Longer term stroke risk in intracerebral haemorrhage survivors

Abstract

ObjectiveTo evaluate the influence of intracerebral haemorrhage (ICH) location on stroke outcomes.MethodsWe included patients recruited to a UK hospital-based, multicentre observational study of adults with imaging confirmed spontaneous ICH. The outcomes of interest were occurrence of a cerebral ischaemic event (either stroke or transient ischaemic attack) or a further ICH following study entry. Haematoma location was classified as lobar or non-lobar.ResultsAll 1094 patients recruited to the CROMIS-2 (Clinical Relevance of Microbleeds in Stroke) ICH study were included (mean age 73.3 years; 57.4% male). There were 45 recurrent ICH events (absolute event rate (AER) 1.88 per 100 patient-years); 35 in patients presenting with lobar ICH (n=447, AER 3.77 per 100 patient-years); and 9 in patients presenting with non-lobar ICH (n=580, AER 0.69 per 100 patient-years). Multivariable Cox regression found that lobar ICH was associated with ICH recurrence (HR 8.96, 95% CI 3.36 to 23.87, p<0.0001); similar results were found in multivariable completing risk analyses. There were 70 cerebral ischaemic events (AER 2.93 per 100 patient-years); 29 in patients presenting with lobar ICH (AER 3.12 per 100 patient-years); and 39 in patients with non-lobar ICH (AER 2.97 per 100 patient-years). Multivariable Cox regression found no association with ICH location (HR 1.13, 95% CI 0.66 to 1.92, p=0.659). Similar results were seen in completing risk analyses.ConclusionsIn ICH survivors, lobar ICH location was associated with a higher risk of recurrent ICH events than non-lobar ICH; ICH location did not influence risk of subsequent ischaemic events.Trial registration numberNCT02513316.

Risks of recurrent stroke and all serious vascular events after spontaneous intracerebral haemorrhage: pooled analyses of two population-based studies

“…Identifying risk factors for recurrent ICH, ischaemic stroke, and all serious vascular events after ICH could help with risk stratification to inform decisions about antithrombotic drugs after ICH. Lobar ICH location has been associated with a higher risk of recurrent ICH in some studies, 5,6,[8][9][10][11][12] but not others. 13,14 The risk of recurrent stroke is particularly high in the first few days and weeks after transient ischaemic attack (TIA) or ischaemic stroke, 15 although less is known about the time course of recurrent ICH.…”

“…Biffi and colleagues 31 Casolla and colleagues 8 Chong and colleagues 32 Banerjee and colleagues 9 Zia and colleagues 13…”

“…Overall, according to data from seven cohorts, 6 , 7 , 8 , 9 ICH survivors seem to have a similar annual risk of recurrent ICH (1·1–3·9%) and ischaemic stroke (1·1–3·2%). However, these estimates of the risk of stroke recurrence originate mostly from hospital-based studies.…”

“…Adults with ICH usually have underlying cerebral small vessel disease, 3 which leaves them at risk of recurrent stroke 4 and systemic comorbidities, which put them at additional risk of stroke and other cardiovascular events. 5,6 Overall, according to data from seven cohorts, [6][7][8][9] ICH survivors seem to have a similar annual risk of recurrent ICH (1•1-3•9%) and ischaemic stroke (1•1-3•2%).…”

“…Risk factors for ischaemic stroke after ICH are also unclear. Although ICH location does not seem to be associated with the risk of ischaemic stroke, 6,8,9 atrial fibrillation (AF) is likely to be a risk factor for ischaemic stroke, but not recurrent ICH. 18 In 2019, findings from RESTART 19 showed that after ICH associated with antithrombotic drug use, survivors had a numerically but non-significantly lower risk of recurrent ICH after starting antiplatelet therapy compared with avoiding these drugs (adjusted hazard ratio [HR] 0•51, 95% CI 0•25-1•03; p=0•060).…”