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intracerebral hemorrhage ( ich ) is the cause of stroke in about 3040% of stroke patients in pakistan .
the hemorrhage volume is an important predictor of outcome in ich patients , and it is well known that an increased hemorrhage volume in ich patients is associated with increased functional disability and mortality .
one study demonstrated that the predicted 30-day mortality was 93% for ich volumes > 60 mm , 64% for those from 30 to 60 mm and 19% for those < 30 mm . in another study , warfarin treatment in patients with inr > 3.0
apart from anticoagulation , it is not well known why some patients have large - volume and others small - volume hemorrhage .
relationships between ich volume and duration of hypertension , number and types of anti - hypertensive medications , drug compliance and blood pressure ( bp ) control 36 months prior to the ich event have not been elucidated yet .
identification of modifiable factors associated with large - volume hemorrhage in hypertensive patients may help to reduce morbidity and mortality related to ich .
therefore , the objective of this study was to identify predictors of large - volume ich in hypertensive patients .
we prospectively analyzed 157 consecutive hypertensive patients admitted for ich in 20082009 at the aga khan university , a tertiary care center in karachi , pakistan .
their ich volumes were assessed using ct or mri , and various factors , including duration of hypertension , medical treatment , compliance , co - morbidity , and hematologic and coagulation profiles , were determined .
an ich volume > 30 mm was defined as high - volume ich , which was calculated using broderick 's method [ 3 , 5 ] .
hypertension was defined as a history of hypertension , bp > 140 ( systolic ) and/or > 90 ( diastolic ) mm hg on 3 measurements during hospitalization or treatment with anti - hypertensive drugs .
diabetes mellitus was defined as a history of diabetes mellitus and fasting serum glucose levels > 110 mg / dl , or treatment with insulin or hypoglycemic drugs .
dyslipidemia was defined as a fasting total blood cholesterol 200 mg / dl and/or ldl cholesterol 100 mg / dl and/or triglycerides 150 mg / dl .
patients or immediate family members were asked about the use of anti - hypertensive medications , compliance to these medications and quality of bp control at home prior to admission .
patients were regarded as non - compliant if they did not take half or more of their anti - hypertensive medication during the preceding month .
bp control was classified as poor if bp was > 140 ( systolic ) and/or > 90 ( diastolic ) mm hg on > 50% of home measurements despite taking anti - hypertensive medication during the 1-month period preceding the ich event .
the  test and student 's t test were used to compare both groups regarding baseline characteristics and outcome .
based on the findings in univariate analysis , a logistic regression model was built to identify predictors of high - volume ich .
of the 157 hypertensive patients with ich analyzed , 133 patients were included in the study .
we excluded 24 patients with brain stem , cerebellum and pure intraventricular hemorrhage , because the volume - outcome relationship of ich in these brain areas could be different from basal - ganglia , thalamic or lobar ich .
mean age of the patients was 55 years ( range 1985 years ) , and 56 patients ( 70% ) were male .
diagnosis of hypertension was known in 119 ( 89% ) patients , while 14 ( 11% ) were unaware of their diagnosis .
only 81 patients ( 61% ) were on any anti - hypertensive medication : 50 ( 38% ) were treated with 1 anti - hypertensive drug while 31 ( 23% ) were on 2 anti - hypertensive drugs .
we were able to retrieve the history of compliance with anti - hypertensive medication for the 1-month period preceding ich in 46 patients ( 35% ) , and 25 ( 19% ) were poorly adherent to their medication .
other co - morbidities included diabetes ( 23 ; 17% ) , dyslipidemia ( 11 ; 8% ) and cigarette smoking ( 20 ; 15% ) .
anti - platelet medication was taken by 49 ( 37% ) patients , while 8 ( 6% ) patients were on warfarin .
ich were located in the basal ganglia and thalamus in 98 ( 74% ) patients , and lobar ich was noted in 35 ( 26% ) patients .
the mean ich volume was 26 mm ( range 896 mm ) , ranging from 23 mm in basal ganglia / thalamus to 29 mm in lobar areas .
