Brain hemorrhage: uncontrollable threat

A new analysis shows that rates of intracerebral hemorrhage (ICH) have not fallen during recent years, as has been seen with ischemic stroke, and rates appear to be increasing in the elderly.

The analysis examined data from more than 10,000 individuals from the Framingham study. "This is the longest running population-based cohort with a follow-up period of 68 years, so gives us a unique opportunity to look at ICH trends in a large population over a long period of time," Lioutas said.

The paper was published online June 8 in JAMA Neurology.

There were 129 cases of a primary ICH incident in the study, with an incidence rate of 43 cases per 100,000 person-years. The unadjusted incidence rate increased over time, but the age-adjusted incidence rate showed a slight decrease since 1987.

An age-stratified analysis indicated a continued increase in ICH incidence among patients aged 75 years or older, reaching 176 cases per 100,000 person-years in the period 2000-2016.

In general, there has been a stabilization of ICH rates since the mid-80s. The rates have flattened out, but we have not seen a large decline in ICH in the past 30 years as has been seen for ischemic stroke. This leads us to ask whether we could be doing better with regard to ICH," Lioutas commented.

Hypertension Contributes to Both Deep and Lobar ICH

The incidence rate increased substantially with age for both the lobar and deep types of ICH.

These results suggest we need to be even more aggressive with blood pressure control. This is the one modifiable risk factor we can absolutely act upon and make a difference.

Many risk factors for ICH and ischemic stroke are similar, so, if ischemic stroke rates are falling, why are ICH rates not falling too? Maybe the answer is the rising use of statins and anticoagulants.

In the study, use of anticoagulant medications increased from 4.4% in period 2 (1987-1999) to 13.9% in period 3 (2000-2016).

In the study, patients with deep ICH had a 4-fold higher likelihood of using statin medications compared with matched individuals in the control group despite no significant differences in cardiovascular disease prevalence.

The beneficial effects of statins and anticoagulants in reducing ischemic events are well proven and their benefits definitely outweigh their risks when used in the right patient populations.

They also probably allow people to live longer so that they may then go on to experience an ICH, but perhaps we could make sure we select patients for these medications more carefully and think about dosage and each individual's risk of hemorrhagic complications.