Journal of the Neurological Sciences 336 (2014) 42–47

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Intracerebral hemorrhage in young from a tertiary neurology center in North India Jayantee Kalita, Gourav Goyal, Pankaj Kumar, Usha K. Misra ⁎ Department of Neurology, Sanjay Gandhi Post Graduate Medical Sciences, Lucknow, India

a r t i c l e

i n f o

Article history: Received 3 June 2013 Received in revised form 31 August 2013 Accepted 27 September 2013 Available online 5 October 2013 Keywords: Etiology Intracerebral hemorrhage Outcome Stroke Young Prognosis Hypertension

a b s t r a c t Objective: There is paucity of information on the etiology and predictors of outcome of intracerebral hemorrhage (ICH) in young which may have regional and ethnic differences. In this study, we report the etiology and predictors of outcome of ICH in young patients from North India. Methods: 404 patients with ICH in young (16–50 years) were retrospectively reviewed who were admitted in neurology service of a tertiary care teaching hospital in North India. The data were retrieved from the computerized hospital information service. The information about the demography, risk factors, clinical status, laboratory findings, CT/MRI features and angiography (CT, MRI or digital substraction) were noted. The etiology of ICH was ascertained based on clinical, laboratory and radiological findings. Outcome at 1 month was assessed using Glasgow Outcome Scale (GOS). Results: The mean age of the patients was 41.6 years and 23.8% were females. Hypertension (57.2%), hypocholesterolemia (33.7%), alcohol (15.8%) and anticoagulant (3.5%) were the important risk factors. The etiology of ICH was hypertension in 320 (79.2%), vascular malformation in 17 (4.2%), coagulopathy in 16 (4%), cerebral venous sinus thrombosis (CVST) in 9 (2.2%), thrombocytopenia in 3 (0.7%), vasculitis in 2 (0.5%) and cryptogenic in 37 (9.2%) patients. The patients with cryptogenic ICH were younger, had better Glasgow coma scale (GCS) on admission and good outcome compared those with known etiology. The most common location of ICH was basal ganglion and thalamus (71.3%). 102 (25%) patients died, 161 (39.9%) had poor and 141 (34.9%) had good outcome. Hypertensive ICH patients had frequent death or disability (P b 0.001). On multivariate analysis, low GCS score (P b 0.001), large ICH (P=0.01) and high leukocyte count on admission (P=0.03) were significantly related to the 1 month mortality. Conclusion: Hypertension is the commonest cause of ICH in young Indian adults and its outcome is related to volume of ICH, GCS score and admission leukocyte count. © 2013 Elsevier B.V. All rights reserved.

1. Introduction Intracerebral hemorrhage (ICH) constitutes about 10–15% of all strokes. The frequency of ICH among young onset stroke varies from 0.7% to 40% among different series [1,2]. The causes of nontraumatic ICH are generally classified into primary and secondary. Primary ICH is the result of spontaneous rupture of the damaged intracranial small vessels secondary to hypertension or amyloid angiopathy. Secondary ICH is associated with underlying vascular malformations, coagulopathy, vasculitis or tumors. The majority of nontraumatic ICH are primary but secondary causes are important etiology of ICH in younger patients. The incidence of ICH is higher in Asian countries compared to the West [3]. This may be due to difference in the prevalence of stroke risk factors as well as dietary, sociocultural and genetic variation. Hypertension is an independent risk factor of ICH. In India, the prevalence of hypertension ⁎ Corresponding author at: Department of Neurology, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Raebareily Road, Lucknow-226014, India. Tel.: +91 522 2668811; fax: +91 522 2668017. E-mail addresses: [email protected], [email protected] (U.K. Misra). 0022-510X/$ – see front matter © 2013 Elsevier B.V. All rights reserved. http://dx.doi.org/10.1016/j.jns.2013.09.037

