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Journal of the association of physicians of india vol 62 november, 2014

Original Article

Hypertension as a Risk Factor for Haemorrhagic

Stroke in Females
Sushiba Nechikkat*, R Chandni**, PK Sasidharan***
Abstract
Aim : To study the effect of hypertension as a risk factor for haemorrhagic stroke in women compared
to men.
Method : Confirmed cases of haemorrhagic stroke by Computed Tomography scan were included in this
study. The participants underwent detailed clinical examination based on preset questionnaire. Relevant
laboratory investigations were done in this group. 100 consecutive cases were studied comparing the
baseline characteristics with male patients admitted with haemorrhagic stroke.
Observations : Among all the risk factors studied hypertension was the single most important risk factor
causing intracerebral bleed. Forty seven point four percentage (47.4%) of females were hypertensive
as against 61% in males. Blood pressure recording of females showed lower systolic and diastolic
measurement compared to males and the difference was statistically significant with a p value of 0.000.
Majority of the female patients were overweight with a significant difference in body mass index compared
to males. (p value 0.006).
Conclusion : Hypertension is an important risk factor for intracerebral bleed. Females developed
intracerebral bleed at a lower blood pressure measurement compared to males. Females require better
control of hypertension than males to prevent intracerebral bleed.

Introduction

erebrovascular disease is the second cause of death worldwide, and all projections
indicate that this will remain in the year 2020. 1,2 The greater prevalence of stroke in
men is well known, but recent issues emphasise the importance of stroke in women. 3 In
the Unites States, it is estimated that 1 in 6 women will die of stroke, whereas 1 in 25
will eventually die of breast carcinoma, 4 and over the entire lifetime, 16% of women
but only 8% of men will die of stroke. 5
Stroke is defined as an abrupt onset of a neurological deficit that is attributable
to a focal vascular cause. It is manifested either, as brain infarction or haemorrhage.
More than any other organ brain depends on adequate oxygenated blood supply.
The presentation may be diverse in that in its more severe form the patient becomes
hemiplegic and even comatose and in its mildest form it may consist of only a trivial
neurological disorder insufficient to arouse concern or demand medical attention. A
variety of causes result in stroke which comes under two sub groups; those resulting
from ischaemia and those from haemorrhage. After thrombosis and embolism
intracranial haemorrhage is the 3 rd most frequent cause of stroke.
*
Junior Resident, **Associate
Professor, ***Professor and Head,
Department of Medicine, Govt.
Medical College, Kozhikode
Received; 25.04.2013;
Accepted: 27.06.2013

Intracerebral haemorrhage is a subgroup of intracranial haemorrhage that occur within

the brain tissue. Intracerebral haemorrhage can be caused by brain trauma or occur
spontaneously as in haemorrhagic stroke. Intracranial haemorrhage can be intra-axial
or extra-axial. Extra-axial hemorrhage are exdradural haemorrhage (EDH), subdural
haemorrahge and (SDH), subarachnoid haemorrhage (SAH) which occur outside
the brain tissue. Intraaxial haemorrhage include intracerebral and intraventricular

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Journal of the association of physicians of india vol 62 november, 2014

