Admission blood glucose and short term survival in primary intracerebral haemorrhage: a population based study

BACKGROUND: The role of admission blood glucose level on the prognosis of patients with intracerebral haemorrhage has not been elucidated. OBJECTIVE: To examine this association on the basis of an epidemiologically representative patient material. METHODS: 249 500 people living in the catchment area of the Central Hospital of Central Finland. The diagnosis of ICH was established if verified by cranial computed tomography (CT) or autopsy. RESULTS: Of the 416 patients who fulfilled the diagnostic criteria, 30 died before admission and 386 were admitted to the Central Hospital. All 329 patients (290 nondiabetics and 39 diabetics) with both admission blood glucose and cranial CT data were included in the study. The mean blood glucose level was 10.6 mmol/l for nondiabetics who died on the day of onset, 8.6 mmol/l for those dying during days 1 to 28, and 6.8 mmol/l for the 28 day survivors. The corresponding figures for diabetics were 13.9 mmol/l, 12.5 mmol/l, and 9.3 mmol/l. In both nondiabetics and diabetics, patients who died had significantly higher mean glucose than the 28 day survivors (p<0.0001 versus p = 0.029). However, blood glucose of the surviving diabetics was as high as that of the deceased nondiabetics (9.3 mmol/l versus 9.1 mmol/l). In nondiabetics, admission blood glucose was associated with parameters signifying severe stroke; disturbed consciousness, large haematoma volume and shift of cerebral midline structures, and high admission mean arterial pressure. In logistic regression analysis, high admission blood glucose in nondiabetics was a significant predictor of death during the first 28 days of onset (odds ratio 1.22, 95% CI 1.07 to 1.40). CONCLUSIONS: High admission blood glucose predicts increased 28 day case fatality rate in both nondiabetic and diabetic patients with ICH. Because high admission blood glucose was associated with markers of severe stroke, we are inclined to support the stress theory; high admission blood glucose is the result of a serious ICH.     

Incidence and outcome of subarachnoid haemorrhage: a retrospective population based study

OBJECTIVES: The purpose was to define the incidence and case fatality rates of subarachnoid haemorrhage in the population of Devon and Cornwall. METHODS: A retrospective population based design was employed with multiple overlapping methods of case ascertainment. A strict definition of subarachnoid haemorrhage was used. Age and sex specific incidence rates and relative risks for death at different time intervals are calculated. RESULTS: Eight hundred cases of first ever subarachnoid haemorrhage were identified; 77% of cases were verified by CT, 22% by necropsy, and 1% by lumbar puncture. The incidence rates are higher than those previously reported in the United Kingdom. The age standardised incidence rate (/100 000 person-years) for females was 11.9 (95% confidence interval (95% CI) 9.5-15.0), for males 7.4 (5.4-10.0), and the total rate was 9.7 (7.5-12.6). The case fatality rates at 24 hours, 1 week, and 30 days were 21 (18-24)%, 37 (33-41)%, and 44 (40-49)% respectively. The relative risk for death at 30 days for those over 60 years:under 60 years was 2.95 (2.18-3.97). CONCLUSION: The incidence of subarachnoid haemorrhage in the United Kingdom is higher than previously reported. Three quarters of the mortality occurs within 3 days.     

Long term survival with early childhood intracerebral tumours.

Three young adults are described who presented during early childhood with a seizure disorder due to an underlying intracerebral tumour. The tumours were excised incompletely 14-19 years later. The histological findings were those of a temporal lobe benign capillary haemangioblastoma (Case 1), parietal lobe subependymoma (Case 2), and parietal lobe ganglioglioma (Case 3). After a mean period of follow-up of 22 years (range 18-26), only mild residual physical disabilities exist in each patient. These three cases illustrate (1) the need promptly to investigate children who present with focal seizures or whose EEG shows definite focal abnormalities, (2) the relevant investigations should include cranial CT or MRI in such cases and (3) that certain supratentorial tumours have a favourable outcome due to their benign biological behaviour rather than their location.     

