scholarly journals Prior intracerebral hemorrhage and white matter hyperintensity burden on recurrent stroke risk

2021 ◽  
Vol 11 (1) ◽  
Author(s):  
Jong-Ho Park ◽  
Sun U. Kwon ◽  
Hyuk Sung Kwon ◽  
Sung Hyuk Heo
Keyword(s):  
Ischemic Stroke ◽  
White Matter ◽  
Intracerebral Hemorrhage ◽  
Hemorrhagic Stroke ◽  
Small Vessel Disease ◽  
Recurrent Stroke ◽  
White Matter Hyperintensity ◽  
Major Adverse Cardiovascular Events ◽  
Stroke Incidence ◽  
Increased Risk

AbstractPrior intracerebral hemorrhage (ICH) is associated with increased risk of ischemic stroke. Since white matter hyperintensity (WMH) is associated with ischemic stroke and ICH, this study aimed to evaluate the relationship between ICH and the risk of recurrent stroke by WMH severity. From a prospective multicenter database comprising 1454 noncardioembolic stroke patients with cerebral small-vessel disease, patients were categorized by presence or absence of prior ICH and WMH severity: mild-moderate WMH (reference); advanced WMH; ICH with mild-moderate WMH; and ICH with advanced WMH. Among patients with ICH, the association with stroke outcomes by WMH burden was further assessed. The primary endpoint was ischemic stroke and hemorrhagic stroke. The secondary endpoint was major adverse cardiovascular events (MACE): stroke/coronary heart disease/vascular death. During the mean 1.9-year follow-up period, the ischemic stroke incidence rate per 100 person-years was 2.7, 4.0, 2.5, and 8.1 in increasing severity, and the rate of hemorrhagic stroke was 0.7, 1.3, 0.6, and 2.1, respectively. The risk of ischemic stroke was higher in ICH with advanced WMH (adjusted HR 2.62; 95% CI 1.22−5.60) than the reference group, while the risk of hemorrhagic stroke trended higher (3.75, 0.85–16.53). The risk of MACE showed a similar pattern in ICH with advanced WMH. Among ICH patients, compared with mild WMH, the risk of ischemic stroke trended to be higher in advanced WMH (HR 3.37; 95% CI 0.90‒12.61). Advanced WMH was independently associated with an increased risk of hemorrhagic stroke (HR 33.96; 95% CI 1.52−760.95). Given the fewer rate of hemorrhagic stroke, the risk of hemorrhagic stroke might not outweigh the benefits of antiplatelet therapy for secondary prevention.

Long-term stroke incidence in proximal thoracic aorta aneurysm survivors

2019 ◽  
Vol 15 (4) ◽  
pp. 421-428
Author(s):  
Jin-Yi Hsu ◽  
Yuan-Chih Su ◽  
Jen-Hung Wang ◽  
Boon Lead Tee
Keyword(s):  
Ischemic Stroke ◽  
Thoracic Aorta ◽  
Hemorrhagic Stroke ◽  
Study Cohort ◽  
Research Database ◽  
Term Care ◽  
Term Survival ◽  
Stroke Incidence ◽  
Increased Risk

Background Aneurysm of proximal thoracic aorta (pTAA) is an often indolent, yet fatal disease. Although advancements in aneurysmal repair techniques have increased long-term survival rates, studies have proven that there are increases in perioperative risk for stroke incidence after pTAA surgery. Conversely, there is little evidence regarding the long-term stroke incidence in pTAA individuals, which strongly influences the morbidity, mortality, and usage of antithrombotic agents. Methods Using the Taiwan National Health Insurance Research Database, a nationwide population-based cohort, we recruited 3013 pTAA survivors hospitalized from 1 January 2000 to 31 December 2012. To ensure study cohort quality, only patients aged 20 years and above who underwent aneurysmal repair surgery are included. The control cohort is identified by matching background features (comorbidities, age, gender) at a 1:4 ratio through the use of frequency matching. The primary outcomes include incidence of ischemic stroke and intracranial hemorrhage one month after aneurysmal repair surgery. Results The mortality of pTAA survivors is nearly twice of the matched controls despite aneurysmal repair (28.5 % vs. 15.2%, p < 0.001). Long-term follow-up of participants indicated that pTAA survivors had a higher risk for hemorrhage stroke (adjusted hazard ratio (aHR): 1.93; 95% confidence interval (CI): 1.47–2.53), but no significant increase in risk for ischemic stroke (aHR: 1.07; 95% CI: 0.92–1.25). Hemorrhagic stroke occurrence was found to be associated with age and diabetes mellitus. Comparison on hemorrhagic stroke subtypes between study and matched cohorts showed no statistical differences in intracerebral hemorrhage and subarachnoid hemorrhage. Conclusions Despite the advancement of aneurysmal repair surgery, this study suggests that pTAA patients may still face an increased risk of hemorrhage stroke. Further investigation is warranted to provide better long-term care for the pTAA population.

