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Long-Term Vascular Outcomes in Patients With Mixed Location Intracerebral Hemorrhage and Microbleeds
Hsin-Hsi Tsai1, Szu-Ju Chen2, Li-Kai Tsai1
1From the Department of Neurology (H.-H.T., S.-J.C., Y.-L.L.), National Taiwan University Hospital Bei-Hu Branch; Departments of Neurology (H.-H.T., S.-J.C., L.-K.T., S.-C.T., J.-S.J.) and Medical Imaging (Y.-F.C.) and Graduate Institute of Clinical Medicine (H.-H.T.), National Taiwan University College of Medicine and Hospital, Taipei; and U1172-LilNCog-Lille Neuroscience & Cognition (M.P.), CHU Lille, Inserm, Univ Lille, France. milikai@ntuh.gov.tw.
Objective:
To determine whether mixed location intracerebral hemorrhages/microbleeds (mixed ICH) is a risk factor for vascular unfavorable outcome compared to cerebral amyloid angiopathy-related ICH (CAA-ICH) or strictly deep hypertensive ICH/microbleeds (HTN-ICH).
Methods:
A total of 300 patients with spontaneous ICH were included. Clinical data, neuroimaging markers, and follow-up outcomes (recurrent ICH, ischemic stroke, and vascular death) were compared among mixed ICH (n = 148), CAA-ICH (n = 32), and HTN-ICH (n = 120). The association between follow-up events and neuroimaging markers was explored using multivariable Cox regression models.
Results:
Patients with mixed ICH were older (65.6 ± 12.1 years vs 58.1 ± 13.3 years, p < 0.001) than patients with HTN-ICH, but younger than patients with CAA-ICH (73.3 ± 13.8 years, p = 0.001). Compared to CAA-ICH, mixed ICH had similar incidence of vascular events (all p > 0.05). Compared to HTN-ICH, mixed ICH is associated with higher ICH recurrence (hazard ratio [HR] 3.0, 95% confidence interval [CI] 1.2-7.7), more ischemic stroke (HR 8.2, 95% CI 1.0-65.8), and vascular composite outcome (HR 3.5, 95% CI 1.5-8.2) after adjustment for age and sex. In patients with mixed ICH, the presence of cortical superficial siderosis (cSS) is associated the development of ICH recurrence (HR 4.8, 95% CI 1.0-23.2), ischemic stroke (HR 8.8, 95% CI 1.7-45.5), and vascular composite outcome (HR 6.2, 95% CI 1.9-20.2). The association between cSS and ischemic stroke (p = 0.01) or vascular composite outcome (p = 0.003) remained significant after further adjustment for other radiologic markers.
Conclusions:
Mixed ICH harbors higher risk of unfavorable vascular outcome than HTN-ICH. Presence of cSS in mixed ICH independently predicts vascular event, suggesting the contribution of detrimental effect due to coexisting CAA.
Insights
Mixed intracerebral hemorrhages (ICH) increase the risk of vascular events compared to hypertensive ICH. Cortical superficial siderosis in mixed ICH predicts recurrence, suggesting a role for coexisting cerebral amyloid angiopathy.
Area of Science:
- Neurology
- Vascular Neurology
- Neuroimaging
Background:
- Intracerebral hemorrhage (ICH) encompasses various etiologies, including hypertensive (HTN-ICH) and cerebral amyloid angiopathy-related (CAA-ICH).
- Mixed ICH, involving both deep and lobar locations, presents a distinct clinical profile.
- Understanding the prognostic implications of mixed ICH is crucial for patient management.
Purpose of the Study:
- To compare the risk of vascular unfavorable outcomes in patients with mixed ICH versus HTN-ICH and CAA-ICH.
- To investigate the association between neuroimaging markers and adverse vascular events in mixed ICH.
Main Methods:
- A cohort of 300 patients with spontaneous ICH was analyzed.
- Patients were categorized into mixed ICH (n=148), CAA-ICH (n=32), and HTN-ICH (n=120).
- Multivariable Cox regression models assessed the association between ICH type, neuroimaging markers (including cortical superficial siderosis - cSS), and follow-up vascular events (recurrent ICH, ischemic stroke, vascular death).
Main Results:
- Mixed ICH patients were older than HTN-ICH but younger than CAA-ICH patients.
- Compared to HTN-ICH, mixed ICH showed significantly higher rates of ICH recurrence (HR 3.0), ischemic stroke (HR 8.2), and composite vascular outcome (HR 3.5).
- In mixed ICH, the presence of cSS independently predicted ICH recurrence (HR 4.8), ischemic stroke (HR 8.8), and composite vascular outcome (HR 6.2), indicating a contribution from coexisting CAA.
Conclusions:
- Mixed ICH is associated with a higher risk of unfavorable vascular outcomes compared to HTN-ICH.
- Cortical superficial siderosis in mixed ICH serves as an independent predictor of vascular events, highlighting the impact of coexisting cerebral amyloid angiopathy.
