ABSTRACT

Background: The aim of present cross-sectional survey to investigate evaluation of the frequency
and factors that increase the risk of intracranial bleeding among patients at DHQ Hospital
Faisalabad. Intracranial bleeding is the most serious form of bleeding that may occur in the
human body since the brain is extremely sensitive to the consequences of tissue injury and its
influence on human daily activities, as well as having the highest risk of fatality and disability.

Objective: The objective of this study to evaluate the frequency and factors that increase the risk
of intracranial bleeding among patients at DHQ hospital at Faisalabad.

Methodology: The study was conducted as a cross-sectional analysis at the Allied and DHQ
Hospitals in Faisalabad. This research involved 101 patients. Demographic data, along with
information on assessment and risk factors, were collected using a custom-designed structured
Performa administered by an interviewer. SPSS software version 23 was used to analyze data
on the investigation of the frequency and factors that enhance the risk of cerebral hemorrhage at
government Allied and DHQ hospitals in Faisalabad.
Results: The study's findings indicate that risk variables enhance the probability of cerebral
hemorrhage among patients. Allied and DHQ hospitals in Faisalabad assist in collecting data on
the risk factors of cerebral bleeding and providing patients' histories for the examination of the
frequency of intracranial hemorrhage. Further research indicates that age and gender have a
crucial role in cerebral hemorrhage. MRI indicators are essential for determining the frequency
of intracranial hemorrhage.

Conclusion: The study on evaluating the frequency and variables that enhance the risk of
cerebral hemorrhage among patients at DHQ Hospital Faisalabad raises awareness about the risk
factors of intracranial bleeding. The study's recommendations include educating patients about
the importance of drug adherence and lifestyle modifications, providing clear guidelines for
identifying signs and symptoms of intracranial hemorrhage, and organizing seminars and
feedback sessions to improve clinical practice for evaluating cerebral bleeding.

Keywords: evaluation of the frequency, risk factors, intracranial bleeding.

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 Chapter# 1

Introduction

1.1 Background:

Intracranial bleeding is defined as the most dangerous type of bleeding that can occur in the
human body due to the brain's exceptional sensitivity to the effects of tissue injury and its impact
on human daily activities, as well as the highest risk of mortality and disability. There are more
and more agents available to use in the acute phase of cerebral bleeding, such as those that
reverse anticoagulation, stimulate normal coagulation, or block fibrinolysis (Meyer &
Associates., 2021).

Cerebellar hemorrhages, also known as hematomas, are intracranial bleedings that take
place in the posterior fossa or cerebellum. The majority of adults who suffer from this ailment
are middle-aged and above. Intracranial bleeding may result in symptoms such as hydrocephalus
and an increase in intracranial pressure (Michelle et al., 2023).

Antithrombotic and thrombolytic medicines usually increase the risk of bleeding, most
severe cerebral hemorrhage (ICH) (Best et al., 2023).

The following factors have been found to increase intracranial bleeding risk: abnormal
renal and liver function; history of stroke or thromboembolism; bleeding or bleeding diathesis
(severe anemia); labile international normalized ratio (INR); elderly (age >65); use of aspirin or
nonsteroidal anti-inflammatory drugs; and alcohol abuse (Gou et al., 2023).

Cerebral amyloid angiopathy (CAA) and persistent hypertension are the main causes of
intracranial bleeding. Secondary patho etiologies include hemorrhagic conversion of an ischemic
stroke, venous thrombosis, and blood loss because of malignancies or image-able vascular
disease. Drug abuse, Coagulopathy, and platelet dysfunction can all cause or worsen cerebral
hemorrhage (Magid-Bernstein et al., 2022).

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 Antithrombotic and thrombolytic medications increase the risk of cerebral bleeding,
however bleeding is always probable, most notably intracranial hemorrhage (ICH). The majority
of those with antithrombotic-associated ICH have cerebral small vascular disease (CSVD),
which may be easily reviewed in patients who may have had a stroke because of the almost
everywhere use of computed tomography (CT), and the accessibility of magnetic resonance
imaging (MRI) (Best et al., 2023).

