A Brazilian series utilizing the SMASH-U system for etiologic classification of intracerebral hemorrhage

Abstract

Background Understanding the causes of intracerebral hemorrhage (ICH) is crucial for effective treatment and preventing recurrences. The SMASH-U scale is a suggested method for classifying and predicting the outcomes of ICH.

Objective To describe the SMASH-U classification and outcomes by etiology in patients admitted to a comprehensive stroke center in São Paulo, Brazil.

Methods A retrospective analysis was conducted on patients admitted to the hospital or outpatient clinic between April 2015 and January 2018. Two stroke neurologists evaluated the SMASH-U classification, and patients with incomplete medical records were excluded.

Results Out of the 2000 patients with a stroke diagnosis evaluated, 140 were included in the final analysis. The mean age was 57.9 (± 15.5) years, and 54.3% were male. Hypertension was the most frequent etiology, accounting for 41.4% of cases, followed by amyloid angiopathy (18.5%) and structural lesions (14.1%). Structural lesions were more common among women and patients under 45 years old. Favorable outcomes were observed in 61% of patients with structural lesions, compared to 10% of patients with medication-related etiologies.

Conclusion This study provides important evidence regarding the etiological classification of Brazilian patients with ICH. Hypertension and amyloid angiopathy were the most frequent causes, while structural lesions and systemic diseases were more common in younger patients.

Resumo

Antecedentes Compreender as causas da hemorragia intracerebral (HIC) é crucial para o tratamento eficaz e prevenção de recorrências. A escala SMASH-U é um método sugerido para classificar e prever os resultados da HIC.

Objetivo Descrever a classificação SMASH-U e os resultados por etiologia em pacientes admitidos em um centro de acidente vascular cerebral (AVC) em São Paulo, Brasil.

Métodos Foi realizada uma análise retrospectiva de pacientes admitidos no hospital ou ambulatório entre abril de 2015 e janeiro de 2018. Dois neurologistas especializados em doenças cerebrovasculares avaliaram a classificação SMASH-U e pacientes com prontuários incompletos foram excluídos.

Resultados Dos 2000 pacientes com diagnóstico de AVC avaliados, 140 foram incluídos na análise final. A idade média foi de 57,9 (±15,5) anos e 54,3% eram do sexo masculino. A hipertensão foi a etiologia mais frequente, correspondendo a 41,4% dos casos, seguida pela angiopatia amiloide (18,5%) e lesões estruturais (14,1%). As lesões estruturais foram mais comuns em mulheres e pacientes com menos de 45 anos. Resultados favoráveis foram observados em 61% dos pacientes com lesões estruturais, em comparação com 10% dos pacientes com etiologias relacionadas a medicamentos.

Conclusão Este estudo fornece evidências importantes sobre a classificação etiológica de pacientes brasileiros com HIC. A hipertensão e a angiopatia amiloide foram as causas mais frequentes, enquanto lesões estruturais e doenças sistêmicas foram mais comuns em pacientes mais jovens.

Keywords

Hemorrhagic Stroke - Prognosis - Outcome Assessment, Health Care

Palavras-chave

Acidente Vascular Cerebral Hemorrágico - Prognóstico - Avaliação de Resultados em Cuidados de Saúde

Authors' Contributions

LHLS: conceptualization, data curation, investigation, validation, writing – original draft; JBCA: formal analysis, project administration, supervision, writing – original draft; AAEM: investigation, validation; MMA: supervision, writing – review & editing; RAV: conceptualization, investigation, methodology, supervision; DLGR: formal analysis, validation, writing – review & editing; GSS: formal analysis, supervision, writing – original draft, writing – review & editing.

Publication History

Received: 10 April 2023

Accepted: 07 November 2023

Article published online:
05 February 2024

• References

• 1 An SJ, Kim TJ, Yoon BW. Epidemiology, Risk Factors, and Clinical Features of Intracerebral Hemorrhage: An Update. J Stroke 2017; 19 (01) 3-10
• 2 van Asch CJ, Luitse MJ, Rinkel GJ, van der Tweel I, Algra A, Klijn CJ. Incidence, case fatality, and functional outcome of intracerebral haemorrhage over time, according to age, sex, and ethnic origin: a systematic review and meta-analysis. Lancet Neurol 2010; 9 (02) 167-176
• 3 Krishnamurthi RV, Moran AE, Forouzanfar MH. et al; Global Burden of Diseases, Injuries, and Risk Factors 2010 Study Stroke Expert Group. The global burden of hemorrhagic stroke: a summary of findings from the GBD 2010 study. Glob Heart 2014; 9 (01) 101-106
• 4 Meretoja A, Strbian D, Putaala J. et al. SMASH-U: a proposal for etiologic classification of intracerebral hemorrhage. Stroke 2012; 43 (10) 2592-2597
• 5 Owolabi M, Ogbole G, Akinyemi R. et al; SIREN Team. Development and Reliability of a User-Friendly Multicenter Phenotyping Application for Hemorrhagic and Ischemic Stroke. J Stroke Cerebrovasc Dis 2017; 26 (11) 2662-2670
• 6 Yeh SJ, Tang SC, Tsai LK, Jeng JS. Pathogenetical subtypes of recurrent intracerebral hemorrhage: designations by SMASH-U classification system. Stroke 2014; 45 (09) 2636-2642
• 7 Hemphill III JC, Bonovich DC, Besmertis L, Manley GT, Johnston SC. The ICH score: a simple, reliable grading scale for intracerebral hemorrhage. Stroke 2001; 32 (04) 891-897
• 8 Cappellari M, Zivelonghi C, Moretto G. et al. The etiologic subtype of intracerebral hemorrhage may influence the risk of significant hematoma expansion. J Neurol Sci 2015; 359 (1-2): 293-297
• 9 Spilker J, Kongable G, Barch C. et al. Using the NIH Stroke Scale to assess stroke patients. . The NINDS rt-PA Stroke Study Group J Neurosci Nurs 1997; 29 (06) 384-392
• 10 Quinn TJ, Dawson J, Walters MR, Lees KR. Reliability of the modified Rankin Scale: a systematic review. Stroke 2009; 40 (10) 3393-3395
• 11 Greenberg SM, Charidimou A. Diagnosis of Cerebral Amyloid Angiopathy: Evolution of the Boston Criteria. Stroke 2018; 49 (02) 491-497
• 12 Caetano A, Ladeira F, Barbosa R, Calado S, Viana-Baptista M. Cerebral amyloid angiopathy - The modified Boston criteria in clinical practice. J Neurol Sci 2018; 384: 55-57
• 13 Corp IBM. Released 2016. IBM SPSS Statistics for Windows, Version 24.0. Armonk, NY: IBM Corp.;
• 14 Wu TY, Yassi N, Shah DG. et al. Simultaneous Multiple Intracerebral Hemorrhages (SMICH). Stroke 2017; 48 (03) 581-586