ANALYSIS OF RISK FACTORS , LOCALIZATION AND 30-DAY PROGNOSIS OF INTRACEREBRAL HEMORRHAGE

Intracerebral hemorrhage is the deadliest, most disabling and least treatable form of stroke despite progression in medical science. Th e aim of the study was to analyze the frequency, risk factors, localization and -day prognosis in patients with intracerebral hemorrhage. We analyzed  patients with intracerebral hemorrhage (ICH) hospitalized at the Department of Neurology Tuzla during a three-year follow up. Th e following data were collected for all patients in a computerized database: age, sex, risk factors (hypertension, heart diseases, diabetes and smoking) and CT fi ndings. Stroke severity was estimated with Scandinavian Stroke Scale, ICH topography was specifi ed by CT, and outcome at st month after onset included information on vital status and disability (modifi ed


Introduction
Among all the neurological diseases of adult life, the cerebrovascular ones clearly rank first in frequency and importance.Despite considerable improvement in primary prevention, diagnostic workup and therapy, stroke is on the second or third place on a mortality list, and all projections indicate that this will remain in the year .Furthermore, stroke is a leading cause of disability ().In classifying the cerebrovascular diseases (CVD) it is most practical, from the clinical viewpoint, to preserve the classic division into ischemic stroke (IS), intracerebral hemorrhage (ICH), and subarachnoid hemorrhage (SAH).Intracerebral hemorrhage accounts  to  of all strokes, with an incidence of - per   and is more common in men.Th e high rates of mortality and morbidity with ICH are well recognized.Th e -day case fatality ranges from  to  and a majority of deaths occurs soon after the onset ().Th e most frequent risk factor in ICH patients is hypertension and other risk factors are cigarette smoking, frequent use of alcohol and low cholesterol level.In evaluation of the outcome of ICH, size of hematoma and level of consciousness were found to be predictive outcome parameters ().Th e roles of age, sex, hypertension, diabetes mellitus, cigarette smoking, exact location of bleeding and intraventricular blood extension are controversial.Th e aim of the study was to analyze the frequency, risk factors, localization and -day prognosis in patients with intracerebral hemorrhage.

Patients and Methods
During a three-year follow up, from January  st .to December  st .,  patients with first ever stroke were admitted at the Department of Neurology Tuzla.Th ere were  patients (, of all strokes) with intracerebral hemorrhage (ICH).Upon admission demographic data, clinical and neurological examinations and laboratory tests were obtained.Th e following data were collected for all patients in a computerized database: age, sex, risk factors (hypertension, heart diseases, diabetes and smoking) and CT fi ndings.Stroke severity was estimated with Scandinavian Stroke Scale (SSS) (), ICH topography was specifi ed by CT and outcome at  st month after onset included information on vital status and disability (modifi ed Rankin Scale, mRS) ().Variables in relation to the region of hemorrhage included internal capsule, basal ganglia, cerebellum, brainstem, lobar, multilobar topographic involvements and intraventricular blood extension.Prognosis was assessed as mortality at  days after ICH, and favorable outcome of the surviving patients as mRS  or less.Univariate analysis for each variable (demographic data, risk factors and neuroimaging fi ndings) was analyzed using chi-square test and student's t-test.Variables that were signifi cantly related to mortality (p<,) or with a p-value of less than , in univariate analysis were subjected to multivariate analysis with a logistical regression procedure.A value of p<, was considered to be signifi cant.

Results
Out of  patients with ICH,  (,) were men.The mean age of ICH patients was ,+, years and women were significantly older comparing with men.The most frequent risk factors were hypertension (), heart diseases (), cigarette smoking () and diabetes mellitus () with some diff erences according to sex (Table ).Th ere were no diff erences in stroke severity on admission and hospital stay between men and women.Within fi rst month died  patients (),  () died within  hours form the onset.Th e localization of intracerebral hemorrhage was showen in Table .Th e most frequent localization was internal capsule/basal ganglia and multilobar.Analysis according to the site of bleeding showed signifi cant differences with regard to mortality.Th e highest mortality rate was in patients with brain stem hemorrhage (,), multilobar hemorrhage (,) and lobar hemorrhage SSS-Scandinavian Stroke Scale SD-standard deviation (,).However, the lowest mortality within -day was in patients with internal capsule/basal ganglia hemorrhage (,) and cerebellar hemorrhage (,).Table .shows univariate analysis in among  patients with intracerebral hemorrhage, of whom  died.Deceased patients were signifi cantly older, more often had intraventricular blood extension and had more severe deficit on admission than patients who survived fi rst month.
After multivariate analysis, age, hypertension, intraventricular blood extension and low Scandinavian Stroke Scale score on admission were independent factors for morality within -day after ICH (Table ).
Mean value of the Rankin scale at fi rst month for surviving patients was ,, which means that majority of the patients were able to walk without assistance.Favorable outcome at fi rst month had  of the surviving patients with ICH.Th e best outcome was for the patients with cerebellar hemorrhage (,), while only  of the patients with hemorrhage in internal capsule/ basal ganglia region had Rankin scale  or less (Table ).