According to the incidence of intracranial bleeding, hemorrhage within the meningeal

gaps or brain parenchyma is more common than bleeding outside of them. Despite a thick layer
of CSF and a strong outer shell, the brain is nonetheless vulnerable to unexpected damage. Any
major physical stress to the inflexible skull will compress the brain and inflict long-term harm.
Contusions, hemorrhagic lesions, infarction, and other complications can occur as a result of
cranial trauma. Traumatic brain injury and cerebral vascular damage can result in intracerebral
bleeding. In compared to subarachnoid hemorrhage and ischemic stroke, there is a larger risk of
death or serious injury. Not only is it a major public medical problem, but head trauma can
induce neurological damage. (Asghar et al., 2022).

According to the evaluation of intracranial bleeding, 40/473 people (or 8.5%) had
intracranial hemorrhage (ICH) within 24 hours of trauma. ICH in DOAC patients has been
shown to be related with a number of risk parameters previously connected to a medium head
trauma predictions. Risk variables included a GCS score <15, post-traumatic LOC (1.6% vs.
37.5%, p < 0.001), at least one vomiting episode (2.8% vs. 17.5%, p < 0.001), and other relevant
factors (Turcato et al., 2021).

The prevalence of cerebral hemorrhage makes stroke one of the primary causes of
mortality and disability. According to the American Heart Association's 2022 heart disease and
stroke Statistics Update, stroke killed roughly one in every 19 people in the United States in
2019, making it the sixth leading cause of death. Cerebrovascular illness killed 7.08 million
people worldwide in 2020; stroke is the third leading cause of death in most Western nations,
behind coronary heart disease and cancer. According to several studies, cerebral bleeding causes
3
10% to 15% of all acute strokes. The prevalence of cerebral hemorrhage is around 24.6 instances
per 100,000 people, with older persons, men, and Asians being more prone to encounter it.
Because cerebral hemorrhage is the most severe and incapacitating subtype of stroke, and there
is a huge public health risk of dependence, dementia, seizures, and even death (Mendiola et al.,
2023).

The global incidence of cerebral hemorrhage is a dreadful disease that disables

countless people and kills a considerable percentage of them. Within the United States,
approximately 795,000 events of stroke occur each year, making it the sixth most common cause
of death and the leading cause of long-term adult disability. In recent years, the frequency of
strokes in Asia has increased dramatically. In comparison to other Asian countries, Pakistan has
one of the highest rates of this devastating sickness. As a result, the country requires additional
resources in the form of money, community workers, health care, and the whole economy.
Intracranial hemorrhage is a dreadful condition that cripples and kills a large number of
individuals globally. Almost 795,000 stroke cases occur each year in the United States, it is the
sixth leading cause of mortality and the primary source of long-term adult disability. According
to reports, Pakistan has the highest per capita prevalence of cerebral hemorrhage in the world,
with 250 strokes per 100,000 people ( Jadoon et al., 2022).

Dialysis patients frequently have co-morbidities such diabetes and hypertension, both of which
are established risk factors for cerebral hemorrhage. Some of the common aspects of the uremic
milieu that enhance the risk of stroke include vascular calcification, hypertension caused by
predialysis, vascular toxin accumulation, platelet dysfunction, and increased micro hemorrhage
in the brain. Chronic renal disease-mineral-bone dysfunction may be the cause of hemodialysis
patients' rapid vascular calcification. High levels of phosphorus and calcium in blood are proven
risk factors (YuHuan et al., 2023).

This cross-sectional study aims to explain the variables that increase the risk of cerebral
bleeding, raise awareness among people about the causes of intracranial bleeding, and analyze
these reasons to determine the frequency of intracranial bleeding.

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5
1.2 Problem statement:

The purpose of this study is to evaluate the frequency and variables that raise the risk of cerebral
bleeding, as well as why the rate of intracranial bleeding is growing on a daily basis. Many
patients are unaware of the causes of cerebral bleeding, which increases the likelihood of it
occurring in people, leading to greater difficulties. Patients are an important target group for
analyzing the incidence of intracranial bleeding and the factors that increase its risk in order to
improve knowledge of intracranial bleeding risk factors and minimize mortality and morbidity.

1.3 Significance of the study:

The goal of this research is to get a better knowledge of the risk factors for cerebral bleeding, as
well as to assess the incidence of intracranial bleeding in order to avoid future difficulties in such
patients. The study's findings will benefit not only cerebral bleeding patients by enhancing their
quality of life, but will also help nurses and healthcare practitioners identify this kind of patient
and reduce intracranial bleeding cases. The frequency of cerebral hemorrhage is evaluated to
help improve patient outcomes. Furthermore, this research will help health-care practitioners
build better programs to help cerebral hemorrhage patients enhance their quality of life. The
study's purpose is to give effective knowledge in assessing the frequency of intracranial bleeding.

