Primary intracerebral hemorrhage

Placebo-Controlled Trials ofUFH, LMWH, and Heparinoids The International Stroke Trial (1ST) was a randomized, placebo-controlled trial of UFH (5000 or 12,500 lU twice daily) and aspirin (300 mg) in 19,435 unselected patients with acute stroke within 48 hours of symptom onset. Because of limited availability of neuroimaging, 33% of participants were enrolled with suspected but not proven ischemic stroke, some of whom may have suffered primary intracerebral hemorrhage (ICH). 

Five randomized primary and secondary prevention trials " have demonstrated the efficacy and safety of warfarin in preventing AF-related stroke. Pooled data from these trials demonstrated a 68% reduction in ischemic stroke (95% Cl 50-79) and an intracerebral hemorrhage rate of <1% per year. The data for aspirin suggested that it had a lesser effect, with a 36% risk reduction (95% Cl 4—57). 

In subarachnoid hemorrhage due to a ruptured intracranial aneurysm or arteriovenous malformation, surgical intervention to clip or ablate the vascular abnormality substantially reduces mortality from rebleeding. The benefits of surgery are less well documented in cases of primary intracerebral hemorrhage. In patients with intracerebral hematomas, insertion of an intraventricular drain with monitoring of intracranial pressure is... 

Recently, Szczudliket al. (4) studied 152 patients with supratentorial primary intracerebral hemorrhage (PICH) confirmed by CT on admission. In that study, outcome was measured by either mortality or Barthel... 

Szczudlik A., Turaj W., Slowik A., and Strojny J. (2002) Hyperthermia is not an independent predictor of greater mortality in patients with primary intracerebral hemorrhage. Med. Sci. Monit. 8, CR702-7. 

Stroke includes ischemic and primary intracerebral hemorrhage but not subarachnoid hemorrhage. 

Fig. 1.4. The proportions of first-ever-in-a-lifetime strokes caused by ischemic stroke (IS), primary intracerebral hemorrhage (RICH), subarachnoid hemorrhage (SAH) and of undetermined cause (UND) in "ideal" incidence studies. Numbers indicate the percentage estimates (Sudlow and Warlow 1997).

Japanese and Chinese populations. Stroke, particularly primary intracerebral hemorrhage, is more common in Japan and China than in Western countries (Huang et al. 1990) and this is accompanied by less extracranial but more intracranial arterial disease (Feldmann et al. 1990 Leung et al. 1993 Sacco et al. 1995 Wityk et al. 1996). 

In most studies, both stroke mortality and hospital admission rates are higher in winter than in summer (Douglas et al. 1991 Pan et al. 1995 Feigin and Weibers 1997). This seasonal variation might be explained by the complications of stroke being more likely to occur in the winter (e.g. pneumonia) and cannot simply be assumed to reflect stroke incidence. Where incidence has been measured in the community, there is little seasonal variation, at least in temperate climates, although primary intracerebral hemorrhage is somewhat more likely in the winter months and on cold days (Rothwell et al. 1996 Jakovljevic et al. 1996). 

Age is the strongest risk factor for ischemic stroke of all subtypes and for primary intracerebral hemorrhage, but it is less important for subarachnoid hemorrhage (Bamford et al. 1990 Rothwell et al. 2005). Overall stroke incidence at age 75-84 is approximately 25 times higher than at age 45-54 (see Fig. 1.2). 

IS, ischemic stroke RICH, primary intracerebral hemorrhage SAH, subarachnoid hemorrhage Three year data from 2002-2005. 

Some of the association between atrial fibrillation and stroke must be coincidental because atrial fibrillation can be caused by coronary and hypertensive heart disease, both of which may be associated with atheromatous disease or primary intracerebral hemorrhage. Although anticoagulation markedly reduces the risk of first or recurrent stroke, this is not necessarily evidence for causality because this treatment may be working in other ways, such as by inhibiting artery-to-artery embolism, although trials of warfarin in secondary prevention of stroke in sinus rhythm have shown no benefit over aspirin (Ch. 24). 

Perihematomal edema in primary intracerebral hemorrhage is plasma derived. Stroke 35 1879-1885... 

Moyamoya seems to be mainly confined to the Japanese and other Asians, and in most cases the cause is unknown (Bruno et al. 1988 Chiu et al. 1998). Some cases are familial (Kitahara et al. 1979) others appear to be caused by a generalized fibrous disorder of arteries (Aoyagi et al. 1996), and a few may result from a congenital hypoplastic anomaly affecting arteries at the base of the brain, or associated with Down s syndrome (Cramer et al. 1996). The syndrome may present in infancy with recurrent episodes of cerebral ischemia and infarction, mental retardation, headache, epileptic seizures and, occasionally, involuntary movements. In adults, subarachnoid or primary intracerebral hemorrhage are also common owing to rupture of collateral vessels. There have also been a few reports of associated intracranial aneurysms (Iwama et al. 1997) and also of cerebral arteriovenous malformations. 

Primary intracerebral hemorrhage is more common than subarachnoid hemorrhage, and its incidence increases with age (see Fig. 1.1). It is more frequent in Southeast Asian, Japanese and Chinese populations than in whites. The most common causes are intracranial small vessel disease, which is associated with hypertension, cerebral amyloid angiopathy and intracranial vascular malformations (Sutherland and Auer 2006). Rarer causes include saccular aneurysms, hemostatic defects, particularly those induced by anticoagulation or therapeutic thrombolysis, antiplatelet drugs, infective endocarditis, cerebral vasculitis and recreational drug use (Neiman et al. 2000 O Connor et al. 2005). 

