title: Simultaneous Multiple Intracerebral Hemorrhages (SMICH).
abstract: Simultaneous multiple intracerebral hemorrhages (SMICHs) are uncommon. Few single-center studies have analyzed characteristics and outcome of SMICH. We analyzed clinical characteristics and outcome of SMICH patients from 2 comprehensive stroke centers.
  
  
  
  Baseline imaging from consecutive intracerebral hemorrhage (ICH) patients (n=1552) from Helsinki ICH study and Royal Melbourne Hospital ICH study was screened for SMICH. ICH pathogenesis was classified according to the structural lesion, medication, amyloid angiopathy, systemic/other disease, hypertension, undetermined classification system (SMASH-U). ICH caused by trauma, tumor, and aneurysmal rupture was excluded. Baseline clinical and radiological characteristics and 90-day mortality were compared between SMICH and single ICH patients. Association of SMICH with 90-day mortality was assessed in multivariable logistic regression models adjusted for predictors of ICH outcome.
  
  
  
  Of 1452 patients, 85 (5.9%) were classified as SMICH. SMICH were more often female (58% versus 42%;P=0.004), had lower baseline Glasgow Coma Scale (12 versus 14;P=0.008), and more frequent lobar location (59% versus 34%;P<0.001) compared with single ICH. The SMASH-U pathogenesis of SMICH patients was less often hypertensive (20% versus 37%;P=0.001), more often systemic coagulopathy (12% versus 3%;P<0.001), and trended toward more cerebral amyloid angiopathy (32% versus 23%;P=0.071). SMICH was not associated with 90-day mortality on univariate (37% versus 35%;P=0.610), multivariable (odds ratio, 0.783; 95% confidence interval, 0.401-1.529;P=0.473), or propensity score-matched analyses (odds ratio, 0.760; 95% confidence interval, 0.352-1.638;P=0.484).
  
  
  
  SMICH occurs in ≈1 in 20 ICH, more commonly with lobar located hematomas and systemic coagulopathy with less hypertensive angiopathy. The associated mortality is similar to single ICH. Given varied etiologies, SMICH management should target the underlying pathology.
authors.affiliation: From the Department of Medicine and Neurology, Melbourne Brain Centre (T.Y.W., N.Y., D.G.S., M.M., B.C.V.C., B.Y., S.M.D., A.M.) and Department of Radiology (G.S., P.M.D.), the Royal Melbourne Hospital, University of Melbourne, Australia; Department of Neurology, Helsinki University Hospital, Finland (J.P., D.S., T.T., A.M.); Department of Neurology, Jinling Hospital, Nanjing University School of Medicine, People's Republic of China (M.M.); Institute of Neuroscience and Physiology, Sahlgrenska Academy at the University of Gothenburg, Sweden (T.T.); and Department of Neurology, Sahlgrenska University Hospital, Gothenburg, Sweden (T.T.).|Guest Editor for this article was Giuseppe Lanzino, MD.|Presented in part at the International Stroke Conference of the American Heart Association, Houston, TX, February 22-24, 2017.
authors.forename: Teddy Y
authors.initials: TY
authors.lastname: Wu
authors.affiliation: From the Department of Medicine and Neurology, Melbourne Brain Centre (T.Y.W., N.Y., D.G.S., M.M., B.C.V.C., B.Y., S.M.D., A.M.) and Department of Radiology (G.S., P.M.D.), the Royal Melbourne Hospital, University of Melbourne, Australia; Department of Neurology, Helsinki University Hospital, Finland (J.P., D.S., T.T., A.M.); Department of Neurology, Jinling Hospital, Nanjing University School of Medicine, People's Republic of China (M.M.); Institute of Neuroscience and Physiology, Sahlgrenska Academy at the University of Gothenburg, Sweden (T.T.); and Department of Neurology, Sahlgrenska University Hospital, Gothenburg, Sweden (T.T.).|Guest Editor for this article was Giuseppe Lanzino, MD.|Presented in part at the International Stroke Conference of the American Heart Association, Houston, TX, February 22-24, 2017.