1.4Objectives of the study:

The objective of this study:

 To Evaluation of the frequency of intracranial bleeding and the factors that

increase its risk among DHQ Hospital Faisalabad.

1.5 Hypothesis:

I-Null Hypothesis:

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 There is no association between evaluation of the frequency of intracranial bleeding and
the factors that increase intracranial bleeding.

II-Alternative Hypothesis: (HA/H1):

There is association between evaluation of the frequency of intracranial bleeding and the
factors that increase intracranial bleeding.

7
 Chapter # 2

Literature Review

2.1 Research Strategy

Reading, digesting, evaluating, synthesizing, and summarizing material are the basic components
of a literature review in order to properly assess the relevance of the literature under
consideration. This study's search tactics include Google Scholar, PubMed, and Opera.
Bullo & Afzal (2023) conducted a descriptive cross-sectional research at JPM's
Neurology and Medicine department in Karachi in 2020. The purpose of this study is to assess
the prevalence and reasons of in-hospital patient death in intracerebral hemorrhage. A simple
sampling procedure was employed to choose a sample size of 147 persons. The data were
collected via a questionnaire. The investigation is based on demographic data and risk factors for
cerebral hemorrhage. The data was examined with SPSS 26, statistical software for social
science. Multiple logistic regression analyses were performed to identify risk variables for ICH
and mortality. The participants' average age was 58.14 ± 8.49 years. Our study indicated that
acute hemorrhagic stroke had an average length of 7.44±5.24 hours, with 26.72±1.56 kg/m2,
158±7 BMI, height, weight, and SBP. Of the 147 patients who experienced an acute hemorrhagic
stroke, 41 and 106 died in the hospital. Of the 147 patients who experienced acute hemorrhagic
bleeding, 41 and 106 died in the hospital. In-hospital mortality rates for patients with
hypertension, type II diabetes, smoking, ischemic heart disease, and GCS < 8 were 78%, 43.9%,
48.8%, 17.1%, and 87.8%, respectively. Based on the study, yearly follow-up examination of
cerebral bleeding patients for a longer period is proposed to obtain prospective data on their
development and to identify the risk factor for rehabilitation (Bullo et al., 2023).

Cloud & Walliasam (2023) performed a cross-sectional study of individuals living in Australian
communities. The study's purpose was to identify the risks of depression, an increase in ischemic
stroke, and intracranial hemorrhage among mentally unstable older people who used low-dose
aspirin on a daily basis. A total of 19,114 older adult patients were selected. Patients' mental
health was assessed using the Beck Anxiety and Depression Inventory. Mental wellness was
assessed using the Short Warwick-Edinburgh Mental Well-Being Scale. Gender, age, marital

8
status, occupation, yearly income, area, current smoking, current alcohol consumption, physical
multimorbidity, any physical symptoms encountered during self-isolation/social distance, and the
number of days of self-isolation were all predictor factors. A multivariable logistic regression
model was used to evaluate the link between potential risk variables and poor mental health. 932
people took part in the study. Factors linked to poor mental health were the participants were
older people who exhibited no signs of cardiovascular disease. Aspirin did not significantly
lower the risk of ischemic stroke. However, aspirin-treated individuals saw a statistically
significant increase in cerebral hemorrhage compared to placebo-treated patients. Aspirin was
associated with a greater risk of subdural, extradural, and subarachnoid hemorrhage when
compared to placebo. Hemorrhagic stroke occurred in 49 of those who got aspirin, compared to
37 in the placebo group. This study implies that low-dose aspirin may have no impact on the
main prevention of stroke, and that caution should be exercised with the use of aspirin in older
adults prone to head trauma and increasing depression in intracranial patient. (cloud et al., 2023).

