Background: Incidence of acute intracerebral hemorrhage (ICH) increases with age, but there is a lack of information about ICH characteristics in the oldest-old (age ≥85 years). In particular, there is a need for information about hematoma volume, which is included in most clinical scales for prediction of mortality in ICH patients. Many of these scales also assume that, independent of ICH characteristics, the oldest-old have a higher mortality than younger elderly patients (age 65-74 years). However, supporting evidence from cohort studies is limited. We investigated ICH characteristics of oldest-old subjects compared to young (<65 years), young-old (65-74 years) and old-old (75-84 years) subjects. We also investigated whether age is an independent mortality predictor in elderly (age ≥65 years) subjects with acute ICH. Methods: We retrospectively collected clinical and neuroimaging data of 383 subjects (age 34-104 years) with acute supratentorial primary ICH who were admitted to an Italian Stroke Unit (SU) between October 2007 and December 2014. Measured ICH characteristics included hematoma location, volume and intraventricular extension of hemorrhage on admission CT scan; admission Glasgow Coma Scale ≤8 and hematoma expansion (HE) measured on follow-up CT-scans obtained after 24 h. General linear models and logistic models were used to investigate the association of age with ICH characteristics. These models were adjusted for pre-admission characteristics, hematoma location and time from symptom onset to admission CT scan. Limited to elderly subjects, Cox models were used to investigate the association of age with in-SU and 1-year mortality: the model for in-SU mortality adjusted for pre-admission and ICH admission characteristics and the model for 1-year mortality additionally adjusted for functional status and disposition at SU discharge. Results: Independent of pre-admission characteristics, hematoma location and time from symptom onset to admission CT-scan, oldest-old subjects had the highest admission hematoma volume (p < 0.01). Age was unrelated to all other ICH characteristics including HE. In elderly patients, multivariable adjusted risk of in-SU and 1-year mortality did not vary across age categories. Conclusions: Oldest-old subjects with acute supratentorial ICH have higher admission hematoma volume than young and young-old subjects but do not differ for other ICH characteristics. When taking into account confounding from ICH characteristics, risk of in-SU and 1-year mortality in elderly subjects with acute supratentorial ICH does not differ across age categories. Our findings question use of age as an independent criterion for stratification of mortality risk in elderly subjects with acute ICH.

Keywords:
Stroke in the elderly, Incidence and mortality rates, Cohort study, Intracerebral hemorrhage, Primary intracerebral hematoma
1.
Ikram MA, Wieberdink RG, Koudstaal PJ: International epidemiology of intracerebral hemorrhage. Curr Atheroscler Rep 2012;14:300-306.
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;9:167-176.
3.
Suzman R, Riley MW: Introducing the ‘oldest old'. Milbank Mem Fund Q Health Soc 1985;63:177-186.
4.
Baltes PB, Smith J: New frontiers in the future of aging: from successful aging of the young old to the dilemmas of the fourth age. Gerontology 2003;49:123-135.
5.
Hwang BY, Appelboom G, Kellner CP, Carpenter AM, Kellner MA, Gigante PR, Sander Connolly E: Clinical grading scales in intracerebral hemorrhage. Neurocrit Care 2010;13:141-151.
6.
LoPresti MA, Bruce SS, Camacho E, Kunchala S, Dubois BG, Bruce E, Appelboom G, Connolly ES: Hematoma volume as the major determinant of outcomes after intracerebral hemorrhage. J Neurol Sci 2014;345:3-7.
7.
Qureshi AI, Mendelow AD, Hanley DF: Intracerebral haemorrhage. Lancet 2009;373:1632-1644.
8.
Brouwers HB, Greenberg SM: Hematoma expansion following acute intracerebral hemorrhage. Cerebrovasc Dis 2013;35:195-201.
9.
Camacho E, LoPresti MA, Bruce S, Lin D, Abraham M, Appelboom G, Taylor B, McDowell M, DuBois B, Sathe M, Sander Connolly E: The role of age in intracerebral hemorrhages. J Clin Neurosci 2015;22:1867-1870.
10.
Steiner T, Petersson J, Al-Shahi Salman R, Christensen H, Cordonnier C, Csiba L, Harnof S, Krieger D, Mendelow D, Molina C, Montaner J, Overgaard K, Roine RO, Schmutzhard E, Tatlisumak T, Toni D, Stapf C: European research priorities for intracerebral haemorrhage. Cerebrovasc Dis 2011;32:409-419.
11.
Arboix A, Vall-Llosera A, García-Eroles L, Massons J, Oliveres M, Targa C: Clinical features and functional outcome of intracerebral hemorrhage in patients aged 85 and older. J Am Geriatr Soc 2002;50:449-454.
12.
Chiquete E, Ruiz-Sandoval MC, Alvarez-Palazuelos LE, Padilla-Martínez JJ, González-Cornejo S, Ruiz-Sandoval JL: Hypertensive intracerebral hemorrhage in the very elderly. Cerebrovasc Dis 2007;24:196-201.
13.
Stein M, Misselwitz B, Hamann GF, Scharbrodt W, Schummer DI, Oertel MF: Intracerebral hemorrhage in the very old: future demographic trends of an aging population. Stroke 2012;43:1126-1128.
14.
Forti P, Maioli F, Arnone G, Nativio V, Zagnoni S, Riva L, Pedone C, Pirazzoli GL, Coveri M, Zoli M, Di Pasquale G, Procaccianti G: Mortality after admission to stroke unit for intracerebral hemorrhage: effect of age 80 and older and multimorbidity. J Am Geriatr Soc 2015;63:812-813.
15.
