European Journal of Cardiovascular Medicine

Intracerebral hemorrhage (ICH) is defined as spontaneous extravasation of blood into the brain parenchyma. Intra cerebral hemorrhage is the most devastating form of stroke, with high mortality and severe disability among survivors. It is twice as frequent in low-income to middle-income countries compared with high-income countries. Approximately half of the deaths occur within the first 24 hours, highlighting the importance of early and effective treatment. Non contrast computed tomography is the most rapidly and commonly available tool for the diagnosis of intracranial hemorrhage.

The present study was conducted in the ASRAM Hospital, Eluru, for a period of 18 months i.e. from December 2022 to May 2024.

Study design: Prospective study

Source of data: ASRAM Hospital

Sample size: Total of 54 patients were included in the study.

Selection criteria: All patients with CT findings of non-traumatic spontaneous intracerebral hemorrhage

Exclusion criteria: Nil

Data collection: Non contrast CT was performed using sixteen slice Multidetector Computed Tomography (MDCT) scanner (GE Revolution ACT 50 slice CT scanner). Contrast CT, follow up CT and additional radiological tests were performed as and when required. The CT scans were analyzed with respect to location of bleed, volume of bleed and associated changes. Patients were followed up with respect to management and final outcome.

History and examination: A detailed history and examination was performed on all patients with SICH

INVESTIGATIONS

 Computed tomography (CT)

Age: A higher incidence of SICH is seen in patients in age group 61-80 years (n=25) and 88% of patients (n = 48) were in age group of 41-80 years.

Sex: There were a total of 54 patients with spontaneous intracerebral hemorrhage of which 56% were males (n = 30) and remaining were females (n= 24).

FIGURE 1: VOLUME OF HEMORRHAGE

D Intracerebral hemorrhage with volume of bleed in the range of 0-29 mL was seen in 32 patients (59%), 30-59 mL was seen in six patients (11%) and greater than 60mL was seen in 16 patients (30%) (figure 1).

TABLE 1: INTRAVENTRICULAR AND SUBARACHNOID EXTENSION OF HEMORRHAGE

Out of 54 patients studied, 25 patients (46%) had intraventricular extension of the bleed (table 1).Subarachnoid extension of bleed is seen in only 1 patient (2%), which was attributed to aneurysmal rupture (table 1).

FIGURE 2: LOCATION OF SPONTANEOUS INTRACEREBRAL HEMORRHAGE

SICH was supratentorially located in 45 patients (83%) and infratentorially located in 9 patients (17%) (figure 2).

TABLE 2: SITES OF INTRACEREBRAL HEMORRHAGE

Basal ganglia is the commonest for SICH and was seen in 20 cases (37%). Pontine and midbrain SCH were least common (table 2).

FIGURE 3: CAUSE OF HEMORRHAGE

The commonest cause for SICH was hypertension seen in 51 cases (94%) and there was only one case of aneurysmal bleed (figure 3).

TABLE 3: TYPE OF HERNIATION

Subfalcine herniation was seen in 10 patients, uncal herniation in 3 patients, remaining 41 patients did not have any herniation (table 3).

A total of 6 patients underwent surgery and 48 were managed conservatively.

TABLE 4: INTRAVENTRICULAR EXTENSION OF SUPRATENTORIAL SICH AND MORTALITY

Uncorrected chi-square P= 0.028

Intraventricular extension of Supratentorial SICH was seen in 25 patients of whom 16 patients died (64%), which was statistically significant compared to mortality in patients who did not have intraventricular extension (P = 0.028) (table 4).

TABLE 5: VOLUME OF SUPRATENTORIAL HEMORRHAGE AND MORTALITY

Uncorrected chi- Square P< 0.001

Supratentorial SICH volume of <30 mL was seen in 26 patients of which only 4 died, where was in remaining 19 patients with supratentorial SICH volume >30 mL, 14 patients died, which was statistically significant (P< 0.001) (table 5).

