Intracerebral haemorrhage — mechanisms, diagnosis and prospects for treatment and prevention

Abstract Background and purpose National quality registries for stroke care operate under the assumption that the included patients are correctly diagnosed. We aimed to validate the clinical diagnosis of spontaneous intracerebral hemorrhage (ICH) in Riksstroke (RS) by evaluating radiological data from a large, unselected ICH population. Methods We conducted a retrospective, multicenter study including all ICH patients registered in RS between 2016 and 2020 residing in Skåne County in Sweden (1.41 million inhabitants). Radiological data from first imaging were evaluated for the presence of spontaneous ICH. Other types of bleeds were registered if a spontaneous ICH was not identified on imaging. The radiological evaluation was independently performed by one radiology fellow and one senior neuroradiologist. Results Between 2016 and 2020, 1784 ICH cases were registered in RS, of which 1655 (92.8%) had a radiological diagnosis consistent with spontaneous ICH. In the 129 (7.2%) remaining cases, the radiological diagnosis was instead traumatic bleed ( n = 80), subarachnoid hemorrhage ( n = 15), brain tumor bleed ( n = 14), ischemic lesion with hemorrhagic transformation ( n = 14), ischemic lesion ( n = 3), or no bleed at all ( n = 3). There was a higher degree of incorrect coding in the older age groups. Conclusion At radiological evaluation, 92.8% of ICH diagnoses in RS were consistent with spontaneous ICH, yielding a high rate of agreement that strengthens the validity of the diagnostic accuracy in the register, justifying the use of high coverage quality register data for epidemiological purposes. The most common coding error was traumatic bleeds that were classified as spontaneous ICH. 

Diagnostic accuracy and radiological validation of intracerebral hemorrhage diagnosis in the Swedish Stroke Register (Riksstroke)

Neues Klassifikationssystem für spontane intrazerebrale Blutungen

Die intrazerebrale Blutung ist ein neurologischer Notfall, der durch die Ruptur eines intrakraniellen Blutgefäßes ausgelöst wird. Die intrazerebrale Blutung trägt wesentlich zur hohen Mortalität und Morbidität neurovaskulärer Erkrankungen bei. Ungefähr 15% aller Schlaganfälle sind intrazerebrale Blutungen, die Inzidenz hat in den letzten Jahren zugenommen. Die Symptome der intrazerebralen Blutung gleichen meist denen eines akuten ischämischen Schlaganfalls; die Unterscheidung ist nur mittels Bildgebung möglich.

Intrazerebrale Blutungen – ein Update

Hémorragies intracérébrales non traumatiques

Background and Objectives Cerebral small vessel disease (SVD) is the major cause of intracerebral hemorrhage (ICH). There is no comprehensive, easily applicable classification of ICH subtypes according to the presumed underlying SVD using MRI. We developed an MRI-based classification for SVD-related ICH. Methods We performed a retrospective study in the prospectively collected Swiss Stroke Registry (SSR, 2013–2019) and the Stroke InvestiGation in North And central London (SIGNAL) cohort. Patients with nontraumatic, SVD-related ICH and available MRI within 3 months were classified as Cerebral Amyloid angiopathy (CAA), Deep perforator arteriopathy (DPA), Mixed CAA-DPA, or Undetermined SVD using hemorrhagic and nonhemorrhagic MRI markers (CADMUS classification). The primary outcome was inter-rater reliability using Gwet's AC1. Secondary outcomes were recurrent ICH/ischemic stroke at 3 months according to the CADMUS phenotype. We performed Firth penalized logistic regressions and competing risk analyses. Results The SSR cohort included 1,180 patients (median age [interquartile range] 73 [62–80] years, baseline NIH Stroke Scale 6 [2–12], 45.6% lobar hematoma, systolic blood pressure on admission 166 [145–185] mm Hg). The CADMUS phenotypes were as follows: mixed CAA-DPA (n = 751 patients, 63.6%), undetermined SVD (n = 203, 17.2%), CAA (n = 154, 13.1%), and DPA (n = 72, 6.3%), with a similar distribution in the SIGNAL cohort (n = 313). Inter-rater reliability was good (Gwet's AC1 for SSR/SIGNAL 0.69/0.74). During follow-up, 56 patients had 57 events (28 ICH, 29 ischemic strokes). Three-month event rates were comparable between the CADMUS phenotypes. Discussion CADMUS, a novel MRI-based classification for SVD-associated ICH, is feasible and reproducible and may improve the classification of ICH subtypes in clinical practice and research.

Cadmus

Ein 77-jähriger Patient war aufgrund kleiner, akuter Ischämien der Grosshirnrinde beidseits und des Caput nuclei caudati rechts hospitalisiert. Nach fünf Tagen meldete er akut aufgetretenen Schwindel sowie Sehstörungen mit Diplopie. 

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