Table 1 : Age group of the patients

Age group

No. of patients

< 20
20 29
30 39
40 49
50-59
60 69
70 79
> 80

1
3
7
16
19
34
12
8

haemorrhage. Intraparenchymal haemorrhage can

be recognised in computed tomography (CT) scan
because blood appears brighter than other tissue and is
separated from the inner table of skull by brain tissue.
The tissue surrounding bleed is often less dense than
rest of the brain tissue.
In India there are only a few studies regarding the
incidence, morbidity and mortality pattern of stroke
and there is difficulty in deriving conclusion from
such limited studies in a diverse population like ours.
Risk factors for haemorrhagic stroke are different in
developed and developing countries. Stroke is more
common among men, but women are more severely
ill. 6 There are several risk factors such as hypertension
(HTN), diabetes mellitus (DM), hyperlipidaemia,use of
cold remedies which contains phenylpropanolamine,
oral anticoagulants, antiplatelets, drugs, malnutrition,
infection and bleeding disorders, which increases
a patients risk to haemorrhagic stroke. Control or
elimination of these risk factors is the best long term
approach to the management and prevention of stroke.
Monitoring the risk factors in a population can
reflect the future trends of incidence of haemorrhagic
stroke. Prevention of intracerebral haemorrhage
is still the most effective method of reducing the
impact of this devastating disease. To facilitate better
development of prevention programme, we need
precise estimation of risk and elucidation of minor
risk factors.
Statistical analysis in the Medicine department,
Calicut Medical College showed a 20% increase in the
incidence of haemorrhagic stroke in females compared
to previous year. There are only a few studies about
the risk factors of the same. Hence we planned to
study the clinical presentation of haemorrhagic
stroke in females and to identify the risk factors of
haemorrhagic stroke in women compared to men
considering hypertension as a key risk factor. This
study was carried out with a hope that by analysing
the cause of haemorrhagic stroke the information
gained would add to our experience in the recognition,
prevention and treatment of CVA.

Material and Methods

This is an observational study done for a period

of one year during December 2009 November 2010.

One hundred consecutive female patients admitted
with haemorrhagic stroke in medical wards, Calicut
Medical College were included in this study. All
the cases of intracranial haemorrhage secondary
to SAH and SDH, EDH, intracerebral haemorrhage
secondary to trauma were excluded. Patients were
grouped according to their age. Equal number of
males with haemorrhagic stroke were studied. Risk
factors for both females and males were compared.
The basis of case selection was plain CT scan of head.
Other investigations were done according to clinical
situation. Informed consent from the patients and
approval from Ethics committee also obtained.
A detailed history including symptoms, occupational
history, address, dietetic history, history of addictions,
history of physical activity, history of diabetes
mellitus, hypertension, ischaemic heart disease,
cerebrovascular accident and family history of obesity,
hypertension, diabetes mellitus, ischaemic heart
disease, cerebrovascular accident were taken from
the conscious patients and from reliable care giver in
unconscious patients.
The patients had been subjected to detailed
clinical examination including Blood pressure,
weight in kilogram, height in metres, BMI (weight
in Kg divided by square of height in metres). Blood
pressure was measured at the time of admission, and
after 24 hours with appropriate sphygmomanometer
using the Phase I and IV Korotkoff sounds. The
mean of 2 measurements were used for systolic and
diastolic blood pressure. A complete nervous system
examination was done. Complete haemogram with
ESR, bleeding time, clotting time, prothrombin time,
lipid profile, urine microscopy, random blood sugar,
renal function, liver function tests, ECG, chest X
ray, computed tomography scan were obtained in
all subjects. Statistical analysis done by Epi-Info
software, Microsoft excel data spread sheet.Mean
and standard deviation were taken for quantitative
variables,frequency for qualitative variables. P value
less than 0.05 was taken as significant. Information
and details of assessment of each individuals was
discussed in all stages between the researchers to
improve further assessment.

Observations
The youngest of the patient was 15 years and oldest
90 years. Highest frequency of intracerebral bleed was
in 61- 70 year age group - 34 patients. Mean age of
hypertensive bleed was 67 yrs. (Table 1).
Of the 100 female patients with intra cerebral
bleed, 47 had past history of hypertension, 20
patients were diabetic, 14 patients had past history
of CAD, 10 patients were on antiplatelets, 4 patients
had past history of CVA. 10 patients had both HTN

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Journal of the association of physicians of india vol 62 november, 2014

