outcomes. Ventriculostomy and intracranial pressure (ICP) monitoring are interventions also used in this patient population. To date, hemostatic medications and neuroprotectants have failed to result in clinical improvement. A multidisciplinary approach is recommended, with participation of vascular neurology, vascular neurosurgery, critical care, and rehabilitation medicine as the main players.

Predictors for recurrent primary intracerebral hemorrhage: a retrospective population-based study

BACKGROUND AND PURPOSE

Underlying comorbidities, previous strokes, and medication may increase the risk for primary intracerebral hemorrhage (PICH) and its recurrence. The aim of this study was to determine the independent predictors for recurrent PICH.

METHODS

We identified 961 subjects with first-ever PICH from 1993 to 2008 among the population of Northern Ostrobothnia, Finland. Hospital and death records were reviewed and data on drug use were obtained from the national register of prescribed medicines. Kaplan-Meier survival curves and Cox proportional hazards models were used to demonstrate predictors for recurrence of PICH.

RESULTS

Total follow-up time of the 961 patients was 3481 person-years. During the follow-up time, 58 subjects had altogether 68 recurrent PICHs. The annual average incidence of first recurrence was 1.67%. Cumulative 5- and 10-year incidence rates were 9.6% and 14.2%, respectively. In univariable analysis, history of ischemic stroke, diabetes mellitus, and aspirin use were associated with a higher recurrence rate. In multivariable analysis, only previous ischemic stroke (adjusted hazard ratio, 2.22; 95% confidence interval, 1.22-4.05; P=0.009) independently predicted PICH recurrence. Diabetes mellitus tended to increase (adjusted hazard ratio, 2.38; 95% confidence interval, 0.98-5.80; P=0.056), whereas treated hypertension tended to decrease (0.45, 0.20-1.01; P=0.054) the risk for fatal recurrent PICH.

CONCLUSIONS

Previous ischemic stroke independent of confounding factors may increase the risk for PICH recurrence.

Prevention of intracerebral hemorrhage recurrence

PURPOSE OF REVIEW

: Limited data are available on the prevention of intracerebral hemorrhage (ICH) recurrence, which is substantial, especially in the case of lobar ICH related to cerebral amyloid angiopathy. In view of the relative paucity of prospectively generated data, current strategies for the secondary prevention of ICH involve the extrapolation of data on primary prevention of ICH to its secondary prevention and the avoidance of certain agents that have been shown in clinical series to be associated with increased risk of ICH recurrence. This review analyzes ways to approach the secondary prevention of ICH in the setting of a paucity of adequate prospectively generated data on the subject.

RECENT FINDINGS

: Risk factors for ICH recurrence identified through data extrapolation include hypertension, diabetes, excessive alcohol consumption, cigarette smoking, and probably migraine with aura. Agents associated with increased risk of ICH recurrence include warfarin, antiplatelet agents, statins, and vitamin E.

SUMMARY

: This article reviews the prevention of ICH recurrence based on extrapolating data from primary prevention of ICH along with the clinically appropriate strategy of avoiding the use of agents that have been shown to carry an increased risk of ICH recurrence.

Interventions in the management of serum lipids for preventing stroke recurrence

BACKGROUND

Studies have shown that interventions which reduce total and low-density lipoprotein cholesterol levels also reduce coronary heart disease (CHD) and stroke events in those with a history of CHD. However, it is uncertain whether treatment to alter cholesterol levels can prevent recurrence of either stroke or subsequent cardiovascular events and whether differences in outcomes exist between classes of lipid-lowering therapy. This is an update of a Cochrane review first published in 2002.

OBJECTIVES

To investigate the effect of altering serum lipids pharmacologically for preventing subsequent cardiovascular disease and stroke recurrence in patients with a history of stroke.

SEARCH STRATEGY

We searched the Cochrane Stroke Group Trials Register (last searched December 2008), the Cochrane Central Register of Controlled Trials (The Cochrane Library Issue 3, 2008), MEDLINE (1966 to December 2008) and EMBASE (1980 to December 2008). We contacted pharmaceutical companies known to produce a lipid-lowering agent for information on relevant publications or unpublished work.

SELECTION CRITERIA

Unconfounded randomised trials of participants aged 18 years and over with a history of stroke or transient ischaemic attack (TIA).