below the age of 50 years is 20% [4]. Incidence of ICH varies in different parts of India. In the Kolkata study, 32% of stroke patients had ICH [5]. This ratio was higher as compared to western countries. On the other hand, one series of stroke in young adults from New Delhi, only 14.5% of young stroke had ICH [6]. In a recent study from the northeast India, tribals had more frequently primary ICH compared nontribals (31% versus 18%) [7]. In a population based study from south India, ICH constituted 11.6% of the all strokes which is similar to western countries [8]. It seems that incidence of ICH is higher in eastern India compared to north and south. Compared to ischemic stroke, ICH has worse outcome. One month mortality rate has been reported from 35% to 52% [9,10]. Half of the deaths occur in the first week of the event. Only 20% of the patients with ICH are independent at 6 months [11]. There are reports of ischemic stroke in young but very few studies have been done on ICH in young patients. A pubMed search using keywords ‘intracerebral hemorrhage”, “young” and “young onset intracerebral hemorrhage” revealed only 11 articles; 9 of these were in English language [2,12–19]. Most of these studies are based on small sample size, mainly focused on the etiology of ICH and only one study reported the outcome (Table 1). The etiology of ICH in young patients may differ in different

Table 1 Tabulation of different studies on young ICH. Patients number

Age (yrs)

Causes

Risk factors

Mortality & outcome

Morality predictors

Toffol GJ et al. [12], 1987

72

15–45

Not mentioned

Mortality 12.5%.

–

Bevan et al. [2], 1990

113, Nontraumatic ICH 46 (41%)

15 – 45

Alcohol 13, Hypertension 7, Illicit drug 2, Coagulopathy 2.

Mortality 26.1%

–

Fuh et al. [13], 1994

170

15 – 45

Not mentioned

Mortality ICH 35.1%

–

Awada et al. [14], 1998

107

0.5- 45

Not mentioned

Mortality 27%. Complete independent 26%.

–

Ruiz_Sandoval et al. [15], 1999

200

15–40

Tobacco 40, Hypocholesterolemia 70, Hypertension 26 & Alcohol 20.

217

18 – 49

Mortality 8% in ICH, 90% CVST had good outcome, 68% with hypertensive ICH had worst prognosis Not studied

–

Feldmann et al. [16], 2005

Cause determined 55; AVM (21), Hypertension (11), Ruptured saccular aneurysms (7), Sympathomimetic drug abuse (5), Tumour (3)& Others (8) Aneurysm 21, AVM 9, Hypertension 7, Tumour 5, Coagulopathy 2, Moya-Moya 1, Eclampsia 1. Hypertension (64), Vascular malformation (39), Blood dyscrasia (13), Toxins (6), Moyamoya (2), Eclampsia (2), Tumour (1), Systemic lupus erythematosus (1), Cryptogenic 42. AVM (25) Hypertension (21) Blood dyscrasias (17) Berry aneurysms (9) Other causes (7) & cryptogenic (28) AVM (67) Cavernous angioma (32), Hypertension (22), Drugs (7), Toxins (7), CVST (10), Others (14), Cryptogenic (29), & Undetermined (12). Not studied.

Lai et al. [17] 2005

296

15 – 45

Ruiz-Sandoval et al. [18], 2006

35 patients 15–40 years & 105 N40 yrs. 109, 61 (56%) ischemic stroke, 25 (22.9%) ICH & 23 (21.1%) embolic stroke

2 groups of 15–40 yrs and N40 yrs 15 – 45

Kumar et al. [19], 2011

Hypertension (138), Vascular anomaly (50), Coagulopathy (16), Tumour (18), Drugs (26), Undetermined (30), Cryptogenic (13) & Others (5). All were hypertensive

Not mentioned

Hypertension, smoking, and regular heavy alcohol Hypertension 146, diabetes 25, smoking 114, alcohol 109, drugs 6, hypocholesterolemia 32, family history 20.

Mortality 24%

Obesity 18, Alcohol10, Smoking 5, diabetes 3, Previous ICH 3.

Mortality 23% in b40 yrs group

Smoking 76, Alcohol 53, Diabetes 59, Hypertension 79 & Family history 42.

Mortality 7.4%, disability 55% & good outcome 37.6%.