HTN
CAD
Ancoagulant
Aneurysm
Corcal vein thrombosis

DM
Aspirin
Bleeding disorder
Haematological malformaon
Post thrombolysis

70

60

50

40

30

20

10

Female

Male

Fig. 1 : Relative frequency of various risk factors for intra cerebral bleed in males and
females
60

patients 47 patients had past

history of hypertension. Only
7 were on regular treatment.
Majority of these had duration
of hypertension > 5 yrs (74%).
39% of female patients had
systolic blood pressure >160
mm of mercury and 22% had
diastolic blood pressure more
than 100 mm of mercury (Figure
2, Figure 3). 61% of male patients
were previously hypertensive.
59% of males had systolic blood
pressure more than 160 mm
of mercury, 53% had diastolic
blood pressure more than 100
mm of mercury (Figure 2, Figure
3). p value was 0.000 comparing
blood pressure as a risk factor for
intra cerebral bleed in females
than males.
Of 100 female patients with
intracerebral bleed 69 patients
h a d s e d e n t a r y l i f e s t yl e . 1 5

50

50

40

40
30

30

20

20
10
0

10

<120

120 - 139

140-159
Female

> 160

0
< 80

80 - 89

90 - 99

Male

p value : 0.000 comparing systolic hypertension as a risk factor

for haemorrhagic stroke in males and females
Fig. 2 : Systolic BP in females and males

and Diabetes. Three patients had history of bleeding

disorder, 2 had immune thrombocytopenia (ITP), 5
patients were on anticoagulants. One patient was a
known case of acute myeloid leukaemia. One case
of intracerebral bleed secondary to cortical vein
thrombosis was present.
Sixty one male patients were hypertensive, 16
patients were diabetic. Twenty one patients had past
history of coronary artery disease, 10 patients were on
aspirin. Two patients were on Warfarin treatment. Two
patients had ITP and 2 patients had haematological
malignancy (Figure 1).
Hypertension was the single most important
risk factor of intracerebral bleed. Of 100 female

Female

> 100
Male

p value : 0.000 comparing diastolic hypertension as a risk factor

for haemorrhagic stroke in males and females
Fig. 3 : Diastolic BP in females and males
70
60
50
40
30
20
10
0

Manual labourer

Moderate

Female

Sedentery

Male

p value : 0.000 comparing physical activity as a risk factor for

haemorrhagic stroke in males and females
Fig. 4 : Physical activity in females and males

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Journal of the association of physicians of india vol 62 november, 2014

60
50
40
30
20
10
0

< 19

19 - 23

Female

> 23

Male

p value : 0.006 comparing BMI as a risk factor for hemorrhagic

stroke in males and females
Fig. 5 : Body mass index in females and males

were manual labourers, 16 patients engaged in

moderate work (Figure 4). Of 100 male patients with
intracerebral bleed 26 patients had sedentary life
style. 70 patients were manual labourers, 4 engaged in
moderate work (Figure 4). Physical activity as a risk
factor for intra cerebral bleed in females compared
to males was statistically significant (p value 0.000).
53% of female patients had BMI more than 23 kg/
m (Figure 5). Only 31% of males had BMI more than
23kg / m 2 (Figure 5). BMI as a risk factor for intra
cerebral bleed in females than males was statistically
significant (p value 0.006).
2

Discussion
Cerebrovascular disease forms the third most
common killer of adult. The overall prevalence of
stroke is higher in men than in women and increases
with age in both sexes. 7 Interest and knowledge about
the importance of stroke in women are increasing
because of the demonstration of a higher mortality,
higher disability, and higher incidence of dementia
in women who survive a stroke. 3 To find the exact
incidence of intra cerebral bleed according to age,
large population based studies are required.
Present st udy included 100 female pat ient s.
Incidence of haemorrhagic stroke was more in
the age group above 60 yrs. Previous studies also
showed higher incidence of haemorrhagic stroke as
the age advances. 8 The increased incidence of intra
cerebral bleed may be due to increased incidence
of hypertension and other risk factors in the elderly
group. In analysing the stroke subtypes, Jaume Roquer
et al in their study did not find any difference between
haemorrhagic strokes according to sex. 9
Of several risk factors observed, hypertension was
the single most important risk factor for intra cerebral
bleed. In this study 47 percentage of the female
patients were previously hypertensive. Hypertension
as the leading cause of intra cerebral bleed was also
highlighted in other studies, done by Muller and Rado
in 1981 10 and Seppo in 1995. 11