DATA COLLECTION AND ANALYSIS

Two review authors independently selected trials, assessed quality and extracted data.

MAIN RESULTS

We included eight studies involving approximately 10,000 participants. The active interventions were pravastatin, atorvastatin, simvastatin, clofibrate, and conjugated oestrogen. Fixed-effect analysis showed no overall effect on stroke recurrence but statin therapy alone had a marginal benefit in reducing subsequent cerebrovascular events in those with a previous history of stroke or TIA (odds ratio (OR) 0.88, 95% confidence interval (CI) 0.77 to 1.00). There was no evidence that such intervention reduced all-cause mortality or sudden death (OR 1.00, 95% CI 0.83 to 1.20). Three statin trials showed a reduction in subsequent serious vascular events (OR 0.74, 95% CI 0.67 to 0.82).

AUTHORS' CONCLUSIONS

There is evidence that statin therapy in patients with a history of ischaemic stroke or TIA significantly reduces subsequent major coronary events but only marginally reduces the risk of stroke recurrence. There is no clear evidence of beneficial effect from statins in those with previous haemorrhagic stroke and it is unclear whether statins should be started immediately post stroke or later. In view of this and the evidence of the benefit of statin therapy in those with a history of CHD, patients with ischaemic stroke or TIA, with or without a history of established CHD, should receive statins.

The risk of recurrent stroke after intracerebral haemorrhage

BACKGROUND AND AIM

The risks of recurrent intracerebral haemorrhage (ICH) vary widely (0-24%). Patients with ICH also have risk factors for ischaemic stroke (IS) and a proportion of ICH survivors re-present with an IS. This dilemma has implications for prophylactic treatment. This study aims to determine the risk of recurrent stroke events (both ICH and IS) following an index bleed and whether ICH recurrence risk varies according to location of index bleed.

PATIENTS AND METHODS

All patients diagnosed with an acute ICH presenting over an 8.5 year period were identified. Each ICH was confirmed by reviewing all of the radiology results and, where necessary, the clinical case notes or post-mortem data. Recurrent stroke events (ICH and IS) were identified by reappearance of these patients in our stroke database. Coronal post-mortem results for the same period were also reviewed. Each recurrent event was reviewed to confirm the diagnosis and location of the stroke.

RESULTS

Of the 7686 stroke events recorded, 768 (10%) were ICH. In the follow-up period, there were 19 recurrent ICH and 17 new IS in the 464 patients who survived beyond the index hospital stay. Recurrence rate for ICH was 2.1/100 in the first year but 1.2/100/year overall. This compares with 1.3/100/year overall for IS. Most recurrences were "lobar-lobar" type.

CONCLUSION

The cumulative risk of recurrent ICH in this population is similar to that of IS after the first year.

Is hypertension a more frequent risk factor for deep than for lobar supratentorial intracerebral haemorrhage?

OBJECTIVE

To determine whether evidence from observational studies supports the widely held belief that hypertension is more commonly a risk factor for deep than for lobar supratentorial intracerebral haemorrhage.

METHODS

Studies comparing the frequency of hypertension as a risk factor for deep versus lobar supratentorial intracerebral haemorrhage, excluding haemorrhages with identified secondary causes, were identified and subjected to a meta-analysis. The effects of predefined methodological quality criteria on the results were assessed and other sources of bias were considered.

RESULTS

The pooled result from all 28 included studies (about 4000 patients) found hypertension to be about twice as common in patients with deep as in those with lobar haemorrhage (odds ratio (OR) 2.10, 95% confidence interval (95% CI) 1.82 to 2.42), but there was significant heterogeneity between studies. The pooled OR was less extreme for studies that used a pre-stroke definition of hypertension, were population based or included first-ever strokes only. In the three studies meeting all criteria (601 patients), deep haemorrhage was associated with a smaller, statistically significant excess of hypertension (OR 1.50, 95% CI 1.09 to 2.07). The OR for studies confined to younger patients seemed to be more extreme (12.32, 95% CI 6.13 to 24.77), but none of these studies fulfilled our methodological quality criteria. Additional, unquantified sources of bias included uncertainty about whether those doctors reporting brain scans were blind to hypertension status, uncertain reliability of the classification of haemorrhage location and variable rates of investigation for secondary causes.

