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

Abstract

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.

Higher Coffee Consumption Is Associated With Reduced Cerebral Gray Matter Volume: A Mendelian Randomization Study

“…However, intake of caffeine may temporarily increase the blood pressure in individuals with hypertension, which may lead to an increased risk of intracranial hemorrhage in hypertensive individuals ( 8 , 40 ). A recently published study confirmed that coffee consumption is the main trigger factor for intracranial hemorrhage ( 41 ). Although caffeine could reinstate the adenosine-inhibited synaptic excitatory signaling in human neurons, it also could attenuate synaptic long-term potentials ( 42 , 43 ).…”

Trigger Factors for Stroke in Young Adults

“…40 In contrast to previous studies in older populations, coffee consumption was not identified as a trigger factor for any type of stroke in our young population. 13,16,24 A possible explanation may be that the effect of a sudden blood pressure surge differs between old and young people, with the elderly individuals more often having long-standing hypertension, atherosclerosis, and reduced vessel wall elasticity. 41,42 In line with previous literature, we did not find cigarette smoking as a trigger factor and even found a negative relative risk.…”

“…23,34,35 Conversely, a sudden rise in blood pressure might trigger rupture of a vessel wall, resulting in an ICH. 13,16 In addition, some drug types are known to cause vasospasms without a blood rise, which can also lead to stroke. 36 Second, fever and flu-like disease may result in an increased stroke risk because it can lead to systemic inflammation with endothelial dysfunction, a prothrombotic condition and increased platelet activation and aggregation.…”

“…For alcohol consumption, coffee consumption, cola consumption, and illicit drug use, patients were also asked for the exact time interval between the last exposure and stroke onset. 13,14,16,23,26 To be able to compare our findings with some of the existing literature on trigger factors for ischemic stroke in an older population that used a hazard period of 2 hours, 14 we also assessed a 2-hour hazard period for alcohol consumption, coffee consumption, cola consumption, and illicit drug use (eTable 1, links.lww.com/WNL/C340). Illicit drug use was examined both combined and by subcategory (type of drugs, soft drugs vs hard drugs).…”

Haemorrhage risk of brain arteriovenous malformation during pregnancy and puerperium

“…4 It was found that various factors could suddenly increase blood pressure and trigger acute vessel rupture, resulting in intracranial haemorrhage, which exhibited as emotional changes, vigorous activity, sexual activity and Valsalva manoeuvres. 4 A case-crossover study (CCOS) design treats every participant as their own control to avoid individual differences, and this approach is widely used to test trigger factors. 5 Since Robinson et al 6 first reported an increased bAVM-related haemorrhage rate in females during pregnancy, pregnancy and WHAT IS ALREADY KNOWN ON THIS TOPIC ⇒ It has been reported that pregnancy and puerperium are associated with brain arteriovenous malformation (bAVM)-related haemorrhage; however, the results of existing studies are controversial, some even contradictory.…”