Jenson & Kondering (2023) conducted a retrospective investigation at eleven university medical
centers in Germany, Switzerland, and Australia. The study aims to look at risk factors for
cerebral hemorrhage. The targeted sample size for the research was 442 patients. Gender, age,
pre-existing disorders, and the use of antithrombotic medications during imaging were all
documented. The risk factors and prediction score models, which comprise clinical, imaging, and
laboratory data, are extensively established, but their sensitivity, specificity, and impact on
clinical practice are limited. Covid-19 was mild in 124 patients. 220 patients initially reported
respiratory problems, followed by 167 with neurological symptoms‫ ۔‬Acute ischemic stroke was
diagnosed in 70, and cerebral hemorrhage in 48. Extracorporeal membrane oxygenation
treatment and invasive ventilation were commonly linked to variables. Another new Hematoma
Expansion Prediction score took into account a history of dementia and smoking while
demonstrating acceptable discrimination performance. A multivariable logistic regression
analysis revealed that a basal ganglia score employing three NCCT markers reliably predicted
HE. Furthermore, to facilitate bedside prediction, three new measures with more practical
predictors were developed from retrospective research and shown acceptable sensitivity and
specificity, but prospective validation is necessary. Predicting and Treating Hematoma CT,
baseline ICH volume, antiplatelet and anticoagulant use, or five predictors, were externally

9
evaluated and demonstrated excellent discrimination. Based on the results, researchers show
that changing these parameters will likely improve patients' health from cerebral hemorrhage
(Jenson et al., 2023).

The study by Jadoon & Khawaja (2022) was conducted as a cross-sectional investigation at the
DHQ Teaching Hospital in Abbottabad. It aimed to identify risk factors for intracerebral
hemorrhage in patients presenting to the hospital. The study enrolled 103 patients through
purposive selection. Data was collected using a questionnaire. Analysis of the data was
performed with STATA 14. Fasting blood glucose, serum cholesterol, and triglycerides were
measured to detect poorly controlled diabetes and hyperlipidemia. A standardized Performa was
used to collect data, which was then analyzed with SPSS 20. The majority of the patients were
over 70 years old, with 71 males and 32 females. Intracerebral hemorrhage was reported in
8.74% of patients with acute cerebrovascular accidents. Among them, 66.67% had uncontrolled
hypertension, 44.44% had hyperlipidemia, and 33.33% had both. The average age of the
participants was 50.9 years. The average awareness score for stroke risk factors and warning
signs was 67.2% and 63.9%, respectively. Based on the identified risk factors, the study suggests

interventions to minimize mortality and morbidity rates (Jadoon et al. 2023) .