Hemphill JC 3rd, Greenberg SM, Anderson CS, Becker K, Bendok BR, Cushman M, Fung GL, Goldstein JN, Macdonald RL, Mitchell PH, Scott PA, Selim MH, Woo D: Guidelines for the management of spontaneous intracerebral hemorrhage: a guideline for healthcare professionals from the American heart association/American stroke association. Stroke 2015;46:2032-2060.
16.
American Diabetes Association: Diagnosis and classification of diabetes mellitus. Diabetes Care 2013;36(suppl 1):S67-S74.
17.
American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition: DSM-IV-TR®. American Psychiatric Publishing, 2000.
18.
van Swieten JC, Koudstaal PJ, Visser MC, Schouten HJ, van Gijn J: Interobserver agreement for the assessment of handicap in stroke patients. Stroke 1988;19:604-607.
19.
Charlson ME, Pompei P, Ales KL, MacKenzie CR: A new method of classifying prognostic comorbidity in longitudinal studies: development and validation. J Chronic Dis 1987;40:373-383.
20.
Flaherty ML, Tao H, Haverbusch M, Sekar P, Kleindorfer D, Kissela B, Khatri P, Stettler B, Adeoye O, Moomaw CJ, Broderick JP, Woo D: Warfarin use leads to larger intracerebral hematomas. Neurology 2008;71:1084-1089.
21.
Falcone GJ, Biffi A, Brouwers HB, Anderson CD, Battey TW, Ayres AM, Vashkevich A, Schwab K, Rost NS, Goldstein JN, Viswanathan A, Greenberg SM, Rosand J: Predictors of hematoma volume in deep and lobar supratentorial intracerebral hemorrhage. JAMA Neurol 2013;70:988-994.
22.
Kothari RU, Brott T, Broderick JP, Barsan WG, Sauerbeck LR, Zuccarello M, Khoury J: The ABCs of measuring intracerebral hemorrhage volumes. Stroke 1996;27:1304-1305.
23.
van Almenkerk S, Smalbrugge M, Depla MF, Eefsting JA, Hertogh CM: What predicts a poor outcome in older stroke survivors? A systematic review of the literature. Disabil Rehabil 2013;35:1774-1782.
24.
Arboix A, García-Eroles L, Massons J, Oliveres M, Targa C: Hemorrhagic lacunar stroke. Cerebrovasc Dis 2000;10:229-234.
25.
Brott T, Adams HP Jr, Olinger CP, Marler JR, Barsan WG, Biller J, Spilker J, Holleran R, Eberle R, Hertzberg V, et al: Measurements of acute cerebral infarction: a clinical examination scale. Stroke 1989;20:864-870.
26.
Kuramatsu JB, Sauer R, Mauer C, Lücking H, Kloska SP, Kiphuth IC, Staykov D, Köhrmann M, Huttner HB: Correlation of age and haematoma volume in patients with spontaneous lobar intracerebral haemorrhage. J Neurol Neurosurg Psychiatry 2011;82:144-149.
27.
Wasay M, Yousuf A, Lal D, Awan S: Predictors of the intracerebral hemorrhage volume in hypertensive patients. Cerebrovasc Dis Extra 2011;1:1-5.
28.
Falcone GJ, Brouwers HB, Biffi A, Anderson CD, Battey TW, Ayres AM, Vashkevich A, Schwab KM, Rost NS, Goldstein JN, Viswanathan A, Greenberg SM, Rosand J: Warfarin and statins are associated with hematoma volume in primary infratentorial intracerebral hemorrhage. Neurocrit Care 2014;21:192-199.
29.
Vasilevko V, Passos GF, Quiring D, Head E, Kim RC, Fisher M, Cribbs DH: Aging and cerebrovascular dysfunction: contribution of hypertension, cerebral amyloid angiopathy, and immunotherapy. Ann N Y Acad Sci 2010;1207:58-70.
30.
Charidimou A, Ni J, Martinez-Ramirez S, Vashkevich A, Ayres A, Rosa nd J, Gurol EM, Greenberg SM, Viswanathan A: Cortical superficial siderosis in Memory Clinic patients: further evidence for underlying cerebral amyloid angiopathy. Cerebrovasc Dis 2016;41:156-162.
31.
Wang J: Preclinical and clinical research on inflammation after intracerebral hemorrhage. Prog Neurobiol 2010;92:463-477.
32.
Zheng H, Chen C, Zhang J, Hu Z: Mechanism and therapy of brain edema after intracerebral hemorrhage. Cerebrovasc Dis 2016;42:155-169.
33.
Caruso D, Perez Akly M, Costantini PD, Fridman S, Esnaola MM: Do elderly patients call 911 when presented with clinical scenarios suggestive of acute stroke? A cross-sectional study. Cerebrovasc Dis 2015;39:87-93.
34.
Weimar C, Benemann J, Diener HC: Development and validation of the Essen intracerebral haemorrhage score. J Neurol Neurosurg Psychiatry 2006;77:601-605.
35.
Broderick JP, Diringer MN, Hill MD, Brun NC, Mayer SA, Steiner T, Skolnick BE, Davis SM: Determinants of intracerebral hemorrhage growth: an exploratory analysis. Stroke 2007;38:1072-1075.
36.
Kazui S, Minematsu K, Yamamoto H, Sawada T, Yamaguchi T: Predisposing factors to enlargement of spontaneous intracerebral hematoma. Stroke 1997;28:2370-2375.
37.
Sato S, Delcourt C, Zhang S, Arima H, Heeley E, Zheng D, Al-Shahi Salman R, Stapf C, Tzourio C, Robinson T, Lindley RI, Chalmers J, Anderson CS: Determinants and prognostic significance of hematoma sedimentation levels in acute intracerebral hemorrhage. Cerebrovasc Dis 2016;41:80-86.
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2016
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