Jarno Satopää

SMASH-U: A Proposal for Etiologic Classification of Intracerebral Hemorrhage

Background and Purpose— The purpose of this study was to provide a simple and practical clinical classification for the etiology of intracerebral hemorrhage (ICH). Methods— We performed a retrospective chart review of consecutive patients with ICH treated at the Helsinki University Central Hospital, January 2005 to March 2010 (n=1013). We classified ICH etiology by predefined criteria as structural vascular lesions (S), medication (M), amyloid angiopathy (A), systemic disease (S), hypertension (H), or undetermined (U). Clinical and radiological features and mortality by SMASH-U (Structural lesion, Medication, Amyloid angiopathy, Systemic/other disease, Hypertension, Undetermined) etiology were analyzed. Results— Structural lesions, namely cavernomas and arteriovenous malformations, caused 5% of the ICH, anticoagulation 14%, and systemic disease 5% (23 liver cirrhosis, 8 thrombocytopenia, and 17 various rare conditions). Amyloid angiopathy (20%) and hypertensive angiopathy (35%) were common, but etiology remained undetermined in 21%. Interrater agreement in classifying cases was high (&kgr;, 0.89; 95% CI, 0.82–0.96). Patients with structural lesions had the smallest hemorrhages (median volume, 2.8 mL) and best prognosis (3-month mortality 4%), whereas anticoagulation-related ICHs were largest (13.4 mL) and most often fatal (54%). Overall, median ICH survival was 5½ years, varying strongly by etiology (P<0.001). After adjustment for baseline characteristics, patients with structural lesions had the lowest 3-month mortality rates (OR, 0.06; 95% CI, 0.01–0.37) and those with anticoagulation (OR, 1.9; 1.0–3.6) or other systemic cause (OR, 4.0; 1.6–10.1) the highest. Conclusions— In our patients, performing the SMASH-U classification was feasible and interrater agreement excellent. A plausible etiology was determined in most patients but remained elusive in one in 5. In this series, SMASH-U based etiology was strongly associated with survival.

The CAVE Score for Predicting Late Seizures After Intracerebral Hemorrhage

Background and Purpose— Seizures are a common complication of intracerebral hemorrhage (ICH). We developed a novel tool to quantify this risk in individual patients. Methods— Retrospective analysis of the observational Helsinki ICH Study (n=993; median follow-up, 2.7 years) and the Lille Prognosis of InTra-Cerebral Hemorrhage (n=325; 2.2 years) cohorts of consecutive ICH patients admitted between 2004 and 2010. Helsinki ICH Study patients’ province-wide electronic records were evaluated for early seizures occurring within 7 days of ICH and among 7-day survivors (n=764) for late seizures (LSs) occurring >7 days from ICH. A Cox regression model estimating risk of LSs was used to derive a prognostic score, validated in the Prognosis of InTra-Cerebral Hemorrhage cohort. Results— Of the Helsinki ICH Study patients, 109 (11.0%) had early seizures within 7 days of ICH. Among the 7-day survivors, 70 (9.2%) patients developed LSs. The cumulative risk of LSs was 7.1%, 10.0%, 10.2%, 11.0%, and 11.8% at 1 to 5 years after ICH, respectively. We created the CAVE score (0–4 points) to estimate the risk of LSs, with 1 point for each of cortical involvement, age <65 years, volume >10 mL, and early seizures within 7 days of ICH. The risk of LSs was 0.6%, 3.6%, 9.8%, 34.8%, and 46.2% for CAVE scores 0 to 4, respectively. The c-statistic was 0.81 (0.76–0.86) and 0.69 (0.59–0.78) in the validation cohort. Conclusions— One in 10 patients will develop seizures after ICH. The risk of this adverse outcome can be estimated by a simple score based on baseline variables.