CONCLUSIONS

An excess of hypertension was found in patients with deep versus lobar intracerebral haemorrhages without an identified secondary cause, but this may be due to residual, unquantified methodological biases.

Amyloid in neurosurgical and neurological practice

The amyloidoses are a diverse group of diseases characterized by the deposition of specific proteins with distinct affinity to the dye Congo red, collectively called amyloid. The amyloidogenic proteins have acquired an abnormal, highly ordered, beta-pleated sheet configuration with a propensity to self-aggregate. The amyloid may be distributed in different organs with a remarkable diversity. Two broad categories of amyloidoses are recognised: The systemic (consisting of the primary or light chain form, the secondary or reactive form and the familial or hereditary form) and the localised that target specific organs. A tropism of amyloid proteins to the neural tissue produces certain patterns of central nervous system diseases: cerebral amyloid angiopathy, a substrate of spontaneous intracerebral haemorrhage; mature neuritic plaques found in Alzheimer disease and a subset of prion diseases; a topographically restricted accumulation of extracellular proteins giving rise to tumour-mimicking masses, the amyloidomas; and finally, spinal extradural amyloid collections that occasionally are found in the context of rheumatoid arthritis. In this review article we present original illustrative cases of amyloid diseases of the central nervous system that may be encountered in neurosurgical and neurological practice. Molecular aspects and clinical management problems are discussed.

Recurrence and extension of lobar hemorrhage related to cerebral amyloid angiopathy: multivariate analysis of clinical risk factors

BACKGROUND

Many recent studies have analyzed clinical risk factors for the recurrence and extension of intracerebral hemorrhage. However, they have not been investigated in patients with lobar hemorrhage related to cerebral amyloid angiopathy (CAA).

METHODS

We studied 40 surgically treated patients with lobar hemorrhage diagnosed histologically as being related to CAA. To determine clinical factors influencing the recurrence and hematoma size their clinical data (demographics, medical history, and radiographic and laboratory data) were examined retrospectively and subjected to multivariate analysis.

RESULTS

Twelve patients (30%) had recurrent lobar hemorrhage. Twenty-one patients had a small hematoma and 19 had a large hematoma. Hypertension was the only significant clinical factor influencing the recurrence of CAA-related lobar hemorrhage. There was no significant clinical factor influencing the hematoma size of CAA-related lobar hemorrhage.

CONCLUSIONS

The history of hypertension is associated with an increase in the recurrence of CAA-related lobar hemorrhage.

Recurrent primary intracerebral hemorrhage in Izumo City, Japan

BACKGROUND

Recurrent intracerebral hemorrhage (ICH) is a devastating illness among stroke survivors. We investigated the rate and characteristics of ICH recurrence in Izumo City, Japan.

METHODS

The recurrence rate of ICH was calculated for 279 patients who suffered their first-ever ICH between 1991 and 1998 and were followed up during a mean period of 3.0 years (range, 1 month to 11 years). The characteristics of recurrent ICH were evaluated for 42 patients who were treated for it between 1991 and 1998.

RESULTS

Of the 279 patients with ICH, 19 (7%) had rebleeding; the recurrence rate was 2.3% per year. Analysis of the 42 patients with recurrent ICH showed that the most common pattern of recurrence was ganglionic-ganglionic (n = 25). The crude and the age- and sex-adjusted annual incidence rates for recurrent ICH were both 6 per 100,000 population. Of the 42 patients with recurrent ICH, 16 (38%) had a favorable outcome at discharge and 10 (24%) died. The overall 1-year survival rate for recurrent ICH was 72%. Intraventricular hemorrhage on computed tomography scans was the only significant predictor of not only ICH recurrence but also the 1-year case-fatality rate in patients with recurrent ICH.

CONCLUSIONS

Recurrence after an initial ICH is not rare, and the most common pattern of recurrence is ganglionic-ganglionic. Whereas the functional outcome of recurrent ICH is unsatisfactory, the 1-year survival rate is not necessarily low. Intraventricular hemorrhage on computed tomography scans is an important predictor of both ICH recurrence and the 1-year case-fatality rate in patients with recurrent ICH.