– Site of ICH, surgery, ventricular extension, hydrocephalus, & GCS score –

J. Kalita et al. / Journal of the Neurological Sciences 336 (2014) 42–47

Author

–

43

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J. Kalita et al. / Journal of the Neurological Sciences 336 (2014) 42–47

Fig. 1. Distribution of risk factors (in percentage) in different age groups in the patients with intracerebral hemorrhage. DM = diabetes mellitus, HTN = hypertension, AC = anticoagulant, HC = hypocholesterolemia, FHS = family history of stroke. (P value for male gender = 0.91, HTN b0.001, DM = 0.002, Smoking = 0.01, alcohol = 0.07, HC = 0.73, AC = 0.95, FHS = 0.58).

geographic and ethnic groups, thereby, may influence the mortality and functional outcome. In this communication, we report the etiology and outcome of ICH in young from a tertiary care teaching hospital in North India.

2. Patients and methods The patients with CT proven ICH between the age of 16 and 50 years admitted to the neurology service of a tertiary care teaching hospital during 2001–2010 were retrospectively analyzed. ICH due to head injury, tumor bleed and aneurismal rupture were not included as they are managed by either neurosurgeons or interventional radiologist. The patients' medical records were retrieved from the discharge

Table 2 Aetiology of intracerebral hemorrhage in young in different age groups. Aetiology (n)

16 – 30 yrs (n = 54)

31 – 40 yrs (n = 101)

41–50 yrs (n = 249)

Essential hypertension (n = 284) Secondary hypertension (n = 36) 1. Secondary to CRF 2. Reno-vascular hypertension 3. Aortic dissection with secondary renal artery stenosis 4. ADPKD 5. Hyperaldosteronism Coagulopathy (n = 16) 1. Anticoagulant induce 2. Cirrhosis AVM (n = 10) Cavernous angioma (n = 4) CVST (n = 9) Thrombocytopenia (n = 3) Vasculitis (n = 2) Mycotic aneurysm (n = 3) Cryptogenic (n = 37)

8

69

207

11

10

15

6 2 1

9 1 0

12 1 0

0 2 4

0 0 3

2 0 9

3 1 7 1 5 0 2 2 15

3 0 1 3 3 1 0 0 11

8 1 2 0 1 2 0 1 11

ADPKD = autosomal dominant polycystic kidney disease, AVM = arteriovenous malformation, CVST = cerebral venous sinus thrombosis, CRF = chronic renal failure.

summary and computerized hospital information service. The patients with incomplete medical records were excluded. 2.1. Clinical evaluation The demographic details of the patients were noted. Their stroke risk factors such as hypertension, diabetes, smoking, alcohol use, heart disease, arteriopathies and vasculitis were recorded. History of drug abuse, anticoagulant and antiplatelet therapy were also noted. The patient was considered hypertensive if there was documented history of hypertension, received antihypertensive treatment or blood pressure was above 140/90mm of Hg 2weeks after the ICH and confirmed on follow up. Hypertension was considered secondary if the patient had prior documented underlying cause or cause was detected during evaluation in the hospital. Hypertension was labelled as primary if no cause was detected on serum chemistry, ultrasound abdomen, renal Doppler and hormonal assay in suspected patients. Compliance to antihypertensive drugs was recorded. The patients were considered diabetic if they were on antidiabetic treatment or fasting blood sugar was ≥126 mg/dl or 2 h post prandial blood sugar ≥200 mg/dl. Hypocholesterolemia was defined if cholesterol level was below 160 mg/dl and hypercholesterolemia if N 250 mg/dl. The patient was considered smoker if ≥10 cigarettes/day were consumed during the previous 6months. Alcoholism was defined by a history of regular consumption of ≥60 g alcohol/day. Family history of stroke in the first degree relatives was also noted. Blood pressure, pulse and respiratory rate at admission were noted. The consciousness was assessed by Glasgow Coma Scale (GCS). The findings on neurological examination were noted. 2.2. Laboratory findings Blood count, erythrocyte sedimentation rate, hemoglobin, prothrombin time, activated partial thromboplastin time, blood sugar, serum creatinine, electrolytes, bilirubin, transaminases, and lipid profile were noted which were done on the day of admission. CT scan or MRI findings were noted including location, size of hematoma and intraventricular extension. The volume of hematoma was calculated by the formula “a x b x c/2” [20] and categorized into small (b 20 ml), medium (20–40 ml) and large (N40 ml) [21]. Magnetic resonance angiography, CT angiography or digital subtraction angiography (DSA) findings

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Table 3 Frequency of location of intracerebral hemorrhage by cause.

