Long-term prognosis after intracerebral haemorrhage

Abstract

Introduction The aim of this study was to determine the risk of recurrent intracerebral haemorrhage (ICH), ischaemic stroke, all stroke, any vascular event and all-cause mortality in 30-day survivors of ICH, according to age and sex. Patients and methods We linked national hospital discharge, population and cause of death registers to obtain a cohort of Dutch 30-day survivors of ICH from 1998 to 2010. We calculated cumulative incidences of recurrent ICH, ischaemic stroke, all stroke and composite vascular outcome, adjusted for competing risk of death and all-cause mortality. Additionally, we compared survival with the general population. Results We included 19,444 ICH-survivors (52% male; median age 72 years, interquartile range 61–79; 78,654 patient-years of follow-up). First-year cumulative incidence of recurrent ICH ranged from 1.5% (95% confidence interval 0.9–2.3; men 35–54 years) to 2.4% (2.0–2.9; women 75–94 years). Depending on age and sex, 10-year risk of recurrent ICH ranged from 3.7% (2.6–5.1; men 35–54 years) to 8.1% (6.9–9.4; women 55–74 years); ischaemic stroke 2.6% to 7.0%, of all stroke 9.9% to 26.2% and of any vascular event 15.0% to 40.4%. Ten-year mortality ranged from 16.7% (35–54 years) to 90.0% (75–94 years). Relative survival was lower in all age-groups of both sexes, ranging from 0.83 (0.80–0.87) in 35- to 54-year-old men to 0.28 (0.24–0.32) in 75- to 94-year-old women. Discussion ICH-survivors are at high risk of recurrent ICH, of ischaemic stroke and other vascular events, and have a sustained reduced survival rate compared to the general population. Conclusion The high risk of recurrent ICH, other vascular events and prolonged reduced survival-rates warrant clinical trials to determine optimal secondary prevention treatment after ICH.

Cardiovascular Events After Intracerebral Hemorrhage

“…16 In a population-based record linkage study from the Netherlands comprising nearly 2000 ICH survivors, the 1-year cumulative rate of an arterial ischemic event or vascular death was slightly higher among men compared with women, in the 55 to 74 years (9.2% versus 7.4%) and 75-to 94-year age groups (14.6% versus 14.1%). 38 The 10-year rates reached as high as 40% in the elderly age group, suggesting that ICH survivors experience major arterial ischemic events, both shortand long-term. 38 In terms of timing of arterial ischemic events after ICH, prior studies have mostly considered the time after discharge from the ICH or the first 30 days after the index ICH, with the follow-up period extending anywhere between 1 and 10 years (Table 1).…”

“…38 The 10-year rates reached as high as 40% in the elderly age group, suggesting that ICH survivors experience major arterial ischemic events, both shortand long-term. 38 In terms of timing of arterial ischemic events after ICH, prior studies have mostly considered the time after discharge from the ICH or the first 30 days after the index ICH, with the follow-up period extending anywhere between 1 and 10 years (Table 1). Exclusion of the first few weeks after ICH was done due to the high 30-day mortality of ICH, which may yield erroneously high rates of arterial ischemic events.…”

Apixaban versus no anticoagulation after anticoagulation-associated intracerebral haemorrhage in patients with atrial fibrillation in the Netherlands (APACHE-AF): a randomised, open-label, phase 2 trial

“…7 Additionally, the risk of ischaemic stroke after intracerebral haemorrhage might be as high as that of recurrent intracerebral haem orrhage. [8][9][10][11] In two systematic reviews and metaanalyses of observational studies, survivors of intracranial haemorrhage who restarted anticoagulation had a lower risk of ischaemic stroke than those in whom anticoagulants were withheld, whereas the risk of intracerebral haem orrhage was similar. 12,13 However, the results of these observational studies could have been confounded by indication, and most patients on anticoagulation were treated with vitamin K antagonists.…”

Non-Invasive Imaging of the Carotid Artery

“…41,42 Alternatively, several reports have shown a relation between small fissures in the fibrous cap and IPH, suggestive that IPH can also originate from hemorrhage from the lumen. 25,[43][44][45] IPH results in plaque destabilization because it associated with rapid plaque expansion and can induce a strong inflammatory response due to the degradation of hemoglobin. 42,46 The second feature of plaque vulnerability, inflammation, is not just important in fatty streak initiation but is a hallmark of plaque destabilization.…”

“…Carotid-femoral PWV has been associated with cardiovascular events and allcause mortality. 45 However, arterial stiffening is not uniformly distributed and may affect elastic and muscular arteries differently. Additionally, carotid-femoral PWV velocity disregards local variations in arterial stiffness, which may be more strongly associated with atherosclerosis than with vascular ageing.…”