Study of clinical features of amyloid angiopathy hemorrhage and hypertensive intracerebral hemorrhage

OBJECTIVE

The purpose of this study was to differentiate between cerebral amyloid angiopathy (CAA) and hypertension (HTN) based on hemorrhage pattern interpretation.

METHODS

From June 1994 to Oct., 2000, 83 patients admitted to our service with acute intracerebral hemorrhage (ICH) were investigated retrospectively; 41 patients with histologically proven diagnosis of cerebral amyloid angiography and 42 patients with clear history of hypertension were investigated.

RESULTS

Patients with a CAA-related ICH were significantly older than patients with a HTN-related ICH (74.0 years vs 66.5 years, P < 0.05). There was a significantly higher number of hematomas > or = 30 ml in CAA (85.3%) when compared with HTN (59.5%). No basal ganglional hemorrhage was seen in CAA, but in 40.5% in HTN. In CAA-related ICH, subarachnoid hemorrhage (SAH) was seen in 26 patients (63.4%) compared to only 11 patients (26.2%) in HTN-related ICH. Intraventricular hemorrhage was seen in 24.4% in CAA, and in 26.2% in HTN. Typical features of CAA-related ICH included lobar distribution affecting mainly the lobar superficial areas, lobulated appearance, rupture into the subarachnoid space, and secondary IVH from the lobar hemorrhage. More specifically, multiplicity of hemorrhage, bilaterality, and repeated episodes also strongly suggest the diagnosis of CAA. Multiple hemorrhages, defined as 2 or more separate hematomas in multiple lobes, accounted for 17.1% in CAA-related ICH.

CONCLUSION

There are certain features in CAA on CT and MRI and in clinical settings. To some extent, these features may contribute to distinguishing CAA from HTN related ICH.

Long-term prognosis after recovery from primary intracerebral hemorrhage

BACKGROUND

Little is known about the long-term outcome for patients who recover from a primary intracerebral hemorrhage. The authors examined the rate of recurrence, vascular events, and death in survivors of a primary intracerebral hemorrhage and the factors related to the long-term prognosis.

METHODS

All 243 patients admitted to one of three hospitals with a primary intracerebral hemorrhage who regained independence were interviewed about vascular events after the index hemorrhage. The authors used the Kaplan-Meier method to estimate the event-free survival and Cox proportional hazards regression analysis to identify predictors of recurrence, any vascular event, or death.

RESULTS

During a mean follow-up of 5.5 years, the annual rates of recurrent primary intracerebral hemorrhage, vascular events, and vascular death were 2.1% (95% CI, 1.4 to 3.3%), 5.9% (95% CI, 4.5 to 7.7%), and 3.2% (95% CI, 2.2 to 4.5%). Age of 65 years or older was the only predictor of a recurrence (hazard ratio [HR], 2.8; 95% CI, 1.3 to 6.1) and vascular death (HR, 3.7; 95% CI, 2.0 to 7.0). In addition to age, male sex predicted the occurrence of vascular events (HR, 1.8; 95% CI, 1.1 to 3.0). Use of anticoagulation after the index bleeding tripled the risk of hemorrhagic events (HR, 3.0; 95% CI, 1.3 to 7.2).

CONCLUSION

Patients who recovered from a primary intracerebral hemorrhage had a 2.1% to 5.9% annual rate of recurrence, vascular death, or vascular events. Age of 65 years or older more than doubled the risk of recurrence, vascular event, or death. The risk of vascular events in men was increased twofold.

Interventions in the management of serum lipids for preventing stroke recurrence

BACKGROUND

A close association between serum lipid levels and the incidence of coronary heart disease (CHD) has been well proven in middle aged and older persons, up to the age of 70-75 years. Individual studies have shown interventions to reduce total and low density lipoprotein (LDL) cholesterol levels, especially with 3-hydroxy-3-methylglutaryl coenzyme a (HMG-CoA) reductase inhibitors (statins), to be of benefit in reducing CHD and stroke events in those with a history of coronary heart disease. However, the relation of serum cholesterol and cholesterol sub-fractions with cerebrovascular disease is less clear. It is unclear whether lipid levels in the post-stroke period are a predictor of recurrence and whether treatment to alter levels can prevent recurrence of either stroke or cardiovascular events.