Essential HTN (n = 284) Secondary HTN (n = 36) Coagulopathy (n = 16) AVM (n = 10) Cavernous angioma (n = 4) CVST (n = 9) Thrombocytopenia (n = 3) Vasculitis (n = 2) Mycotic aneurysm (n = 3) Cryptogenic (n = 37)

Putaminal (n = 220)

Thalamic (n = 50)

Caudate (n = 18)

Lobar (n = 67)

Brainstem (n = 29)

Primary IVH (n = 8)

Non aneurysmal SAH (n = 2)

Cerebellum (n = 9)

Multiple (n = 1)

176

41

13

24

24

2

0

4

0

19

7

2

3

3

1

0

1

0

3

0

0

10

0

0

0

3

0

2

0

1

5

1

1

0

0

0

1

0

0

3

0

0

0

0

0

0

0

0

8

0

0

1

0

0

0

1

0

2

0

0

0

0

0

2

0

0

0

0

0

0

0

0

0

0

0

3

0

0

0

0

0

17

1

2

9

1

4

1

1

1

AVM = arteriovenous malformation, CVST = cerebral venous sinus thrombosis, AVM = arteriovenous malformation, CVST = cerebral venous sinus thrombosis.

were noted. The location of hematoma was categorized into putaminal, caudate, thalamic, lobar, brainstem and cerebellar. Renal Doppler findings were recorded in hypertensive patients. The etiology of hematoma was categorized into hypertensive, vascular malformation, cerebral venous sinus thrombosis (CVST), coagulopathy, vasculitis, mycotic aneurysm and cryptogenic. Hypertension was considered responsible for ICH after excluding other possible causes. Cryptogenic ICH was defined if there was no risk factor, predisposing condition and structural or vascular abnormalities on neuroimaging for ICH [15,17]. The patients were managed conservatively as per ICH management guideline.

best set of predictors of one month mortality. The variables were considered significant if the two tailed P value wasb0.05. All the statistical analysis was carried out using SPSS 15 version soft ware. 3. Results There were total 927 patients with stroke between 16 and 50 years of age during last 10 years. Out of 927, 420 (45.3%) patients had ICH. Sixteen patients were excluded because of incomplete record hence the study is based on 404 patients. Their mean age was 41.6 years and 96 (23.8%) were females.

2.3. Outcome 3.1. Risk factors The outcome at 1 month was defined using Glasgow Outcome Scale (GOS) and was categorized into good (GOS 4 and 5), poor (GOS 2 and 3) and death [22]. The cause of death was noted. 2.4. Statistical analysis The relationship of death with demographic, clinical, laboratory, radiological and etiological variables was evaluated using univariate regression analysis followed by multivariate regression analysis. For discrete variables odd ratio and 95% confidence interval was calculated. The variables having a P value of b0.1 on uninvariate analysis were included in the multivariate logistic regression analysis to derive the

320 (79.2%) patients were hypertensive which was more common in the fifth decade (89.2%). Only 183 (57.2%) of these patients were known hypertensive and 173 (94.5%) of them were noncompliant to antihypertensive drugs. 38 (9.4%) patients were diabetic, 56 (13.9%) smoker, 73 (18.1%) chewed tobacco, 64 (15.8%) consumed alcohol, 136 (33.7%) had hypocholesterolemia, 14 (3.5%) were on anticoagulant and 38 (9.4%) patients had family history of stroke. Amongst the risk factors, diabetes, hypertension, smoking, alcohol intake and family history of stroke were more common in the 5th decade. Hypocholesterolemia and anticoagulant use were evenly distributed in 2nd, 3rd, 4th and 5th decade (Fig. 1). Out of 320 patients with hypertension, 36 (11.3%) had secondary cause

Table 4 Predictors of in hospital mortality on univariate regression analysis in intracerebral hemorrhage in young. Variables

