Nontraumatic intracerebral haemorrhage in young adults

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Key Points

  • The incidence of intracerebral haemorrhage (ICH) increases steeply with age and has an annual incidence of 5 per 100,000 individuals in young adults (<50 years of age).

  • Classic risk factors for ICH are common even in young adults; drug abuse, pregnancy and the postpartum period are additional important young-adult-specific risk factors.

  • Hypertension is the predominant cause of ICH in young adult Indian and Asian populations, whereas hypertension and vascular abnormalities are equally important in white populations.

  • Potential causes of ICH in young people are many and require systematic diagnostic studies with imaging of the intracranial vasculature as the cornerstone of the diagnostic work-up.

  • Observational evidence supports an aggressive approach to the management of ICH in young patients, including lowering of elevated blood pressure, surgical haematoma evacuation (in selected patients) and vigorous rehabilitation.

  • ICH in young adults has a dismal prognosis: 3-month mortality is 17%, 10-year mortality is >25% and long-term disability is common.

Abstract

Nontraumatic intracerebral haemorrhage (ICH) is a common subtype of stroke with a poor prognosis, high mortality and long-term morbidity. The incidence of ICH increases with age. ICH has not been widely investigated in young adults (herein defined as aged 18–50 years) despite an annual incidence of 5 per 100,000 individuals. Furthermore, ICH characteristics differ between young and elderly patients. Risk factors for ICH are surprisingly common in young adults, in whom ICH is often caused by structural lesions or hypertension, and only rarely by anticoagulation therapy and cerebral amyloid angiopathy (which are common predisposing factors in elderly patients). High short-term mortality (17% at 3 months) and long-term mortality (>25% at 10 years) persist even in contemporary series from high-income countries, and long-term disability is very common. Thus, an aggressive approach to identifying treatable underlying conditions and preventing ICH recurrence is indicated in young patients, although treatment strategies have generally not been investigated specifically in this age group. This narrative Review summarizes existing knowledge on the epidemiology, risk factors, causes, diagnosis, treatment and outcomes of ICH in young adults. We provide comparisons with the population of elderly patients with ICH and discuss challenges for future research.

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Figure 1: An approach to the diagnosis of intracerebral haemorrhage in young adults (aged 18–50 years).
Figure 2: Brain CT, MRI and angiography scans showing intracerebral haemorrhages of various aetiologies in young adults.

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Acknowledgements

The authors thank A. Eräkanto for secretarial help.

Author information

J.P. and T.T. conducted the literature search for the article. All authors contributed to the original idea and planning for the article, to drafting the initial version and to critical revision or editing of the manuscript before submission.

Correspondence to Turgut Tatlisumak.

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Competing interests

T.T. declares that he has received grants for research into intracerebral haemorrhage from Helsinki University Central Hospital, Sahlgrenska University Hospital, University of Gothenburg, and the Sigrid Juselius Foundation. The other authors declare no competing interests.

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Surgical equipoise

A principle according to which patients who are eligible for enrolment in randomized clinical trials of medical versus surgical treatments are excluded from randomization if the clinician decides that (despite a lack of scientific evidence) surgical treatment will be superior, or life-saving. Such considerations often result in the exclusion of young patients from clinical trial cohorts.

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Tatlisumak, T., Cucchiara, B., Kuroda, S. et al. Nontraumatic intracerebral haemorrhage in young adults. Nat Rev Neurol 14, 237–250 (2018) doi:10.1038/nrneurol.2018.17

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