Prevalence of Hemorrhagic Stroke Subtypes, Etiological Causes and Its Association with Various Stroke Related Risk Factors: An Observational Study

DISCUSSION

The present study effectively analyzes the risk factors and causes of acute HS in the Indian setting and provides a distribution of the various etiological HS subtypes in a hospital-based sample. During the review period, we inspected 38 patients who had a clinical and radiologically affirmed diagnosis of HS tentatively.

In cases of intra-parenchymal bleeding, the median age was 64.4 ± 2.6 years, while in cases of subarachnoid bleeding, it was 61.5 ± 3 years, with ages ranging from 18 to 76 years. It was clear that the strokes were most pervasive in the age-gathering of 60–69 years. This study’s findings were comparable to those of other Indian studies.⁶ Age is a nonmodifiable factor that has been shown to increase the risk of stroke with age. The Neurological Society of India reported that, like ours, the age-specific incidence of stroke was higher in the 60s and 70s.⁷

The male:female proportion was 5.3:1; In general, there was a male preponderance, which was similar to what was found in other studies.⁸ Moreover, a meta-analysis from 19 countries reported that the incidence (33%) and prevalence (41%) of HS were more noteworthy in men than women. The fact that men are more likely to seek medical attention may also be a factor in the lower percentage of women.

In our study, the most frequent site of HS was observed to be the basal ganglia (50%) followed by the thalamus (23.7%). Chen et al. in their review expressed that the common sites of HS were the basal ganglia (50%), cerebral lobes (10–20%), pons and the brain stem (10–20%), thalamus (15%), and cerebellum (10%).⁹ Lee et al. also reported that intraventricular hemorrhage was more common in the thalamus and basal ganglia.¹⁰ In our study, ACA (80%) was the most common site of aneurysmal rupture, followed by the MCA (20%). According to the International Study of Unruptured Intracranial Aneurysms, which included 4,060 patients with unruptured intracranial aneurysms, the majority of aneurysms occur in the anterior circulation of the circle of Willis, whereas only 12% of intracranial aneurysms occur in the posterior circulation of the vertebral and basilar systems. Likewise, the latest Japanese cohort study showed the comparative frequency of rupture for anterior and posterior circulations. In addition, the authors discovered that ACA aneurysms had a higher rate of rupture than PCA aneurysms.

According to Siddique et al.¹¹ and Baidya et al.,¹² hemiplegia was the most common presentation of HS in India (80%), followed by dysarthria (60%), and aphasia (59%), respectively. Hemiparesis and hemiplegia were the most common presentations of stroke (87.6%). Patients with dysarthria/aphasia had fewer speech defects (43. 8%) in our study. This distinction could be attributed to the type of study, such as the current forward cohort study or the backward cohort study.

The risk factors for HS can be arranged into modifiable (HTN, diabetes, cardiovascular infection, dyslipidemia smoking, and customary liquor consumption) and nonmodifiable elements (counting age, orientation, and earlier history of stroke).

In general, the prevalence of HS has been linked to a number of risk factors, including smoking, alcohol consumption, diabetes, HTN, dyslipidemia, and DM. It is now well-known that high blood pressure (BP) is a significant risk-factor for HS.

Although HTN was found to be the most common risk-factor for HS (78.9%), the Chi-squared test found that these findings were statistically significant (P0.05). 64% of stroke patients in Gorgan, according to Hosaini and Bazrafshan;¹³ had high BP, regardless of the type of stroke. Law et al.’s study of clinical trial meta-analysis (2009) expressed that the frequency of HS was lessened by 41% when both systolic and diastolic pulses were reduced.¹⁴ It appears to be that antihypertensive treatment along with modifications in lifestyle can diminish the risk of HS and its recurrence. A review has revealed that inadequate BP control has a more prominent likelihood of ICH relapse than patients with ICH who have a history of admission of antiplatelet drugs, the incidence of ICH relapse and volume of hemorrhage didn’t increase.¹⁵

This study entails a significant connection between diabetes and HS. According to our findings, 21% of all HS patients were diabetic. Diabetes management may also reduce mortality and prevent both primary and secondary HS. Variable data exist for diabetes to be a risk-factor for ICH. Pooled investigations of Atherosclerosis Risk in Communities and Cardiovascular Health Studies disclosed an age-adjusted relative rate of 1.11 for people who have diabetes and ICH.¹⁶ Men in the Honolulu Heart Program and the Framingham Study had similar rates of bleeding, but only those with diabetes were at an increased risk for ICH in the Framingham group (relative risk, 3.1).¹⁷

Dyslipidemia was a significant risk factor that was observed in 5. 3% of the HS patients, which was consistent with previous findings that were reported by Tziomalos et al.¹⁸ In-hospital mortality rate is almost twice as high in patients who do not have diabetes compared to those who do¹⁹ and Sarti et al.²⁰ A total serum cholesterol level of 4.62 mmol/L (178 mg/dL) was associated with a significantly greater risk for ICH in men aged 65 years or older (relative risk, 2.7; Kaiser Permanente Study).²¹ This relationship between total serum cholesterol and low-density lipoprotein cholesterol and hemorrhages is consistently reported²² (95% confidence interval, 1.4–5.0). Patients with lower total serum cholesterol levels have been found to have a higher rate of in-hospital mortality within the first 48 hours of admission.

