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 Table of Contents  
ORIGINAL ARTICLE
Year : 2020  |  Volume : 6  |  Issue : 1  |  Page : 19-23

Location and volume of intracerebral hemorrhage and their association with outcome


1 Department of General Medicine, Pondicherry Institute of Medical Sciences, Kalapet, Puducherry, India
2 Department of Radiology, Pondicherry Institute of Medical Sciences, Kalapet, Puducherry, India

Date of Submission10-Jan-2020
Date of Decision16-Apr-2020
Date of Acceptance19-Apr-2020
Date of Web Publication20-Jul-2020

Correspondence Address:
Nayyar Iqbal
Associate Professor Department of General Medicine, Pondicherry Institute of Medical Sciences, Kalapet - 605 014, Puducherry
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jcrsm.jcrsm_2_20

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  Abstract 


Background: Intracerebral hemorrhage (ICH) accounts for around 10% to 20% of all stroke cases worldwide. It is one of the most fatal and disabling subtype of strokes. Volume of hemorrhage is well documented risk factor for mortality.
Aims and Objectives: The objectives of this study is to find whether the location of ICH is an independent risk factor for morbidity and mortality.
Material and Methods: It is a prospective cohort study involving adult patients with age more than 18 years presenting with ICH. All patients satisfying inclusion criteria were subjected to CT scan brain. The location of hemorrhages and volume were noted. The four independent variables – gender, presence of hypertension, location and volume of bleed were documented. Their association with modified Rankin scale was calculated using chi – square test, the significance was calculated with P < 0.05.
Result: Eighty patients were recruited in the study. 72.5% were male and 27.5% were female. Mean age was 56.25 + 14.3 years. Hypertension was one of the commonest risk factor for ICH (80%). Volume of bleed more than 60 cc was associated with 100% mortality. The majority of the patients presented with ganglio – capsular hemorrhage (64%). Cerebellar and lobar hemorrhage had mortality of 66.7% and 100% respectively. The volume of bleed had odds ratio of 1.2 (P < 0.05). The logistic regression analysis adjusting location of bleed for volume was not significant (P = 0.47).
Conclusion: Hypertension is one of the commonest risk factor for ICH. The volume of bleed is an independent predictor of mortality irrespective of location of hemorrhage, gender and other co-morbidity.

Keywords: Intracerebral hemorrhage, location of intracerebral hemorrhage, volume of intracerebral hemorrhage


How to cite this article:
Tangella VR, Iqbal N, Nayakar GL. Location and volume of intracerebral hemorrhage and their association with outcome. J Curr Res Sci Med 2020;6:19-23

How to cite this URL:
Tangella VR, Iqbal N, Nayakar GL. Location and volume of intracerebral hemorrhage and their association with outcome. J Curr Res Sci Med [serial online] 2020 [cited 2020 Sep 26];6:19-23. Available from: http://www.jcrsmed.org/text.asp?2020/6/1/19/290245




  Introduction Top


Stroke is one of the leading cause of disability and death.[1] The burden of stroke is likely to increase across the world with increasing life expectancy. The prevalence of stroke ranges from 84 to 262/100,000 in rural and 334 to 424/100,000 in urban areas as per various studies done across India.[2] A recent systematic review showed that the prevalence of stroke in different parts of India ranged from 44.29 to 559/100,000 persons and its incidence ranged from 105 to 152/100,000 persons/year during the past two decades.[3] Intracerebral hemorrhage (ICH) accounts for around 10%–20% of stroke. It is the second most common subtype of stroke next to ischemic stroke.[4]

The rupture of blood vessels within the brain parenchyma causes ICH. ICHs can be classified as primary and secondary. Primary ICH is the most common among the two. The location of bleed, volume of the bleed along with age and gender of the patient, and other comorbidities influence the clinical manifestations of the patient in primary ICH.[5] Secondary ICH can occur as a complication of a preexisting lesion, such as vascular malformation or tumor. ICH in the absence of any underlying vascular malformation, tumor, or coagulopathy is termed as primary ICH. Intracerebral bleed has a high mortality rate of approximately 40% at 1 month.[6] When one takes into account the economic aspects of patient treatment and care, an early assessment of the prognosis of such patients is very desirable and of significant consequence in terms of treatment optimization. It is very essential to provide patients' families with the likelihood of survival and outcome of the patient with a reasonable accuracy.

