Intracranial haemorrhage is a major cause of severe morbidity and mortality in child abuse cases in developed countries. However, similar data are not available in most developing countries. This study therefore aimed to determine the incidence of intracranial haemorrhage amongst all cases of child physical abuse, the nature of the injuries incurred, and the morbidity and mortality resulting therefrom. Among 369 cases of physical abuse seen over a 4-year period, 41 (11.4%) had intracranial haemorrhage, of whom 37 (90%) were 2 years old or less. A history of trauma was present in only eight (20%), of which only two were compatible with the injuries incurred. Subdural haemorrhages accounted for 80% of the cases, with skull fractures present in only nine cases. Fifty-four per cent of the 37 children aged 2 years of age or less had no external signs of trauma, but 11 of them had retinal haemorrhages. This is in contrast to the children older than 2 years of age who all had external signs of trauma. The overall prognosis was dismal with an early mortality of almost 30% (13 cases) and at least seven cases with severe neurological sequelae. These findings are comparable with studies from developed countries which have established that non-accidental injury must be considered as a cause of intracranial haemorrhage in any young child, despite the absence of external signs of trauma.
OBJECTIVE: We assessed whether hematoma expansion (HE) and favorable outcome differ according to type of intracerebral hemorrhage (ICH).
METHODS: Among participants with ICH enrolled in the TICH-2 (Tranexamic Acid for Hyperacute Primary Intracerebral Haemorrhage) trial, we assessed baseline scans for hematoma location and presence of cerebral amyloid angiopathy (CAA) using computed tomography (CT, simplified Edinburgh criteria) and magnetic resonance imaging (MRI; Boston criteria) and categorized ICH as lobar CAA, lobar non-CAA, and nonlobar. The main outcomes were HE and favorable functional outcome. We constructed multivariate regression models and assessed treatment effects using interaction terms.
RESULTS: A total of 2,298 out of 2,325 participants were included with available CT (98.8%; median age = 71 years, interquartile range = 60-80 years; 1,014 female). Additional MRI was available in 219 patients (9.5%). Overall, 1,637 participants (71.2%) had nonlobar ICH; the remaining 661 participants (28.8%) had lobar ICH, of whom 202 patients had lobar CAA-ICH (8.8%, 173 participants according to Edinburgh and 29 participants according to Boston criteria) and 459 did not (lobar non-CAA, 20.0%). For HE, we found a significant interaction of lobar CAA ICH with time from onset to randomization (increasing risk with time, pinteraction
Primary intracerebral haemorrhage (ICH) results in significant morbidity and mortality among patients. There is a paucity of epidemiological data on this condition in Malaysia. The purpose of this hospital based study was to define the clinical profile in patients with primary spontaneous intracerebral haemorrhage at University of Malaya Medical Centre (UMMC) and to determine the mortality rate of intracerebral haemorrhage at the time of discharge, the prognostic factors and one year outcome of this cohort of patients. Sixty-six patients were admitted at the Neurosurgical unit of University of Malaya Medical Centre for a period of 13 months from March 2002 to March 2003. Fifty percent of the subjects were female. The mean age was 61.6 +/- 16.7 years. Among our patients with intracerebral haemorrhage, the common risk factors were: hypertension (80.3%), diabetes mellitus (25.7%) and smoking (27.2%). Common presenting features for our series were: weakness (61.8%), LOC (58.5%), headache (56.3%) and speech disturbances (45.3%). On neuroimaging, the lesions were seen in basal ganglia/thalamus (45.1%), lobar (32.9%), brainstem (13.4%) and cerebelli (8.5%). The overall 30 days mortality rate for intracerebral haemorrhage (ICH) was 43.9%. The important predictors of for mortality were the GCS score on admission (p < 0.0001), haematoma volume > 30 mls (p < 0.0001), evidence of intraventricular extension (p = 0.011) and ICH score (p < 0.0001). At one year follow up, 48.5% (n = 32) were dead, 33.3% (n = 11) obtained good recovery, 36.4% (n = 12) moderate disability, 18.2% (n = 6) severe disability and 3% remain vegetative state. The overall mortality rate for our series of patients with primary intracerebral haemorrhage is quite similar to previously published epidemiological studies. ICH scoring is useful in the prognostication.