Distal Posterior Inferior Cerebellar Artery Aneurysms: Clinical Features and Outcome of 80 Patients

OBJECTIVE Aneurysms of the posterior inferior cerebellar artery (PICA) distal to its origin are rare. Beside their rarity, their treatment is challenged by a high proportion of fusiform aneurysms, torturous course of PICA, and often severe bleeding. Our aim is to represent the characteristics of these aneurysms and their treatment, as well as to analyze outcome. METHODS We reviewed retrospectively 80 patients with PICA aneurysms who were treated at the Department of Neurosurgery, Helsinki, Finland. RESULTS The 80 patients had altogether 91 distal PICA aneurysms. Subarachnoid hemorrhage occurred in 74 (93%), and the distal PICA aneurysm was ruptured in 68 (85%). Compared with aneurysms at other locations, distal PICA aneurysms were smaller, more often fusiform, and more often caused an intraventricular hemorrhage as well as rebleeding. Modified surgical techniques (trapping, wrapping, proximal occlusion, resection, coagulation) were used in 10 (32%) fusiform and in 3 (6%) saccular aneurysms. Revascularization was needed in 3 (4%) cases. One aneurysm was primarily embolized. Within a year after aneurysm diagnosis, 18 patients had died. Among survivors, most returned to independent or previous state of living: 52 (91%); only 1 patient was unable to return home. CONCLUSIONS Microsurgery is a feasible treatment for distal PICA aneurysms. Despite the challenge of often severe hemorrhage, wide-necked aneurysms, and some risk for laryngeal palsy, most patients surviving the initial stage return to normal life. Because of the greater number of rebleedings than for aneurysms at other locations, immediate treatment is crucial.

Incidence, risk factors, etiology, severity and short-term outcome of non-traumatic intracerebral hemorrhage in young adults.

Intracerebral hemorrhage (ICH) is a common and severe form of stroke but is scarcely studied in young adults. Our aim was to study risk factors, clinical presentation and early mortality of ICH in the young and compare these features with older patients.

Predictors of Early Mortality in Young Adults After Intracerebral Hemorrhage

Background and Purpose— Patient and radiological characteristics of intracerebral hemorrhage (ICH), surgical treatment, and outcome after ICH are interrelated. Our purpose was to define whether these characteristics or surgical treatment correlate with mortality among young adults. Methods— We retrospectively reviewed clinical and imaging data of all first-ever nontraumatic patients with ICH between 16 and 49 years of age treated in our hospital between January 2000 and March 2010 and linked these data with national causes of death registry. A logistic regression analysis of factors associated with 3-month mortality and a propensity score comparison between patients treated conservatively and operatively was performed. Results— Among the 325 eligible patients (59.4% men), factors associated with 3-month mortality included higher National Institutes of Health Stroke Scale score, infratentorial location, hydrocephalus, herniation, and multiple hemorrhages. Adjusted for these factors, as well as demographics, ICH volume, and the underlying cause, surgical evacuation was associated with lower 3-month mortality (odds ratio, 0.06; 95% confidence interval, 0.02–0.21). In propensity score–matched analysis, 3-month case fatality rates were 3-fold in those treated conservatively (27.5% versus 7.8%; P<0.001). Conclusions— The predictors of short-term case fatality are alike in young and elderly patients with ICH. However, initial hematoma evacuation was associated with lower 3-month case fatality in our young patients with ICH.

Higher baseline international normalized ratio value correlates with higher mortality in intracerebral hemorrhage during warfarin use

Intracerebral hemorrhage (ICH) is the most feared complication of oral anticoagulation (OAC). Our aim was to investigate the impact of the international normalized ratio (INR) level on mortality in OAC‐associated ICH compared with non‐OAC‐associated ICH.

Extent of secondary intraventricular hemorrhage is an independent predictor of outcomes in intracerebral hemorrhage: data from the Helsinki ICH Study.

Background Intraventricular hemorrhage is a severe subtype of intracerebral hemorrhage associated with high mortality and poor outcome. Aim We analyzed various intraventricular hemorrhage scores at baseline to find common parameters associated with increased mortality. Methods Consecutive intracerebral hemorrhage patients treated in Helsinki University Central Hospital during 2005— 2010 were included in the Helsinki Intracerebral Hemorrhage Study registry and analyzed for three-month mortality. Results After excluding lost-to-follow-up patients, 967 intracerebral hemorrhage patients were included, out of whom 398 (41%) had intraventricular hemorrhage. Intraventricular hemorrhage patients, compared with nonintraventricular hemorrhage patients, had lower baseline Glasgow Coma Scale [median 12 (IQR 6–15) vs. 15 (13–15); P < 0·001] and higher National Institutes of Health Stroke Scale [18 (10–27) vs. 7 (3–14); P < 0·001] scores; larger intracerebral hemorrhage volumes [17 ml (7·2–42) vs. 6·8 (2·4–18); P < 0·001] and more often hydrocephalus (51% vs. 9%; P < 0·001); and higher mortality rates (54% vs. 18%; P < 0·001). In multivariable analysis, the presence of intraventricular hemorrhage was independently associated with mortality [OR 2·05 (95% CI 1·36–3·09)] when adjusted for well-known prognostic factors of intracerebral hemorrhage, i.e. age, gender, baseline National Institutes of Health Stroke Scale, intracerebral hemorrhage volume, infratentorial location, and etiology. Conclusions The presence of intraventricular hemorrhage was independently associated with increased mortality, and all the intraventricular hemorrhage scores were strong predictors of three-month mortality.