There are various scoring systems to predict the outcome of patients with spontaneous intracerebral bleeding. For clinical use, scoring systems that are often used and widely accepted are ICH score (ICH score), FUNC score, and modified Rankin scale (mRS). The ICH score is used to estimate the 30-day mortality.[7] ICH score is calculated by using the following five parameters – Glasgow Coma Scale, age more than 80, infratentorial origin of hemorrhage, volume of hemorrhage, and intraventricular hemorrhage. The score ranges from 0 to 6. Zero is associated with a favorable outcome and six predicts 100% mortality. Ruiz et al. modified the ICH score by modifying the parameters such as age and volume of hemorrhage and developed another scoring system – ICH-grading scale. This scale also predicts the outcome mortality at 30 days and ranges between 5 and 16 points.[8] Rost et al. developed another scoring system to predict the functional independence at day 90 of ICH. The functional independence (FUNC) at 90 day is estimated by using ICH volume, age, ICH location, Glasgow Coma Scale score, and pre-ICH cognitive impairment. The score ranges from 0 to 11.[9] High score predicts poor functional outcome. The neurological outcome can also be assessed using the mRS. The score ranges from 0 to 6.[10] Favorable outcome is considered if the mRS score was ≤2 and unfavorable when the mRS score is >2. The purpose of the present study is to determine the important risk factors for ICH and to assess the outcome of patients based on the volume and location of ICH.


  Methodology Top


This was a prospective cohort study conducted at Pondicherry Institute of Medical Sciences, Puducherry, a tertiary care hospital in South India. All adult patients of age more than 18 years admitted with ICH within 48 h of onset, during the period from December 2015 to April 2017, were included in the study. Patients with traumatic ICH and subdural, extradural, and subarachnoid hemorrhage; patients with cerebral venous thrombosis and arteriovenous malformation; those who were taken up for neurosurgical intervention for ICH; pregnant women and postpartum women; and patients with chronic liver failure, chronic kidney disease, and malignancy were excluded from the study.

All patients satisfying the inclusion and exclusion criteria were included in the study. Detailed medical history was obtained, and thorough general and systemic examination was done after obtaining the informed consent. All the participants were subjected to routine blood investigation, coagulation profile, computed tomography of the brain (CT scan), and/or magnetic resonance imaging with magnetic resonance angiography, particularly in young patients with ICH. The site of hemorrhage was detected by a thin-section continuous axial image on CT scan by our expert radiologist. The site of hemorrhage was identified as basal ganglia, internal capsule, thalamus, cerebellum, or lobar. The volume of hemorrhage was calculated and recorded in cubic centimeter (cc). All the information was recorded in a specified proforma.

Thirty-day morbidity and mortality was calculated using mRS. The score ranges from 0 to 6, with 0 being completely symptom free at day 30 and 6 representing death. Mild, moderate, and severe disabilities were graded from 1 to 5.

Statistical analysis

Sample size was estimated on the basis of effect on one independent variable; it was estimated that twenty participants will be required to study the effect on that one independent variable. There were four independent variables in the study – volume of hemorrhage, site of hemorrhage, gender, and presence of hypertension, hence, a total of eighty participants were recruited in the study. Data were entered in Microsoft Excel and all analysis was done using statistical software SPSS version 17 (IBM SPSS Ltd, Honk Kong). The clinical characteristics of the study patients were expressed using mean and standard deviation for continuous variables and percentage for dichotomous and categorical variables. Independent risk associated with the volume of hemorrhage and site of hemorrhage was estimated using logistic regression model. Chi-square test was used to find the significance of mRS as dependent variable with independent variables such as gender, volume of hemorrhage, site of hemorrhage, and presence of hypertension.

Ethical consideration

Written consents were obtained from the patients prior to enrolling them in the study. Ethical clearance was also obtained from the institute's ethics committee (RC/15/39).


  Results Top


A total of 175 patients presented with the symptoms of stroke during the study period, out of which, only eighty patients who satisfied the inclusion criteria were included in the study. Among the eighty participants, 58 were male and 22 were female, constituting 72.5% and 27.5%, respectively. The mean age of presentation was 56.25 ± 14.3 years. Systemic hypertension and Type 2 diabetes mellitus were the common comorbid conditions present among the participants. The most common site of intracranial hemorrhage was ganglio–capsular region, 64% of the total ICH (basal ganglia [30%] and internal capsule [34%]). The maximum volume of bleed was between 31 and 60 cc [Table 1].
Table 1: Characteristics of the participants (n=80)

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According to the mRS, mild disability was more in males (31%) and moderately severe disability was more among females (22.7%). The incidence of death was almost same in both the genders. Chi-square test for the association of gender with morbidity and mortality was statistically significant with P = 0.03. The most common risk factor associated with ICH in our study was systemic hypertension, followed by coronary artery disease, smoking, and Type 2 diabetes mellitus [Table 2].
Table 2: Association of different variables with mortality and morbidity as per the modified Rankin scale at day 30