BACKGROUND:Stroke is a leading cause of death and disability, especially in low-income and middle-income countries. We sought to quantify the importance of potentially modifiable risk factors for stroke in different regions of the world, and in key populations and primary pathological subtypes of stroke.
METHODS:We completed a standardised international case-control study in 32 countries in Asia, America, Europe, Australia, the Middle East, and Africa. Cases were patients with acute first stroke (within 5 days of symptom onset and 72 h of hospital admission). Controls were hospital-based or community-based individuals with no history of stroke, and were matched with cases, recruited in a 1:1 ratio, for age and sex. All participants completed a clinical assessment and were requested to provide blood and urine samples. Odds ratios (OR) and their population attributable risks (PARs) were calculated, with 99% confidence intervals.
FINDINGS: Between Jan 11, 2007, and Aug 8, 2015, 26 919 participants were recruited from 32 countries (13 447 cases [10 388 with ischaemic stroke and 3059 intracerebral haemorrhage] and 13 472 controls). Previous history of hypertension or blood pressure of 140/90 mm Hg or higher (OR 2·98, 99% CI 2·72-3·28; PAR 47·9%, 99% CI 45·1-50·6), regular physical activity (0·60, 0·52-0·70; 35·8%, 27·7-44·7), apolipoprotein (Apo)B/ApoA1 ratio (1·84, 1·65-2·06 for highest vs lowest tertile; 26·8%, 22·2-31·9 for top two tertiles vs lowest tertile), diet (0·60, 0·53-0·67 for highest vs lowest tertile of modified Alternative Healthy Eating Index [mAHEI]; 23·2%, 18·2-28·9 for lowest two tertiles vs highest tertile of mAHEI), waist-to-hip ratio (1·44, 1·27-1·64 for highest vs lowest tertile; 18·6%, 13·3-25·3 for top two tertiles vs lowest), psychosocial factors (2·20, 1·78-2·72; 17·4%, 13·1-22·6), current smoking (1·67, 1·49-1·87; 12·4%, 10·2-14·9), cardiac causes (3·17, 2·68-3·75; 9·1%, 8·0-10·2), alcohol consumption (2·09, 1·64-2·67 for high or heavy episodic intake vs never or former drinker; 5·8%, 3·4-9·7 for current alcohol drinker vs never or former drinker), and diabetes mellitus (1·16, 1·05-1·30; 3·9%, 1·9-7·6) were associated with all stroke. Collectively, these risk factors accounted for 90·7% of the PAR for all stroke worldwide (91·5% for ischaemic stroke, 87·1% for intracerebral haemorrhage), and were consistent across regions (ranging from 82·7% in Africa to 97·4% in southeast Asia), sex (90·6% in men and in women), and age groups (92·2% in patients aged ≤55 years, 90·0% in patients aged >55 years). We observed regional variations in the importance of individual risk factors, which were related to variations in the magnitude of ORs (rather than direction, which we observed for diet) and differences in prevalence of risk factors among regions. Hypertension was more associated with intracerebral haemorrhage than with ischaemic stroke, whereas current smoking, diabetes, apolipoproteins, and cardiac causes were more associated with ischaemic stroke (p<0·0001).
INTERPRETATION: Ten potentially modifiable risk factors are collectively associated with about 90% of the PAR of stroke in each major region of the world, among ethnic groups, in men and women, and in all ages. However, we found important regional variations in the relative importance of most individual risk factors for stroke, which could contribute to worldwide variations in frequency and case-mix of stroke. Our findings support developing both global and region-specific programmes to prevent stroke.
FUNDING: Canadian Institutes of Health Research, Heart and Stroke Foundation of Canada, Canadian Stroke Network, Health Research Board Ireland, Swedish Research Council, Swedish Heart and Lung Foundation, The Health & Medical Care Committee of the Regional Executive Board, Region Västra Götaland (Sweden), AstraZeneca, Boehringer Ingelheim (Canada), Pfizer (Canada), MSD, Chest, Heart and Stroke Scotland, and The Stroke Association, with support from The UK Stroke Research Network.