JStroke Cerebrovasc Dis 1991;1:111-116 © 1991 Demos Publications
Incidence of Progression or Rebleeding in Hypertensive Intracerebral Hemorrhage Martha A. Fehr, M.D., and David C. Anderson, M.D.
The incidence of progression or rebleeding in hypertensive intracerebral hemorrhage (HICH) has not been clearly established. We review 56 cases of HICH involving the basal ganglia or thalamus and found four cases (one thalamic, three basal ganglia) in which progression or rebleeding occurred. These cases represent 7% (4/56) of the total number of cases and 13.8% (4/29) of the cases in which serial computer tomography (CT) was performed. In two cases, progression or rebleeding occurred during the first 24 h after onset of symptoms, whereas in the other two cases rebleeding appeared to be delayed (CT changes noted 5 and 6 days later). This study suggests that the incidence of progression or rebleeding in HICH occurs more commonly than had been believed and that rebleeding may occur ·early or late. Key Words: Hypertensive intracerebral hemorrhage-Rebleeding.
Hypertensive intracerebral hemorrhage (HICH) has been considered to be a monophasic event resulting from rupture of the penetrating arteries and arterioles supplying the basal ganglia, thalamus, brainstem, cerebellum, and, less commonly, the lobar white matter (l). The impression that this type of hemorrhage is a self-limited single event has been based on follow-up computed tomography (CT) studies in which there was no evidence of enlargement of the hematoma (2-4), a study demonstrating absence of rebleeding using slCr-labeled erythrocytes (5), and clinicopathologic correlations (6). However, there have been a few reports of progression of HICH documented by CT (7-I2). The incidence of progression or rebleeding has not been clearly established, although it has been estimated to occur in no less than 0.8% of cases of HICH (II) .
From the Department of Neurology, Hennepin County Medical Center, Minneapolis, MN, U.s.A. Address correspondence and reprint requests to Dr. M. A. Fehr at Department of Neurology, Hennepin County Medical Center, 701 Park Avenue, Minneapolis, MN 55415, U.S.A.
In order to better establish the incidence of progression or rebleeding of HICH, we conducted a retrospective review of 56 cases of HICH.
Patients and Methods Fifty-six cases of HICH involving the thalamus or basal ganglia were identified in a retrospective chart review of 205 cases of spontaneous intracerebral hemorrhage admitted to Hennepin County Medical Center (90 cases) and St. Paul Ramsey Medical Center (115 cases) during the period from January 1984 to January 1990. Our purpose was to select cases in which a hypertensive etiology could be inferred primarily by location of the hematoma, clinical history, and the absence of other predisposing medical conditions, such as bleeding diathesis, trauma, known vascular malformation, or use of anticoagulants. All patients with a specific etiology other than HICH were excluded from further study. All patients with lobar or multiple hemorrhages were excluded because a hypertensive etiology was often in doubt. Patients with cerebellar hemorrhage were excluded because 10 underwent emergency surgery, and the
J STROKE CEREBROVASC DIS, VOL.
1, NO.3, 1991
111
M. A. FEHR AND D. C. ANDERSON
Location and etiology of 205 cases of spontaneous intracerebral hemorrhage
Table 1.
Location (total cases) Thalamus or basal ganglia (65)
Lobar (112)
Cerebellum (15) Brainstem (13)
Etiology (total cases) CJ
Hypertension (56") Coagulopathy (8) Moyamoya (1) Undetermined (69 b) Aneurysm (15) Coagulopathy (22) Amyloid (4) Tumor (2) Hypertension (14) Coagulopathy (I) Hypertension (11) Aneurysm (I) Coagulopathy (l)
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...
~
;:3 CJ
Z
'Study patients. bCases in which etiologies other than hypertension could not be excluded.
.§
other 5 died on admission. Patients with brainstem hemorrhage were also excluded because eight died acutely, and only three survivors had follow-up CT (unchanged). The distribution of the initial 205 cases by location of the hemorrhage and presumptive etiology is shown in Table l. The 56 cases of HICH involving the thalamus or basal ganglia were reviewed. All admission and follow-up CT scans were examined. In cases in which progression of HICH occurred, an HP9874A digitizing pad was used to trace the perimeter of the hematoma on consecutive CT slices. The digitized data were entered into an HP9845A computer programmed to calculate the volume of the hematoma.