FIGURE 4: DETAILS OF TREATMENT PROVIDED AND OUTCOME

A total of 27 patients died in our study after an interval of 3 hours to 3 days from the time of admission with a mean of 12.5 hrs. The remaining 27 live patients were followed up for a period of 3 months. Of the 4 patients who underwent surgery all of them  have little or noresidual disability. Of the remaining who were offered non-surgical management 18 patients have little or no residual disability (figure 6). Of the 18 patients 17 had bleed volume less than 30 mL and 1 had bleed volume of 37 mL lobar in location. A volume of >60 mL, infratentorial location and intraventricular extension of SICH were predictors of poor prognosis. Volume of <30 mL was a predictor of favourable outcome. There was no visible relation between location of bleed, midline shift or presence/absence of herniation on final outcome.

FIGURE 5: A 40 year old male patient with hemorrhage in right basal ganglia with volume of 64mL and with intraventricular extension, he was treated medically and patient was dead.

FIGURE 6: A 76 year old male patient with hemorrhage in thalamus with volume of 3mL and he was treated medically and patient is alive.

Non contrast computed tomography is the most rapidly and commonly available tool for the diagnosis of intracranial hemorrhage. Besides providing the definitive diagnosis, computed tomography also show basic characteristics of the hematoma, such as Location, volume, age, extension to subarachnoid spaces and ventricular system, presence and extent of surrounding edema and brain herniation^[2]. In our study we observed that incidence of SICH was higher among males (56% vs 44%; males vs females). Our results are in agreement with a study carried out on 157 patients of which 89 patients (57%) were males^[3]. Incidence of SICH was maximum in age group ranging between 61-80 years (25 cases). Our results are in agreement with a study on spontaneous intracerebral hemorrhage which showed most common age being 65 to 70 years^[3]. This is expected as there is an increase in risk of SICH with increasing age^[3,4]. Hypertension was present in 51 patients (i.e. 94 %) in whom it was determined as the primary cause for spontaneous intracerebral hemorrhage. Of the remaining three patients, one patient had aneurysmal bleed and two patients had hemorrhagic infarcts. Our results are similar to that of a study conducted on 120 cases on spontaneous intracerebral hemorrhage, 90 cases (75%) had hypertension as a major risk factor^[5]. Hypertension has been considered as the most important risk factor for nontraumatic spontaneous intracerebral haemorrhage^[5,6]. In our study, patients were grouped based on intracerebral hemorrhage volume into 3 groups: group I (1-29 mL), group II (30-59 mL) and group III (≥ 60 mL). 32 patients (59%) belong to group I, 6 patients (11%) belong to group II and 16 patients (30%) in group III. Volume of hemorrhage in our study ranged from 1.5 mL to 337 mL. Our results are similar to a study done in south India, where intracerebral hemorrhage volume of less than 30 mL was seen in 56.7% of patients and 11.4% with volume of 30-59 mL ^[5]. of 16 patients with intracerebral hemorrhage volume of ≥ 60 mL mortality was seen in 14(87.5%). Studies have shown increased risk of mortality with increasing volume, with mortality rates reaching as high as 85% with intracerebral hemorrhage volume of more than 60 mL^[5,7]. In our study intraventricular extension of hemorrhage was seen in 25 patients of whom 16 patients (64%) died, this is statistically significant (P = .028). Rost et al. developed a functional outcome score, FUNC score, based on data from 629 patients. They have suggested intraventricular hemorrhage to be one of the factors predicting poor outcome^[8]. Most of our cases (20 of 25 patients- 80%) of intraventricular hemorrhage were associated with capsuloganglionic or thalamic hemorrhage which is consistent with data available ^[9]. In the current study supratentorial location of hemorrhage (81%) was more common compared with infratentorial location. The mortality was 100% in infratentorial bleeds. Studies have shown that infratentorialhemorrhage tend to have poorer prognosis compared with supratentorialhemorrhage. The incidence of 30 day mortality has been reported in one study to be about 53% with infratentorialhemorrhage^[7]. Out of 54 patients in our study, 20 patients had basal ganglia hemorrhage (37%) followed by 11 patients each in lobar (20%) and thalamic (20%) location, three patients with thalamoganglianic hemorrhage (6%), four patients with cerebellar hemorrhage (7%), two patients with mid brain (4%), two patients with midbrain and pontine hemorrhage (4%) and one patient with only pontine hemorrhage (2%).The location and distribution of intraparenchymalhemorrhage is similar to that reported in a study in which location of hypertensive intracerebral hemorrhage was putaminal in 33%, lobar 23%, thalamic 20%,cerebellar 8%, pontine 7% and miscellaneous 9% ^[10]. There was no relation between location of supratentorial lesions and outcome in our study. A total of 48 patients of our study were treated medically and six patients underwent surgery.There are no clear guidelines on surgical versus medical management. The management options depend on the location of hemorrhage, volume of hemorrhage and diameter of bleed. The European Stroke Organization (ESO) guidelines (2014) have recommended that there is no evidence to support surgical intervention routinely in supratentorial ICH, although surgery may be helpful in patients with Glasgow Coma Scale (GCS) score of 9 to 12 ^[11]. The American Heart Association (AHA)/American Stroke Association (ASA) guidelines (2010) have suggested that surgical management be considered in patients with spontaneous cerebellar ICH more than 3 cm in diameter or those with brainstem compression or hydrocephalus as medical management is associated with poor outcomes ^[9]. All our patients (n = 4) with cerebellar ICH had bleed diameter of more than 3 cm. They were treated medically but had fatal outcome. In the present study all five patients with brainstem hemorrhage (pontine and/or midbrain) had fatal outcome. Current evidence suggests that hypertensive pontine hemorrhages tend to result in fatal outcomes with sometimes rapid death ^[12]. Similar data exists for primary brainstem hemorrhages, with mortality rates up to 57% and good recovery in about modest 6% of patients ^[13]. Of 54 patients in our study, 45 patients had supratentorial bleed of which, 6 were treated surgically and 39 were managed medically. Of the 6 patients treated surgically for supratentorial bleeds survival rate was 66.67% (4 of 6 patients).