scholarly journals Elevated Pulse Pressure and Recurrent Hemorrhagic Stroke Risk in Stroke With Cerebral Microbleeds or Intracerebral Hemorrhage

2021 ◽  
Author(s):  
Jong‐Ho Park ◽  
Juneyoung Lee ◽  
Sun U. Kwon ◽  
Hyuk Sung Kwon ◽  
Min Hwan Lee ◽  
...  
Keyword(s):  
Blood Pressure ◽  
Ischemic Stroke ◽  
Intracerebral Hemorrhage ◽  
Cardiovascular Events ◽  
Operating Characteristic ◽  
Hemorrhagic Stroke ◽  
Stroke Risk ◽  
Characteristic Curve ◽  
Cerebral Microbleeds ◽  
Major Adverse Cardiovascular Events

Background Which type of recurrent stroke is associated with pulse pressure (PP) remains uncertain in ischemic stroke with cerebral microbleeds or intracerebral hemorrhage. Methods and Results The (PICASSO) Prevention of Cardiovascular Events in Ischemic Stroke Patients With High Risk of Cerebral Hemorrhage database involving 1454 subjects was analyzed. Subjects were stratified into quartiles according to the distribution of mean PP (mm Hg) during follow‐up (mean, 1.9 years): <47 (first quartile), 48 to 53 (second quartile), 54 to 59 (third quartile), and ≥60 mm Hg (fourth quartile). The primary end point was hemorrhagic stroke, and the secondary end points were ischemic stroke, stroke of any type, and major adverse cardiovascular events. Adjusted time‐dependent area under the receiver operating characteristic curve analysis was performed to assess the prediction accuracy of mean PP. The mean frequency of visit for blood pressure checkup was 9.4±5.5 times. The stroke incidence rate per 100 person‐years was 3.14, 2.24, 5.52, and 6.22, respectively in increasing quartile of mean PP, and the rate of major adverse cardiovascular events was 3.82, 2.84, 6.37, and 7.14, respectively. In the presence of mean arterial pressure, hemorrhagic stroke risk was higher in the highest quartile (adjusted hazard ratio, 6.03; 95% CI, 1.04–34.99) versus the lowest quartile, which was evident at higher mean systolic blood pressure. Higher mean PP as a continuous variable was also a predictor of hemorrhagic stroke (1.09, 1.03−1.15). The time‐dependent area under the receiver operating characteristic curve for hemorrhagic stroke was 0.79. Conclusions Long‐term elevated PP with higher systolic blood pressure confers a greater risk of subsequent hemorrhagic stroke among stroke patients with cerebral microbleeds or intracerebral hemorrhage. Registration URL: https://www.clinicaltrials.gov ; Unique identifier, NCT01013532.

Abstract WMP60: Association Between Liver Cirrhosis and Stroke in a Nationally Representative Cohort

Stroke ◽  
2017 ◽  
Vol 48 (suppl_1) ◽  
Author(s):  
Neal S Parikh ◽  
Babak B Navi ◽  
Yecheskel Schneider ◽  
Hooman Kamel
Keyword(s):  
Risk Factors ◽  
Liver Cirrhosis ◽  
Ischemic Stroke ◽  
Subarachnoid Hemorrhage ◽  
Intracerebral Hemorrhage ◽  
Cox Proportional Hazards ◽  
Medicare Beneficiaries ◽  
Stroke Incidence ◽  
Increased Risk ◽  
Thrombotic Complications