Myserlis (2023) did an observational study in Karachi. The purpose of this study, which uses a
genetic risk score, is to identify people in Karachi who are at high risk of intracerebral
hemorrhage. Purposive sampling yielded a sample size of 226 persons. We developed a meta-
agenomic risk score for ICH and related factors by merging genome-wide association data from
European ancestry people. In a held-out validation dataset, we investigated the connection
between ICH, prediction performance, and clinical risk factors. In age-, gender-, and clinical risk
factor-adjusted models, a one-standard deviation increase in the metaGRS was linked to a 31%
higher risk of ICH. The metaGRS identified similarities between lobar and nonlocal ICH. The
metaGRS was associated with a higher risk of ICH. The correlations were significant in both a
relatively high-risk sample of antithrombotic medication users and a relatively low-risk group
that received acceptable vascular risk factor therapy however, they did not take anticoagulants.
This study reveals that the use of antithrombotic drug has a substantial function in increasing the
risk of cerebral bleeding, which must be analyzed to aid in lowering the risks of intracranial
hemorrhage ( Myserlis et al .,2023).
10
 Yang & Qin (2023) conducted a cross-sectional research at the Department of Neurology
at Beijing Chaoyang Hospital of Capital Medical University. The study's objective was to
evaluate CMB patients' performance on several cognitive tasks following intracranial bleeding.
Linear regression analysis was used to select a sample size of 563 individuals. The association
between ICH and factors is calculated using regression models, which yield odds ratios (OR) and
95% confidence intervals (CI). We also used regression models to look at the link between ICH
and mortality. Discrete data are represented as frequency and percentage, whereas continuous
variables are provided as mean and standard deviation (SD) or median with interquartile range.
In all cognitive tests, CMB patients fared worse than non-CMB controls. A correlation study
discovered that the total number of CMB lesions was positively associated with the timing of
TMT, Maze, and Stroop tests, but negatively associated with the performance of MMSE, VF,
DSST, and DCT. The outcomes of this study suggest that cognitive dysfunction is caused by
cerebral hemorrhage, which results in impairment and loss of conciseness. As a result, cognitive
function must be evaluated during the cerebral hemorrhage assessment (Yang et al, 2023).
Zeng & Chen (2023) conducted a systematic review at the College of Clinical Medicine
for Obstetrics and Gynecology and Pediatrics at Fujian Medical University, located at #18
Daoshan Road in Fuzhou, China. The study aimed to investigate risk factors for anticoagulant-
related cerebral hemorrhage. It included data from 7,322 participants. The review found a
probable association between cerebral hemorrhage and race, Glasgow Coma Scale score, history
of stroke, leukoaraiosis (white matter abnormalities), cerebrovascular disease, tumors, atrial
fibrillation, prior bleeding events, international normalized ratio (INR, a measure of blood
clotting), serum albumin levels, prothrombin time, diastolic blood pressure, and use of
anticoagulants. The evidence for an association with age, cerebral micro bleeds, smoking,
alcohol consumption, platelet count, and use of antiplatelet medications was of lower certainty.
Additionally, the study found very low-certainty evidence suggesting little to no association
between risk of cerebral hemorrhage and hypertension or creatinine clearance. The authors noted
that most risk assessment models currently overlook factors such as leukoaraiosis, brain
microbleeds, cerebrovascular disease, and INR. This study suggests that several additional
characteristics increase the frequency of cerebral bleeding. However, anticoagulant use itself also
elevates the risk of intracranial bleeding, particularly in older patients and those on long-term
anticoagulant therapy (Zeng et al., 2023).
11
 Nam & Kwon (2020) performed a cross-sectional study at Seoul National University
Hospital's Institutional Review Board. A total of 2615 participants were evaluated (median age:
56, male gender: 53%). The study's purpose is to see how often intracranial bleeding happens. In
a multivariate logistic regression analysis, the TyG index was associated with the prevalence of
ICH. Further quantitative research demonstrated that the TyG index and SBI load have a good
dose-response relationship. A multivariable linear regression analysis found a relationship
between the TyG index and WMH volume. Furthermore, the TyG index demonstrated a
comparable or slightly stronger connection with SBI prevalence and WMH volume than HOMA-
IR. This study reveals that the TyG index is connected with cerebral hemorrhage, and we must
examine these elements when identifying intracranial bleeding (Nam et al., 2020).

Iversen & Blauenfeldt (2020) conducted a cross-sectional research in neurovascular outpatient

clinics at two stroke hospitals in Central Denmark, a region with 1.3 million people. The study
examined consecutive individuals who suffered an acute ischemic stroke, intracerebral
hemorrhage, or a transient ischemic episode. The sample size of 435 patients was calculated
using easy sampling. Data were collected through interviews. Bystander presence at symptom
start and knowledge of ≥2 core stroke symptoms were associated with a main emergency
medical care contact. Outdoor patients with severe strokes and witnesses who deemed the
situation to be highly serious had their initial contact with emergency medical services at 2.01
hours after arrival and the initiation of reperfusion therapy. Acute stroke patients who are aware
of more than 2% of the core symptoms and understand the gravity of the situation are more
likely to seek help, have a shorter pre-hospital delay, and are more likely to receive reperfusion
therapy. According to the study, detecting ischemic stroke during cerebral bleeding is critical, as
are other variables that enhance the risk of an ischemic stroke. This study emphasizes the need of
properly checking the patient with an ischemic stroke to avoid the severity of cerebral bleeding
(Iverson et al., 2020).

Waseem & Akhtar (2020) did an observational research in a clinic in Karachi. The study's goal
was to determine the prevalence of cerebral bleeding in individuals with head trauma and a GCS
of 10-15 on computed tomography. The sample size of 50 patients was selected using simple
sampling, and all data were analyzed in Microsoft Excel 365. Means and percentages were

12
calculated for all numerical or quantitative variables, such as age, gender, and frequency. 22
people experienced a cerebral hemorrhage. Nine out of the 22 patients had EDH, nine had
subdural, two had SAH, and two had ICH. Microsoft Excel 365 was used to evaluate data for
various attributes. According to study, there is no conflict of interest. It is crucial to monitor GCS
during brain hemorrhage (Waseem et al., 2020).