authors.forename: Nawaf
authors.initials: N
authors.lastname: Yassi
authors.affiliation: From the Department of Medicine and Neurology, Melbourne Brain Centre (T.Y.W., N.Y., D.G.S., M.M., B.C.V.C., B.Y., S.M.D., A.M.) and Department of Radiology (G.S., P.M.D.), the Royal Melbourne Hospital, University of Melbourne, Australia; Department of Neurology, Helsinki University Hospital, Finland (J.P., D.S., T.T., A.M.); Department of Neurology, Jinling Hospital, Nanjing University School of Medicine, People's Republic of China (M.M.); Institute of Neuroscience and Physiology, Sahlgrenska Academy at the University of Gothenburg, Sweden (T.T.); and Department of Neurology, Sahlgrenska University Hospital, Gothenburg, Sweden (T.T.).|Guest Editor for this article was Giuseppe Lanzino, MD.|Presented in part at the International Stroke Conference of the American Heart Association, Houston, TX, February 22-24, 2017.
authors.forename: Darshan G
authors.initials: DG
authors.lastname: Shah
authors.affiliation: From the Department of Medicine and Neurology, Melbourne Brain Centre (T.Y.W., N.Y., D.G.S., M.M., B.C.V.C., B.Y., S.M.D., A.M.) and Department of Radiology (G.S., P.M.D.), the Royal Melbourne Hospital, University of Melbourne, Australia; Department of Neurology, Helsinki University Hospital, Finland (J.P., D.S., T.T., A.M.); Department of Neurology, Jinling Hospital, Nanjing University School of Medicine, People's Republic of China (M.M.); Institute of Neuroscience and Physiology, Sahlgrenska Academy at the University of Gothenburg, Sweden (T.T.); and Department of Neurology, Sahlgrenska University Hospital, Gothenburg, Sweden (T.T.).|Guest Editor for this article was Giuseppe Lanzino, MD.|Presented in part at the International Stroke Conference of the American Heart Association, Houston, TX, February 22-24, 2017.
authors.forename: Minmin
authors.initials: M
authors.lastname: Ma
authors.affiliation: From the Department of Medicine and Neurology, Melbourne Brain Centre (T.Y.W., N.Y., D.G.S., M.M., B.C.V.C., B.Y., S.M.D., A.M.) and Department of Radiology (G.S., P.M.D.), the Royal Melbourne Hospital, University of Melbourne, Australia; Department of Neurology, Helsinki University Hospital, Finland (J.P., D.S., T.T., A.M.); Department of Neurology, Jinling Hospital, Nanjing University School of Medicine, People's Republic of China (M.M.); Institute of Neuroscience and Physiology, Sahlgrenska Academy at the University of Gothenburg, Sweden (T.T.); and Department of Neurology, Sahlgrenska University Hospital, Gothenburg, Sweden (T.T.).|Guest Editor for this article was Giuseppe Lanzino, MD.|Presented in part at the International Stroke Conference of the American Heart Association, Houston, TX, February 22-24, 2017.
authors.forename: Gagan
authors.initials: G
authors.lastname: Sharma
authors.affiliation: From the Department of Medicine and Neurology, Melbourne Brain Centre (T.Y.W., N.Y., D.G.S., M.M., B.C.V.C., B.Y., S.M.D., A.M.) and Department of Radiology (G.S., P.M.D.), the Royal Melbourne Hospital, University of Melbourne, Australia; Department of Neurology, Helsinki University Hospital, Finland (J.P., D.S., T.T., A.M.); Department of Neurology, Jinling Hospital, Nanjing University School of Medicine, People's Republic of China (M.M.); Institute of Neuroscience and Physiology, Sahlgrenska Academy at the University of Gothenburg, Sweden (T.T.); and Department of Neurology, Sahlgrenska University Hospital, Gothenburg, Sweden (T.T.).|Guest Editor for this article was Giuseppe Lanzino, MD.|Presented in part at the International Stroke Conference of the American Heart Association, Houston, TX, February 22-24, 2017.