In these patients, the causative factor for intracerebral bleed was hypertension with volumes of bleeds more than 30 mL. The remaining two patients succumbed. Of these one patient had ruptured anterior communicating artery (ACOM) aneurysm and aneurysmal clip was placed. However, the patient later succumbed to postoperative uncontrolled hypertension. The other patient had a large hemorrhagic infarct. Of the 39 patients treated medically for supratentorial ICH, 23 patients survived. Among these patients, 22 (95%) patients had ICH volume of less than 30 mL and one patient had an ICH volume 37 mL (5%). Among the 16 patients who succumbed to ICH, only two patients had ICH volume of less than 30 mL. Both these patients had thalamic bleed with intraventricular extension. In the remaining 14 patients the ICH volume was more than 60 mL. Relation between volume of hemorrhage and mortality was significant (P = 0.006). Our results are similar to a study conducted on 120 patients, in which bleed volume more than 60 mL showed mortality rate of 66.6% and patients with volume less than 30ml had mortality rate of 6% ^[5]. Midline shift was observed in 25 cases (46%) of whom 9 are alive and 16 died. Herniation was seen in 13 patients (24%), of whom 10 patients had subfalcine herniation and 3 patients had infratentorial herniation. Of these 13 patients, 8 died. However the relation between presence or absence of herniation and midline shift with mortality is not statistically significant. There was no obvious relation of site of supratentorial bleed to outcome.Our study has certain limitations. Our study was not sufficiently powered to evaluate the effect of individual risk factors alone. Also as there are no clear cut guidelines for treatment, we cannot evaluate the efficacy of medical versus surgical management. In patients with poor prognosis, conservative treatment was preferred over surgical options, considering a poor outcome and the fact that there was very little survival chances. We cannot determine if surgery would have helped in these patients. Although patients with ICH volume of less than 30 mL had good prognosis with medical management and ICH volume more than 30 mL had good prognosis with surgical management, data is not strong enough to make appropriate conclusion. Nonetheless, further studies may help to arrive at an appropriate algorithm to help in management of patients with SICH.