Survived (n = 302)

Death (n = 102)

Odd ratio (95% CI)

P value

Age ± SD Hypertension Use of anticoagulant (n) GCS score SBP at admission DBP at admission Lobar ICH Brain stem ICH Large supratentorial ICH (N40 ml) TLC on admission Serum creatinine on admission Blood sugar on admission

41.16 ± 8.66 234 7 12.4 ± 2.9 162.2 ± 30.5 101.1 ± 19.5 57 19 45 11,816.3 ± 4862 1.6 ± 1.1 117.6 ± 53.5

42.81 ± 7.2 86 7 6.7 ± 3.5 171.7 ± 40.8 112.5 ± 102.8 10 10 83 16,645.6 ± 15,111.3 2.1 ± 1.7 158.2 ± 86.9

– 0.64 (0.34 to 1.21) 0.32 (0.1 to 1.05) – – – 2.14 (1.01 to 4.67) 0.62 (0.26 to 1.48) 24.95 (13.32 to 47.19) – – –

0.08 0.18 0.03 b0.0001 0.014 0.067 0.04 0.33 b0.0001 b0.0001 0.001 b0.0001

DBP = diastolic blood pressure, GCS = Glasgow Coma Scale, ICH = intracerebral hemorrhage, SBP = systolic blood pressure.

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which was more frequent in the second and third decades. The etiology of secondary hypertension included renal parenchymal disease in 27 (75%), renovascular in 4 (13.9%), autosomal dominant polycystic kidney disease in 2 (5.6%) and hyperaldosteronism in 2 (11.1%) patients. A young woman had hypertension secondary to renal artery stenosis with dissection of descending aorta. Among the 16 patients with coagulopathy, 14 were on anticoagulant and 2 had cirrhosis of liver. 3.2. Etiology of ICH The ICH was attributed to hypertension in 320 (79.2%), coagulopathy in 16 (4%), vascular malformation in 17 (4.2%), CVST in 9 (2.2%), thrombocytopenia in 3 (0.7%), vasculitis in 2 (0.5%), and cryptogenic in 37 (9.2%) patients. Arteriovenous malformation (AVM), CVST, coagulopathy, vasculitis and cryptogenic etiology were more common in the 2ndand 3rd decades whereas hypertension was more common in the 5th decade. The details about the etiology of ICH at different age groups are presented in Table 2. 3.3. Radiological findings Majority of the patients (288, 71.3%) had deep seated ICH which was putaminal in 220 (54.5%), thalamic in 50 (12.4%), and caudate in 18 (4.5%) patients. Sixty seven (16.6%) patients had lobar, 29 (7.2%) brainstem, 9 (2.2%) cerebellar, 8 (2%) primary intraventricular hemorrhage and 2 (0.5%) patients had non aneurysmal subarachnoid hemorrhage. Intraventricular extension of ICH was present in 190 (47%) of these patients. The hypertensive ICHs were in the typical sites (basal ganglia and thalamus) whereas vascular malformations and CVST related ICH were lobar in location. The location of ICH in different etiological categories is presented in Table 3. 3.4. Predictors of outcome 102 (25.2%) patients died, 161 (39.9%) had poor and 141 (34.9%) had good outcome at one month. The outcome was related to the etiology of ICH. Hypertensive ICH patients had more frequent death and disability (P = 0.001) whereas ICH due to AVM (P = 0.007) and CVST (P = 0.02) had good outcome. Deep seated ICH had higher mortality compared to lobar; out of 67 patients with lobar ICH, 46 (68.7%) had good outcome whereas 72 (25%) out of 288 patients with basal ganglia/thalamic ICH had good outcome. Among the deep seated ICH, putaminal ICH had higher mortality (67/220; 30.5%) compared to thalamic (8/50; 16%) and caudate (3/18; 16.7%). Patients with cryptogenic ICH were significantly younger in age (34.6 ± 9.1Vs42.3 ± 7.9 years, P b0.0001), had more frequently primary intraventricular ICH (P = 0.0006) and better outcome (P = 0.03) compared to those with known etiology. On univariate analysis, the use of anticoagulants (P = 0.03), high systolic blood pressure (P = 0.014), low GCS score (P b 0.0001), leucocytosis (P b 0.0001), raised serum creatinine (P = 0.001), hyperglycaemia (P b 0.0001) and location and size of hematoma (P b 0.0001) were significantly related to one month mortality. The details of the prognostic variables related to outcome on univariate analysis are summarized in Table 4. On multivariate analysis, low GCS (OR 0.76, 95% CI 0.66–0.87, P b 0.001), large size ICH (OR 1.1, 95% CI 1.07– 1.13, P = 0.01) and high leukocyte counts (OR 1.02, 95%CI 1–1.04, P = 0.03) were significantly related to one month mortality. The death was due to brain herniation in 76 (74.5%), septicemia in 23 (22.6%), myocardial infarction in 1 (0.99%) and undetermined in 2 (2%) patients. Death due to brain herniation occurred mostly in the first (n = 70, 92.1%) than second week (n = 6, 7.9%). 4. Discussion In the present study, hypertension (79.2%) was the most common cause of ICH in young followed by vascular malformations, bleeding