The site of primary intracerebral hemorrhage provides information as to the cause hypertensive hemorrhages (Fig. 7.1a) tend to occur in the basal ganglia, thalamus, and pons, while lobar hemorrhages are more often caused by cerebral amyloid angiopathy, vascular malformations and hemostatic failure (Dickinson 2001 Smith and Eichler 2006 Sutherland and Auer 2006) (Table 7.1) (Fig. 7.1b). Multiple hemorrhages suggest certain specific causes ... 

Table 7.1. Structural causes of primary intracerebral hemorrhage according to location and patient age, listed according to relative frequency (hematological causes excluded)...

Fig. 7.1. Intracerebral hemorrhage, (a) A CT brain scan showing a typical deep "hypertensive" primary intracerebral hemorrhage, (b) These CT brain scans showing a right frontal arteriovenous malformation causing hemorrhage.

Cerebral microbleeds are seen frequently in patients with primary intracerebral hemorrhage, less commonly in patients with ischemic stroke and rarely in healthy controls (Cordonnier et al. 2007). Risk factors for cerebral microbleeds include hypertension, increasing age, diabetes, cerebral amyloid angiopathy and, less commonly, cerebral autosomal dominant arteriopathy with silent infarcts and leukoaraiosis (CADASIL) (Cordoimier et al. 2007). It is unclear whether previous use of antiplatelet agents or anticoagulants is a risk factor for cerebral microbleeds. 

Sutherland GR, Auer RN (2006). Primary intracerebral hemorrhage. Journal of Clinical Neuroscience 13 511-517... 

Headache is not uncommon around the time of stroke onset. It is more often severe in primary intracerebral hemorrhage than ischemic stroke, and more often severe with posterior than anterior circulation strokes. If the headache is localized at all, it tends to be over the site of the lesion. Headache is more common in cortical and posterior circulation than lacunar infarcts (Kumral et al. 1995). Severe unilateral neck, orbital or scalp pain suggests internal carotid artery dissection, particularly if there is an ipsilateral Horner s syndrome. Severe occipital headache can occur with vertebral artery dissection. Headache is also a particular feature of venous infarcts. Unusual headache in the days before stroke would suggest giant cell arteritis or perhaps a mass lesion rather than a stroke. 

Dennis MS, Bamford JM, Molyneux AJ et al. (1987). Rapid resolution of signs of primary intracerebral hemorrhage in computed tomograms of the brain. British Medical Journal 295 379-381... 

Brain imaging is required to distinguish between primary intracerebral hemorrhage and cerebral infarction since this distinction cannot be made reliably on clinical criteria alone (Hawkins et al. 1995). Recent developments in brain imaging, in particular new MRI sequences, and to a lesser extent CT techniques, have enabled visualization of the pathophysiological processes involved in brain infarction. These new techniques are being developed to select patients suitable for thrombolytic treatment beyond the three-hour time window (Ch. 21) and may in the future enable targeting of treatments such as neuroprotection. 

One to two days after stroke onset, the infarcted area appears as an ill-defined hypodense area as vasogenic edema becomes predominant. Within two or three days, the attenuation values become lower, the ischemic area is better demarcated and there may be evidence of mass effect (Figs. 5.1 and 11.3). Later, there may be ipsilateral ventricular dilatation owing to loss of brain substance. Hemorrhagic transformation usually occurs a few days after stroke onset in large infarcts, but it may develop within hours and result in appearances very similar to primary intracerebral hemorrhage (Fig. 16.1) (Bogousslavsky 1991). 

There are limitations to the information on cerebrovascular pathophysiology in vivo that can be provided by CT and conventional MRI. Specifically, these include lack of sensitivity for acute ischemic stroke, difficulty in determining infarct age, lack of demonstration of the ischemic penumbra and low sensitivity and specificity for primary intracerebral hemorrhage in the case of MRI. New imaging techniques address some of these deficiencies and thereby impact on the management of patients with acute stroke. 

The prognosis is much better for ischemic stroke overall than for intracranial hemorrhage, with approximately 10% and 50% dying, respectively (Bamford et al. 1990 Lovelock et al. 2007). Early characteristics predicting death in patients with primary intracerebral hemorrhage are ... 

So far predictive models only apply to a small proportion of patients and are not sufficiently accurate to inform treatment decisions in routine clinical practice. The various subtypes of ischemic stroke have very different outcomes patients with total anterior circulation infarction (TACI) have just as poor an outcome as those with primary intracerebral hemorrhage (Table 16.1). The best single predictor of early death is impaired consciousness, but many other predictors of survival have been identified (Table 16.2). Many of these variables are inter-related, but prognostic models based on independent variables do not provide much more information than an experienced clinician s estimate (Counsell and Dennis 2001 Counsell et al. 2002). 

Mannitol is widely used in patients with primary intracerebral hemorrhage and a depressed level of consciousness to decrease intracranial pressure and alleviate the space-occupying effect of the hematoma in a deteriorating patient, although there is a lack of randomized trials looking at clinical outcomes. 

Fig. 22.1. A CT brain scan showing a primary intracerebral hemorrhage with rupture into the ventricular system (open arrow) and considerable mass effect (black arrow).

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