Adeola Olowu, 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.

Spontaneous intracerebral hemorrhage (sICH) management involves stabilization, management, and secondary prevention. When treating sICH patients, it’s intuitive to create a medical plan to prevent recurrent ICH. However, what if ischemic vascular processes need to be considered as a complication in this population?

The authors of “Five-Year Risk of Major Ischemic and Hemorrhagic Events After Intracerebral Hemorrhage” conducted a prospective observational study of patients from the Prognosis of Intracerebral Hemorrhage (PITCH) trial from November 3, 2004 to March 29, 2009. A total of 310 sICH survivors (defined as being alive at 30 days) were observed with a 6-month follow up and an annual follow-up for 6 years. 55% were men, the median age was 70 years old, ICH was divided into deep and lobar with 195 and 115 patients, respectively. During this time, the study found a 20% incidence of major vascular events 5 years after ICH. Both major ischemic and hemorrhagic events incidences increased from 1 year to 5 years. Major ischemic events described as ischemic stroke, coronary events, acute limb ischemia, severe peripheral artery disease, and severe internal carotid stenosis occurred at 5.9% at 1 year to 15.2% at 5 years. Major hemorrhagic events were intracerebral hemorrhage and major systemic bleeding which occurred at 4.9% at 1 year and increased to 6.2% at 5 years. Rate of ischemic events was 6x higher than hemorrhagic events in the deep sICH population. The supplemental data was significant for demonstrating small vessel disease as the highest proportion of ischemic stroke etiology for patients with deep sICH during follow up, deep sICH patients were at high risk for having coronary events and severe peripheral artery disease, while patients with lobar sICH developed ischemic stroke, ICH, and major systemic bleeding using the Bleeding Academic Research Consortium (BARC) classifications.

Drawbacks from the article involved excluding transient ischemic attacks (TIAs) from analysis. I wonder if deep sICH patients had TIAs. This could have been a statistically significant risk factor for developing an ischemic stroke in this population and a reason to consider aggressive overall vascular risk factor management. Can the results be applied to our population in the U.S.? Absolutely, to a degree. The U.S. is more ethnically diverse and has a higher BMI than France. So, we may have an increased incidence of ischemic events in our subcortical sICH population.

Despite the drawbacks, this article is eye-opening in managing ischemic events in the sICH population, specifically deep sICH. Ischemic stroke and ischemic events were found to have an ever-increasing recurrence rate in patients with ICH. Data collected was objective with the use of imaging to solidify the diagnosis of ischemic and hemorrhagic events. Most importantly, this study affects stroke practice/management. Ischemic stroke work up should be applied to those with deep sICH, and those cerebrovascular risk factors should be managed aggressively. 

New areas of research could include prospective observation of ischemic events in the subcortical sICH population with aggressive management of ischemic risk factors. An interesting aspect of potential future research would be conducting a retrospective study in the U.S. to determine if there’s a difference in ischemic event incidence. Another important area for study is to determine if deep sICH patients had TIAs and if this event was significantly associated with increased incidence of ischemic events.

Do you agree or disagree with my view in this article? Let us know your thoughts and why.