title: SMASH-U: a proposal for etiologic classification of intracerebral hemorrhage.
abstract: OBJECTIVE
  The purpose of this study was to provide a simple and practical clinical classification for the etiology of intracerebral hemorrhage (ICH).
  
  
  METHODS
  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.
  
  
  RESULTS
  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 5&frac12; 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.
  
  
  CONCLUSIONS
  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.
authors.affiliation: Department of Neurology, Helsinki University Central Hospital, PO Box 340, FI-00029 HUS, Finland. atte.meretoja@fimnet.fi
authors.forename: Atte
authors.initials: A
authors.lastname: Meretoja
authors.forename: Daniel
authors.initials: D
authors.lastname: Strbian
authors.forename: Jukka
authors.initials: J
authors.lastname: Putaala
authors.forename: Sami
authors.initials: S
authors.lastname: Curtze
authors.forename: Elena
authors.initials: E
authors.lastname: Haapaniemi
authors.forename: Satu
authors.initials: S
authors.lastname: Mustanoja
authors.forename: Tiina
authors.initials: T
authors.lastname: Sairanen
authors.forename: Jarno
authors.initials: J
authors.lastname: Satopää
authors.forename: Heli
authors.initials: H
authors.lastname: Silvennoinen
authors.forename: Mika
authors.initials: M
authors.lastname: Niemelä
authors.forename: Markku
authors.initials: M
authors.lastname: Kaste
authors.forename: Turgut
authors.initials: T
authors.lastname: Tatlisumak
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D016657:Cerebral Amyloid Angiopathy / Q000150:complications; D002543:Cerebral Hemorrhage / Q000145:classification* / Q000209:etiology* / Q000401:mortality; D002965:Classification / Q000379:methods*; D005260:Female; D006801:Humans; D006973:Hypertension / Q000150:complications; D008297:Male; D008875:Middle Aged; D011379:Prognosis; D015203:Reproducibility of Results; D012189:Retrospective Studies; D015996:Survival Rate; D014652:Vascular Diseases / Q000150:complications