The risk of a second stroke after intracerebral hemorrhage (ICH) did not differ by index hematoma location, and this risk was higher for ischemic stroke than ICH.
Results from a recent cohort study found that among survivors of intracerebral hemorrhage (ICH), lobal hematoma location was associated with an increased risk of subsequent major cardiovascular events (MACE).
Survivors of spontaneous ICH have a known increased risk of MACEs, including recurrent ICH, ischemic stroke, and myocardial infarction. Despite this association, limited data are available from large, unselected population studies assessing the risk of MACEs based on hematoma location.
Earlier studies have investigated the association between hematoma location and risk of recurrent ICH, but few have also reported the overall risk of other MACEs in addition to separate risks of ischemic stroke and myocardial infarction. Most of these studies were from single centers and were predominantly small and, therefore, accrued few outcomes.
The main objective of the new study was to examine the risk of MACEs by hematoma location from an unselected, large cohort of patients with spontaneous ICH. Secondary objections were to investigate the association of hematoma location in patients with 2 established cardiovascular risk factors (previous atrial fibrillation and diabetes) and previous occlusive vascular disease, and to investigate the association between hematoma location and the risk of subsequent stroke and myocardial infarction.
The cohort study identified 2819 patients in southern Denmark, aged 50 years or older, who were hospitalized with first-ever spontaneous ICH between January 1, 2009, and December 31, 2018. ICH was categorized as lobar or non-lobar, and the cohorts were linked to registry data until the end of 2018 to identify the occurrence of MACEs and separately recurrent ICH, ischemic stroke, and myocardial infarction. Outcome events were validated using medical records and associations were adjusted for potential confounders using inverse probability weighting.
Investigators identified 1034 patients with lobar ICH and 1255 with non-lobar ICH. Further imaging evaluation had been performed in 587 patients (56.8%) with lobar ICH and 650 (51.8%) with non-lobar ICH. Additionally, 522 (73.6%) patients with lobar ICH and 558 (64.3%) with non-lobar ICH survived more than 30 days.
Compared with patients with non-lobar ICH, those with lobar ICH had higher rates of MACEs per 100 person-years and recurrent ICH, but not ischemic stroke or myocardial infarction. The baseline prevalence was lower in patients with lobar ICH versus non-lobar ICH for hypertension (67.8% and 73.3%, respectively) and prior ischemic stroke (12.6% and 15.2%, respectively). Use of platelet antiaggregants but not oral anticoagulants was more frequent among patients with lobar than non-lobar ICH.
In patients with baseline comorbid atrial fibrillation, the relative rates of the main outcomes did not differ by hematoma location, although the rate of ischemic stroke was lower after lobar ICH. Among patients without comorbid atrial fibrillation, the risk of recurrent ICH was higher than the risk of ischemic stroke in the lobar cohort, as was the risk of MACEs. Compared with the non-lobar cohort, patients with lobar ICH and no occlusive vascular disease had a higher risk for ICH recurrence, which was even higher among patients who had a history of previous occlusive vascular disease.
Their finding that the risk of a second stroke after ICH did not differ by index hematoma location and that this risk was higher for ischemic stroke than ICH merits further study, according to the investigators.
Boe NJ, Hald SM, Jensen MM, et al. Major Cardiovascular Events After Spontaneous Intracerebral Hemorrhage by Hematoma Location. JAMA Netw Open. 2023;6(4):e235882. doi:10.1001/jamanetworkopen.2023.5882