Evaluation of Clinical Presentation and Associated Comorbid Conditions in Patients with Spontaneous Intracerebral Hemorrhage in a Tertiary Care Hospital in Bangladesh

Spontaneous intracerebral hemorrhage (ICH) has remained the least treatable form of stroke despite recent improvements in medical treatment. Treatment usually supportive and medical such as ventilatory support, blood pressure reduction, osmotherapy, fever control, seizure control and nutritional support and treatment of co morbidconditions. This study was carried out to see demographic variability, clinical presentation, causes and outcome of spontaneous intracerebral hemorrhage. Methods and materials: This was a cross sectional observational prospective in study on 50 spontaneous ICH patients admitted in Medicine department of Khulna Medical College Hospital from November 2020 to April, 2021. Result: The study showed that spontaneous ICH was most common in between 41-70 years. Their age frequency were 14 (28%) in 41-50 years, 15 (30%)in 5160 years, 12 (24%) in 61-70 years, 5 (10%) in 7180 years and 4 (8%) in more than 81 years age group. Among the patients, 64% (32) were male and 36% (18) were female. No of smoker male was 25(50%) and female was 1(2%) and no of nonsmoker male was 7(14%) and female was 17(34%). Headache was present in 56% (28) and absent in 44% (22) of patients. Vomiting was present in 54% (27) and was absent in 46% (23)of patients.Seizure was present in 16% (8) and was absent in 54% (42) of patients. Diabetes mellitus was present in 22% (11) of patients and absent in 78% (39) patients. Range of blood pressure –<140/90 in 24%(12), Systolic BP:140-159/Diastolic BP:90-99 (mm Hg) in 10%(5), Systolic BP:160-179/Diastolic BP:100-109 (mm Hg) in 22%(11),Systolic BP:180 or more/Diastolic BP:110 or more (mm Hg) in 44%(22) patients. Dyslipidemia was present in 30% (15) & absent in 70% (35) patients. Glasgow Coma Scale Score was 8 or less in 42% (21) and 9 or more in 58% (29) patients. Conclusion: Spontaneous ICH is common in Indian subcontinent. As death occur due to ICH itself, associated co morbidities or due to complications, management in stroke care unit, High dependency unit and Intensive care unit is required.


Introduction
Cerebrovascular diseases are the third leading cause of death after heart disease and cancer in developed countries. They also come first in terms of causing death and disability in neurologic diseases in adults [1]. Nontraumatic intracerebral hemorrhage is bleeding into the parenchyma of the brain that may extendinto the ventricles and, in rare cases, the subarachnoid space. Spontaneous intracerebral hemorrhage is second most common causes of stroke following ischemic stroke.Depending on the underlying cause of bleeding; intracerebral hemorrhage is classified as either primary or secondary. Primary intracerebral hemorrhage accounting for 78%-88% of all cases, originates from the spontaneous rupture of small vessels damaged by chronic hypertension or amyloid angiopathy [2]. The worldwide incidence of intracerebral hemorrhage from 10-20 cases per 100000 population, [3,4] and increases with age [3,5]. Intracerebral hemorrhage is more common in men than women, particularly those older than 55 years of age, [5,6] and in certain populations, including blacks and Japanese [3,7]. into the ventricles occurs in association with deep, large hematomas.The classic presentation of intracerebral hemorrhage is sudden onset of a focal neurological deficit that progress over minutes to hours with accompanying headache, nausea, vomiting, decreased consciousness and elevated blood pressure. Computed tomography is the key part of the initial diagnostic evaluation. First, it clearly differentiates hemorrhage from ischemic strokes. In addition computed tomography demonstrates the side and location of the hemorrhage and may reveal structural abnormality as well as structural complications such as herniation, intraventricular hemorrhage or hydrocephalus. [10] Initial management should first be directed toward the basics of air way, breathing, and circulation, and detection of focal neurologicaldeficits [10].
Other supportive medical care includes reduction of the intracranial pressure by diuretics (Mannitol 20% and furosemide, use of anticonvulsants (Diazepam, Midazolam or Phenobarbital) and control of hyperthermia (In order to decrease the neural metabolism) achieved by: external refrigeration, cold saline, sedation, and mechanical ventilation [11]. The optimal level of patients' blood pressure should be based on individual factors such as chronic hypertension, elevated intracranial pressure, age, presumed cause of hemorrhage, and interval since onset [12]. In general recommendation for treatment of elevated blood pressure in patients with ICH are more aggressive than those for patients with ischemic stroke [19]. Antihypertensive agents recommended for treatment of blood pressure in ICH: nitroprusside, labetalol, enalapril, esmolol, hydralazine [10]. In one fourth of patients with intracerebral hemorrhage who are initially alert, a deterioration in the level of consciousness occurs within first 24 hours after onset of hemorrhage [13,14]. Expansion of the hematoma is the most common cause of underlying neurologic deterioration within the first three hours the onset of hemorrhage. Worsening cerebral edema is also implicated in neurologic deterioration that occurs within 24-48 hours after the onset of hemorrhage [14].