Eo ~
CJ
0:9
.-
0;
Incidence of Progression or Rebleeding in Hypertensive Intracerebral Hemorrhage Martha A. Fehr, M.D., and David C. Anderson, M.D.
The incidence of progression or rebleeding in hypertensive intracerebral hemorrhage (HICH) has not been clearly established. We review 56 cases of HICH involving the basal ganglia or thalamus and found four cases (one thalamic, three basal ganglia) in which progression or rebleeding occurred. These cases represent 7% (4/56) of the total number of cases and 13.8% (4/29) of the cases in which serial computer tomography (CT) was performed. In two cases, progression or rebleeding occurred during the first 24 h after onset of symptoms, whereas in the other two cases rebleeding appeared to be delayed (CT changes noted 5 and 6 days later). This study suggests that the incidence of progression or rebleeding in HICH occurs more commonly than had been believed and that rebleeding may occur ·early or late. Key Words: Hypertensive intracerebral hemorrhage-Rebleeding.
Hypertensive intracerebral hemorrhage (HICH) has been considered to be a monophasic event resulting from rupture of the penetrating arteries and arterioles supplying the basal ganglia, thalamus, brainstem, cerebellum, and, less commonly, the lobar white matter (l). The impression that this type of hemorrhage is a self-limited single event has been based on follow-up computed tomography (CT) studies in which there was no evidence of enlargement of the hematoma (2-4), a study demonstrating absence of rebleeding using slCr-labeled erythrocytes (5), and clinicopathologic correlations (6). However, there have been a few reports of progression of HICH documented by CT (7-I2). The incidence of progression or rebleeding has not been clearly established, although it has been estimated to occur in no less than 0.8% of cases of HICH (II) .
From the Department of Neurology, Hennepin County Medical Center, Minneapolis, MN, U.s.A. Address correspondence and reprint requests to Dr. M. A. Fehr at Department of Neurology, Hennepin County Medical Center, 701 Park Avenue, Minneapolis, MN 55415, U.S.A.
In order to better establish the incidence of progression or rebleeding of HICH, we conducted a retrospective review of 56 cases of HICH.
Patients and Methods Fifty-six cases of HICH involving the thalamus or basal ganglia were identified in a retrospective chart review of 205 cases of spontaneous intracerebral hemorrhage admitted to Hennepin County Medical Center (90 cases) and St. Paul Ramsey Medical Center (115 cases) during the period from January 1984 to January 1990. Our purpose was to select cases in which a hypertensive etiology could be inferred primarily by location of the hematoma, clinical history, and the absence of other predisposing medical conditions, such as bleeding diathesis, trauma, known vascular malformation, or use of anticoagulants. All patients with a specific etiology other than HICH were excluded from further study. All patients with lobar or multiple hemorrhages were excluded because a hypertensive etiology was often in doubt. Patients with cerebellar hemorrhage were excluded because 10 underwent emergency surgery, and the
J STROKE CEREBROVASC DIS, VOL.
1, NO.3, 1991
111
M. A. FEHR AND D. C. ANDERSON
Location and etiology of 205 cases of spontaneous intracerebral hemorrhage
Table 1.
Location (total cases) Thalamus or basal ganglia (65)
Lobar (112)
Cerebellum (15) Brainstem (13)
Etiology (total cases) CJ
Hypertension (56") Coagulopathy (8) Moyamoya (1) Undetermined (69 b) Aneurysm (15) Coagulopathy (22) Amyloid (4) Tumor (2) Hypertension (14) Coagulopathy (I) Hypertension (11) Aneurysm (I) Coagulopathy (l)
E o u
;;..-..
o eft u ...... 'to _ 0 o ";;j ~ o
...
~
;:3 CJ
Z
'Study patients. bCases in which etiologies other than hypertension could not be excluded.
.§
other 5 died on admission. Patients with brainstem hemorrhage were also excluded because eight died acutely, and only three survivors had follow-up CT (unchanged). The distribution of the initial 205 cases by location of the hemorrhage and presumptive etiology is shown in Table l. The 56 cases of HICH involving the thalamus or basal ganglia were reviewed. All admission and follow-up CT scans were examined. In cases in which progression of HICH occurred, an HP9874A digitizing pad was used to trace the perimeter of the hematoma on consecutive CT slices. The digitized data were entered into an HP9845A computer programmed to calculate the volume of the hematoma.
Eo ~
CJ
0:9
.-
0;
