Spontaneous Intracerebral Hemorrhage Risk Factors [Neurosurgery Wiki]

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====== Spontaneous Intracerebral Hemorrhage Risk Factors ======


[[Hypertension]], [[obesity]], [[smoking]], and [[cerebral small vessel disease]] were important factors associated with non-lesional spontaneous intracerebral hemorrhage in young patients. Radiologic changes corresponding to cerebral small vessel disease appeared in young patients (in their 30s) and they were associated with hypertension
((Jang JS, Park YS. Contributing factors of spontaneous intracerebral hemorrhage development in young adults. J Cerebrovasc Endovasc Neurosurg. 2024 Jun 20. doi: 10.7461/jcen.2024.E2023.11.001. Epub ahead of print. PMID: 38897595.)).
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Psychosocial, ethnic, and economic factors play a role in the prevalence of [[Spontaneous Intracerebral Hemorrhage]], with ICH being twice as common in low-income and middle-income countries compared with high-income countries. Other identified risk factors for ICH include age (i.e., each decade from 50 years of age is associated with a 2-fold increase in the incidence of ICH) and an elevated alcohol intake.

Etiologies of ICH to always consider include intracranial aneurysms (typically presenting as subarachnoid hemorrhage); arteriovenous malformations (ICH is the first presentation of AVMs in 60 % of cases); cerebral venous sinus thrombosis and venous infarction; brain tumors (<5 % of all ICH cases) including cerebral metastases (e.g., lung cancer, melanoma, renal cell carcinoma, thyroid carcinoma, and choriocarcinoma) and primary CNS tumors (e.g., glioblastoma multiforme and oligodendrogliomas); and drugs of abuse (e.g., [[cocaine]], amphetamines). Because of the differing etiologies of ICH, a rapid and accurate diagnosis of the underlying etiology of ICH is essential to direct appropriate management strategies.

===== Hypertensive intracerebral hemorrhage =====

The most important modifiable risk factor in spontaneous ICH is chronic arterial hypertension:

see [[Hypertensive intracerebral hemorrhage]].

===== Amyloid angiopathy =====

Besides hypertension, cerebrovascular amyloid deposition (i.e., [[cerebral amyloid angiopathy]]) is associated with ICH in older patients.
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Although [[cerebral amyloid angiopathy]] (CAA), which is Aβ deposition in the cerebral vessels, related [[cerebral hemorrhage]] rarely develops in young people, several patients with CAA-related cerebral hemorrhage under the age of 55 with histories of neurosurgeries with and without dura mater graft in early childhood have been reported. These patients might show that Aβ pathology is often recognized as Aβ-CAA rather than parenchymal Aβ deposition in the transmission of cerebral β-amyloidosis in humans, and Hamaguchi et al. proposed an emerging concept, "acquired CAA". Considering that there have been several patients with acquired CAA with an incubation period from neurosurgery and the onset of CAA-related cerebral hemorrhage of longer than 40 years, the number of cases is likely to increase in the future, and detailed epidemiological investigation is required. It is necessary to continue to elucidate the pathomechanisms of acquired CAA and urgently establish a method for preventing the transmission of cerebral β-amyloidosis among individuals
((Hamaguchi T, Ono K, Yamada M. Transmission of Cerebral β-Amyloidosis Among Individuals. Neurochem Res. 2022 Mar 11. doi: 10.1007/s11064-022-03566-4. Epub ahead of print. PMID: 35277809.)).

===== Intracranial vascular malformation =====

It is a common initial symptom of [[intracranial vascular malformation]]s. 

see [[Intracerebral hemorrhage from ruptured cerebral arteriovenous malformation]].

see [[Aneurysmal intracerebral hemorrhage]].

see [[Cerebral venous sinus thrombosis]] and venous infarction.

===== Neoplasm =====

see [[Spontaneous intracranial hematoma caused by neoplasm]].

===== Vasculitis =====

[[Vasculitis]].

===== AIDS =====

Complication of [[AIDS]].

===== NPH =====


[[Shunt]]ing for [[NPH]]

===== Coagulopathy =====

Coagulopathies (i.e., the use of antithrombotic or thrombolytic agents, congenital or acquired factor deficiencies) and systemic diseases, such as [[thrombocytopenia]], are possible causes of ICH. The use of oral anticoagulants, especially vitamin K inhibitors (i.e., warfarin), has increased coagulopathy-associated ICH in recent years, accounting for more than 15 % of all cases.

