nontraumatic spontaneous intracranial hemorrhage ( ich ) causes significant morbidity and mortality throughout the world .
ten to 20% of strokes are caused by ich in western countries.6 ) over 45 years of age , ich is common,5)16)21 ) but rare before then .
therefore , the goal of our study was to perform a descriptive analysis of ich etiology and prognostic factors in patients aged  40 years .
we selected 39 consecutive patients who were  40 years of age diagnosed between january 2001 and june 2012 .
all cases of ichs were confirmed using computed tomography ( ct ) or magnetic resonance imaging ( mri ) .
traumatic ich , insufficient medical information , previously diagnosed intracranial tumors , arteriovenous malformation ( avm ) , and primary subarachnoid hemorrhage were exclusion factors for this study .
for each patient , we analyzed the following prognostic factors : smoking history ( the consumption of  5 cigarettes at least 2 days per week over a period of 12 months ) , alcohol use ( the ingestion of 100 g / d or more every day for at least 20 days per month during the last 2 months or acute alcoholic intoxication during the 24 hours prior to the attack ) , previously diagnosed underlying disease such as hypertension or diabetes mellitus , the use of antihypertensive or antidiabetic agents , high serum cholesterol ( fasting cholesterol values  200 mg / dl at admission ) or low serum cholesterol ( < 150 mg / dl ) , and bleeding tendency ( prolongation of prothrombin time > 14.3 seconds or activated partial thromboplastin time > 43.5 seconds ) . the hematoma volume was estimated via the analysis of ct scans using the abc/2 method.12 ) the hematoma site was denoted by lobe ( frontal , parietal , temporal or occipital ) , thalamus , basal ganglia , cerebellum , or brain stem .
hypertensive ich was defined as hemorrhage into the brain parenchyma in the absence of causal trauma or a structural disease process on a macroscopic level , such as a tumor , aneurysm , vascular malformation , or arteriovenous fistula , in patients treated for hypertension ( or who were previously diagnosed with hypertension ) , as well as the absence of another cause of ich .
avm , venous angioma and other vascular malformations were confirmed using ct angiography , conventional cerebral angiography , or magnetic resonance angiography .
if there was no explanatory underlying disease or abnormal structural lesion in the image workup , the ich was defined as cryptogenic ich .
patients with an ich volume greater than 30 ml in the basal ganglia or thalamus received surgical treatment , with the exception of 4 patients .
one patient was a high surgical risk because of disseminating intravascular coagulopathy associated with acute myelocytic leukemia , and the others showed no definite neurological deterioration and tolerated the event with conservative management . for the patients with an ich volume of less than 30 ml , conservative management was indicated .
however , for the patients with an ich volume of less than 30 ml , if progressive acute hydrocephalus due to intraventricular hemorrhage and neurological deterioration was present , external ventricular drainage was performed . in cerebellar ich ,
regardless of the hemorrhage volume , a decompressive craniectomy with hematoma removal was performed if the patient showed progressive neurological deterioration .
a good outcome was defined as a gos score  4 , and a poor outcome was defined as a gos score < 4 .
fisher 's exact test was applied to assess statistical significance , and null hypotheses of no difference were rejected if p values were less than 0.05 .
the mean age was 33.21  6.42 years ( range 15 - 40 years ) , and there were 11 females and 28 males .
the characteristics of the study subjects by outcome at discharge and 6 months after discharge are described in table 1 .
we assessed outcomes by reviewing the gos of medical record at discharge and 6 months after discharge .
based on the outcomes at discharge and 6 months after discharge , smoking history was significantly associated with prognosis .
alcohol use , previously diagnosed hypertension and bleeding tendency were not statistically significantly associated with outcome .
all of the patients with cholesterol levels less than 200 mg / dl had good outcomes at 6 months after discharge ; this finding was statistically significant ( p = 0.047 ) .
patients with an initial systolic blood pressure ( sbp ) < 160 mmhg had better outcomes ( good outcomes in 65.4% of patients ) , while those patients with an sbp  160 mmhg had poorer prognoses ( poor outcomes in 69.2% of patients ) ; this result was statistically significant ( p = 0.044 ) .
the level of diastolic blood pressure ( dbp ) upon admission showed similar results ( < 90 mmhg : 66.7% experienced good outcomes ;  90 mmhg : 57.1% experienced poor outcomes ) although , these results were not significant . the ich location , as well as the presence or absence of intraventricular hemorrhage ( ivh ) , had no significant effect on outcome ( p = 0.451 ) .
there were also no statistically significant findings associated with ich direction ( left or right ) .
in particular , patients with gcs  8 had a higher proportion of poor outcomes , compared to patients with gcs > 8 ; this finding was statistically significant ( p = 0.02 via fisher 's exact test ) .
variations in the volume of the hematoma showed no significant difference ( p = 0.051 ) in gcs score .
lobar hemorrhage was the most common location of ich in young adults , and there were no statistically significant findings associated with hematoma location ( table 3 ) .
in our institution , 280 patients were diagnosed with ich during the investigation period ; of these patients , 39 ( 13.9 % ) were aged  40 years . in western countries ,
only 3 - 5% of ich patients were younger than 45 years.14)24 ) the distribution of ich reflects the characteristics of the population ( ethnic / racial groups and the criteria of a young adult ) although these studies were not standardized.4 ) in this study , 11 ( 28.2% ) of the patients diagnosed with ich had also been diagnosed with hypertension . in young adults , hypertension is a primary cause of ich , and this hypertension / ich ratio varies from 11 to 15%.2)3)23 ) as with other published literature , our study showed that a poor prognosis is more likely in patients with hypercholesterolemia .