2.2 Gap Analysis:

At DHQ Hospital Faisalabad, major research gaps were revealed when investigating the
frequency and characteristics that raise the risk of cerebral hemorrhage. The previous study
concentrated on the factors that induce cerebral bleeding but did not assess the prevalence of
intracranial hemorrhage. The study aims to look at the prevalence and risk factors for cerebral
bleeding. Previous study that did not consider these parameters may have produced more precise
statistics on the occurrence of cerebral hemorrhage. As a result, this study offered an accurate
picture of the frequency and risk factors for cerebral hemorrhage. Previous studies rely just on
demographic data, but this study takes into account additional factors that raise the incidence of
cerebral hemorrhage.

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 Chapter#3

Methodology

3.1 Study design:

A Cross sectional descriptive study design will be used to get evaluation of the frequency
and factors that increase risk of intracranial bleeding among District Head Quarter hospital,
Faisalabad. A cross sectional design is the type of research design that involves looking at data
from a population at one specific point in time.

3.2 Study Variable:

Independent Variable:
 Risk factor
Dependent variables:
 Intracranial bleeding

Operational Definitions:

Risk factors:

Risk factors is a agent that cause impairment in the body normal body functioning and
impair to maintain activities of daily living further cause complication and even death.
 Measuring Tool: A checklist serves as a tool to assess risk factors for intracranial
bleeding.
 The checklist, developed by Harrison G. Gough, consists of a series of questions where
the assessor asks each question and the respondent simply answers "yes" or "no".

Intracranial Bleeding:

Intracranial bleeding is described as a disorder that increases blood flow to the brain and
ruptures brain cells, resulting in impairment and disruption of brain function as measured on
a likert scale.

14
  Measuring Tool: A Likert scale is used that is a rating scale used to measure opinions,
attitudes, or behaviors. It consists of a statement or a question, followed by a series of
five or seven answer statements.
 Likert Scale was developed by Rensis Likert in 1932.
3.3Study setting:

Data will be collected from Allied and District Head Quarter Hospital, Faisalabad.

3.4Study population:

Patient’s who will admit in Allied and District Head Quarter Hospital Faisalabad will
be recruited for the study.

3.5Sampling technique:

Simple random sampling will be employed in this investigation.

3.6Sample Size:

The target population of 139 draws a sample size of 101.This sample size is insufficient to
conduct the statistical test efficiently. As a result, 103 individuals will be selected. The number
of samples is 101.

2∗¿ P ( 1− P)
N∗z
n= 2 ¿
E 2∗¿(N−1)+z ∗P (1−P) ¿

 N=population
 n=sample size
 E=Margin of error 0.5% (If we take confidence interval 95%)
 P=Proportion of the population(0.5)
 Z=Z score
2∗¿0.5 ( 1−0.5)
139∗1.96
n= 2 ¿
0.052∗¿(139−1)+ 1.96 ∗0.5 (1−0.5 ) ¿
15
 135.42
n= =104.3333
1.3104
n=101

3.7Study Duration:

The study will be conducted on the day of September 2023 to April 2024.

3.8Inclusion criteria:
 All intracranial bleeding patients admitted to the neurologic units.

 Both genders will be represented equally.


 Patients age 18 to 70 years old.

 Patients discharge to home and having cell phone/land line no.

 Voluntary participate and give consent.

3.9Exclusion criteria:
 Severe neuropsychiatric condition

 Patient with congenital brain disease

 Refuse to participate in study

 Patient with another serious medical condition like stroke, brain traumatic

injury.

 Age limitation

3.10Research tool:

 For data collection a structured questionnaire adopted by the researcher article.

 And the questionnaire will be filling from patients after taking permission from Medical
superintendent and Head nurse of ward of Allied and DHQ hospital of Faisalabad.
 The consent will be taken from patients.
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  A checklist scale is used to measure risk factors and likert scale is used to evaluate the
frequency of intracranial bleeding.

3.11Validity and reliability:

The validity of data collecting tools was tested to confirm that the study's contents included all
assessment items linked to the investigation, and that each tool had assessment items covering
the study's goal and research objectives. A panel of five experts determined the content validity
by reviewing the tool for clarity, relevance, comprehensiveness, comprehension, application, and
simplicity of implementation, and minor modifications were made based on their
recommendations.
Cronbach's alpha test was used to ensure the reliability of data gathering technologies.
Cronbach's alpha test is a reliability coefficient that assesses the internal consistency of tests and
measurements. Cronbach's alpha is 0.9.