and coagulation disorders and CVST. In 37 (9.1%) patients, no cause was found. Hypertension has been reported to result in ICH in young in 11% to 46.6% patients. In Asian studies, hypertension is the most common cause of primary ICH compared to western countries where vascular malformation is the most common cause [17]. Higher incidence of hypertension in our study could be due to inclusion of patients up to 50years age, exclusion of aneurysmal bleed and higher prevalence of hypertension in Indian population compared to the West [23], In our study, the frequency of vascular malformation was relatively low (4.7%) compared to reported frequency of 18.2%–33% in ICH in young. In the vascular malformation group, we included AVM, cavernous angioma, mycotic aneurysm and central nervous system vasculitis whereas in other studies ruptured aneurysm has also been included which might explain the difference. ICH was due to coagulopathy in 4.7% of our patients, which is similar to the reported incidence of 4.3% to 5.3% in the literature [2,17]. In the other studies on ICH, coagulopathy has not been mentioned [12–16,18,19]. None of our patient had ICH due to drug abuse, though it was the cause of young ICH in 7.0% patients in one study [18]. CVST although is a cause of hemorrhagic infarct but rarely it may result in ICH [24,25]. In our study, 2.3% patients with ICH were due to CVST. Lower serum cholesterol has been reported as a risk factor of ICH in 35% of patients in a study from Asia and it was significantly more frequent in the patients below the age of 20years in whom hypertension was uncommon [15]. In our study, low serum cholesterol was found in 33.7% patients and its frequency did not differ in different age groups. It has been suggested that low cholesterol is associated with high risk of ICH in elderly [26–28]. Low serum cholesterol leads to weakness of the endothelium of intracerebral arteries resulting in ICH in the presence of hypertension [29]. Smoking and alcohol intake were less frequent in our study compared to other studies and it may be due to socio-cultural reason [15]. In our study, deep seated ICH constituted in about three-fourth patients which may be due to high frequency of hypertension in our study. In the present study, 8.4% hypertensive ICHs were lobar which is in agreement with the frequency of lobar ICH in hypertension [30,31]. The frequency of cryptogenic ICH in young ranges between 4.4% and 15% [12,15,16]. In the present study, 9.2% had cryptogenic ICH and they had higher GCS score at admission and good outcome at 1 month compared those with known etiology. In our study, 25.2% patients died. In the reported literature, the mortality is widely variable ranging from 8% and 35% [2,12–19]. The higher mortality in young ICH may be attributed to underlying cause of ICH. Hypertensive deep seated ICH usually has raised intracranial pressure and poor outcome. In our study, 79.2% patients were hypertensive and about 70.1% of these patients had basal ganglia or thalamic hematoma. The predictors of mortality in young ICH have been evaluated by only one study and none evaluated functional outcome. In that study, location, surgical intervention, intravenrticular extension, hydrocephalus and GCS score were poor outcome predictors [17]. In our study, anticoagulant use, low GCS score at admission, large hematoma and deep seated ICH, leukocytosis, raised serum creatinine and blood sugar were significantly associated with one month mortality on univariate analysis. Volume of ICH and GCS score are well known predictors of poor outcome in ICH [32,33]. ICH due to coagulopathy is likely to increase for long time and have poor outcome [34–36]. Two out of 16 patients with coagulopathy had cirrhosis in our study. The remaining prognostic variables (blood sugar, leukocyte count, serum creatinine) suggest acute stress response and are surrogate markers of more severe stroke. On multivariate analysis, however, only low GCS score, large hematoma and admission leukocytosis were significantly related to one month mortality. 39.8% of our patients had poor and 34.9% had good outcome. The deep seated ICH had worse outcome compared to lobar. In our earlier study, the importance of location of stroke in the outcome has been highlighted [37]. Retrospective nature and hospital based data are the major limitations of the present study. Hospital based data is prone to have referral bias and may not represent the spectrum in the community. ICH due to

