Author Response: Location-Specific Risk Factors for Intracerebral Hemorrhage: Systematic Review and Meta-Analysis

Intracerebral hemorrhage (ICH) is a devastating form of stroke with high morbidity and mortality. This review article focuses on the epidemiology, cause, mechanisms of injury, current treatment strategies, and future research directions of ICH. Incidence of hemorrhagic stroke has increased worldwide over the past 40 years, with shifts in the cause over time as hypertension management has improved and anticoagulant use has increased. Preclinical and clinical trials have elucidated the underlying ICH cause and mechanisms of injury from ICH including the complex interaction between edema, inflammation, iron-induced injury, and oxidative stress. Several trials have investigated optimal medical and surgical management of ICH without clear improvement in survival and functional outcomes. Ongoing research into novel approaches for ICH management provide hope for reducing the devastating effect of this disease in the future. Areas of promise in ICH therapy include prognostic biomarkers and primary prevention based on disease pathobiology, ultra-early hemostatic therapy, minimally invasive surgery, and perihematomal protection against inflammatory brain injury.

show abstract

“…Coagulopathy, platelet dysfunction, and illicit drug use can contribute to ICH or its severity (Table 1). 17,18…”

Section: Cause and Risk Factorsmentioning

confidence: 99%

Cerebral Hemorrhage: Pathophysiology, Treatment, and Future Directions

Magid-Bernstein

Girard

Polster

et al. 2022

Circulation Research

148

View full text Add to dashboard Cite

show abstract

“…Established long-term risk factors for ICH include higher age, male sex, hypertension, diabetes, underweight, high alcohol intake, being black or from Hispanic origin, and apolipoprotein E genotype. 3–6 Most of these risk factors are involved only in the development of the underlying small vessel disease but not in the actual vessel rupture resulting in an ICH. Hypertension might be an exception, because it not only increases the underlying small vessel disease, but may also be involved in the actual rupture of the vessel.…”

mentioning

confidence: 99%

Trigger Factors for Spontaneous Intracerebral Hemorrhage: A Case-Crossover Study

Etten

Kaushik

Jolink

et al. 2022

Stroke

Self Cite

View full text Add to dashboard Cite

Background and Purpose: Whether certain activities can trigger spontaneous intracerebral hemorrhage (ICH) remains unknown. Insights into factors that trigger vessel rupture resulting in ICH improves knowledge on the pathophysiology of ICH. We assessed potential trigger factors and their risk for ICH onset. Methods: We included consecutive patients diagnosed with ICH between July 1, 2013, and December 31, 2019. We interviewed patients on their exposure to 12 potential trigger factors (eg, Valsalva maneuvers) in the (hazard) period soon before onset of ICH and their normal exposure to these trigger factors in the year before the ICH. We used the case-crossover design to calculate relative risks (RR) for potential trigger factors. Results: We interviewed 149 patients (mean age 64, 66% male) with ICH. Sixty-seven (45%) had a lobar hemorrhage, 60 (40%) had a deep hemorrhage, 19 (13%) had a cerebellar hemorrhage, and 3 (2%) had an intraventricular hemorrhage. For ICH in general, there was an increased risk within an hour after caffeine consumption (RR=2.5 [95% CI=1.8–3.6]), within an hour after coffee consumption alone (RR=4.8 [95% CI=3.3–6.9]), within an hour after lifting >25 kg (RR=6.6 [95% CI=2.2–19.9]), within an hour after minor head trauma (RR=10.1 [95% CI=1.7–60.2]), within an hour after sexual activity (RR=30.4 [95% CI=16.8–55.0]), within an hour after straining for defecation (RR=37.6 [95% CI=22.4–63.4]), and within an hour after vigorous exercise (RR=21.8 [95% CI=12.6–37.8]). Within 24 hours after flu-like disease or fever, the risk for ICH was also increased (RR=50.7 [95% CI=27.1–95.1]). Within an hour after Valsalva maneuvers, the RR for deep ICH was 3.5 (95% CI=1.7–6.9) and for lobar ICH the RR was 2.0 (95% CI=0.9–4.2). Conclusions: We identified one infection and several blood pressure related trigger factors for ICH onset, providing new insights into the pathophysiology of vessel rupture resulting in ICH.

show abstract

“…8 Additionally, variability and surges in SBP, appear to be important in the etiology of ICH, 9 which most commonly arises in the deeper structures of the brain (ie, thalamus, basal ganglia, brain stem, and cerebellum), where rupture of penetrating arteries is attributed to endothelial stress from hypertensive arteriopathy. However, elevated BP is also important for lobar ICH, which is often attributed to cerebral amyloid angiopathy 10–13 and in relation to anticoagulation-associated ICH. 14–16 Thus, BP management is critical in all presumed mechanisms of ICH.…”

Section: Bp and Acute Ich And Subsequent Adverse Outcomesmentioning

confidence: 99%

Review of Long-Term Blood Pressure Control After Intracerebral Hemorrhage: Challenges and Opportunities

Mullen

Anderson

2022

Stroke

View full text Add to dashboard Cite

Blood pressure (BP) is the most important modifiable risk factor for intracerebral hemorrhage (ICH). Elevated BP is associated with an increased risk of ICH, worse outcome after ICH, and in survivors, higher risks of recurrent ICH, ischemic stroke, myocardial infarction, and cognitive impairment/dementia. As intensive BP control probably improves the chances of recovery from acute ICH, the early use of intravenous or oral medications to achieve a systolic BP goal of <140 mm Hg within the first few hours of presentation is reasonable for being applied in most patients. In the long-term, oral antihypertensive drugs should be titrated as soon as possible to achieve a goal BP <130/80 mm Hg and again in all ICH patients regardless of age, location, or presumed mechanism of ICH. The degree of sustained BP reduction, rather than the choice of BP-lowering agent(s), is the most important factor for optimizing risk reduction, with varying combinations of thiazide-type diuretics, long-acting calcium channel blockers, ACE (angiotensin-converting enzyme) inhibitors or angiotensin receptor blockers, being the mainstay of therapy. As most patients will require multiple BP-lowering agents, and physician inertia and poor adherence are major barriers to effective BP control, single-pill combination therapy should be considered as the choice of management where available. Increased population and clinician awareness, and innovations to solving patient, provider, and social factors, have much to offer for improving BP control after ICH and more broadly across high-risk groups. It is critical that all physicians, especially those managing ICH patients, emphasize the importance of BP control in their practice.

show abstract

Author Response: Location-Specific Risk Factors for Intracerebral Hemorrhage: Systematic Review and Meta-Analysis

Cited by 12 publications

References 2 publications

Cerebral Hemorrhage: Pathophysiology, Treatment, and Future Directions

Cerebral Hemorrhage: Pathophysiology, Treatment, and Future Directions

Trigger Factors for Spontaneous Intracerebral Hemorrhage: A Case-Crossover Study

Review of Long-Term Blood Pressure Control After Intracerebral Hemorrhage: Challenges and Opportunities

Contact Info

Product

Resources

About