As the duration of hypertension increased the

incidence of intra cerebral bleed also increased. High
systolic and diastolic blood pressure is associated
with increased risk of intra cerebral bleed. The
incidence of intra cerebral bleed was found to increase
stepwise with elevation of either systolic or diastolic
blood pressure by Omar and Ueda 1987. 12 Since the
pressure inside the haematoma is equal to the arterial
blood pressure, a high BP might be predisposing to
large haematoma or re-bleeding. In this study blood
pressure recording of females showed lower systolic
and diastolic measurements compared to males and
the difference was statistically significant with p value
of 0.000. So it may be noted that females develop intra
cerebral bleed at a lower blood pressure level.
Majority of the female patients with intra cerebral
bleed had sedentary life style compared to males.
M a j o r i t y o f t h e m a l e s we r e m a n u a l l a b o u r e r s .
Bleeding happened in females with sedentary life style
compared to males and was statistically significant
with the p value of 0.000.
Obesity has been positively and independently
associated with stroke. Incidence in several studies
including the Framingham study (Hubert et al, 1983) 13
and study done in Korea (Jong Ku Park) 14 showed that
body mass index is an independent risk factor for
intra cerebral bleed. This result suggests that obesity
is a risk factor for ha` emorrhagic stroke. In this
study majority of the female patients were overweight
and male patients had BMI within normal range and
the BMI as a risk factor for intracerebral bleed in males
and females was compared and the p value was found
to be significant (0.006).

Conclusions
Hypertension was an important risk factor for intra
cerebral bleed in both males and females.. Maximum
incidence of intra cerebral bleed was in above 60yrs.
Females developed intracerebral bleed at a lower
blood pressure measurements compared to males.
Females had increased risk of intra cerebral bleed
compared to males considering body mass index as a
risk factor. Majority of the female patients with intra
cerebral bleed had sedentary life style compared to
male patients.

Limitations of study
Analysis of 100 hospitalised patients may not reflect
pattern of disease in the community and requires a
large population study. Cases were selected from a
tertiary care centre, so reference bias may be present.

Recommendations
Life style modification

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Journal of the association of physicians of india vol 62 november, 2014

Better control of systemic hypertension.

8.

Murray CJL, Lopez AD. Mortality by cause for eight regions of the
world: Global Burden of Disease Study. Lancet 1997;349:12691276.
PMID9142060

van Asch CJ, Luitse MJ, Rinkel GJ, van der Tweel I, Algra A, Klijn CJ.
Incidence, case fatality, and functional outcome of intracerebral
haemorrhage over time, according to age, sex, and ethnic origin: a
systematic review and meta-analysis. Lancet Neurol 2010;9:167-76.
PMID: 20056489

9.

Roquer J, Campello AR, Gomis M. Sex differences in first-ever acute

stroke. Stroke 2003;34:1581-5. PMID: 12805490

2.

Murray CJL, Lopez AD. Alternative projections of mortality and

disability by cause 19902020: Global Burden of Disease Study. Lancet
1997;349:14981504. PMID: 9167458

10. R Muller, EW Radu. Intracerebral hematoma. Neurology 1981;13:320351.

3.

Bousser MG. Stroke in women. Circulation 1999;99:463467.

PMID:9927389

4.

1997 Heart and Stroke Facts: Statistical Update. Dallas, Tex: American
Heart Association; 1996.

5.

Bonita R. Epidemiology of stroke. Lancet 1992;339:342344.

PMID:1346420

6.

Appelros P, Stegmayr B, Ternt A. Sex Differences in Stroke

Epidemiology A Systematic Review Stroke. 2009;40:1082-90. PMID:
19211488

7.

Prencipe M, Ferretti C, Casini AR, Santini M, Giubilei F, Culasso F.

Stroke, disability, and dementia: results of a population survey. Stroke
1997;28:531536. PMID: 9056607.

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