Five-Year Risk of Major Ischemic and Hemorrhagic Events After Intracerebral Hemorrhage

Abstract

Background and Purpose— We aimed to determine incidences and predictors of major vascular events in intracerebral hemorrhage (ICH) survivors. Methods— We did a prospective observational cohort study in patients with spontaneous ICH from the Prognosis of Intracerebral Hemorrhage cohort in Lille, France. We studied incidences and predictors of long-term vascular events (cerebral and extracerebral, ischemic and hemorrhagic) in patients alive at 30 days with a prespecified subgroup analysis according to ICH location. We performed multivariable analyses (competing risk analyses, with death during follow-up as a competing event). Results— From the 560 patients with spontaneous ICH enrolled between November 2004 and March 2009, we included 310 patients (median age, 70 years). Eighty-two patients presented at least 1 major vascular event leading to an incidence rate of 20.0% (95% CI, 15.7–24.7) at 5 years after ICH. In the overall cohort, ischemic events were more frequent than hemorrhagic events. However, the incidence strikingly differed according to ICH location: deep ICH was associated with future ischemic events (subhazard ratio, 1.85; 95% CI, 1.01–3.40), whereas lobar ICH with hemorrhagic events (subhazard ratio, 2.38; 95% CI, 1.17–4.86). In deep ICH, the incidence of ischemic events at 5 years was 6× higher than the incidence of hemorrhagic events. Conclusions— ICH survivors are at high risk of both cerebral and extracerebral vascular events. The ischemic or hemorrhagic risk profile varies according to the index ICH location with a stronger ischemic risk in deep ICH. Secondary prevention, tailored on ICH location, should target not only cerebral recurrences but also extracerebral vascular events.

Long-term prognosis after intracerebral haemorrhage

“…31 Our finding that in the youngest age-group, the risk of ICH appeared higher than the risk of ischaemic stroke may be explained by a larger proportion of underlying macrovascular causes (e.g., arteriovenous malformation, aneurysm, cavernoma) 33 and a lower prevalence of hypertension in this age-group compared to those of 55 years and older. 34 For ischaemic stroke, the one-year rate varied among previous studies between 0% and 7.0% (Supplementary Table e-5), 10,13,[16][17][18][19][20][21]24,27,28 with again the highest rate in the Scottish population. 27 The oneyear risk of a composite vascular outcome was assessed in six previous studies in ICH survivors and varied between 1 and 25%/year, 10,13,21,27,28,35 whereas in our study this risk was 4.3% in the youngest age-group and up to 14.6% in the elderly.…”

Ten-year risks of recurrent stroke, disability, dementia and cost in relation to site of primary intracerebral haemorrhage: population-based study

“…Optimising healthcare after ICH will therefore depend on the prognosis of ICH during long-term follow-up. However, currently available estimates come predominantly from hospital-based studies performed in the 1990s with relatively short follow-up, and focused mainly on recurrent stroke risk 2 3…”

“…Given the different balance of pathologies for lobar versus non-lobar ICH, the long-term prognosis of ICH could be expected to differ by haematoma location. However, while some studies suggested that haematoma location was associated with recurrent stroke,3–6 others have not 7 8. The impact of haematoma location on disability, dementia or quality of life in survivors up to 10 years after the initial ICH is also unclear.…”

STudy of Antithrombotic Treatment after IntraCerebral Haemorrhage: Protocol for a randomised controlled trial

“…5 The annual risk of ICH recurrence is estimated to be 1.8-7.4%, 6 but in the long term, these patients are at even higher risk of ischaemic events like myocardial infarction and ischaemic stroke. 7,8 A substantial proportion of patients presenting with ICH are on antithrombotic treatment: a quarter use anticoagulant drugs, 9,10 and more than one-third use antiplatelet drugs. 11,12 Overall, 40-50% use, or have an indication for, antithrombotic treatment.…”