Discussion
Intracerebral hemorrhage is the deadliest, most disabling and least treatable form of stroke despite progression in medical science.The frequency of ICH in this study (,) is double lower than in the previously analyzed period (-) ().Improvement in detection, better control and treatment of hypertension are the main reasons for the reduction of ICH frequency in our region.Hypertension was the most frequent vascular risk factor in patients with ICH () followed by heart disease (), smoking () and diabetes () (Table ).Other authors also reported hypertension as the most frequent vascular risk factor in patients with ICH while the frequency of other risk factors varied from study to study (,).Mortality at fi rst month was  and  of deaths occurred in the first day.These results correlated with some previous reports.In the study of Karnik, Valentin and Ammerer () ICH mortality within fi rst month was ,,  died during the fi rst  days after the acute event.At the other hand, in the study of Nilsson et al. () mortality rate among  cases of primary ICH was  at the -day.In the period - -day ICH mortality at our region was  () and in this study was lower ().We think that treating of stroke as emergency and treatment of ICH according to the European Stroke Initiative (EUSI) recommendations played the leading role in the reduction of ICH mortality at our region.In our study multilobar involvement (,) and internal capsule/basal ganglia (,) were the most frequent sites of bleeding, and the site of bleeding had infl uence on the mortality (Table ).Localization of ICH was similar in the study of Rosenow et al. ().It this study main localizations were cerebral lobes in , and basal ganglia in , of the patients.Authors also suggested a diff erence in mortality according to the site of bleedeing.Togha and Bakhtavar () found that internal capsule/basal ganglia (,) and lobar hematoma (,) were more frequent sites of ICH than other regions.Th is study indicated signifi cantly higher mean age among deceased patients without sex diff erences in mortality rate.Even though diabetes mellitus was often reported as independent factor on mortality rate among ICH patients (,), we could not supported this thesis.Our fi ndings confi rmed previously reported results that intraventricular blood extension and severity of ICH on admission can be predictors for death (,).We also found age and hypertension as independent predictors of -day mortality (

Conclusion
Hypertension is the most frequent risk factor in patients with ICH, followed with heart disease and cigarette smoking.ICHs are mainly localized in lobar and internal capsule/basal ganglia regions.Independent predictors of mortality following ICH are age, hypertension, intraventricular blood extension and stroke severity.Mortality, as well as good outcome at one month, is related to the localization of bleeding.

TABLE 1 .
General characteristics and risk factors of patients with intracerebral hemorrhage according to sex

Table  )
. Rosenow et al.()reported that a higher case fatality correlated with ventricular extension, increasing age, surgical treatment, localization in basal ganglia and hypertension as only etiology.In the recent publication of Ruiz-Sandoval et al.()independent predictors of death followed ICH were age, Glasgow Coma Scale, ICH location, ICH volume, and intraventricular extension.Favourable outcome (mRS <) at fi rst month had  patients () and it depended of the localization of hemorrhage (Table).Th e best outcome had patients with cerebellar bleeding and lobar ICH, while less than  of surviving patients with multilobar ICH and internal capsule/basal ganglia hemorrhage had favorable outcome at fi rst month.Mortality in patients with internal capsule/basal ganglia hemorrhage within -day was the lowest () but only  of them had mRS < at  month.Lampl et al.()reported worse functional outcome in putaminocapsular and lobar bleeding.In the study ofBarber et al. ()poor outcome at  days after ICH (dead or mRS at least ) had  of the patients, while only  of survivors had mRS less than .