Medical

Communication

Biosci. Biotech. Res. Comm. 9(3): 475-480 (2016)

Investigations on non-traumatic brain hemorrhage

cases of 30 year below decedents from Tehran

Fares Najari*

Mohammad A. E. Hadi

, B. Nazparvar

and K. Saravanei

Faculty member of Shahid Beheshti University of Medical Sciences, Tehran, Iran

Faculty Member of Legal Medicine Organization, Tehran, Iran

Forensics Assistant, Shahid Beheshti University of Medical Sciences, Tehran, Iran

ABSTRACT

Cerebral hemorrhage due to tumours is as one of the most common reasons of mortality especially in the age group

of 15-30 years, hence timely diagnosis of the place and the type of bleeding is quite important. Since the bleeding

occurs in 5 to 10 percent of brain tumors, the bleeding inside the brain tumor is more common in brain metastases.

As in Iran no any comprehensive study has done in this regards, this study has been conducted. In a descriptive

cross-sectional and retrospective study, the medical documents of under 30 years decedents with non-traumatic brain

hemorrhage referred to the anatomy hall of Tehran forensics Organization were investigated. A checklist containing

credible cases was designed; and the data related to personal information, clinical features and the epidemiology

indexes were extracted from the available documents and records of patients. It was observed that over 10 years

ago, 100 people under 30 years with non-traumatic brain hemorrhage have been referred to the anatomy hall of

Kahrizak; out of which, 77 percent had no any history of drug use, 16 percent with the history of smoking, 4 percent

had the history of using crystal and the rest 3 percent had the history of using the drug. In investigating the type

of non-traumatic brain hemorrhage, 12 people had cerebellar hemorrhage, 3 people epidural, 11 people subdural,

18people cerebral ventricles, 29 people subarachnoid and 27 people had inside brain tissue hemorrhage that the most

frequency of hemorrhage was related to subarachnoid. The obtained results of the present study demonstrate that

non-traumatic brain hemorrhage in the persons with the history of drug abuse and women and men and the age

groups has signi cant difference (P- < 0.05).

KEY WORDS: NON-TRAUMATIC BRAIN HEMORRHAGE, SUBARACHNOID HEMORRHAGE, SUBDURAL HEMORRHAGE

475

ARTICLE INFORMATION:

*Corresponding Author: fares.hospital@yahoo.com

Received 24

July, 2016

Accepted after revision 1

Sep, 2016

BBRC Print ISSN: 0974-6455

Online ISSN: 2321-4007

Thomson Reuters ISI ESC and Crossref Indexed Journal

NAAS Journal Score 2015: 3.48 Cosmos IF : 4.006

reserved.

Online Contents Available at: http//www.bbrc.in/

476 INVESTIGATIONS ON NON-TRAUMATIC BRAIN HEMORRHAGE CASES BIOSCIENCE BIOTECHNOLOGY RESEARCH COMMUNICATIONS

Fares Najari et al.

INTRODUCTION

Braine hemorrhage is one of the most common and

important vascular events caused by mostly high blood

pressure and the brain degenerative changes; and based

on the obtained results of a study conducted by Ray-

mond, (2000), it can lead to mortality and physical dis-

ability in the different grades. As annually in U.S.A in

about three hundred and  fty thousand people physical

disability occurs due to this disease, ( Broderick et al.,

(2003).

According to the obtained results of a study conducted

by Rincon et al., (2011) the inside brain hemorrhage with

the incidence rate of 11 to 33 cases per 100000 people

annually is considered as a common disease. Results of

Rincon and Mayer (2013) have shown that these hemor-

rhages are two times more common than bleeding in the

subarachnoid space. These hemorrhages in men is a little

more common than in women and among the blacks is

more common than their whites peers.

The study conducted by Korkman et al., (2010)

showed that inside brain hemorrhage is as the dead-

liest form of stroke; and the mortality rate in them is

4%.Basically, surgeons believe that the young patients

have better prognosis; accordingly, they are more inter-

ested that the surgery to be done on them. Based on the

study conducted by Ghsemi, (2014) there is not any rela-

tion between age and prognosis.

The inside brain hemorrhage due to lack or presence

of trauma is classi ed to two groups of traumatic or non-

traumatic hemorrhage. Based on above data, non- trau-

matic inside brain hemorrhage or spontaneously is said to

the brain inside parenchyma hemorrhage that may extend

to inside the ventricles and rarely subarachnoid space

Pursuance to the conducted study by Zuccarello, et al.,

(1999), the reasons of inside brain hemorrhage are such as

vascular problems, tumors, coagulation disorders, trauma

vasculitis and drug causes.The most common drugs that

lead to inside brain hemorrhage are sympathomimetics

that are amphetamines, which can lead to hemorrhage

in the brain sub cortical white tissue in form of intrave-

nous, oral and intranasal within a few hours, followed by

cocaine and crack which lead to internal brain hemor-

rhage, (Joynt, 1991, Bambakidis and Selman 2004, Koo-

sarei et al., 2009 and Lip et al., 2011).