Severe [[thrombocytopenia]] can result in petechial hemorrhages or [[spontaneous intracerebral hemorrhage]] (ICH).

===== Anticoagulant Related Intracerebral Hemorrhage =====

see [[Anticoagulant Related Intracerebral Hemorrhage]].



===== Posterior fossa surgery =====
Remote [[supratentorial]] [[hematoma]] soon after [[posterior fossa surgery]] for the removal of a space-occupying lesion is a rare but dramatic and dreaded complication, carrying significant morbidity and mortality
((Bucciero A, Quaglietta P, Vizioli L. Supratentorial intracerebral hemorrhage after posterior fossa surgery: Case report. J Neurosurg Sci. 1991;35:221–4.))
((Haines SJ, Maroon JC, Jannetta PJ. Supratentorial intracerebral hemorrhage following posterior fossa surgery. J Neurosurg. 1978;49:881–6.))
((Harders A, Gilsbach J, Weigel K. Supratentorial space occupying lesions following infratentorial surgery early diagnosis and treatment. Acta Neurochir (Wien) 1985;74:57–60.))
((Seiler RW, Zurbrugg HR. Supratentorial intracerebral hemorrhage after posterior fossa operation. Neurosurgery. 1986;18:472–4.))
((Tondon A, Mahapatra AK. Superatentorial intracerebral hemorrhage following infratentorial surgery. J Clin Neurosci. 2004;11:762–5.))
((Vrettou CS, Stavrinou LC, Halikias S, Kyriakopoulou M, Kollias S, Stranjalis G, et al. Factor XIII deficiency as a potential cause of supratentorial haemorrhage after posterior fossa surgery. Acta Neurochir (Wien) 2010;152:529–32.))
((Pandey P, Madhugiri VS, Sattur MG, Devi BI. Remote supratentorial extradural hematoma following posterior fossa surgery. Childs Nerv Syst. 2008;24:851–4.))
((Wolfsberger S, Gruber A, Czech T. Multiple supratentorial epidural haematomas after posterior fossa surgery. Neurosurg Rev. 2004;27:128–32.)).

===== Posterior reversible encephalopathy syndrome =====
see [[Posterior reversible encephalopathy syndrome]].

===== Ethanol =====
[[Ethanol]]

===== Cocaine =====
[[Cocaine]]

===== Inadvertent intrathecal injection of unapproved contrast agents =====
[[Inadvertent intrathecal injection of unapproved contrast agents]].

===== Vitamin D =====


The evidence linking [[vitamin D]] (VitD) levels and [[Spontaneous Intracerebral Hemorrhage Risk Factors]] remains inconclusive. Szejko et al. tested the hypothesis that lower genetically determined VitD levels are associated with a higher risk of ICH. They conducted a 2-sample [[Mendelian Randomization]] (MR) study using publicly available summary statistics from published [[genome-wide association study]] of VitD levels (417 580 study participants) and ICH (1545 ICH cases and 1481 matched controls). They used the [[inverse variance-weighted average method]] to generate causal estimates and the MR [[Pleiotropy]] Residual Sum and Outlier and MR-Egger approaches to assess for horizontal pleiotropy. To account for known differences in their underlying mechanism, we implemented stratified analysis based on the location of the hemorrhage within the brain (lobar or nonlobar). Our primary analysis indicated that each SD decrease in genetically instrumented VitD levels was associated with a 60% increased risk of ICH (odds ratio [OR], 1.60; [95% CI, 1.05-2.43]; P=0.029). They found no evidence of horizontal pleiotropy (MR-Egger intercept and MR Pleiotropy Residual Sum and Outlier global test with P>0.05). Stratified analyses indicated that the association was stronger for nonlobar ICH (OR, 1.87; [95% CI, 1.18-2.97]; P=0.007) compared with lobar ICH (OR, 1.43; [95% CI, 0.86-2.38]; P=0.17). 
Lower levels of genetically proxied VitD levels are associated with higher ICH risk. These results provide evidence for a causal role of VitD metabolism in ICH
((Szejko N, Acosta JN, Both CP, Leasure A, Matouk C, Sansing L, Gill TM, Hongyu Z, Sheth K, Falcone GJ. Genetically-Proxied Levels of Vitamin D and Risk of Intracerebral Hemorrhage. J Am Heart Assoc. 2022 Jun 22:e024141. doi: 10.1161/JAHA.121.024141. Epub ahead of print. PMID: 35730641.)).

===== COVID-19 and Intracerebral Hemorrhage =====

[[COVID-19 and Intracerebral Hemorrhage]]


===== References =====