Andrea Morotti, MD

Casolla B, Moulin S, Kyheng M, Hénon H, Labreuche J, Leys D, et al. Five-Year Risk of Major Ischemic and Hemorrhagic Events After Intracerebral Hemorrhage. Stroke. 2019;50:1100–1107.

Intracerebral hemorrhage (ICH) survivors are at high risk of stroke recurrence. Most of the available studies focused on the risk of future cerebrovascular events whether the occurrence of extracranial vascular diseases remains poorly characterized. In this single center prospective cohort study, Dr. Casolla and colleagues described the incidence and predictors of cerebral (ischemic and hemorrhagic) and extracranial (ischemic and hemorrhagic) vascular events in patients alive at 30 days after acute ICH.

A total of 310 patients met the inclusion criteria and were followed for a median of 6 years. The overall cumulative incidence of major vascular events was 20%. The long-term natural history of ICH in terms of vascular events was remarkably different in deep versus lobar ICH survivors, with deep ICH being associated with greater ischemic risk (subhazard ratio, 1.85; 95% CI, 1.01–3.40) and lobar ICH having a higher risk of future hemorrhagic events (subhazard ratio, 2.38; 95% CI, 1.17–4.86).

Despite an overall low absolute number of major events, this article provided an accurate characterization of the long-term vascular risk of ICH survivors. About one in five patients will experience a new vascular event at 5 years after ICH. This highlights the need to improve preventive strategies and reduce the burden of potentially preventable vascular events that have a significant impact on morbidity and mortality. The risk of future cerebral and extracranial vascular disease differed by ICH location, providing an opportunity for personalized secondary prevention strategies in ICH survivors. In particular, deep ICH was associated with a low risk of future hemorrhagic events and high risk of cerebral and extracranial ischemic events. Therefore, the fear of recurrent intracranial bleeding should not discourage clinicians from restarting antithrombotic treatment in deep ICH survivors with compelling indications such as ischemic vascular disease or atrial fibrillation.

In conclusion, patients surviving an acute ICH have a significant long-term risk of future vascular events. This risk goes beyond ICH recurrence or ischemic stroke and has a major impact on outcome. Preventive strategies and, in particular, antithrombotic treatment should focus on all vascular events. A simple and rapidly available marker such as ICH location may provide helpful insights for personalized vascular prevention.