Long term follow up after perimesencephalic subarachnoid haemorrhage

OBJECTIVES: To evaluate the long term sequelae of perimesencephalic subarachnoid haemorrhage (PMSAH). METHODS: Twenty one consecutive patients were studied. All patients were examined by CT, angiography, MRI, multimodal evoked potentials, and transcranial Doppler sonography. All relevant clinical data during hospital stay and outcome at discharge were obtained by reviewing the charts. Long term follow up was evaluated by reviewing the outpatient files and dedicated outpatient review. Patients were specifically questioned about their perceived recovery, residual complaints, and present occupational status. RESULTS: Apart from the initial CT confirming the diagnosis of PMSAH all other examinations disclosed no abnormalities. None of the patients developed any complications during hospital stay, and all patients were discharged in good clinical condition and without neurological deficits. At long term follow up 62% of the patients had residual complaints consisting of headaches, irritability, depression, forgetfulness, weariness, and diminished endurance. Apart from four patients who had already retired before the PMSAH, only seven of the remaining 17 patients (41%) returned to their previous occupation, whereas nine patients (53%) retired from work and one man became unemployed. One patient had a recurrence of PMSAH 31 months after the first event. CONCLUSION: PMSAH can have considerable long term psychosocial sequelae, and may also recur. Prognosis may not be as good as previously reported.     

A population based study of outcomes after evacuation of primary supratentorial intracerebral hemorrhage

Background and Purpose

The role of surgery after primary intracerebral hemorrhage (ICH) is controversial. To explore whether hematoma evacuation after ICH had improved short-term survival or functional outcome we conducted a retrospective observational population-based study.

Methods

We identified all subjects with primary ICH between 1993 and 2008 among the population of Northern Ostrobothnia, Finland. Hematoma evacuation was carried out by using standard craniotomy or through a burr hole. We compared mortality rates and functional outcomes of patients with hematoma evacuation with those treated conservatively.

Results

Of 982 patients with verified ICH during the study period, 127 (13%) underwent hematoma evacuation. Surgically treated patients were significantly younger (mean ± SD, 63 ± 11 vs. 70 ± 12 years; p < 0.001), had larger hematomas (66 ± 36 vs. 28 ± 40 ml; p < 0.001), lower Glasgow Coma Scale scores (median, 11 vs. 14; p < 0.001) and more frequently subcortical hematomas (68% vs. 24%; p < 0.001) than those treated conservatively. In multivariable analysis, hematoma evacuation independently lowered 3-month mortality (adjusted hazard ratio [HR], 0.62; 95% confidence interval [CI], 0.43–0.88; p < 0.03), particularly among patients aged ≤70 years with ≥30 ml supratentorial hematomas (adjusted HR, 0.26; 95% CI, 0.14–0.49; p < 0.001). However, poor outcome was not improved by surgery (adjusted odds ratio 0.71; 95% CI 0.29–1.70).

Conclusions

Improved 3-month survival was observed in patients who had undergone hematoma evacuation relative to patients not undergoing evacuation particularly in the subgroup of patients aged ≤70 years with ≥30 ml supratentorial hematomas. Surgery might improve outcome if cases could be selected more precisely and if performed before deterioration.     

Association of low cholesterol with primary intracerebral haemorrhage: a case control study

Objectives – Epidemiological studies have shown that the incidence of intracerebral haemorrhage (ICH) is high in patients with low cholesterol levels. The aim of this study was to investigate the correlation between ICH and low cholesterol in cases of primary ICH. Material and methods – Two hundred and fifty‐nine patients with primary intracerebral haemorrhage and 137 healthy individuals were included in this study. Patients with prior cerebrovascular accident, secondary ICH, hereditary lipid metabolism disorders, thyroid diseases and those using lipid‐lowering drugs were excluded. In all subjects, cholesterol levels were measured after 12 h of fasting. Results – Mean cholesterol levels were 205.8 ± 51.4 mg/dl in the ICH group and 230.2 ± 38.9 mg/dl in the control group. Mean cholesterol levels of patients were significantly lower than the controls (P < 0.000). In ICH group, the frequency of patients who had very low cholesterol levels was significantly higher than the control group (P < 0.000). Conclusions – Individuals with lower cholesterol levels have an increased risk of ICH. Therefore, before treatment with statins, clinicians must be aware of the possible ICH risk.     

