CLINICAL PROFILE OF INTRA-CEREBRAL HAEMORRHAGIC STROKE PATIENTS IN AN ETHNIC POPULATION OF NORTH INDIA.

1. Post DM Senior, Resident Department of Neurology GSSH, Srinagar. 2. Post MD Senior, Resident Department of Nuorology GSSH, Srinagar. ...................................................................................................................... Manuscript Info Abstract ......................... ........................................................................ Manuscript History Received: 08 February 2019 Final Accepted: 10 March 2019 Published: April 2019


561
common cause of disability in developed countries. 2,3 It is estimated that by 2020, 19 out of 25 million annual stroke deaths will be in developing countries. 4 Intra-Cerebral Haemorrhage (ICH) victims have a grim outcome with ensuing death or severe disability for more than 50%. 5 Of the thousands of stroke survivors each year, approximately 30% require assistance with activities of daily living, 20% require assistance with ambulation, and 16% require institutional care. 6 About 85% of strokes are due to cerebral ischemia and 15% are due to primary intracerebral hemorrhage 7,8 , especially in the western literature. However, overall, ICH accounts for 10-35% of stroke cases depending on the population studied 9 Like some series from Asian countries such as that from Shibata, Japan, with reported severalfold higher incidence rates of ICH 10 , ICH in our valley was reported to be the commonest stroke-type observed in Kashmir accounting for close to two third of strokes with male preponderance. 11 Consequently it becomes more relevant to study ICH in Kashmir, especially the study of clinical parameters that in turn has potential to be translated into preventive strategies.

Aim and methodology:-
We aimed to study various clinical parameters of ICH patients presenting to the tertiary care hospital in Neurology department. 150 ICH patients were considered. A pretested, semi-structured questionnaire was used to collect the information on clinical parameters with prior consent of the patients. The data collected included Gender, Age and Hypertension. Also based on non-contrast CT scan patients were recognized as Lobar vs Non-Lobar ICH and ICH Scoring for severity of ICH 12 was assessed. Statistical analysis was performed by using SPSS software (V.11.5). Statistical significance was considered with p-value ≤ 0.05. The data was collected from a relevant study approved by the ethical committee of the institute (No. SIMS 1 131/IEC-SKIMS/2017-239).

Results:-
The incidence of ICH was higher with increasing age and was less common below 40 years of age (14.6% below 40 years of age). Majority of patients (46% of all) belonged to age > 60 years. 38.6% of patients belonged to age group 41 -60 years.
There was no significant difference between the occurrence of ICH in males vs females (p value < 0.05), although males patients were slightly more below 60 years of age and female patients were more > 60 years of age.
More than two thirds of all ICH patients were hypertensive (75.33%). Underlying hypertension was more frequently seen with ICH patients in the middle age group, 40 -60 years (84.4%), and was seen comparatively less frequently in patients aged 40 or less (63.6%). In the age group > 60 years, 77% of patients had underlying hypertension. There was no significant difference between the incidence of hypertension between Males and Females in each age group (p value < 0.05).
Only about 28% of all ICH cases were Lobar haemorrhages, while the rest were Nonlobar (72%). There was no significant gender difference in the distribution of Lobar and Nonlobar ICH (p value <0.05). Lobar ICH was proportionately much less common in the age group of 40 -60 years. Nonlobar ICH had a significant association with underlying hypertension (p value > 0.05).
The significant majority of ICH patients were having an ICH Score of 2 or 3 at presentation, in all age groups and among both genders (p value >0.05). Severity of ICH was seen proportionately more in the age group of > 60 years.

Discussion:-
Consistent with the fact that the incidence of ICH increases with advancing age 13,14 which is a feature that applies to all types of stroke, both ischemic and hemorrhagic, the incidence of ICH was higher with increasing age in our study. CAA related ICH also plays its role in this age dependent increase in incidence 15 .
Although gender in general is not considered a specific risk factor for ICH, however studies have shown gender disparities-men having higher incidence of ICH compared to women. 16,17 Our study also showed a non-significant but higher incidence of ICH in men in Age < 60 patients. In age > 60 years, women were more in number, though non-significantly but consistent with the overall predilection of men getting ICH at younger age than women. 16,17 The role of hypertension as a leading risk factor is well established, and its frequency has been estimated to be between 72% and 81%. 18,19 In the INTERSTROKE study, hypertension (self-reported history or mean blood pressure >160/90) was the strongest risk factor for ICH, accounting for 73.6% of the population-attributable risk. 20 Likewise, our study cases also showed a high prevalence of hypertension, i.e., 75 %, a percentage consistent with that of previous studies , 72% and 81%. 18,19 Moreover, Kashmir population, in particular, is known to have a high prevalence of hypertension. In a community based survey in rural Kashmir, 58% were detected to have hypertension. 21 Lobar ICH was seen less frequently than Non-Lobar (Gangiono-Thalamic) ICH and was seen predominantly in the higher age group. Around 20% of all ICH patients below 40 years of age were Lobar ICH, while as around 35 % of all ICH patients above 40 years of age were Lobar ICH. Stroke Registry (Dijon, France) found that, although incidence of ICH appeared stable between 1985 and 2008, the incidence had decreased 50% in individuals below 60. Conversely, it had increased roughly 80% in people aged ≥ 75 years. This increased incidence was driven largely by lobar ICH which in-turn in its substantial part can be attributed to CAA related increase in ICH with age 15,22 , and also coincides with an increase in use of antithrombotic therapy. Along with the non-significant gender difference seen, the age related high frequency of Lobar ICH is consistent with advancing age being the strongest clinical risk factor for CAA-related ICH, as predicted by the age dependence of the underlying disease 23,24 , and is also consistent with the finding that there is no marked predilection for gender in either clinical (54% men, 46% women) 18 or pathologic (49% men, 51% women) 25 series 563 Non-Lobar ICH had a significant association with underlying hypertension which was not as strong the case Lobar ICH. The etiologic factors in lobar ICH may be somewhat different from those in other forms of ICH, particularly with regard to a less significant role of hypertension. 26,27 Ropper and Davis 28 reported chronic hypertension in only 31% of their cases of lobar ICH, and in the series reported by Kase et al., 29 only 50% of the patients had elevated blood pressure on admission; in half of this group high blood pressure had been documented before the hemorrhage. In Weisberg's 30 study, only 33% of the patients with lobar ICH had hypertension compared with 81% of the patients with deep (ganglionic-thalamic) ICHs.
The severity of ICH, as was assessed by ICH Scoring, showed a trend of higher severity with advancing age. This finding is also consistent with the general trend including the finding of Stein and colleagues project, that by the year 2050, the proportion of all patients with ICH ≥ 80 years will be 2.5-fold higher than in 2009, with substantial increases in ICH cases (35.2% increase), severe disability (36.8%), and in-hospital mortality (60.2%). 31 Bibliography:-