Intracerebral hemorrhage at young age: long‐term prognosis

Intracerebral hemorrhage (ICH) is a devastating disorder associated with dismal outcomes. The long‐term mortality and functional outcome of ICH in young patients was studied – areas so far poorly investigated.

Medical Acute Complications of Intracerebral Hemorrhage in Young Adults

Background. Frequency and impact of medical complications on short-term mortality in young patients with intracerebral hemorrhage (ICH) have gone unstudied. Methods. We reviewed data of all first-ever nontraumatic ICH patients between 16 and 49 years of age treated in our hospital between January 2000 and March 2010 to identify medical complications suffered. Logistic regression adjusted for known ICH prognosticators was used to identify medical complications associated with mortality. Results. Among the 325 eligible patients (59% males, median age 42 [interquartile range 34–47] years), infections were discovered in 90 (28%), venous thrombotic events in 13 (4%), cardiac complications in 4 (1%), renal failure in 59 (18%), hypoglycemia in 15 (5%), hyperglycemia in 165 (51%), hyponatremia in 146 (45%), hypernatremia in 91 (28%), hypopotassemia in 104 (32%), and hyperpotassemia in 27 (8%). Adjusted for known ICH prognosticators and diabetes, the only independent complication associated with 3-month mortality was hyperglycemia (plasma glucose >8.0 mmol/L) (odds ratio: 5.90, 95% confidence interval: 2.25–15.48, P < 0.001). Three or more separate complications suffered also associated with increased mortality (7.76, 1.42–42.49, P = 0.018). Conclusions. Hyperglycemia is a frequent complication of ICH in young adults and is independently associated with increased mortality. However, multiple separate complications increase mortality even further.

Seventy Aneurysms of the Posterior Inferior Cerebellar Artery: Anatomical Features and Value of Computed Tomography Angiography in Microneurosurgery

OBJECTIVE Aneurysms at the junction of the vertebral artery (VA) and posterior inferior cerebellar artery (PICA) are relatively rare. Their treatment is challenged by the diverse anatomy of the VA and PICA, close involvement of the PICA in the aneurysm neck, and scant space deep in the posterior fossa next to the cranial nerves, brain stem, and obstructing structures of the skull base. Computed tomography angiography (CTA) visualizes bony structures in addition to the vasculature, and being noninvasive and easily available, it can serve for planning microsurgical treatment. We analyzed the anatomy of PICA aneurysms imaged by CTA to promote planning the treatment. METHODS We examined the CTA images of 70 consecutive patients with a saccular PICA aneurysm who were all treated in the Department of Neurosurgery, Helsinki, Finland, 2001 to 2011. RESULTS Each of the 70 patients had 1 aneurysm at the VA-PICA junction. The proportion of small aneurysms (<7 mm) was high, 67%. The dome-to-neck ratio was <1.2 in 24 (34%) of the aneurysms. In the coronal view, 58 (83%) aneurysms projected cranially, and only 2 (3%) caudally. The aneurysms were located from 1 mm below the foramen magnum to 31 mm above it, most arising at the level of the jugular tubercle. The median distance to the aneurysm from the midline was 6 mm, ranging from 7.5 mm contralateral to the origin of the parent artery to 14 mm ipsilateral. Compared with the right VA, the left VA was larger, it harbored the most aneurysms, and its aneurysms were more often ruptured. CONCLUSIONS Relation of PICA aneurysms to skull base structures is highly variable; the aneurysms can also be extracranial, or lie on the site of the skull contralateral to the origin of the parent artery. These anatomical variations demand meticulous study of the angiography in each individual case, especially before surgical treatment of the aneurysm.