Department of Neurology, Helsinki University Central Hospital, PO Box 340, FI-00029 HUS, Finland.
Stroke. 2012 Oct;43(10):2592-7. doi: 10.1161/STROKEAHA.112.661603. Epub 2012 Aug 2.
The purpose of this study was to provide a simple and practical clinical classification for the etiology of intracerebral hemorrhage (ICH).
We performed a retrospective chart review of consecutive patients with ICH treated at the Helsinki University Central Hospital, January 2005 to March 2010 (n=1013). We classified ICH etiology by predefined criteria as structural vascular lesions (S), medication (M), amyloid angiopathy (A), systemic disease (S), hypertension (H), or undetermined (U). Clinical and radiological features and mortality by SMASH-U (Structural lesion, Medication, Amyloid angiopathy, Systemic/other disease, Hypertension, Undetermined) etiology were analyzed.
Structural lesions, namely cavernomas and arteriovenous malformations, caused 5% of the ICH, anticoagulation 14%, and systemic disease 5% (23 liver cirrhosis, 8 thrombocytopenia, and 17 various rare conditions). Amyloid angiopathy (20%) and hypertensive angiopathy (35%) were common, but etiology remained undetermined in 21%. Interrater agreement in classifying cases was high (κ, 0.89; 95% CI, 0.82-0.96). Patients with structural lesions had the smallest hemorrhages (median volume, 2.8 mL) and best prognosis (3-month mortality 4%), whereas anticoagulation-related ICHs were largest (13.4 mL) and most often fatal (54%). Overall, median ICH survival was 5½ years, varying strongly by etiology (P<0.001). After adjustment for baseline characteristics, patients with structural lesions had the lowest 3-month mortality rates (OR, 0.06; 95% CI, 0.01-0.37) and those with anticoagulation (OR, 1.9; 1.0-3.6) or other systemic cause (OR, 4.0; 1.6-10.1) the highest.
In our patients, performing the SMASH-U classification was feasible and interrater agreement excellent. A plausible etiology was determined in most patients but remained elusive in one in 5. In this series, SMASH-U based etiology was strongly associated with survival.
本研究旨在为颅内出血（ICH）的病因提供一种简单实用的临床分类方法。
我们对 2005 年 1 月至 2010 年 3 月在赫尔辛基大学中心医院接受治疗的连续ICH 患者进行了回顾性图表审查（n=1013）。我们根据预先确定的标准将 ICH 病因分类为结构性血管病变（S）、药物（M）、淀粉样血管病（A）、系统性疾病（S）、高血压（H）或未确定（U）。通过 SMASH-U（结构性病变、药物、淀粉样血管病、系统性/其他疾病、高血压、未确定）病因分析了临床和影像学特征以及死亡率。
结构性病变，即海绵状血管瘤和动静脉畸形，占 ICH 的 5%，抗凝治疗占 14%，系统性疾病占 5%（23 例肝硬化，8 例血小板减少症和 17 例各种罕见疾病）。淀粉样血管病（20%）和高血压性血管病（35%）很常见，但仍有 21%的病因未确定。分类病例的观察者间一致性很高（κ，0.89；95%CI，0.82-0.96）。结构性病变患者的出血灶最小（中位数体积为 2.8ml），预后最好（3 个月死亡率为 4%），而抗凝治疗相关的 ICH 最大（13.4ml），且最常致命（54%）。总体而言，ICH 的中位生存时间为 5 年半，病因差异很大（P<0.001）。在调整基线特征后，结构性病变患者的 3 个月死亡率最低（OR，0.06；95%CI，0.01-0.37），抗凝治疗（OR，1.9；1.0-3.6）或其他系统性病因（OR，4.0；1.6-10.1）患者死亡率最高。
在我们的患者中，进行 SMASH-U 分类是可行的，观察者间一致性很好。大多数患者可以确定合理的病因，但仍有五分之一的患者病因难以确定。在本系列中，基于 SMASH-U 的病因与生存率密切相关。
