Major Cardiovascular Events After Spontaneous Intracerebral Hemorrhage by Hematoma Location

Boe, Nils Jensen; Hald, Stine Munk; Jensen, Mie Micheelsen; Kristensen, Line; Bojsen, Jonas Asgaard; Elhakim, Mohammad Talal; Clausen, Anne; Möller, Sören; Hallas, Jesper; Rodrı́guez, Luis A. Garcı́a; Selim, Magdy; Goldstein, Larry B.; Salman, Rustam Al‐Shahi; Garcı́a-Dorado, David

doi:10.1001/jamanetworkopen.2023.5882

Cited by 10 publications

(9 citation statements)

References 27 publications

(98 reference statements)

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“…[1][2][3][4] This increased risk of MACCE is influenced by demographic factors, mainly race and ethnicity, 7 and ICH-related factors, particularly hematoma location. 8,9 However, since prior studies mainly examined large population cohorts, they lacked important ICH characteristics such as admission hematoma volume and the presence of IVH. In this context, our findings from 2 large prospective ICH cohorts, with protocolized, blinded ascertainment of neuroimaging markers and blinded outcome assessment, offer novel insight into the relationship between hematoma volume and the risk of subsequent ischemic stroke.…”

Section: Discussionmentioning

confidence: 99%

“…Finally, although we had information on ICH location, we did not have data on the etiology of ICH, a factor that may have impacted the risk of recurrent stroke in our ICH cohort. 9…”

Section: Discussionmentioning

confidence: 99%

“…7 Furthermore, hematoma location may play a role in the fact that the risk of MACCE is higher after a lobar ICH, mainly due to a heightened risk of recurrent ICH, while there appears to be a trend toward more ischemic events among patients with a deep ICH. 5,8,9 It is, however, unknown whether other hematoma characteristics, such as hematoma volume, are also associated with ischemic stroke risk. We, therefore, sought to evaluate the association between admission hematoma volume and the subsequent risk of an ischemic stroke in a pooled, prospective cohort of patients with ICH.…”

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confidence: 99%

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Association Between Hematoma Volume and Risk of Subsequent Ischemic Stroke: A MISTIE III and ATACH-2 Analysis

Harris,

Kaiser,

Liao

et al. 2024

Stroke

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BACKGROUND: Nontraumatic intracerebral hemorrhage (ICH) is independently associated with a long-term increased risk of major arterial ischemic events. While the relationship between ICH location and ischemic risk has been studied, whether hematoma volume influences this risk is poorly understood. METHODS: We pooled individual patient data from the MISTIE III (Minimally Invasive Surgery Plus Alteplase for Intracerebral Hemorrhage Evacuation Phase 3) and the ATACH-2 (Antihypertensive Treatment of Acute Cerebral Hemorrhage-2) trials. The exposure was hematoma volume, treated as a continuous measure in the primary analysis, and dichotomized by the median in the secondary analyses. The outcome was a symptomatic, clinically overt ischemic stroke, adjudicated centrally within each trial. We evaluated the association between hematoma volume and the risk of an ischemic stroke using Cox regression analyses after adjustment for demographics, vascular comorbidities, and ICH characteristics. RESULTS: Of 1470 patients with ICH, the mean age was 61.7 (SD, 12.8) years, and 574 (38.3%) were female. The median hematoma volume was 17.3 mL (interquartile range, 7.2–35.7). During a median follow-up of 107 days (interquartile range, 91–140), a total of 30 ischemic strokes occurred, of which 22 were in patients with a median ICH volume of ≥17.3 mL and a cumulative incidence of 4.6% (95% CI, 3.1–7.1). Among patients with a median ICH volume <17.3 mL, there were 8 ischemic strokes with a cumulative incidence of 3.1% (95% CI, 1.7–6.0). In primary analyses using adjusted Cox regression models, ICH volume was associated with an increased risk of ischemic stroke (hazard ratio, 1.02 per mL increase [95% CI, 1.01–1.04]). In secondary analyses, ICH volume of ≥17.3 mL was associated with an increased risk of ischemic stroke (hazard ratio, 2.5 [95% CI, 1.1–7.2]), compared with those with an ICH volume <17.3 mL. CONCLUSIONS: In a heterogeneous cohort of patients with ICH, initial hematoma volume was associated with a heightened short-term risk of ischemic stroke.

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Section: Discussionmentioning

confidence: 99%

“…Finally, although we had information on ICH location, we did not have data on the etiology of ICH, a factor that may have impacted the risk of recurrent stroke in our ICH cohort. 9…”

Section: Discussionmentioning

confidence: 99%

mentioning

confidence: 99%

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Association Between Hematoma Volume and Risk of Subsequent Ischemic Stroke: A MISTIE III and ATACH-2 Analysis

Harris,

Kaiser,

Liao

et al. 2024

Stroke

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“…16 Using data from the same smaller cohort data as in this study, we reported that the location of the recurrent ICH was largely similar to the index ICH. 41 We also lacked information on brain MRI biomarkers of small vessel disease that may influence prognosis. In particular, MRI findings such as the presence of convexity superficial siderosis and other radiographic features of CAA 18 would have allowed analyses of the associations between statin use and risk of stroke within strata defined by convexity superficial siderosis/CAA status.…”

Section: Discussionmentioning

confidence: 99%

Association of Statin Use With Risk of Stroke Recurrence After Intracerebral Hemorrhage