Socio economic condition Frequency Percent
Poor 20 40 Middle class 29 58 High class 1 2 Total 50 100.0                [21] showed that compared with woman, men had a younger age of onset.
All studies have shown a steep rise in incidence with increasing age.
In this study, spontaneous ICH is more common in male 64% (32) than female 36% (18). In study by Ong and Raymond, (2002) [19] showed that male to female ratio was 1:0.77. Adnan et al. (1997) [21] in a study showed that compared with woman, men had a younger age of onset (54 versus 60 years; p<0.001). Juvela et al (1995) [20] in a study of consecutive patients, 96 were men and 60 were women where male female ratio was 1:0.63. Zaharia B et al (2005) [11] studied, from 93 studied cases 51 were men and 42, women. 52.6% were in the 5 th and 6 th decade. Results of all the above studies regarding age distribution correspond with our study.
In the study regarding the occupation of the patients having Spontaneous ICH, farmer/day labour was 26% (13), businessman was 24% (12), and house-wife was 36% (18), and service holder was14% (7). Giulia et al. (2009) [23] found men with low SEP(socioeconomic position) with an ischemic event were more likely to be hospitalized for a new stroke than men with high SEP. Women with low SEP with hemorrhagic stroke were more likely to be hospitalized for cardiovascular disease compared with women with high SEP.
In our study, we found that spontaneous ICH was common in poor and middle class family. Among the patients, poor was 40% (20), solvent 58% (29), very good 2% (1). In a study by Giulia et al. (2009) [22] showed that stroke incidence strongly differs between socioeconomic groups reflecting a heterogeneous distribution of lifestyle and clinical risk factors. Strategies for primary prevention should target less affluent people.
In this study, we found that spontaneous ICH was more common in smoker. Among 50 cases, male smoker were 25(50%) and female 1(2%) and nonsmoker male was 7(14%) and female was17 (34%).Kafle R D [16], showed that 21 percent of patients were smoker. In study by Zaharia et al (2005) [11] found that, cigarette smoker (13.1%). Doctor et al (2013) [15], showed in their study, history of smoking was present in 24 cases (48%), all were male and 17 patients (34%) were currently smoking. Craig S. Anderson reported history of smoking in 29% of patients and exsmoking in 19% of patients out of 60% cases of spontaneous intracerebral hemorrhage.
In our study we found that spontaneous intracerebral hemorrhage is commonly associated with high blood pressure. Among 50 patients, Systolic blood pressure(SBP): Less than 140/diastolic blood pressure(DBP): Less than 90 (mm Hg) found in 24% (12) [18] conducted a prospective hospital-based study of 60 consecutive Chinese patients where they found 50% of the patients had complains of hypertension, but only 20% of these patients were treated with antihypertensive medication. Ong and Raymond, (2002) [19] studied to identify the prevalence of major risk factor for stroke and to determine predictors of one-month mortality. They found hypertension was the commonest risk factor (71.5%) followed by diabetes mellitus (40.2%) and dyslipidemia (37%). Study by Adnan et al. (1997) [21] showed most common risk factors in intracerebral hemorrhage were preexisting hypertension (77.0%). In their study among the 91 non hypertensive patients, 21 (23.0%) were diagnosed with hypertension after onset.
In our study we found that dyslipidemia was present in 30% (15) [15] in their study they showed that vomiting was present in 23 (46%) cases.

Conclusion:
Spontaneous ICH is a major cause of morbidity and mortality among stroke patients. Hypertension is the most common cause of spontaneous ICH;others are smoking, dyslipidemia, diabetes mellitus and family history of stroke. Mainstay of treatment is supportive, including airway maintenance, diabetes control, blood pressure control, treatment and prophylaxis of convulsion, temperature control, nutritional support, careful fluid therapy and rehabilitation is also needed for improved mortality and morbidity.

Limitation of Study:
The present study did not represent the actual scenario of spontaneous ICH in Bangladesh because the study was conducted in one tertiary level hospital (Khulna Medical College and Hospital (KMCH). Sample size and duration of the study was short. Actual measurement of intracranial pressure was not possible. Advanced investigation facilities (Cerebral angiogram, MRI of brain) were limited. There was no advanced life support available.