many studies describe serum cholesterol level and smoking history as risk factors for ich.2)18)20)22)23 ) in our study , the serum cholesterol level and smoking history were also prognostic factors . according to ruiz - sandoval and coworkers,18 )
avm contributes to 33% of ich cases , cavernous angioma contributed to 16% of cases , and hypertension contributed to 11% of cases ( all under the age of 40 years ) , similar to our study results .
however , among the elderly , hypertension was the most common cause of ich , and the putamen was the most common location.11)20 ) our results indicate that the most common causes of ich were cryptogenic cases ( n = 16 , 41.03% ) and the most common structural etiology of ich was avm .
we found that an initial sbp greater than 160 mmhg indicated a poor prognosis , and patients with a sbp less than 160 mmhg were more likely to have a good prognosis .
some authors reported a low ( < 130 mmhg ) or high (  200 mmhg ) initial sbp as a prognostic factor that was independently associated with mortality.9 ) smoking , alcohol , and bleeding tendency in younger patients were determined to be prognostic factors of ich.13)18 ) regarding the serum cholesterol , the patients with levels < 200 mg / dl ( 63.3% ) showed a good prognosis , and patients with levels  200 mg / dl ( 77.8% ) showed a poor prognosis .
six months after discharge , this difference was statistically significant and suggests that serum cholesterol levels can be a prognostic factor , as seen in the literature.1 ) ruiz - sandoval and coworkers19 ) reported that hypertension and hypercholesterolemia are 2 main risk factors for ich .
some authors reported that hypocholesterolemia can cause ich and that the interaction between high diastolic blood pressure and low cholesterol levels weakens the endothelium of the intracerebral arteries , resulting in a hemorrhagic stroke in the presence of hypertension.10 ) however , in that study , the association between low cholesterol levels and the prognosis was not clearly presented . a study to investigate the association between serum low - density lipoprotein cholesterol ( ldl - c ) and mortality in ich found that lower ldl - c levels were associated with higher mortality rates.17 ) in our study , 7 patients ( 58.3% ) with ldl - c levels < 150 mg / dl had good outcomes and statistically significant improvements 6 months after discharge .
however , the sample size was limited in our study , age was limited to  40 years , and cholesterol was the only factor used to assess the outcome via lipid profile . a statistically significant difference in outcomes ( p = 0.034 by the t - test ) by the initial gcs score was observed .
a score of 8 or less predicted a higher risk of death within 2 days ( odds ratio , or = 3.9).7 ) among patients with a pre - hospital neurological decline , the gcs score was lower by an average of 6 points , and the mortality rate was 75%.15 ) the usefulness of surgical treatment of ich is still under debate.8 ) in this study , there was no statistically significant difference in prognosis between patients who did or did not receive surgical treatment ( p = 0.109 ) .
ich is rare in young adults aged  40 years ; thus , the existing large - scale studies are not sufficient for studying either etiology or prognosis in this group of patients . due to the small number of patients and limited study period ,
more accurate and reliable outcome results could be obtained be comparative analysis of across several institutions and groups in the regional community . in this study , smoking , serum cholesterol , sbp on admission , and the initial gcs were significant prognostic factors .
avm was the most common structural etiology of non - traumatic spontaneous ich in the patients aged  40 years .
eight points or more on the initial gcs , sbp < 160 mmhg , serum cholesterol < 200 mg / dl , and low initial sbp indicated a good prognosis . a history of smoking was associated with a good prognosis in this study , although , the initial gcs score influenced this result .
our study had some limitations , including its retrospective nature , its involvement of a single institution , the small number of cases , and the relatively short follow - up periods .
thus , longer follow - up periods in prospective , multi - institutional studies that include large numbers of patients are necessary to better understand the prognosis of ich in young adults .
 objectivespontaneous intracerebral hemorrhage ( ich ) in young adults is rare . the purpose of this study was to investigate causes , sites and other factors affecting the prognosis of ich in young adults aged  40 years.methodswe reviewed 39 consecutive patients diagnosed with spontaneous ich between january 2001 and june 2012 . 
 patients with primary subarachnoid hemorrhage , previously diagnosed brain tumor bleeding , or vascular malformation were excluded . 
 we analyzed the differences in prognostic factors such as hemorrhage location and vascular structural etiology . 
 the outcome was measured using the glasgow outcome scale ( gos ) , and a good outcome was defined as a score of 4 or more.resultswe retrospectively evaluated 39 patients ( mean age , 33 years ; sd = 6.4 , range 17 to 40 years ) . 
 the most common structural etiology was arteriovenous malformation . 
 a statistically significantly higher proportion of patients with good outcomes had a lower initial systolic blood pressure ( sbp  160 mmhg , p = 0.036 ) , a higher initial glasgow coma scale ( gcs ) ( 9 or more , p = 0.034 ) , lower cholesterol levels ( < 200 mg / dl , p = 0.036 ) , and smoking history ( at discharge , p = 0.008 ; 6 months after discharge , p = 0.019).conclusionin this study , cryptogenic ich was the leading cause of spontaneous ich . a gcs score of 9 or more on admission , a lower serum cholesterol level ( < 200 mg / dl ) , and a lower sbp ( < 160 mmhg ) predicted a good outcome . 
INTRODUCTION
METHODS
RESULTS
DISCUSSION
CONCLUSION