Gaist,

García Rodríguez,

Hallas

et al. 2023

Neurology

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Background and Objectives Survivors of spontaneous intracerebral hemorrhage (ICH) may have indications for statin therapy. The effect of statins on the risk of subsequent hemorrhagic and ischemic stroke (IS) in this setting is uncertain. We sought to determine the risk of any stroke (ischemic stroke, IS or recurrent ICH), IS, and recurrent ICH associated with statin use among ICH survivors. Methods Using the Danish Stroke Registry, we identified all patients admitted to a hospital in Denmark (population 5.8 million) with a first-ever ICH between January 2003 and December 2021 who were aged 50 years or older and survived >30 days. Patients were followed up until August 2022. Within this cohort, we conducted 3 nested case-control analyses for any stroke, IS, and recurrent ICH. We matched controls for age, sex, time since first-ever ICH, and history of prior IS. The primary exposure was statin use before or on the date of subsequent stroke or the equivalent date in matched controls. Using conditional logistic regression, we calculated adjusted odds ratios (aORs) and corresponding 95% confidence intervals (CIs) for any stroke, IS, and recurrent ICH associated with statin exposure. Results We identified 1,959 patients with any stroke (women 45.3%; mean [SD] age, 72.6 [9.7] years) who were matched to 7,400 controls; 1,073 patients with IS (women 42.0%; mean [SD] age, 72.4 [10.0] years) who were matched to 4,035 controls and 984 patients with recurrent ICH (women 48.7%; mean [SD] age, 72.7 [9.2] years) who were matched to 3,755 controls. Statin exposure was associated with a lower risk of both any stroke (cases 38.6%, controls 41.1%; aOR 0.88; 95% CI 0.78–0.99) and IS (cases 39.8%, controls 41.8%, aOR 0.79; 95% CI 0.67–0.92), but was not associated with recurrent ICH risk (cases 39.1%, controls 40.8%, aOR 1.05; 95% CI 0.88–1.24). Discussion Exposure to statins was not associated with an increased risk of recurrent ICH but was associated with a lower risk of any stroke, largely due to a lower risk of IS. Confirmation of these findings in randomized trials is needed. Classification of Evidence This study provides Class III evidence that statin use in patients with ICH is associated with a lower risk of any stroke and IS and not with increased risk of recurrent ICH.

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“…[14][15][16] The risks of MACE after ICH and ischemic stroke are similar. 17,18 Despite blood pressure-lowering, the annual rate of all MACE for ICH survivors is 4% to 8% in high income countries 9,16,19,20 and ≈10% in lower income countries, 21 resulting in between 826 400 and 2,066 000 MACE each year in ICH survivors worldwide. These ICH survivors who develop MACE are at higher risk of dying than ICH survivors without MACE.…”

Section: Mace Are Common After Ichmentioning

confidence: 99%

Antiplatelet Agent Use After Stroke due to Intracerebral Hemorrhage

Al-Shahi Salman,

Greenberg

2023

Stroke

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This focused update about antiplatelet agents to reduce the high risk of major adverse cardiovascular events after stroke due to spontaneous (nontraumatic) intracerebral hemorrhage (ICH) complements earlier updates about blood pressure-lowering, lipid-lowering, and oral anticoagulation or left atrial appendage occlusion for atrial fibrillation after ICH. When used for secondary prevention in people without ICH, antiplatelet agents reduce the risk of major adverse cardiovascular event (rate ratio, 0.81 [95% CI, 0.75–0.87]) and might increase the risk of ICH (rate ratio, 1.67 [95% CI, 0.97–2.90]). Before 2019, guidance for clinical decisions about antiplatelet agent use after ICH has focused on estimating patients’ predicted absolute risks and severities of ischemic and hemorrhagic major adverse cardiovascular event and applying the known effects of these drugs in people without ICH to estimate whether individual ICH survivors in clinical practice might be helped or harmed by antiplatelet agents. In 2019, the main results of the RESTART (Restart or Stop Antithrombotics Randomized Trial) randomized controlled trial including 537 survivors of ICH associated with antithrombotic drug use showed, counterintuitively, that antiplatelet agents might not increase the risk of recurrent ICH compared to antiplatelet agent avoidance over 2 years of follow-up (12/268 [4%] versus 23/268 [9%]; adjusted hazard ratio, 0.51 [95% CI, 0.25–1.03]; P =0.060). Guidelines in the United States, Canada, China, and the United Kingdom and Ireland have classified the level of evidence as B and indicated that antiplatelet agents may be considered/reasonable after ICH associated with antithrombotic agent use. Three subsequent clinical trials have recruited another 174 participants with ICH, but they will not be sufficient to determine the effects of antiplatelet therapy on all major adverse cardiovascular events reliably when pooled with RESTART. Therefore, ASPIRING (Antiplatelet Secondary Prevention International Randomized Study After Intracerebral Hemorrhage) aims to recruit 4148 ICH survivors to determine the effects of antiplatelet agents after ICH definitively overall and in subgroups.

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Major Cardiovascular Events After Spontaneous Intracerebral Hemorrhage by Hematoma Location

Cited by 10 publications

References 27 publications

Association Between Hematoma Volume and Risk of Subsequent Ischemic Stroke: A MISTIE III and ATACH-2 Analysis

Association Between Hematoma Volume and Risk of Subsequent Ischemic Stroke: A MISTIE III and ATACH-2 Analysis

Association of Statin Use With Risk of Stroke Recurrence After Intracerebral Hemorrhage

Antiplatelet Agent Use After Stroke due to Intracerebral Hemorrhage

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