3.12Data collection process

In order to fulfill the requirements of the present research a sample of 101 Patients from
DHQ and allied Hospital Faisalabad will approach. Formal permission to collect data will sought
out from the Institute authority participants were introduced to the topic and aim of the research.
Informed consent will be obtained. After receiving the verbal or written consent for enrollment,
will contact the eligible patients. Before signing written informed consent, participants will brief
with complete introduction to the research, its objective and process. The questioner contains:

 Patient’ socio-demographic characteristics as regards their age, gender and about family
history.
 Participant’s knowledge will be assessed by multiple response questions as follows:
each question has a group of 3 and 4 answers. One point will be answered.
Intracranial bleeding will be assessed by multiple response questions as follows:
each question has a group of yes or no statement and 4 or 5 answers according to

17
 Likert scale.
3.13Data Analysis Plan:

Data will be analyzed using computer software SPSS Version 26. The analysis will
include descriptive and inferential statistics to answer the research questions. The socio-
demographic data will be described using frequency (percentage) while categorical
variables were represented in terms of frequencies and variables, continuous variables
were described in terms of means and standard deviations. P-values have been
calculated, contingency tables and graphs have been created, and p-values less than
0.05 were regarded as significant values.
3.14Ethical Consideration:
Permission for data collection will be sought from the faculty of the neurological
department at Faisalabad. Data will be collected from patients admitted to the
neurological department of District Head Quarter Hospital Faisalabad. These patients will
be those who voluntarily participate in the study after approval is obtained from the
Superintendent of District Head Quarter Hospital Faisalabad and informed consent is
signed by the participants. Subjects will be informed of their right to participate or not
participate and assured that their information will be kept confidential.

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 Chapter#4

Results

This chapter is based on data collected from patients at Faisalabad's Allied and DHQ Hospital. The first
section comprises the participants' demographic information, the second section provides risk factors for
cerebral bleeding, and the third section evaluates the frequency of intracranial bleeding. The following
tables are ascribed to the observation and analysis of the data acquired from patients, and is described as
follows:

Table 1 showed that 74(73.3%) of male with intracranial bleeding were between 50-70 years of age
75(74.3%) of male were older, 53(52.5%) patients are lived in urban area, 66(65.3%) patients have left
intracranial bleeding site, 57(54.4%) have no family history of intracranial bleeding.

Data from Table 2 revealed interesting findings. While a majority (68.3%) of the participants were still
able to perform daily activities, a significant number (62.4%) had a history of a complex medical condition.
Immunosuppressant use was prevalent, with 63.4% of patients taking these medications. Interestingly, the
same percentage (63.4%) had a prior hospitalization, suggesting potential underlying health issues.
Smoking was another common risk factor, reported by 62.4% of participants. Alcohol dependence,
however, appeared less frequent, affecting only 6.9% of the study group. Finally, a high proportion
(71.3%) were already on some form of medication.

Table 3 showed that 68(66.3%) patients felt change in hematoma size regarding intracranial bleeding,
60(59.4%) patients experienced loss of activity during intracranial bleeding, 67(66.3%) patients have
history of loss of consciousness during intracranial bleeding, 76(75.3%) patients have done brain MRI to
confirm intracranial bleeding, 75(74.3%) patients don not showed history of atrial fibrilliation during
intracranial bleeding, 50(50.4%) agree with the history of vascular lesion during intracranial bleeding.

19
20
 Chapter#5

Discussion

5.1Disscussion of result:

Stroke is a prominent cause of death and disability across the world. Although the prevalence is
falling in the West, it is anticipated to increase in Asia. In Pakistan, stroke risk factors are quite prevalent.
The purpose of this study is to investigate the assessment and variables that increase the risk of cerebral
hemorrhage. According to the current study findings, 74 (73.3%) of men with cerebral bleeding were
between 50 and 70 years old, 75 (74.3%) were older, 53 (52.5%) resided in an urban area, 66 (65.3%) had
a left intracranial bleeding site, and 57 (54.4%) had no family history of intracranial bleeding. Risk factors
for cerebral hemorrhage include 63 (62.4%) patients having a past severe disease process, 64 (63.4%)
individuals taking immunosuppression, 64 (63.4%) patients having a previous stay, and 63 (62.4%)
Patients smoked, and 72 (71.3%) were taking medication. In terms of cerebral bleeding, 68 (66.3%)
patients reported a change in hematoma size, 60 (59.4%) reported loss of activity, 67 (66.3%) reported a
loss of consciousness, and 76 (75.3%) had a brain MRI to confirm intracranial bleeding.