In the present study, we evaluated the CT findings in SICH. Various factors influence clinical outcomes in SICH, including volume of ICH, intraventricular extension and location of ICH (supratentorial versus infratentorial). CT provides an excellent imaging modality for detection of intracerebral hemorrhage and also quantifying the bleed. This can help in further management. Based on the findings we conclude that SICH volume involving more than 60 mL, infratentorial location and intraventricular extension are all predictors for poor outcome. Patients with ICH volume of less than 30 mL have a better prognosis and patients with ICH volume more than 30 mL may be considered as patients suitable for surgery. The management options in these patients depend on various clinical and CT findings. Further studies will help to develop management algorithm for better patient management.

1. Macellari F, Paciaroni M, Agnelli G, Caso V. Neuroimaging in intracerebral hemorrhage. Stroke 2014;45:903-908.
2. Caceres JA, Goldstein JN. Intra cranial hemorrhage. Emerg Med Clin N Am 2012;30:771-794.
3. Franke CL, van Swieten JC, Algra A, van Gijn J. Prognostic factors in patients with intracerebral haematoma. J NeurolNeurosurg Psychiatry. 1992;55:653-7.
4. Camacho EJ, LoPresti MA, Bruce S, Lin D, Abraham ME, et al. The role of age in intracerebral hemorrhage: An intricate relationship. Austin J Cerebrovasc Dis & Stroke 2014;1: 1022.
5. Prem Krishnan R, Mohanty N, Acharya SS, Babu SK. Evaluation of relationship between volume of intracerebral bleed with mortality rate: a hospital based study. Intl J Res Pharm Biomed Sci. 2013;4:100-5.
6. Brott T, Broderick J, Kothari R, Barsan W, Tomsick T, Sauerbeck L, et al. Early hemorrhage growth in patients with intracerebral hemorrhage. Stroke 1997;28:1–5.
7. Hemphill JC 3rd, Bonovich DC, Besmertis L, Manley GT, Johnston SC. The ICH score: a simple, reliable grading scale for intracerebral hemorrhage. Stroke. 2001 ;32:891-7.
8. Rost NS, Smith EE, Chang Y, Snider RW, Chanderraj R, Schwab K, et al. Prediction of functional outcome in patients with primary intracerebral hemorrhage: the FUNC score. Stroke. 2008;39:2304-9.
9. Morgenstern LB, Hemphill JC 3rd, Anderson C, Becker K, Broderick JP, Connolly ES Jr, et al. Guidelines for the management of spontaneous intracerebral hemorrhage: a guideline for healthcare professionals from the American Heart Association/American Stroke Association. Stroke. 2010;41:2108-29.
10. Kase CS, Williams JP, Wyatt DA, Mohr JP. Lobar intracerebral hematomas: clinical and CT analysis of 22 cases. Neurology 1982;32:1146-50.
11. Steiner T, Al-Shahi Salman R, Beer R, Christensen H, Cordonnier C, Csiba L, et al. European Stroke Organisation (ESO) guidelines for the management of spontaneous intracerebral hemorrhage. Int J Stroke. 2014;9:840-55.
12. Nishizaki T, Ikeda N, Nakano S, Sakakura T, Abiko M, Okamura T. Factors determining the outcome of pontine hemorrhage in the absence of surgical intervention. Open J Mod Neurosurg 2012;2:17-20.
13. Takeuchi S, Suzuki G, Takasato Y, Masaoka H, Hayakawa T, Otani N, et al. Prognostic factors in patients with primary brainstem hemorrhage. ClinNeurolNeurosurg. 2013;115:732-5.