OBJECTIVES

To investigate the effect of altering serum lipids in the prevention of cardiovascular disease and stroke recurrence in subjects with a history of stroke.

SEARCH STRATEGY

The Cochrane Group Trials Register was searched up to 8 May 2001 along with MEDLINE (from 1966), EMBASE (from 1980) and the Cochrane Controlled Trials Register. All pharmaceutical firms known to produce a lipid lowering agent were also contacted and asked to provide information on publications or unpublished work relevant to this review.

SELECTION CRITERIA

This review included unconfounded randomised trials of subjects aged 18 years and over with a history of stroke or Transient Ischaemic Attack (TIA).

DATA COLLECTION AND ANALYSIS

The data were extracted independently by the three reviewers. MetaView 4.1 was used for all statistical analyses.

MAIN RESULTS

Five studies involving 1700 patients were included in the review. The active intervention in two of the studies was Clofibrate, Pravastatin in another two and Conjugated Oestrogen in the fifth. Fixed effects analysis showed no evidence of a difference in stroke recurrence between the treatment and placebo groups for those with a previous history of stroke or TIA (odds ratio 0.96, 95% confidence interval 0.71 to 1.30). In addition there was also no evidence, based on two studies, that intervention reduced the odds of all cause mortality (odds ratio 0.87, 95% confidence interval 0.55 to 1.39) nor, from one study, that there was any effect on subsequent vascular events (odds ratio 1.27, 95% confidence interval 0.84 to 1.89).

REVIEWER'S CONCLUSIONS

These trials do not provide evidence for a benefit, or harm, from interventions to alter serum lipid levels in patients with a history solely of cerebrovascular disease. Their use, therefore, cannot yet be recommended routinely in this patient group, but ischaemic stroke patients with a history of myocardial infarction should receive statin therapy along the lines of the previous recommendations for those patients with a history of myocardial ischaemia. There are currently three ongoing trials which will recruit approximately 30,000 patients, including those with a history of stroke, and the results of these trials may have a significant effect on these conclusions.

Repeated thalamic haemorrhage: case report and review of the literature

Recurrence of thalamic haemorrhage has rarely been reported. A 70-year-old woman had recurrent thalamic haemorrhage five-times during a period of 6 years. The first, second and fifth haemorrhages were located in the right thalamic region, and the third and fourth haemorrhages in the left thalamic region. Cranial computed tomography and magnetic resonance imaging revealed no abnormal lesion. After the first, second, and third haemorrhage with medical treatments, the patient recovered her functional ability or was at least capable of self-care at home. However, after the fourth and fifth haemorrhage, with medical therapy the patient's prognosis was severe disability. In this case, systemic blood pressure was normalized without antihypertensive agents after the first attack. However, there was an episode of sudden hypertension at each attack. Although the mechanism of rebleeding has not been clarified, rebleeding might be associated with changes of cerebral circulation following the previous haemorrhage.

Assessment of lacunar hemorrhage associated with hypertensive stroke by echo-planar gradient-echo T2*-weighted MRI

BACKGROUND AND PURPOSE

Echo-planar gradient-echo T2*-weighted MR imaging (GRE-EPI) may detect hypointense lesions representing microhemorrhages with high sensitivity. The aim of this study was to evaluate the effectiveness of GRE-EPI for detecting old lacunar hemorrhages in hypertensive patients with stroke.

METHODS

GRE-EPI was performed with a 1.5-T MRI system in 198 hypertensive patients with stroke (130 patients with hemorrhagic stroke and 68 patients with multiple lacunar stroke) and 66 age-matched healthy elderly individuals.

RESULTS

Concomitant hypointense foci were found in 84 (66%) patients with hemorrhagic stroke, 46 (68%) patients with multiple lacunar stroke, and 3 (5%) healthy elderly individuals. These hypointense foci were noted in the lentiform nucleus in 61 (47%) patients with hemorrhagic stroke, in the caudate nucleus in 9 (7%) patients, in the thalamus in 54 (42%) patients, in the corticosubcortical region in 57 (44%) patients, in the brain stem in 40 (34%) patients, and in the cerebellum in 32 (25%) patients.