A risk-factor for HS includes heart disease. People with coronary course sickness or ongoing cardiovascular breakdown are 2–4 times as prone to have HS.²³ Examinations showed that HS accounted for 20–32%, with extracranial (25–26%) and intracranial (30%) carotid diseases.²⁴ In this study, cardiac diseases accounted for 42.1% of HS patients.

In India, the rising prevalence of tobacco use is a major health concern. In addition, a rise in noncommunicable diseases can be attributed to the lifestyle changes brought about by urbanization and industrialization. Two HS patients, or 5.3%, in our study, were smokers. In accordance with this study, Donnan et al.²⁵ discovered that smoking was a significant risk-factor for SAH. Numerous studies have identified smoking as a risk-factor for cerebral hemorrhage. This connection to SAH is well established, particularly among Asians.²⁶ However, smoking is not as strongly associated with primary intracranial bleeding. Similar findings were obtained in studies conducted in Australia, Norway, and Poland.²⁷ Excessive alcohol consumption has been identified as a risk-factor for HS. In our study, 4.5% of the patients had previously consumed alcohol. It is thought that alcohol has an effect on the coagulation pathway and the integrity of the cerebral vessels.²⁸

Drug abusers have a higher risk of HS. It is a frequent cause of ICH in young adults in areas with a high prevalence of illicit drug use. Psychomotor stimulants like cocaine and amphetamine, are more frequently linked to HS.²⁹ The case reports of amphetamine use and ICH are generally seen in the youth.³⁰ A 1-year long case series of all deadly ICH cases inspected by the Connecticut office of the Main Clinical Inspector reported that 59% were related to cocaine misuse.³¹

The current study found a significant link between smoking and HS. In our study, 26. 3% of HS patients smoked. Nicotine starts with many different pathological mechanisms like platelet activation, endothelial dysfunction, atherogenesis, sympathoadrenal activation, arrhythmia, relative insulin resistance, and dyslipidemia, all of this prompt vascular damage and causes CVD including stroke.³² Consumption of snuff was linked to an increased risk of SAH in one Swedish study.³³

A condition known as CAA is responsible for around 12–15% of all cerebral hemorrhages in elderly people. Amyloid-β precursor protein–associated CAA is the most common type of ischemic and HS. CAA was seen during post-mortem in over half of individuals aged 90 years or more.³⁴ Clinical series revealed that CAA-related ICH may specially influence the frontal lobe, despite the fact that posteriorly found hemorrhages in the brain hemisphere are accepted to be common.³⁵ Amyloid angiopathy is additionally connected with repetitive ICH and warfarin-related bleeds.³⁶

Oral anticoagulation (OAC) increases the risk for ICH. Patients receiving OAC have a 7–10 fold increased risk of ICH compared to those receiving no treatment, according to numerous studies. Two of the patients in our study had previously taken anticoagulants. Anticoagulant medications may be linked to between 10 and 12% of all ICH. OAC-related ICH has a mortality rate of approximately 50%. In contrast to spontaneous ICH, the initial event is followed by 12–24 hours of bleeding.³⁷

Anticoagulants have a greater impact on ICH than antiplatelet medications do. According to, Gorelick and Weisman patients taking aspirin for primary prevention of myocardial infarction have a risk of 0.2 events per 1,000 patient in years³⁸ Several studies have shown that antiplatelet use is associated with worse outcomes. Biffi et al. have discovered that antiplatelet therapy may increase the likelihood of ICH recurrence in lobar hemorrhage patients.³⁹

Arteriovenous malformations (AVMs) are a relatively rare condition, with an estimated prevalence of 0.1–0.5% in the general population. The most common presentation of AVMs is HS, which occurs in approximately 50% of cases. AVMs can cause HS by rupturing and bleeding into the brain tissue, leading to neurological deficits and potentially life-threatening complications.

Bleeding disorders can build the risk of HS by debilitating the body’s capacity to form clots and keep up with hemostasis. ICH and SAH are more likely to happen to people who have bleeding disorders. Hemophilia, specifically, is related to a higher risk of ICH, with a reported incidence of up to 5% in severe hemophilia patients. Patients with bleeding disorders who have an HS may also be at higher risk of poor outcomes and are more likely to die or become disabled. In the current review, one patient had idiopathic thrombocytopenic purpura. Around 23.7% with ICH died. Similar outcomes were also observed in other studies.