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aneurismal rupture was not included in this study as they were directly admitted to neurosurgery. These may be limitation of this study. The present study is based on a large cohort of young ICH patients evaluating the etiology, location and prognostic predictors. This study highlights that hypertension is the most important modifiable but commonly ignored risk factor of ICH in young adults especially between 40 and 50 years of age. The acute stress responses are also predictors of the prognosis along with size of hematoma and GCS score. Attention should be paid to detect and treat hypertension even in young adults. Financial disclosure None Conflict of interest There is no conflict of interest to declare. Acknowledgment We thank Mr. Rakesh Kumar Nigam for secretarial help. References [1] Nencini P, Inzitari D, Baruffi MC, Fratiglioni L, Gagliardi R, Benvenuti L, et al. Incidence of stroke in young adults in Florence, Italy. Stroke 1988;19:977–81. [2] Bevan H, Sharma K, Bradley W. Stroke in young adults. Stroke 1990;21:382–6. [3] Das SK, Banerjee TK. Stroke: Indian scenario. Circulation 2008;118:2719–24. [4] Gupta R. Trends in hypertension epidemiology in India. J Hum Hypertens 2004;18:73–8. [5] Banerjee TK, Mukherjee CS, Sarkhel A. Stroke in the urban population of Calcutta- an epidemiological study. Neuroepidemiology 2001;20:201–7. [6] Mehndiratta MM, Agarwal P, Sen K, Sharma B. Stroke in young adults: a study from a university hospital in north India. Med Sci Monit 2004;10(9):CR535–41. [7] Singh JK, Ranjan P, Kumari A, Dahale AS, Jha R, Das R. Types, outcome and risk factors of stroke in tribal patients. Int J Stroke 2012;7:1747–4949. [8] Sridharan SE, Unnikrishnan JP, Sukumaran S, Sylaja PN, Nayak SD, Sarma PS, et al. Incidence, types, risk factors, and outcome of stroke in a developing country: the Trivandrum Stroke Registry. Stroke 2009;40(4):1212–8. [9] Anderson CS, Chakera TM, Stewart-Wynne EG, Jamrozik KD. Spectrum of primary intracerebral haemorrhage in Perth, Western Australia, 1989–90: incidence and outcome. J Neurol Neurosurg Psychiatry 1994;57:936–40. [10] Counsell C, Boonyakarnkul S, Dennis M, Sandercock P, Bamford J, Burn J, et al. Primary intracerebral haemorrhage in the Oxfordshire Community Stroke Project, 2: prognosis. Cerebrovasc Dis 1995;5:26–34. [11] Flaherty ML, Haverbusch M, Sekar P, Kissela B, Kleindorfer D, Moomaw CJ, et al. Long-term mortality after intracerebral hemorrhage. Neurology 2006;66:1182–6. [12] Toffol GJ, Biller J, Adams Jr HP. Nontraumatic intracerebral hemorrhage in young adults. Arch Neurol 1987;44:483–5. [13] Fuh JL, Liu HC, Wang SJ, Lo YK, Lee LS. Nontraumatic hemorrhagic stroke in young adults in Taiwan. Cerebrovasc Dis 1994;4:101–5.

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