Distinctive mortality patterns and the survival paradox in intracerebral haemorrhage subtypes: a 15-year longitudinal...

We investigated long-term outcomes, survival trajectories and cause-specific mortality in intracerebral haemorrhage (ICH) subtypes stratified by aetiology, location and recurrence status.

This retrospective cohort study analysed 15,186 nontraumatic ICH patients enrolled in the multi-centre Stroke Registry of the Chang-Gung Healthcare System (SRICHS) in Taiwan (2007-2018). Registry data were linked to the Chang Gung Research Databank (clinical data, 2007-2018), the National Health Insurance Research Databank (longitudinal comorbidities, 2007-2022) and the Taiwan Death Registry (cause of death, 2007-2022). Patients were stratified into 4 subtypes: hypertensive (deep) ICH (first-ever = HICH-F and recurrent = HICH-R) and non-hypertensive including lobar ICH (first-ever = NHICH-F and recurrent = NHICH-R).

Hypertensive ICH patients had a higher burden of metabolic risk factors compared to NHICH. A distinct "survival paradox" was observed in the NHICH-F group: despite having the highest initial stroke severity and 30-day mortality (22.9%, lobar = 19.5%), survivors demonstrated the best long-term survival probability among all subtypes. Conversely, HICH-F patients had the highest rate of subsequent ICH recurrence (50.5%). Recurrent ICH groups (HICH-R/NHICH-R) had the highest overall mortality (~66%), driven significantly by pneumonia and diabetes. While stroke was the most common primary cause of death across all groups, cancer was the second most common primary cause in first-ever ICH, whereas infectious and metabolic causes drove mortality in recurrent cases.

Long-term ICH prognosis is highly heterogeneous. First-ever non-hypertensive ICH carries high acute lethality but favourable long-term survival for 30-day survivors. In contrast, hypertensive and recurrent subtypes face a continuous risk of vascular events and comorbidity-related mortality.