Effect of aspirin and warfarin on early survival after intracerebral haemorrhage

Background To determine whether taking aspirin or warfarin at the time of an intracerebral haemorrhage (ICH) has an independent effect on early survival. Methods All people with ICH presenting in Christchurch, New Zealand over a three-year period were identified. Independent predictors of mortality at 7, 14 and 28 days were calculated using binary logistic regression. Results Two hundred and fifty three cases were identified. Unadjusted 28-day mortality was 43% overall, but 53 % for warfarin associated ICH and 43% for patients taking aspirin. Haemorrhage volume, haemorrhage location, intraventricular spread and the use of warfarin were all independently and significantly associated with mortality at all three time intervals (7, 14 and 28 days). The effect of warfarin was apparent despite similar volumes of bleed in each group. Aspirin was not associated with increased early mortality. Increasing age was also an independent predictor associated with death at 28 days. Interpretation Use of warfarin (but not aspirin) immediately prior to ICH was independently associated with increased mortality, after controlling for comorbidities. Thus therapeutic efforts to rapidly reverse the warfarin induced coagulopathy may be justified to lower mortality.     

Steroid treatment in primary intracerebral haemorrhage

The efficiency of two types of steroid treatment was assessed in primary intracerebral haemorrhages. No significant difference in clinical evolution was observed between 57 cases treated with dexamethasone, 28 cases with methylprednisolone and 44 cases without corticosteroids. In a subgroup of 46 patients with putamino-capsular bleedings the non-steroid-treated group did significantly better than the steroid-treated one. Adverse reactions occurred at the same rate in the three groups.     

Hospital admissions prior to primary intracerebral haemorrhage and relevant factors associated with survival

BackgroundIdentification and modification of risk factors are essential for preventing intracerebral hemorrhage (ICH). Prior hospital admissions provide opportunities to intervene. We reported hospital admissions prior to primary ICH and investigated factors associated with survival.MethodsCohort design using patient-level data from the Australian Stroke Clinical Registry (2009-2013) linked with hospital administrative datasets from four states (VIC, NSW, WA, QLD). Prior hospital admission is divided into within 90 days and more than 90 days prior to the index ICH event. The International Classification of Diseases and Related Health Problems, Tenth Revision, Australian Modification codes were used to define principal diagnoses of previous admissions/presentations and comorbidities. Factors associated with survival after ICH were investigated using Cox proportional hazards regression.ResultsAmong 15,482 admissions for stroke, 2,098 (14%) had an ICH (median age 76 years, 52% male), 1,732 patients (83%) had a prior hospital admission, including 440 patients (21%) within 90 days of their index ICH admission. Patients with prior admission were older, had more comorbidities, and greater hospital frailty risk score than those without prior admission. Diseases of the circulatory system (14%) were the most common principal diagnoses for hospital admissions prior to ICH. Of the comorbidities associated with survival, neoplasms conferred the greatest hazard of death at 180 days after ICH (adjusted hazard ratio 1.42, 95% confidence interval 1.15 – 1.76, p = 0.001).ConclusionHospital presentations in the 90 days prior to ICH are common. Future research should be focussed on identifying opportunities for preventing ICH.     

The decreasing incidence of primary intracerebral hemorrhage: a population study.

This population study describes the experience with primary intracerebral hemorrhage (PIH) in residents of Rochester, MN, for the 32-year period from 1945 through 1976. The average annual age-adjusted incidence rate for PIH was 12.1 per 100,000 population, and the incidence for all cases of spontaneous intracerebral hemorrhage was 15.2 per 100,000. The PIH rates were higher for males than for females, and they increased steadily with age. When patients on long-term anticoagulant therapy were excluded, there was a steady decrease in the average annual age-adjusted incidence rate for PIH in each succeeding 8-year interval since 1945. Prehemorrhage hypertension, present overall in 89% of patients, was much more frequent and severe in the earlier years of the study. The frequency and severity of prehemorrhage hypertension also varied inversely with age in the population with PIH. The median age at the onset of PIH increased from 65 years for the period 1945 through 1952 to 71 years for 1969 through 1976.     