The major risk factors that are amendable are such as

smoking, the disease of increasing the blood pressure,

cocaine and alcohol consumption . The patients that their

 rst-degree relative have the history of hemorrhage, are

in the high risk . The high blood pressure almost dou-

bles the risk of hemorrhage, Ingall et al (2000) and Vic-

tor and Ropper, (2001): apart from high blood pressure,

there are three predisposing factors of brain hemorrhage

such as smoking, (27%), increase of cholesterol with or

without increasing triglyceride (21%) and diabetic (10%).

Brain hemorrhage based on the place of bleeding are

classi ed to the inside brain, subarachnoid, subdural

and epidural hemorrhage that all of them except sub-

dural hemorrhage almost are occurred due to arterial

bleeding. Based on studies by Massagli et al., (1996),

and Biller et al., (2008) acute subdural hematomas occur

due to fall or invasion and proportionally less because

of road traf c accidents. In the present investigation,

it has been observed that the most important clinical

features is increasing of acute blood pressure inside the

skull. As till now, no any study has been conducted in

Iran regarding the cause of the reasons of non-traumatic

brain hemorrhage, in the under 30 year age group, so we

decided to conduct this study.

MATERIAL AND METHODS

This descriptive study is cross-sectional as its studied

population consists of the record of the referred dece-

dents to anatomy hall over 10 years ago. Inclusion crite-

ria 1- the referred decedents to Tehran Forensics Organi-

zation since early in 2004 till the end of 2014 , 2- if the

reason of brain hemorrhage is non- traumatic 3- if the

age of decedents is less than 30 year. Then, among the

decedents, those who had traumatic brain hemorrhage

and had the age more than 30 years were excluded. The

minimum volume of sample was obtained 100 by using

the Cochran’s formula. And at the end, the record of

100 under 30 year patients with non- traumatic brain

hemorrhage was investigated and analyzed. To analyze

the data, the descriptive statistics such as gender, the

age group and the history of drug consumption and the

percent of all types of brain hemorrhage were used; and

for inferential analysis, the Chi-square test with 5% sig-

ni cant level (P < 0.05) was used.

RESULTS AND DISCUSSION

The  ndings showed that among the under studied dece-

dents with non- traumatic brain hemorrhage, 64% were

man and the maximum percent (30%) allocated to the

age group of 21 to 30 year and the minimum percent

(15%) belonged to the age group of 11 to 20 year.

36 percent were women that the most percent (16%)

allocated to the age group of 21 to30 and the minimum

percent 9% allocated to the age group less than 10 year

(table 1). According to the  ndings among men, the

inside brain tissue hemorrhage with 22 % people had

the most frequency and the cerebella hemorrhage and

epidural with 3 people 3% had the minimum frequency.

Among the women with hemorrhage of subarachnoid

with 14 people (14%) the most frequency and the epi-

BIOSCIENCE BIOTECHNOLOGY RESEARCH COMMUNICATIONS INVESTIGATIONS ON NON-TRAUMATIC BRAIN HEMORRHAGE CASES 477

Fares Najari et al.

dural hemorrhage was not seen (table2). Based on the

 ndings the under 10 year people with 9 cases (9%),

the most frequency was related to the hemorrhage of

cerebral ventricles and with 2 cases (2%) the minimum

frequency was related to the inside the brain tissue hem-

orrhage.

Among the people 11 to 20 year with 12 cases (12%)

the most frequency was related to the inside brain tissue

hemorrhage; and epidural hemorrhage and subarach-

noid were not seen.

In the age group of 21 to 30 year with 24 cases (24%),

the most frequency was related to the subarachnoid

hemorrhage and the cerebella hemorrhage and epidural

were not seen (table 3).

Pursue to the  ndings in the people with the his-

tory of smoking with 8 cases (8%), the most frequency

was related to the brain inside tissue hemorrhage; and

cerebella and epidural hemorrhage were not seen; and

abusing the crystal had the most frequency relevant to

the subarachnoid hemorrhage and the drugs abusing

had the most frequency related to the cerebral ventricles

hemorrhage (table 4).

The  ndings showed that totally the docents with

brain non- traumatic hemorrhage with 29 people (29%)

had the most frequency related to the subarachnoid

hemorrhage and with 3 people (3%) the least frequency

was related to epidural hemorrhage.

