Assessing etiological classification systems and their relationship with neurological deterioration in patients with intracerebral hemorrhage

Abstract

Unlike ischemic stroke, there is no consensus on the etiological classification of intracerebral hemorrhage (ICH). Our study focuses on two commonly used classification systems: SMASH-U and H-ATOMIC. The association between these classifications and neurological deterioration (ND) as well as clinical outcomes remains largely unexplored. We aimed to determine whether the etiological groups defined by these classifications are related to ND during hospitalization. We prospectively recruited consecutive ICH patients from 2015 to 2022. Demographic, radiological and clinical characteristics were systematically recorded. Etiology was determined at discharge. Variables and etiological groups associated with ND were included in a multivariate logistic regression analysis. A total of 301 patients were recruited, of whom 124 patients (41.2%) experienced ND. The hypertensive subtype was the most frequent etiology with both classifications systems. In 149 (49.5%) more than one possible etiology for ICH was identified, with the most common combination being hypertension and either probable or possible amyloid angiopathy, in 64 patients (21.3%). ICH related to anticoagulation (AC) was associated with a greater risk of ND. In the multivariate analysis, certain etiological subtypes were independently associated with ND. In the SMASH-U classification, medication-related ICH was linked to a higher risk of ND (OR 6.02 95% CI 1.87-19.34). while in H-ATOMIC, the combination of HT and AC (OR 9.91 CI: 2.54-38.69), and combined groups (OR 17.49, CI: 3.86-79.30), were related to ND. Intraventricular extension, blood pressure control and initial volume were also related to ND. In addition, intraventricular extension, blood pressure control, and initial hematoma volume were also found to be related to ND. The etiology of the ICH could be related to the risk of ND during hospitalization. AC-related etiologies appear to confer the highest risk, particularly when combined with HT-related mechanisms.

We are grateful to all recruited patients, the members of Clinical Neuroscience group at IRBLleida and personal of Neurology Department at Hospital Universitari Arnau de Vilanova de Lleida for scientific discussions and instrumental help. The study was supported by a grant from RICORS Network (Carlos III Health Institute), Government of Catalonia-Agència de Gestió d’Ajuts Universitaris i de Recerca (2017SGR1628 and 2021SGR01479); Carlos III Health Institute and co-funded by European Union (ERDF/ESF,"Investing in your future“and”A way to build Europe"): PI20/01575. In preparing this manuscript, we utilized the artificial intelligence tool ChatGPT, developed by OpenAI, solely for enhancing the English language expression. This assistance was confined to linguistic and grammatical aspects, with no impact on the scientific content, data interpretation, or study conclusions