Clinical Factors Associated With Progressing Hemorrhagic Stroke

Purpose:Hemorrhagic stroke, also known as intracerebral hemorrhage, is a severe stroke subtype with high rates of morbidity and mortality. Progressing hemorrhagic stroke has a worse prognosis than non-progressing ones, therefore it’s of great clinical significance to research into the etiology, mechanism, prediction and treatment of the progressing hemorrhagic stroke. According to the time scale, progressing hemorrhagic stroke can be categorized into three categories, which are acute progressing haemorrhagic stroke, subacute haemorrhagic stroke, and chronic progressing haemorrhagic stroke. The main clinical manifestation of acute progressing hemorrhagic stroke is early neurologic deterioration and the primary reason is early hematoma expansion. The main clinical manifestation of subacute progressing haemorrhagic stroke is subacute neurologic deterioration and the primary reason is perihematomal edema. This study, consisting of prospective clinical observational study on acute hemorrhagic stroke and retrospective case-control study on subacute hemorrhagic stroke, is aimed at exploring the primary associated clinical factors and the possible prediction methods. For acute progressing hemorrhagic stroke, we studied the factors associated with early hematoma expansion, especially serum glycoslated hemoglobin and lipid level, and the prediction of early hematoma expansion. For subacute progression stroke, we identified the subacute progressing cases and analyzed the clinical features and explored the possible associated clinical factors.Methods:This study consists of two parts. Part1:Prospective clinical observational study:Collect the patients diagnosed as acute spontaneous intracerebral hemorrhage identified by CT scan in the2nd Xiangya Hospital, Central South University from Oct.1st,2013to April.1st,2014and select the cases according to the inclusion and exclusion criterias. Evaluate the patients at the emergency department, admission to the ward, and within24-72hours. Record the general condition, vital signs on admission to the emrgency department, medical and personal history, information about initial and repeated CT scan, treatment protocal and whether or not the patient has early hematoma expansion or early neurological deterioration. Do statistical analyse on the collected data. Part2:Retrospective case-control study:Obtain al the cases admitted with the first diagnosis of "intracerebral hemorrhage" in the2nd Xiangya Hospital, Central South University from Dec.2007to Dec.2010through the electrical miniature copies of medical records system and select the cases according to the inclusion and exclusion criterias. Extract the clinical data such as general condition, vital signs on admission, medical and personal history, information about initial and repeated CT scan and treatment protocal of the patients. Identify whether the patient has subacute progression. Select all the patients who underwent subacute progression as the cases group and select the control group with the ratio of1:2. Do statistical analyse on the collected data.Results:Part1:Prospective clinical observational study:We enrolled40patients into the study and10of the patiens underwent eraly neurological deterioration, the rates of which is25%. The reason for deterioration is early hematoma expansion for9of these patients and pulmonary infection. Of the40patients11underwent eraly hematoma expansion, the rates of which is27.5%. The PT,INR,and APTT level in the early hematomal expansion group is significantly lower than in the non-early hematomal expansion group (PT:11.7±0.7s VS12.7±0.9, p=0.002; INR:0.9±0.1VS l±0.1, p=0.002; APTT:33.7±3.1sVS38±5.8s, p=0.033), and the HDL-C level in the early hematomal expansion group is significantly higher than in the non-early hematomal expansion group (1.17±0.33mmol/L VS0.82±0.29mmol/L, P=0.003) We screened the relevent factors of early hematomal expansion,such as onset-initial-CT interval,age, PT, APTT, INR, HDL, and the interaction of APTT and PT, and do a multivariate logistic regression analyze. The variates which are finally enrolled in the logistic regression model are: age<55.5years, HDL-C>1.005mmol/L and the interaction of APTT< 37.1s and PT<12.05s. Part2:Retrospective case-control study:After examining the medical records carefully,21cases were enrolled as subacute progressing hemorragic stroke cases group. The possible progression reason for these21patients are:brain edema for9patients, infection for5patients, brain edema complicated with infection for1patient, intraventricular hemorrhage extension for1patient, new-onset pontine and cerebellar hemorrhage for1patient, and unknown reason for4patients.5patients died among the21subacute progression cases. The fasting blood glucose level and neutrophil proportion proportion are significantly elevated in the subacute progressing cases group (glucose,8.98±3.8VS6.45＋3.29, p=0.030; neutrophil proportion,82.3%＋8.43%VS77.3%＋8.33%, p=0.037), and the lymphocyte counts proportion is significantly decreased in the cases group (10.88%＋5.99%VS14.99%＋5.98%, p=0.014). The odds ratio of neutrophil proportion above74.6%to neutrophil proportion below74.6%is4.93, and the odds ratio of lymphocyte proportion below6.75%to lymphocyte proportion above6.75%is24.62.Discussion:Part1:Prospective clinical observational study: Glycoslated hemoglobin cannot work as a prediction factor of early hematomal expansion. Hematomal heterogeneity needs more studies to determine whether it is a predictive factor of hematoma expansion. HDL-C is significantly associated with early hematomal expansion. Age <55.5years, HDL-C≥1.005mmol/L and the interaction of APTT<37.1s and PT<12.05s may work as prediction factors of early hematomal expansion. Part2:Retrospective case-control study:The primary reasons for subacute progression are perihematomal edema and pulmonary infection, as well as extension or new-onset of intracerebral hemorrhage. The fasting blood glucose, neutrophil count proportion and lymphocyte count proprtion may be relevent to subacute progression. Neutrophil proportion above74.6%and lymphocyte proportion below6.75%to are possible risk factors of subacute progression.