Since subdural bleeding does not occur without

trauma, 3 cases of baby boys following to hard deliv-

ery and 9 cases of subdural bleeding in the wake of the

blood cancer were observed.

During this study, three premature birth of baby girl

with subarachnoid hemorrhage and three cases of two-

day baby girls with cerebral and subarachnoid hemor-

rhage along with under the scalp hematoma in tem-

pro and left parietal as well as bilateral occipital were

observed. In addition, three cases of 10day boy baby

with extensive hemorrhage of cerebral ventricles and

Table 3: The frequency distribution of different non-traumatic brain hemorrhage in under 30year

decedents referred to the anatomy hall of Tehran Forensic Organization during 2004-2014 based

on the age

Sum

Total

Inside

brain

tissue

Subarachnoid Cerebral

ventricles

Subdural Epidural Cerebellum The type of

hemorrhage

Age

28 2 6 9 3 3 6 Less than 10

year

26 12 0 3 5 0 6 11-20 year

46 13 24 6 3 0 0 21-30 year

Pearson Chi-Square: 49.65 df: 10 Sig: 0.000

Table 2: The frequency distribution of non-traumatic brain hemorrhages under 30 year decedents referred

to the anatomy hall of Tehran Forensic Organization during 2004-2014 based on the gender

Sum

total

Inside the

brain tissue

Subarachnoid Cerebral

ventricles

Subdural Epidural Cerebellum The kind of

hemorrhage

Gender

64 22 15 15 6 3 3 Men

36 5 14 3 5 0 9 Women

Pearson Chi-Square: 18.43 df: 5 Sig: 0.002

Table1: The frequency distribution of gender and the age group of under 30 year decedents

with the non-traumatic brain hemorrhage referred to the anatomy hall of Tehran Forensic

Organization during 2004-2014

Age Age

mean

Standard

deviation

Average

age

Total

sum

21-30

year

11-20

year

Less than

10 year

Age

Gender

27 22 9/98 19/25 64 30 15 19 Men

30 17 9/74 16/36 36 16 11 9 Women

20 9/95 18/21 100 46 26 28 Total sum

478 INVESTIGATIONS ON NON-TRAUMATIC BRAIN HEMORRHAGE CASES BIOSCIENCE BIOTECHNOLOGY RESEARCH COMMUNICATIONS

Fares Najari et al.

under the scalp as well as mild bleeding in right parietal

head was seen. Based on Biller et al., (2008)  ndings,

the acute subdural hematoma occurs due to fall or attack

and invasion and in comparison less as a result of road

traf c accidents.During this study, 3 cases boy baby fol-

lowing a hard delivery (CPD or Birth canal stenosis) and

9 cases subdural hemorrhage following the blood cancer

were observed. In this study, the subdural hemorrhage

of babies just were seen in the male gender; that were

not seen in no other study,( Lot et al., (2001). The con-

ducted study by Massagli et al., (1996) earlier had shown

that epidural hematoma occurred due to bleeding in the

space between dora and skull; and usually was present

due to rupture of the membranes of brain vessels and

almost was along with the skull fracture.

In the present study, three cases of epidural hemor-

rhage in new born boys, in the  eld of congenital dis-

orders in the region of occipital were seen; that in these

cases the bleeding was observed just in the male gen-

der. In terms of prevalence, it is compatible with the

obtained results of Giroud et al., (1991); however based

on the results of Sacco, (2000) no important statisti-

cal difference among the bleeding prevalence was seen

among men and women (54 % men and 46% women).

This difference may be due to the variety, country and

circumstances of the subjects under study.

In the present study, by increasing the age, the risk

of death increased and the age average of under stud-

ied population was 18.21 year. The age average of men

was 19.25 and age average of women was 15.36 year.

Based on the study conducted Nick-Seresht et al., (2003)

, the age of the patient had relation with the inside brain

hemorrhage; and for each decade of increasing life, the

risk of death increased 1.13 times as well.

Lip et al., (2011) have also showed that by increasing

the age, the risk of bleeding increases as well. According

to the earlier  ndings of Ghandeharei et al, (2009) and

Khoda et al., (2011) inside brain hemorrhage occurrence

increased as well. That is consistence with the results

of this study. It can be said that by increasing the age,

due to erosion of blood vessels and body members and

occurrence of numerous diseases lead to increasing the

risk of non- traumatic hemorrhage.In the present study,

epidural hemorrhage with three cases showed the least

cause of death. The hemorrhage of subdural was 11 cases

in the Xuming et al., (2007),the rate of subdural hem-

orrhage was reported to be 42%. The reason was the

regional differences and life habits. Based on the inves-

tigations, none of the studies has been done regarding

spontaneous occurrence of epidural and subdural hem-

orrhage. In this study, prevalence of cerebella hemor-

rhage was 12 cases (12%). Based on the work of Ingall et

al., (2000), the cerebella hemorrhage had 7% prevalence.