A previous study found that the majority of patients with risk factors for cerebral hemorrhage were
above the age of 70, with males accounting for 68.93 percent and women for 31.07 percent. Intracerebral
hemorrhage was observed in 8.74% of individuals with acute cerebrovascular events. The current study
discovered that cerebral hemorrhage happens as a result of having any condition and utilizing
immunosuppressive medicine, as well as having uncontrolled hypertension, diabetes, and hyperlipidemia
( Jadoon et al. , 2023).

Another study discovered that patients with intracerebral hemorrhage were more likely to develop
intracranial bleeding if they had at least a 10-day hospital stay, a consecutive procedure, surgery lasting at
least 4 hours, and utilized EVD for at least 7 days. According to the present study's findings, cerebral
hemorrhage can occur as a result of a prior long-term hospitalization or the usage of any drug. Thus, the
findings of both studies are similar, demonstrating that the same combination of variables increases the risk
of cerebral hemorrhage in those with intracranial bleeding.

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 One of the study's primary findings is that being aware of the risk factors for cerebral hemorrhage is
beneficial. However, a significant number of patients claimed a lack of knowledge about risk factors for
cerebral hemorrhage, as well as inadequate examination and awareness. The study also showed a
significant difference in patient attitudes between the two institutions, with patients at the associated
hospital responding more positively to the risk factors for cerebral hemorrhage. This study improves
patients' quality of life by increasing knowledge of the risk factors for cerebral bleeding, as well as nurses'
comprehension of how to identify patients with intracranial bleeding in order to reduce future delays and
provide efficient treatment.

A research discovered that fewer people with cerebral bleeding have a family history. As MRI is
clearly utilized to confirm cerebral hemorrhage, and more than half of the patients had a loss of activity
during intracranial bleeding, the current study suggests that examination of intracranial bleeding provides a
measure. According to Mendiola's findings, brain imaging is required to determine the location and volume
of the ICH. Every patient who suffered intracranial hemorrhage reported that they received an MRI to
confirm the illness (Mendiola et al., 2020).

Overall result of study related to other study that intracranial mostly occur in men and mostly in old
age and person have less immunity because they already suffer in disease and taking medications.
5.2 Conclusion:
Immunosuppression is the most common risk factor for cerebral bleeding, and it is also seen in individuals
with ongoing medical conditions, previous hospitalizations, and immunological deficits. Male patients over
the age of 65 are more likely to have this condition. The findings of this study may assist guide future
research into the relationship between intracerebral hemorrhage risk factors and fatality rates in these
people. One of the study's weaknesses was that we failed to include these people' fatality rates, which
would have been valuable in increasing awareness of the need of efficient medical treatment to prevent
morbidity.

5.3Strength:

The benefits of assessing the frequency and risk factors for intracranial bleeding include guiding clinical
practice, implementing public health initiatives, improving patient education, optimizing resource

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allocation, developing new therapies, improving evidence-based practice, and providing data for future
research.
5.4 Limitations:

This study has some limitations which include:

 Small sample size is short the finding could not be applicable.

 The time is limited for data collection and analysis.

 Data collected at a particular point in time may provide little information about causal links or
temporal changes.

 Limited financial resources may limit the breadth and extent of the study project.

5.5Implications:

There are following important implications:

• Provides evidence-based guidelines to improve clinical practice by identifying risk factors and
frequency of cerebral hemorrhage.
• Early detection and management of cerebral bleeding risk factors leads to better patient outcomes.
• Identifying high-risk patients and giving timely management can lower the risk of cerebral
hemorrhage.
• Assist in managing healthcare resources and doing research to enhance patient outcomes and
prevent complications.

5.6Recommendations:

Based on the discussion of this study, the following recommendations can be made to improve the
knowledge about the evaluation and risk factors of intracranial bleeding:

o Establish a stringent blood pressure measurement protocol.

o Educate patients on the importance of drug adherence and lifestyle modifications.

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o Establish clear guidelines for identifying signs and symptoms of intracranial hemorrhage.

o Organize seminars and feedback sessions to enhance clinical practice for evaluating cerebral
bleeding.

o Create hospital policy to manage high-risk patients.

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