Applicability and relevance of models that predict short term outcome after intracerebral haemorrhage

OBJECTIVES: Several models for prediction of short term outcome after intracerebral haemorrhage (ICH) have been published, however, these are rarely used in clinical practice for treatment decisions. This study was conducted to identify current models for prediction of short term outcome after ICH and to evaluate their clinical applicability and relevance in treatment decisions. METHODS: MEDLINE was searched from 1966 to June 2003 and studies were included if they met predefined criteria. Regression coefficients of multivariate models were extracted. Two neurologists independently evaluated the models for applicability in clinical practice. To assess clinical relevance and accuracy of each model, in a validation series of 122 patients the proportion with a >or=95% probability of death or poor outcome and the actual 30 day case fatality in these patients were calculated. Receiver operator characteristic (ROC) curves were computed for assessment of discriminatory power. RESULTS: A total of 18 prognostic models were identified, of which 14 appeared easy to apply. In the validation series, the proportion of patients with a >or=95% probability of death or poor outcome ranged from 0% to 43% (median 23%). The 30 day case fatality in these patients ranged from 75% to 100% (median 93%). The area under the ROC curves ranged from 0.81 to 0.90. CONCLUSIONS: Most models are easy to apply and can generate a high probability of death or poor outcome. However, only a small proportion of patients have such a high probability, and 30 day case fatality is not always correctly predicted. Therefore, current models have limited relevance in triage, but can be used to estimate the chances of survival of individual patients.     

Physical activity and subarachnoid haemorrhage: a population based case-control study

OBJECTIVE: To evaluate physical activity as a risk factor for subarachnoid haemorrhage. METHODS: A population based case-control study in King County, Washington. A standardised, personal interview was used to determine physical activity during the past year and at the onset of the bleed for case patients and a similar reference time for control subjects. Conditional logistic regression and a case cross over analysis were performed in which each case patient served as his or her own control. Subjects were 149 men and women with incident, spontaneous subarachnoid haemorrhage and two control subjects per case patient. Control subjects were identified through random digit dialing and matched on age, sex, and respondent type. RESULTS: Four of the 149 (2.7%) case patients were engaged in vigorous physical activity at the time of their subarachnoid haemorrhage. With those who were engaged in non-vigorous or no physical activity serving as the reference group, the relative risk of sustaining a subarachnoid haemorrhage for those engaged in vigorous physical activity was 11.6 (95% confidence interval (95% CI) 1.2-113.2). In the case cross over analysis, the relative risk was 15.0 (95% CI 4.3-52.2). Higher levels of long term regular physical activity over the past year were associated with a lower, but not statistically significant, risk of subarachnoid haemorrhage (test for trend, p=0.3). CONCLUSION: The risk of subarachnoid haemorrhage is increased during vigorous physical activity, although only a few result from this mechanism.     

Cigarette smoking and risk of primary intracerebral haemorrhage

From September 1985 to December 1989 a total of 158 patients had primary intracerebral haemorrhage in the population of 116000 in the Jyväskylä Region, Central Finland. All had the diagnosis confirmed by either computerised tomography or necropsy, and information on cigarette smoking habits was available in 155 patients, 20% of whom were current cigarette smokers. One control was selected for each of the 155 patients matched on sex, age, and residence from the census of Central Finland. The odds ratio of primary intracerebral haemorrhage of current cigarette smokers compared with current non-smokers was estimated on basis of the number of discordant pairs as 1.4 (95% confidence interval 0.7 to 2.8). Adjustment for hypertension or diabetes did not change this estimate. Our data did not show evidence of an positive association of cigarette smoking and risk of primary intracerebral haemorrhage. This assumption was strenghtened when the results of previous studies and the present study were pooled giving an odds ratio of 1.0 (95% confidence interval 0.8 to 1.3).