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The most common site of ICH in our study was ganglio–capsular area, 64% of the total ICH. Three out of the eighty patients had lobar ICH with volume >30 cc, and all of them had mortality. Cerebellar ICH had a mortality of 66.7% (4 out of the 80 patients). The number of deaths was more in internal capsule ICH. Twenty-two patients had a volume of ICH >60 cc and recorded 100% mortality. The volume of ICH was statistically significantly associated with mortality (P < 0.05) with an odds ratio (OR) of 1.2. The site of bleed when adjusted for volume was not statistically significant for mortality (P = 0.47). Mortality in case of ICH at the cerebellum and internal capsule had OR of 53.5 and 6.7, respectively [Table 3].
Table 3: Association of volume and site of intracerebral hemorrhage with mortality and morbidity as per the modified Rankin scale at day 30

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  Discussion Top


The available studies suggest that ICH is found in 10%–15% of all first-time strokes. The incidence is higher among Asians as compared to Caucasians. The incidence of ICH is higher among males than females. In our study, 72.5% of males presented with ICH, which was similar to other studies.[11],[12] The mean age of presentation in our study was 56 years, similar to studies by Hsieh et al. and Galati et al. In a population-based study, older age, Asian ethnicity, and male gender were found to be essential risk factors for ICH.[4],[13] A study by Hsieh et al. did not show significant differences in morbidity and 30-day mortality among genders. In our study, we noted that among genders, there was a statistically significant difference in morbidity (P < 0.05), but no significant difference in case of mortality. A study by Sankalp et al. also showed no significant difference among genders with respect to mortality.[14]

The important risk factors for ICH are systemic hypertension and cerebral amyloid angiopathy. Basal ganglia and internal-capsule hemorrhages are more commonly seen with hypertension, and lobar hemorrhage is more common in cerebral amyloid angiopathy. Other risk factors for ICH are increased alcohol consumption, genetics, use of anticoagulants, and sympathomimetic drug abuse such as cocaine.[15],[16],[17] In our study, hypertension was one of the most common risk factors associated with ICH, although it was not statistically significant (P = 0.06). A study done by Ariesen et al. showed that hypertension is the single most important risk factor for ICH. The study found that elevated blood pressure of >160/90 mmHg is associated with ninefold increased risk of ICH. The overall OR was 3.68 (95% confidence interval, 2.52–5.38).[16] Another study by Martin et al. revealed that hypertensive patients had an almost 3.5-fold increased risk of ICH compared with normotensives.[18]

The most common site for ICH is either basal ganglia or internal capsule. Nearly 35%–70% of ICH occurs in these areas. This is followed by lobar, cerebellum, and brain stem.[19] Our study too demonstrated that the most common site of ICH is ganglio–capsular area. The mortality in our study was higher in patients with cerebellar and lobar hemorrhage, 67% and 100%, respectively. A study by Satopaa et al. showed that patients with cerebellar hemorrhage (76.3%) had moderately severe functional outcome including death at the time of hospital discharge and Long-term mortality in the study was 49.1%.[20] In another population-based study, 1-year mortality was lower in lobar ICH compared to nonlobar ICH.[21] In another study by Salihović et al., there was no statistical significance between the localization of the hemorrhage and the outcome.[22]

In the present study, there is a strong association between the volume of bleed and mortality. The proportion of death was high (100.0%) when the volume of bleed was above 60 cc as compared to 31–60 cc (12.8%) and up to 30 cc (5.3%). Both “mild symptoms” (15.8%) and “no significant disability” were high when the volume of bleed was up to 30 cc. Slight disability and moderate disability were high when the volume of bleed was 31–60 cc. A Chi-square test showed a statistically significant association of volume of hemorrhage with morbidity and mortality (P = 0.005, OR: 1.2).

A study conducted by Salihović et al.[22] showed that the mortality is directly proportional to the volume of bleed, 64% survived when the hemorrhage was<30 cc. The highest mortality rate was recorded in patients with the bleed volume >60 cc (85%). Kaplan–Meier's analysis showed that there was a statistical significance between the size of the hemorrhage and the 6-month survival (P < 0.0001). Another study by Panchal et al. showed that mortality increases with the increase in the volume of ICH.[23]

Limitation

In the present study, the sample size was calculated on the basis of cases presented to our hospital during previous 2 years and the effect of ICH on four independent variables; hence, it does not represent the true prevalence of the ICH in the population.

The most common site for ICH is the basal ganglia as described in the literature. In our study, the prevalence of internal-capsule hemorrhage was slightly more as compared to basal-ganglia hemorrhage. This may be due to the small sample size of our study.

The follow-up period in our study was short (only 30 days). This result cannot be interpolated for long-term morbidity and mortality.


  Conclusion Top


Hypertension is one of the most common etiologies for ICH. Ganglio–capsular hemorrhage is the most common site for ICH. The location of ICH has no significant association with mortality. Mortality increases with the increase in the volume of ICH (P < 0.05, OR: 1.2), and is an independent predictor of mortality.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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