authors.forename: Jukka
authors.initials: J
authors.lastname: Putaala
authors.affiliation: From the Department of Medicine and Neurology, Melbourne Brain Centre (T.Y.W., N.Y., D.G.S., M.M., B.C.V.C., B.Y., S.M.D., A.M.) and Department of Radiology (G.S., P.M.D.), the Royal Melbourne Hospital, University of Melbourne, Australia; Department of Neurology, Helsinki University Hospital, Finland (J.P., D.S., T.T., A.M.); Department of Neurology, Jinling Hospital, Nanjing University School of Medicine, People's Republic of China (M.M.); Institute of Neuroscience and Physiology, Sahlgrenska Academy at the University of Gothenburg, Sweden (T.T.); and Department of Neurology, Sahlgrenska University Hospital, Gothenburg, Sweden (T.T.).|Guest Editor for this article was Giuseppe Lanzino, MD.|Presented in part at the International Stroke Conference of the American Heart Association, Houston, TX, February 22-24, 2017.
authors.forename: Daniel
authors.initials: D
authors.lastname: Strbian
authors.affiliation: From the Department of Medicine and Neurology, Melbourne Brain Centre (T.Y.W., N.Y., D.G.S., M.M., B.C.V.C., B.Y., S.M.D., A.M.) and Department of Radiology (G.S., P.M.D.), the Royal Melbourne Hospital, University of Melbourne, Australia; Department of Neurology, Helsinki University Hospital, Finland (J.P., D.S., T.T., A.M.); Department of Neurology, Jinling Hospital, Nanjing University School of Medicine, People's Republic of China (M.M.); Institute of Neuroscience and Physiology, Sahlgrenska Academy at the University of Gothenburg, Sweden (T.T.); and Department of Neurology, Sahlgrenska University Hospital, Gothenburg, Sweden (T.T.).|Guest Editor for this article was Giuseppe Lanzino, MD.|Presented in part at the International Stroke Conference of the American Heart Association, Houston, TX, February 22-24, 2017.
authors.forename: Bruce C V
authors.initials: BC
authors.lastname: Campbell
authors.affiliation: From the Department of Medicine and Neurology, Melbourne Brain Centre (T.Y.W., N.Y., D.G.S., M.M., B.C.V.C., B.Y., S.M.D., A.M.) and Department of Radiology (G.S., P.M.D.), the Royal Melbourne Hospital, University of Melbourne, Australia; Department of Neurology, Helsinki University Hospital, Finland (J.P., D.S., T.T., A.M.); Department of Neurology, Jinling Hospital, Nanjing University School of Medicine, People's Republic of China (M.M.); Institute of Neuroscience and Physiology, Sahlgrenska Academy at the University of Gothenburg, Sweden (T.T.); and Department of Neurology, Sahlgrenska University Hospital, Gothenburg, Sweden (T.T.).|Guest Editor for this article was Giuseppe Lanzino, MD.|Presented in part at the International Stroke Conference of the American Heart Association, Houston, TX, February 22-24, 2017.
authors.forename: Bernard
authors.initials: B
authors.lastname: Yan
authors.affiliation: From the Department of Medicine and Neurology, Melbourne Brain Centre (T.Y.W., N.Y., D.G.S., M.M., B.C.V.C., B.Y., S.M.D., A.M.) and Department of Radiology (G.S., P.M.D.), the Royal Melbourne Hospital, University of Melbourne, Australia; Department of Neurology, Helsinki University Hospital, Finland (J.P., D.S., T.T., A.M.); Department of Neurology, Jinling Hospital, Nanjing University School of Medicine, People's Republic of China (M.M.); Institute of Neuroscience and Physiology, Sahlgrenska Academy at the University of Gothenburg, Sweden (T.T.); and Department of Neurology, Sahlgrenska University Hospital, Gothenburg, Sweden (T.T.).|Guest Editor for this article was Giuseppe Lanzino, MD.|Presented in part at the International Stroke Conference of the American Heart Association, Houston, TX, February 22-24, 2017.