Based on the results, the brain ventricles inside hem-

orrhage were 18cases and inside the brain tissue was

27 cases as well. Based on the studies conducted by

Khoda et al., (2011),the primary inside brain ventricles

bleeding is as the most common place of brain bleed-

ing. In the study conducted by Lot et al., 2001) 35% of

cases had inside ventricle bleeding. The results of Badiei

(2006) on the newborns showed that 19.5% of them had

inside brain ventricles hemorrhage. Similarly,Parnia et

al.,(2006), have reported that the inside ventricle hem-

orrhage had the most frequency. Based on the obtained

results of this study, the most percent of hemorrhage

was related to subarachnoid bleeding with 29 cases

prevalence.

In a review, it has been reported that the prevalence

of subarachnoid hemorrhage in the difference popula-

tion was from 2 percent of 1000 people annually for

China and up to 22.5 % of 1000 people, annually for

Finland ( Rincon and Mayer 2013).In an earlier con-

ducted study by Lot et al., (2001) about half of bleeding

cases in the newborns hemorrhage (48%) were related to

subarachnoid. Based on the results of this study on new-

borns, the highest amount of hemorrhage rate (6%) was

Table 4: The frequency distribution of non-traumatic brain hemorrhages types in under30 year decedents

referred to the anatomy hall of Tehran Forensic Organization during 2004-2014 based on the history of

abusing drug

Sum

Total

Inside

the brain

tissue

Subarachnoid Cerebral

ventricles

Subdural Epidural Cerebellum The type of

hemorrhage

History of drug

abusing

77 Without history of

consuming drugs

16 8 3 0 5 0 0 Cigarette

4 1 3 0 0 0 0 Crystal

3 0 0 3 0 0 0 Drug

Pearson Chi-Square: 35.54 df: 15 Sig: 0.002

BIOSCIENCE BIOTECHNOLOGY RESEARCH COMMUNICATIONS INVESTIGATIONS ON NON-TRAUMATIC BRAIN HEMORRHAGE CASES 479

Fares Najari et al.

related to subarachnoid, the cerebella hemorrhage was

(3%) subdural hemorrhage (3%) , epidural hemorrhage

(3%), bleeding in the brain ventricles (3%) was seen; that

the bleeding in the brain ventricles has been seen just in

boy newborn; and the cerebella hemorrhage was seen in

girl newborn.

The results of the present work, show that the fre-

quency of non- traumatic brain hemorrhage among

the persons with the history of consuming the drugs

was different. The most factor of hemorrhage in these

patients was smoking and the minimum role was related

to drugs consumption (P< 0.05). According to the results

of Joynt, (1991), the most common and important disor-

ders, among the neurological diseases was cerebrovas-

cular occurrences, arising from numerous factors, which

can lead to physical disabilities of different degrees fol-

lowed by death. Pursuant to a conducted study by Koo-

sarei et al., (2009), consuming drugs such as ampheta-

mines is also as one of the effective factors to cause

these types of hemorrhages which can lead to damage in

the white sub-cortical brain tissue within a few hours. In

a study conducted by Broderick et al.,(2003), using such

drugs increase the risk of brain hemorrhage. Data of the

present study also demonstrate that consuming drugs

such as cigarettes, crystal and amphetamines induce

brain hemorrhages, which were effective respectively in

the following order > subdural and subarachnoid hem-

orrhage > Subarachnoid hemorrhage > Bleeding of the

brain ventricles.

CONCLUSION

As the subdural bleedings are not created without

trauma, 3 cases of boy newborn following the hard

delivery (CPD birth canal stenosis) and 9 cases of sub-

dural hemorrhage following the blood cancer were seen.

Since, epidural hemorrhage without trauma is not pos-

sible. In the newborn’s boy with vascular impairment

in the  eld of congenital malformations, the epidural

hemorrhages in the occipital areas without trauma were

seen, as the subdural and epidural hemorrhages just

occurred in traumatic cases (hit on head). In the present

study, some cases of epidural or subdural bleeding in

the newborns have also been seen, that show that the

epidural and subdural hemorrhage always do not occur

along with trauma. By considering that high prevalence

of brain hemorrhage in the age group of under 30 years

with the history of drugs consuming, it is required that

the treating physicians should always consider the risk

of these kinds of hemorrhages in the young people with

drug abuse. It is proposed that in the future more studies

should be conducted for investigating the other reasons,

such as coagulation disorders, tumors, use of alcohol

and others in the patients with hemorrhage.

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