CONCLUSIONS

GRE-EPI is effective for the detection of lacunar hemorrhages induced by hypertension.

Recurrent intracerebral hemorrhages in cerebral amyloid angiopathy: a case report

Cerebral amyloid angiopathy frequently causes recurrent intracerebral hemorrhages in elderly patients who do not have systemic hypertension. Surgery should be reserved for conditions which cannot be controlled by medical treatment. When surgery is needed, potential complications (such as bleeding near the operation site or remote area) should be kept in mind. A case study of a 66-year-old woman with cerebral amyloid angiopathy and recurrent intracerebral hemorrhages is presented.

[Primary intracerebral hemorrhage. Retrospective study of 72 operated cases]

We analysed 72 cases of primary intracranial hemorrhage surgically treated from 1970 to 1999. The hemorrhages were diagnosed by computerized axial tomography in 52 patients. Most hematomas were situated in the cerebral hemispheres (30 percent in thalamus-basal ganglia region and 50 percent in the subcortical matter). There were 10 patients with cerebellar hemorrhage. Hypertension (based in blood pressure recordings in the hospital and history) was found in 24 patients (33 percent). The most frequent findings were coma, intracranial hypertension and hemimotor deficit. The death rate registered was 27.7 percent; however, it was found a significant difference in the mortality index when considering the 70-79 decade (62.7 percent) and the 90-99 decade (20.7 percent). A critical analysis was made about depth hematomas, consciousness state and intracranial hypertension with herniation related to surgical procedure.

Apolipoprotein E genotype and the risk of recurrent lobar intracerebral hemorrhage

BACKGROUND

Recurrent lobar intracerebral hemorrhage is the hallmark of cerebral amyloid angiopathy. The factors that predispose patients to early recurrence of lobar hemorrhage are unknown. One candidate is the apolipoprotein E gene, since both the epsilon2 and the epsilon4 alleles of apolipoprotein E appear to be associated with the severity of amyloid angiopathy.

METHODS

We performed a prospective, longitudinal study of consecutive elderly patients who survived a lobar intracerebral hemorrhage. The patients were followed for recurrent hemorrhagic stroke by interviews at six-month intervals and reviews of medical records and computed tomographic scans.

RESULTS

Nineteen of 71 enrolled patients had recurrent hemorrhages during a mean follow-up period of 23.9+/-14.8 months, yielding a 2-year cumulative rate of recurrence of 21 percent. The apolipoprotein E genotype was significantly associated with the risk of recurrence. Carriers of the epsilon2 or epsilon4 allele had a two-year rate of recurrence of 28 percent, as compared with only 10 percent for patients with the common apolipoprotein E epsilon3/epsilon3 genotype (risk ratio, 3.8; 95 percent confidence interval, 1.2 to 11.6; P=0.01). Early recurrence occurred in eight patients, four of whom had the uncommon epsilon2/epsilon4 genotype. Also at increased risk for recurrence were patients with a history of hemorrhagic stroke before entry into the study (two-year recurrence, 61 percent; risk ratio, 6.4; 95 percent confidence interval, 2.2 to 18.5; P<0.001).

CONCLUSIONS

The apolipoprotein E genotype can identify patients with lobar intracerebral hemorrhage who are at highest risk for early recurrence. This finding makes possible both the provision of prognostic information to patients with lobar hemorrhage and a method of targeting and assessing potential strategies for prevention.

Intracerebral haemorrhage and cerebral amyloid angiopathy: CT features with pathological correlation

AIMS

To review the computed tomography (CT) features of intracerebral haemorrhage pathologically proven to be associated with cerebral amyloid angiopathy in order to facilitate recognition of the presence of cerebral amyloid angiopathy in life.

METHODS

We prospectively collected the clinical and brain imaging records of patients dying following an intracerebral haemorrhage who underwent a post-mortem examination and were found to have cerebral amyloid angiopathy. We reviewed the brain imaging to highlight features of the haemorrhage and of the rest of the brain common to these cases.

RESULTS

Seven patients aged 60-86 years were examined over a 30-month period. On CT, the notable features were that the haemorrhages appeared large, lobar, often extended through the cortex to the subarachnoid space or into the ventricles, and were multiple and recurrent in patients who survived the initial bleed. The high density (blood) within the haematoma tended to sediment posteriorly.

