Background and Purpose
There are no generally accepted criteria for the etiologic classification of intracerebral hemorrhage
(ICH). For this reason, we have developed a set of etiologic criteria and have
applied them to a large number of patients to determine their utility.
Methods
The H-ATOMIC classification includes 7 etiologic categories: Hypertension, cerebral Amyloid
angiopathy, Tumour, Oral anticoagulants, vascular Malformation, Infrequent causes
and Cryptogenic. For each category, the etiology is scored with three degrees of certainty:
Possible(3), Probable(2) and Definite(1). Our aim was to perform a basic study consisting of
neuroimaging, blood tests, and CT-angio when a numerical score (SICH) suggested an
underlying structural abnormality. Combinations of >1 etiologic category for an individual
patient were acceptable. The criteria were evaluated in a multicenter and prospective study
of consecutive patients with spontaneous ICH.
Results
Our study included 439 patients (age 70.8 ± 14.5 years; 61.3% were men). A definite etiology
was achieved in 176 (40.1% of the patients: Hypertension 28.2%, cerebral Amyloid
angiopathy 0.2%, Tumour 0.2%, Oral anticoagulants 2.2%, vascular Malformation 4.5%,
Infrequent causes 4.5%). A total of 7 patients (1.6%) were cryptogenic. In the remaining
58.3% of the patients, ICH was attributable to a single (n = 56, 12.7%) or the combination of
2 (n = 200, 45.5%) possible/probable etiologies. The most frequent combinations of etiologies
involved possible hypertension with possible CAA (H3A3, n = 38) or with probable CAA
(H3A2, n = 29), and probable hypertension with probable OA (H2O2, n = 27). The most frequent category with any degree of certainty was hypertension (H1+2+3 = 80.6%) followed
by cerebral amyloid angiopathy (A1+2+3 = 30.9%).
Conclusions
According to our etiologic criteria, only about 40% patients received a definite diagnosis,
while in the remaining patients ICH was attributable to a single possible/probable etiology or
to more than one possible/probable etiology. The use of these criteria would likely help in
the management of patients with ICH.This work was supported by Ministery of Health-Instituto de Salud Carlos III: RETICS (Redes temáticas de Investigación Cooperativa) INVICTUS RD012/0014 (JM-F, PC-R, AM-D, LP-S, RD-M), FEDER (Fondo Europeo de Desarrollo Regional)