ich volume was < 30 mm in 86 ( 65% ) patients , while 47 ( 35% ) patients had high - volume ich ( > 30 mm ) .
mortality was significantly higher ( 32% ) in patients with high - volume ich compared to patients with low - volume ich ( 6% ) .
male gender ( p = 0.005 ) , use of warfarin ( p = 0.05 ) , inr > 3.0 on admission ( p = 0.04 ) , use of > 1 anti - hypertensive agent ( p = 0.001 ) and poor compliance with medication ( p = 0.001 ) were associated with large - volume ich in univariate analysis ( table 1 ) . in multivariate analysis ,
predictors of large - volume ich were use of > 1 anti - hypertensive agent and poor compliance ( table 2 ) .
these findings indicate that more than one third of patients in this tertiary hospital referral setting had high - volume ich , and use of 2 anti - hypertensive agents and poor compliance with anti - hypertensive medication were the strongest predictors of high - volume hemorrhage .
patients treated with 2 anti - hypertensive drugs most likely represent aggressive forms of hypertension , and non - compliance is probably associated with sustained uncontrolled bp .
these findings may also be a sign of more careful management of hypertension ( despite lesser compliance ) by doctors .
they may also suggest that during acute bleeding , the presence of more vasoplegic medication triggers a longer and more intense hemorrhage , or that a lower bp in the acute phase is associated with lower intracranial pressure ( compared with patients with higher bp ) , resulting in prolonged and larger bleeding .
poor compliance with warfarin , in addition to anti - hypertensive medication , may be associated with an increased risk of hemorrhage .
morbidity and mortality related to high - volume ich could be reduced by interventions aiming to lower hemorrhage volume among these patients .
it is well known from non - randomized subgroup evaluation in randomized trials ( e.g. progress ) and extrapolation from observation studies that aggressive bp control is associated with a lower incidence of ich , suggesting that aggressive bp control may lead to smaller - volume hemorrhage with lower mortality .
our study confirms previous reports of a correlation between warfarin treatment and high inr and large - volume ich .
a limitation of this study is its small number of study patients and limited available information regarding some aspects of bp control and medication compliance .
backgroundhemorrhage volume is an important predictor of outcome in patients with intracerebral hemorrhage ( ich ) . 
 it is not clear why in some patients ich volume is larger than in others . 
 identification of modifiable factors responsible for large - volume hemorrhage in hypertensive patients may help to reduce ich - related morbidity and mortality.objectivethe objective of this study was to identify predictors of large - volume ich in hypertensive patients.methodsat a tertiary care center in karachi ( pakistan ) , 157 hypertensive patients with ich were prospectively analyzed in 20082009 , and hemorrhage volumes were determined using ct or mri and various factors , including duration of hypertension , medical treatment , compliance , co - morbidity , and hematologic and coagulation profiles . 
 logistic regression analysis was used to identify predictors of high - volume hemorrhage . a volume 
 > 30 mm3 was defined as high - volume hemorrhage.resultsof 157 patients with hypertensive ich evaluated , 133 patients were included in the study , and 24 patients with brain stem , cerebellum and pure intraventricular hemorrhage were excluded . 
 the mean age of the study patients was 55 years ; 56 patients ( 70% ) were male . 
 high - volume hemorrhage ( > 30 mm3 ) was noted in 47 ( 35% ) patients . 
 mortality was significantly increased in patients with high - volume ich ( 32 vs. 6% in patients with low - volume ich ) . in univariate analysis , factors significantly associated with large - volume ich were male gender ( p = 0.002 ) , hypertension lasting > 10 years ( p = 0.03 ) , warfarin treatment ( p = 0.05 ) , use of > 1 anti - hypertensive agent ( p = 0.001 ) and poor compliance with medication ( p = 0.001 ) . in multivariate analysis , 
 use of > 1 anti - hypertensive agent and poor compliance were also predictors of large - volume ich.conclusionhigh-volume hemorrhage was less common ( 28% ) in our patients with hypertension and ich . 
 use of > 1 anti - hypertensive agent and poor compliance were predictors of large - volume ich .