Non-Traumatic Brain Hemorrhage in Kerman, Iran
H.A. Ebrahimi MD, M.A. Shafa MD, M. Saba MD
Department of Neurology, Shafa Medical Center, Kerman University of Medical Sciences, Kerman, Iran
Spontaneous non-traumatic brain hemorrhage has been investigated for clinical manifestations, possible etiologic factors, and different epidemiological indices in stroke patients hospitalized in Shafa Medical Center, Kerman from March 1998 to March 1999. In this cross-sectional prospective study, data analyses is performed using X2 and t-test. The prevalence of spontaneous brain hemorrhage is observed 15.5/100,000 in the general population and 123/100,000 in the high-risk population (above 50) respectively, in Kerman city. Approximately 85% of patients above 50 years of age had a previous history of primary hypertension, which was assumed to be the main precipitating factor. CT scan data revealed that the ganglionic region is involved in 53% of cases, and subarachnoid or ventricular hemorrhages are seen in 61% of cases.
Keywords · Brain hemorrhage · non-traumatic · primary hypertension
Introduction
Brain hemorrhage is defined as the extravasation of blood from the vascular bed into the intracranial space, resulting in clinical dysfunction of the nervous system. Brain hemorrhage may occur due to head trauma, coagulopathy, brain surgery, or it may occur spontaneously. There are several causes for non-traumatic brain hemorrhage, the commonest is perhaps chronic hypertension. Less common causes include rupture of a saccular aneurysm and other vascular disorders.
Hypertension has been implicated as a factor causing weakening in the arteriolar walls with subsequent microaneurysm formation. Approxi-mately 40%-50% of the cases of intracerebral hemorrhage are associated with systemic hyper-tension and show a peak incidence in 50-60 year age group.1 Hypertension is the most important risk factor causing intracerebral hemorrhage, but its prevalence has declined over the past few years.2 In 30% of reported cases, there was no history of hypertension.3 In these cases, the site of hemorrhage was often found to be in the cortical and subcortical white matter (lobar). These patients are usually older than other non-traumatic patients.There are several classifications for brain hemorrhage depending on: a) Site of hemorrhage (extradural, subdural, subarachnoid, parenchym-atous and intraventricular). b) Ruptured vessel involved (arterial, capillary, or venous). c) Other factors such as, coagulopathies and degenerative or hypertensive disorders.4
In this study the prevalence of non-traumatic brain hemorrhage in the city of Kerman, was evaluated and different causes of this disorder were investigated.
Materials and Methods
All non-traumatic patients admitted in Shafa Medical Center, Kerman, in 1997, who were found to have brain hemorrhage on brain CT scan or patients in whom a lumbar puncture revealed blood, were entered into our study and their demographic status, clinical profile, and CT scan findings were evaluated.
Results
A total of 750 cases with clinical signs and symptoms of central nervous system involvement were admitted to the CT-scan section of Shafa Medical Center in 1998. Ninety-seven of these patients had spontaneous brain hemorrhage, out of which, 60 patients were from the city of Kerman.
Since the population of Kerman is 384,991 5 , the incidence of non-traumatic brain hemorrhage could be calculated as 15.5/100,000 per year. Of this population, 41,000 residents are aged above 50 6, therefore the annual incidence of non-traumatic brain hemorrhage among the high-risk group was 123/100,000. In this study no significant difference was found between male and female involvement. About 85% of our cases were above 50 years of age, with a peak incidence at 65 years.
Overall, 70% of cases, were hypertensive (71.5% with systolic blood pressure more than than 150 mmHg and 60% with diastolic greater than 85 mmHg).
In 13.5% of cases, the type of hemorrhage was found to be lobar hemorrhage, which was mostly seen in the younger hypertensive patients. In our cases the temporal and occipital lobes were the most frequently involved sites of hemorrhage. Convulsion as a major complication of brain hemorrhage was also found in 6% of cases.
Discussion
Cerebrovascular accident is one of the four major causes of death in most countries and is responsible for a large proportion of the neurologic disorders. The incidence of stroke can be calculated as the sum of the hospitalized sudden death, and non-hospitalized stroke cases. 4 Patients with high blood pressure have a lower level of consciousness. Markedly elevated blood pressure on admission and persistent inadequate blood pressure control adversely affects the prognosis of hypertensive intracerebral hemorrhage. 7
In case of lobar hemorrhage, factors other than hypertension are also involved. Generalized progressive vascular muscle wall weakness induced by chronic hypertension 8, and amyloid angiopathy may be causes of lobar hemorrhage.9 Patients with lobar hemorrhage are usually younger than patients with non-lobar hemorrhage. In other studies however, opposite findings were seen. In our study, the frontal lobes were the least and the temporal lobes the most frequent sites of lobar hemorrhage, while in other studies the highestrate of involvement occurred in the occipital lobes.10
Most brain parenchymal hemorrhage arises in the region of the small arteries that serve the basal ganglia, thalamus, and brainstem and are mostly caused by arteriopathy due to chronic hyper-tension.11 In cerebral hemorrhage, blood leaks from the vessel directly into the brain, forms a hematoma in the brain substance, and then spreads into the ventricles and subarachnoid space. In 61% of our cases, blood had spread to involve the ventricles and subarachnoid space. This was mostly seen among females in present study in contrast to other reports which show a male to female ratio of 2:1, 3:2, and 1.6:1.12
References