CONCLUSIONS

There are features on CT of cerebral amyloid angiopathy associated with spontaneous intracerebral haemorrhage which should raise the possibility of this underlying diagnosis. We suspect this condition is under-recognized in life, and should perhaps be considered more widely.

Intracerebral Hemorrhage

Patients with intracerebral hemorrhage should be admitted to an intensive care unit for experienced neurologic nursing care and close attention to vital signs. We recommend gentle reduction in blood pressure in individuals who present with elevated readings and in whom hemorrhage is felt to be secondary to hypertension. For the vast majority of nontraumatic intracerebral hemorrhages, the indications for surgery and use of intracranial pressure monitoring devices remain unproven. Surgery is indicated for notable exceptions, such as for patients with cerebellar hematomas (3 mL or larger) and for patients with temporal lobe hematoma and impending brain stem compression. In general, intracranial pressure (ICP) monitoring is advised to help guide treatment with hyperosmolar agents and hyperventilation when increased ICP is suspected. For patients with smaller supratentorial hematomas who are alert or somnolent, conservative treatment is optimal. Similarly, we support conservative management in patients older than 70 years of age who present with a hemorrhage of more than 50 mL and a Glasgow Coma Scale (GCS) score of less than 8. Insufficient data exist from large randomized and controlled studies to recommend surgical intervention as definitive treatment for the group between these two extremes.

Blood pressure control and recurrence of hypertensive brain hemorrhage

BACKGROUND AND PURPOSE

Recent studies have demonstrated that recurrence of hypertensive brain hemorrhage (HBH) is not uncommon. However, risk factors for the recurrence of HBH have not been evaluated systematically.

METHODS

We analyzed 74 patients with HBH who were admitted to our clinic and followed up as outpatients for a mean of 2.8 years. Blood pressure (BP) and other clinical features were compared between the groups of patients with and without rebleeding. We determined the recurrence rate of HBH in relation to BP.

RESULTS

Diastolic BP was significantly higher in the recurrence group than in the nonrecurrence group (88+/-8 versus 82+/-7 mm Hg; P=0.04). Systolic BP and other clinical variables were not different between the groups. The recurrence rate was 10.0% per patient-year in patients with diastolic BP >90 mm Hg and <1.5% in those with lower diastolic BP (P<0.001). No patients with diastolic BP <70 mm Hg experienced rebleeding.

CONCLUSIONS

Higher diastolic BP was related to an increased rate of rebleeding. Diastolic BP >90 mm Hg may be regarded as a factor predictive of the recurrence of HBH.

Recurrent primary cerebral hemorrhage: frequency, mechanisms, and prognosis

BACKGROUND AND PURPOSE

The frequency of recurrent primary cerebral hemorrhage (RPCH), mainly in cases related to hypertension, has been considered low. This study investigated the frequency, mechanisms, and prognosis of RPCH.

METHODS

We evaluated 359 patients with neuroimaging evidence of cerebral hemorrhage and selected 22 with RPCH.

RESULTS

Five patients (23%) were older than 70 years at the first cerebral hemorrhage. Mean ages at the first and second hemorrhages were 60 and 63 years, respectively. Risk factors included hypertension (86%), diabetes (27%), and tobacco and alcohol use (each 14%). Hypocholesterolemia was demonstrated in 35% of the patients. The most common pattern of recurrent bleeding was ganglionic-ganglionic, mainly related to hypertension. Overall mortality was 32%. Forty-one percent and 27% of patients, respectively, had incapacitating and nonincapacitating sequelae; 2 of the latter had RPCH with a lobar location. Ganglionic-ganglionic hemorrhage was associated with a poor prognosis; otherwise, this pattern was uncommon in patients with nonincapacitating sequelae. Analysis of the control of risk factors, primarily hypertension after the first cerebral hemorrhage, disclosed that 56% of patients did not gain subsequent control.

CONCLUSIONS

Rebleeding after a first primary intracerebral hemorrhage is not uncommon. The main topographic pattern of bleeding, ganglionic-ganglionic, is likely the result of hypertension; the less common lobar-lobar pattern probably results from amyloid angiopathy.