Intracerebral Hemorrhage: The Most Common Causes

An AAN 2014 Poster Brief

Bret S. Stetka, MD; James P. Klaas, MD


May 09, 2014

Intracranial Hemorrhage Etiologies

Editor's Note: While attending the American Academy of Neurology 66th Annual Meeting, held in Philadelphia, Pennsylvania, from April 26 through May 3, 2014, Medscape interviewed James P. Klaas, MD, Instructor, Department of Neurology, Mayo Clinic, Rochester, Minnesota, about his study assessing the most common causes of intracerebral hemorrhage (ICH).[1]

Medscape: Despite improved hypertension management, the incidence of ICH hasn't changed. Why might this be, and have the causes of ICH changed with advances in management?

Dr. Klaas: Hypertension is traditionally considered the biggest risk factor for primary, nontraumatic ICH. With increasing emphasis on stricter control of hypertension and newer antihypertensive agents, one might expect the incidence of ICH to have decreased over the years.

However, several recent ICH epidemiology studies have demonstrated that the incidence of ICH has not changed. The demographics have shifted, with an increased incidence of ICH in elderly persons (age > 75) and a corresponding decrease in younger individuals. The increased incidence in elderly persons has been attributed to hemorrhages from cerebral amyloid angiopathy (CAA) and the increased use of antithrombotic medications.

For our study, we attempted to evaluate this hypothesis by analyzing the etiology of ICH in our patient population. We reviewed the medical records and imaging studies of patients with primary, nontraumatic, and nonstructural ICH admitted to our institution from 2009-2012. We established a classification scheme based on the existing literature to categorize the etiology of a patient's ICH.

Medscape: What did you find were the most common causes of ICH?

Dr. Klaas: In our population, hypertension remained the most common etiology of ICH, regardless of patient age. There was a nonsignificant trend toward older age in patients with an ICH due to CAA, but hypertension was still the most common etiology, even in patients older than 75 years.

Medscape: Were antithrombotics associated with an increased risk for ICH?

Dr. Klaas: We found a similar proportion of patients taking anticoagulants among patients with ICH due to CAA and those with ICH due to other causes. Because we did not study the changing demographics of ICH over time in this population, the results of our study cannot answer this question directly.

Medscape: Which antithrombotic medications were most commonly used by the patients in the study? And were there any significant differences in ICH incidence between different medications?

Dr. Klaas: Aspirin was the most commonly used antithrombotic in this study. The majority of patients in the study were on an antithrombotic medication (61.3%). There were no significant differences between the medications and the different ICH etiologies.

Given the numerous microhemorrhages associated with CAA, we expected there to be a higher percentage of patients on antithrombotic medications in this group. However, the proportion of patients taking antiplatelet or anticoagulant medications did not differ between patients with an ICH from CAA and those with other etiologies.

Medscape: On the basis of your findings, do you have any take-home messages for clinicians?

Dr. Klaas: Hypertension remains an important risk factor for ICH, and it is imperative to treat hypertension in patients of all ages. Although our study did not show a difference in antithrombotic use in terms of ICH etiology, population-based studies have shown an increase in the use of antithrombotic medications over time. The elderly are at risk for other vascular diseases, such as myocardial infarction and ischemic stroke, and antithrombotics are important preventive medications. We recommend judicious use of antithrombotics in elderly persons, given the potentially increased risk for ICH.


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