Recurrence of Bleeding in Patients with Hypertensive Intracerebral Hemorrhage

Abstract

To characterize the recurrence of bleeding in patients who had hypertensive intracerebral hemorrhage (HICH), the authors reviewed 989 patients who underwent treatment for HICH between 1989 and 1995. Fifty-three patients (5.4%) had two episodes of HICH within a median interval of 22.9 ± 16.3 months (range 1.5–72 months), and of these 3 (5.7%) had three episodes of HICH. The recurrence of bleeding most commonly occurred within 2 years of the first hemorrhage: in 66% of the 53 patients the second hemorrhage occurred soon after the first (within 1 year in 34%, within 1–2 years in 32.1%). The site of the second hemorrhage was different from the initial site in all patients. Only 1 patient had a third hemorrhage in the same site as the second hemorrhage. The common patterns of recurrence were ‘ganglionic (putamen/caudate nucleus)-thalamic’ in 26.8% and ‘ganglionic-ganglionic’ in 21.4%. The ‘lobar-lobar’ pattern was noted in only 2 patients. The volume of the hematoma was increased at the second hemorrhage. The overall mortality was 28.3%. The risk of recurrent hemorrhage significantly increased in the patients who had antihypertensive therapy of less than 3 months after the initial attack compared to those with further long-term therapy (p < 0.005). Long-term regular control for hypertension is needed to prevent recurrent hemorrhage.

Primary cerebral amyloidoma

“…3,6,9 The rate of recurrent ICH was higher during the initial year following the index ICH in one study. 9 Ischemic stroke.…”

“…2 Lobar location of the index ICH appeared to confer a higher risk of recurrent ICH compared with deep, hemispheric ICH (table 3; rate ratio 2.2; p ϭ 0.002) based on data from four studies. 6,8,9,11 The aggregate rate of recurrent ICH in the 192 patients with initial lobar ICH was 4.4% per patient-year (95% CI, 3.1% to 6.3%) versus 2.1% per patient-year (95% CI, 1.6% to 2.7%) among the 823 patients whose index event was a deep, hemispheric ICH. When data from an additional trial that was restricted to survivors of primary lobar ICH were added to the analysis, the rate of ICH recurrence in patients surviving primary lobar ICH was 5.4% per patient-year (95% CI, 4.1% to 7.1%).…”

“…This series did not appear to represent purely hypertensionrelated ICH, but rather primary ICH, much like the other studies. 6 Another study attempted to exclude ICH not associated with hypertension, but this exclusion was not clearly defined, as the authors did not provide data on the number of patients with primary ICH who failed to meet criteria for hypertension and were excluded from the study. In addition, relatively short follow-up and a small patient population make difficult any determination as to whether the lack of observed recurrence reflected a real difference between hypertension-related ICH and the play of chance.…”

Can Patients Be Anticoagulated After Intracerebral Hemorrhage?

“…27,28 Risk of recurrent hypertensive ICH can be limited by control of hypertension. 29,30 Cerebral amyloid angiopathy, on the other hand, lacks any known treatment. It is associated with both recurrent hemorrhagic strokes 12 and small, clinically asymptomatic hemorrhagic lesions 31 that might serve as the substrate for larger hemorrhagic strokes on warfarin.…”

Update in Intracerebral Hemorrhage

“…Advanced age is strongly predictive of these 3 outcomes. 71 The risk of ICH recurrence is driven by the underlying etiology 11,12,73,74 ; the most consistently identified risk factor for recurrent ICH is a lobar location of the initial bleed (ie, lobar ICH). Lobar bleeds (often caused by CAA) carry higher risk of re-bleeding than deep or ganglionic hematomas.…”