authors.forename: Turgut
authors.initials: T
authors.lastname: Tatlisumak
authors.affiliation: From the Department of Medicine and Neurology, Melbourne Brain Centre (T.Y.W., N.Y., D.G.S., M.M., B.C.V.C., B.Y., S.M.D., A.M.) and Department of Radiology (G.S., P.M.D.), the Royal Melbourne Hospital, University of Melbourne, Australia; Department of Neurology, Helsinki University Hospital, Finland (J.P., D.S., T.T., A.M.); Department of Neurology, Jinling Hospital, Nanjing University School of Medicine, People's Republic of China (M.M.); Institute of Neuroscience and Physiology, Sahlgrenska Academy at the University of Gothenburg, Sweden (T.T.); and Department of Neurology, Sahlgrenska University Hospital, Gothenburg, Sweden (T.T.).|Guest Editor for this article was Giuseppe Lanzino, MD.|Presented in part at the International Stroke Conference of the American Heart Association, Houston, TX, February 22-24, 2017.
authors.forename: Patricia M
authors.initials: PM
authors.lastname: Desmond
authors.affiliation: From the Department of Medicine and Neurology, Melbourne Brain Centre (T.Y.W., N.Y., D.G.S., M.M., B.C.V.C., B.Y., S.M.D., A.M.) and Department of Radiology (G.S., P.M.D.), the Royal Melbourne Hospital, University of Melbourne, Australia; Department of Neurology, Helsinki University Hospital, Finland (J.P., D.S., T.T., A.M.); Department of Neurology, Jinling Hospital, Nanjing University School of Medicine, People's Republic of China (M.M.); Institute of Neuroscience and Physiology, Sahlgrenska Academy at the University of Gothenburg, Sweden (T.T.); and Department of Neurology, Sahlgrenska University Hospital, Gothenburg, Sweden (T.T.).|Guest Editor for this article was Giuseppe Lanzino, MD.|Presented in part at the International Stroke Conference of the American Heart Association, Houston, TX, February 22-24, 2017.
authors.forename: Stephen M
authors.initials: SM
authors.lastname: Davis
authors.affiliation: From the Department of Medicine and Neurology, Melbourne Brain Centre (T.Y.W., N.Y., D.G.S., M.M., B.C.V.C., B.Y., S.M.D., A.M.) and Department of Radiology (G.S., P.M.D.), the Royal Melbourne Hospital, University of Melbourne, Australia; Department of Neurology, Helsinki University Hospital, Finland (J.P., D.S., T.T., A.M.); Department of Neurology, Jinling Hospital, Nanjing University School of Medicine, People's Republic of China (M.M.); Institute of Neuroscience and Physiology, Sahlgrenska Academy at the University of Gothenburg, Sweden (T.T.); and Department of Neurology, Sahlgrenska University Hospital, Gothenburg, Sweden (T.T.). atte.meretoja@hus.fi.|Guest Editor for this article was Giuseppe Lanzino, MD. atte.meretoja@hus.fi.|Presented in part at the International Stroke Conference of the American Heart Association, Houston, TX, February 22-24, 2017. atte.meretoja@hus.fi.
authors.forename: Atte
authors.initials: A
authors.lastname: Meretoja
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D001778:Blood Coagulation Disorders / Q000453:epidemiology*; D002543:Cerebral Hemorrhage / Q000453:epidemiology* / Q000209:etiology* / Q000401:mortality; D015897:Comorbidity; D005260:Female; D005387:Finland / Q000453:epidemiology; D006406:Hematoma / Q000453:epidemiology*; D006801:Humans; D008297:Male; D008875:Middle Aged; D014739:Victoria / Q000453:epidemiology
keywords: cerebral hemorrhage; mortality; multiple; pathogenesis