Simultaneous Multiple Intracerebral Hemorrhages (SMICH)

Teddy Y Wu; Nawaf Yassi; Darshan G Shah; Minmin Ma; Gagan Sharma; Jukka Putaala; Daniel Strbian; Bruce C V Campbell; Bernard Yan; Turgut Tatlisumak; Patricia M Desmond; Stephen M Davis; Atte Meretoja

doi:10.1161/STROKEAHA.116.015186

Simultaneous Multiple Intracerebral Hemorrhages (SMICH)

Stroke. 2017 Mar;48(3):581-586. doi: 10.1161/STROKEAHA.116.015186.

Authors

Teddy Y Wu^{1

2

3}, Nawaf Yassi^{1

2

3}, Darshan G Shah^{1

2

3}, Minmin Ma^{1

2

3}, Gagan Sharma^{1

2

3}, Jukka Putaala^{1

2

3}, Daniel Strbian^{1

2

3}, Bruce C V Campbell^{1

2

3}, Bernard Yan^{1

2

3}, Turgut Tatlisumak^{1

2

3}, Patricia M Desmond^{1

2

3}, Stephen M Davis^{1

2

3}, Atte Meretoja^{4

5

6}

Affiliations

¹ From the Department of Medicine and Neurology, Melbourne Brain Centre (T.Y.W., N.Y., D.G.S., M.M., B.C.V.C., B.Y., S.M.D., A.M.) and Department of Radiology (G.S., P.M.D.), the Royal Melbourne Hospital, University of Melbourne, Australia; Department of Neurology, Helsinki University Hospital, Finland (J.P., D.S., T.T., A.M.); Department of Neurology, Jinling Hospital, Nanjing University School of Medicine, People's Republic of China (M.M.); Institute of Neuroscience and Physiology, Sahlgrenska Academy at the University of Gothenburg, Sweden (T.T.); and Department of Neurology, Sahlgrenska University Hospital, Gothenburg, Sweden (T.T.).
² Guest Editor for this article was Giuseppe Lanzino, MD.
³ Presented in part at the International Stroke Conference of the American Heart Association, Houston, TX, February 22-24, 2017.
⁴ From the Department of Medicine and Neurology, Melbourne Brain Centre (T.Y.W., N.Y., D.G.S., M.M., B.C.V.C., B.Y., S.M.D., A.M.) and Department of Radiology (G.S., P.M.D.), the Royal Melbourne Hospital, University of Melbourne, Australia; Department of Neurology, Helsinki University Hospital, Finland (J.P., D.S., T.T., A.M.); Department of Neurology, Jinling Hospital, Nanjing University School of Medicine, People's Republic of China (M.M.); Institute of Neuroscience and Physiology, Sahlgrenska Academy at the University of Gothenburg, Sweden (T.T.); and Department of Neurology, Sahlgrenska University Hospital, Gothenburg, Sweden (T.T.). atte.meretoja@hus.fi.
⁵ Guest Editor for this article was Giuseppe Lanzino, MD. atte.meretoja@hus.fi.
⁶ Presented in part at the International Stroke Conference of the American Heart Association, Houston, TX, February 22-24, 2017. atte.meretoja@hus.fi.

PMID: 28232593
DOI: 10.1161/STROKEAHA.116.015186

Abstract

Background and purpose: Simultaneous multiple intracerebral hemorrhages (SMICHs) are uncommon. Few single-center studies have analyzed characteristics and outcome of SMICH. We analyzed clinical characteristics and outcome of SMICH patients from 2 comprehensive stroke centers.

Methods: Baseline imaging from consecutive intracerebral hemorrhage (ICH) patients (n=1552) from Helsinki ICH study and Royal Melbourne Hospital ICH study was screened for SMICH. ICH pathogenesis was classified according to the structural lesion, medication, amyloid angiopathy, systemic/other disease, hypertension, undetermined classification system (SMASH-U). ICH caused by trauma, tumor, and aneurysmal rupture was excluded. Baseline clinical and radiological characteristics and 90-day mortality were compared between SMICH and single ICH patients. Association of SMICH with 90-day mortality was assessed in multivariable logistic regression models adjusted for predictors of ICH outcome.

Results: Of 1452 patients, 85 (5.9%) were classified as SMICH. SMICH were more often female (58% versus 42%; P=0.004), had lower baseline Glasgow Coma Scale (12 versus 14; P=0.008), and more frequent lobar location (59% versus 34%; P<0.001) compared with single ICH. The SMASH-U pathogenesis of SMICH patients was less often hypertensive (20% versus 37%; P=0.001), more often systemic coagulopathy (12% versus 3%; P<0.001), and trended toward more cerebral amyloid angiopathy (32% versus 23%; P=0.071). SMICH was not associated with 90-day mortality on univariate (37% versus 35%; P=0.610), multivariable (odds ratio, 0.783; 95% confidence interval, 0.401-1.529; P=0.473), or propensity score-matched analyses (odds ratio, 0.760; 95% confidence interval, 0.352-1.638; P=0.484).

Conclusions: SMICH occurs in ≈1 in 20 ICH, more commonly with lobar located hematomas and systemic coagulopathy with less hypertensive angiopathy. The associated mortality is similar to single ICH. Given varied etiologies, SMICH management should target the underlying pathology.

Keywords: cerebral hemorrhage; mortality; multiple; pathogenesis.

Publication types

Research Support, Non-U.S. Gov't

MeSH terms

Aged
Aged, 80 and over
Blood Coagulation Disorders / epidemiology*
Cerebral Hemorrhage / epidemiology*
Cerebral Hemorrhage / etiology*
Cerebral Hemorrhage / mortality
Comorbidity
Female
Finland / epidemiology
Hematoma / epidemiology*
Humans
Male
Middle Aged
Victoria / epidemiology