Introduction: Liver cirrhosis is characterized by a coagulopathy associated with both hemorrhagic and thrombotic complications. However, the risk of stroke - hemorrhagic and ischemic - in patients with cirrhosis has not been rigorously assessed. Methods: We performed a retrospective cohort study of Medicare beneficiaries ≥66 years of age using a 5% sample of inpatient and outpatient claims from 2008-2014. Our predictor was liver cirrhosis, defined by presence of at least two ICD-9-CM inpatient or outpatient claims for liver cirrhosis or its complications, a validated algorithm previously used to study cirrhosis in Medicare beneficiaries. The primary outcome was stroke, and the secondary outcomes were ischemic stroke, intracerebral hemorrhage, and subarachnoid hemorrhage. Outcomes were defined by validated ICD-9-CM algorithms. Patients were censored at the time of an outcome, death, or on December 31, 2014. We used survival analysis to compare stroke incidence in patients with and without liver cirrhosis. Cox proportional hazards analysis was used to evaluate the association between cirrhosis and stroke while adjusting for demographics and established stroke risk factors. Results: Among the 1,564,277 beneficiaries in our sample, we identified 10,512 (0.7%) patients with liver cirrhosis. The mean age of patients with cirrhosis was 74.1 (±6.5) years. Over a median follow-up of 5 years, 76,195 patients were hospitalized with a stroke. The incidence of stroke was 1.9% (95% confidence interval [CI], 1.7-2.1%) per year in patients with cirrhosis and 1.1% (95% CI, 1.1-1.1%) per year in patients without cirrhosis. After adjusting for demographics and vascular risk factors, patients with cirrhosis experienced a higher risk of stroke (hazard ratio [HR], 1.4; 95% CI, 1.2-1.5); however, associations appeared more robust for intracerebral hemorrhage (HR, 2.2; 95% CI, 1.7-2.8) and subarachnoid hemorrhage (HR, 2.0; 95% CI, 1.2-3.1) than for ischemic stroke (HR, 1.3; 95% CI, 1.1-1.4). Conclusions: We found that liver cirrhosis was associated with an increased risk of stroke, particularly hemorrhagic stroke. Our results build on recent work investigating the hemorrhagic and thrombotic complications of liver cirrhosis outside of the portal circulation.

Abstract 3726: Rate of Inappropriate Statin Use after Intracerebral Hemorrhage

Stroke ◽  
2012 ◽  
Vol 43 (suppl_1) ◽  
Author(s):  
Daniel Woo ◽  
Mary Comeau ◽  
Matthew L Flaherty ◽  
Mark Brown ◽  
Mary Haverbusch ◽  
...  
Keyword(s):  
Ischemic Stroke ◽  
Coronary Artery ◽  
Intracerebral Hemorrhage ◽  
Hemorrhagic Stroke ◽  
Artery Bypass ◽  
Stroke Care ◽  
Community Hospitals ◽  
Increased Risk ◽  
Time Of Admission ◽  
Statin Use

Background: Statin use has been associated with an increased risk of intracerebral hemorrhage (ICH) and an increased risk of recurrent ICH. Statin use after ICH would be justified for indications where the benefits outweigh the risks of complications per randomized trial evidence. We evaluated the use of statins after ICH in both academic and community hospitals in a population-based study. Methods: The Genetic and Environmental Risk Factors for Hemorrhagic Stroke Study (NS36695) prospectively identifies hemorrhagic strokes in the Greater Cincinnati/Northern Kentucky region. Chart abstraction was performed by nurses and case verification performed by physician review. Discharge medications were obtained and classified by type of medication including statin use. For this analysis, acceptable indications for statin use at discharge included history of coronary artery disease, myocardial infarction, angina, coronary artery bypass and prior ischemic stroke. Academic center was defined as having a neurosurgical or neurology residency program. Results: During the period 7/08 to 12/09, 403 cases of ICH were enrolled of which 110 died during the hospitalization and 36 were discharged to hospice. Of the remaining 257 cases, 75 (29%) were on statins at the time of admission of which 12 had their statins stopped prior to discharge. Of the remaining 63 patients, 33 (52%) were discharged on statins without a proper indication. Of 182 ICH patients not on statins at the time of admission, 13 were discharged on statins, of whom 6 (46%) had no compelling indication for a statin. A total of 39 (15%) surviving ICH patients were discharged on statins without a clear indication. No difference in discharge on statins was observed for academic vs. community hospitals. Conclusions: While statin use is appropriate after ischemic stroke, there is no evidence that use in ICH prevents recurrence or improves outcomes and evidence suggests that statin use increases the risk of ICH. We found that roughly 1 in 6 ICH patients were discharged on a statin without a justifiable indication given the associated risks. Education of medical providers regarding statins and hemorrhagic stroke may improve stroke care following ICH.

scholarly journals White Matter Hyperintensity, Immediate Antihypertensive Treatment, and Functional Outcome After Acute Ischemic Stroke

Stroke ◽  
2020 ◽  
Vol 51 (5) ◽  
pp. 1608-1612
Author(s):  
Shiguang Zhu ◽  
Sifan Qian ◽  
Tan Xu ◽  
Hao Peng ◽  
Ruiguo Dong ◽  
...  
Keyword(s):  
Ischemic Stroke ◽  
White Matter ◽  
Acute Ischemic Stroke ◽  
Functional Outcome ◽  
Hospital Discharge ◽  
Scale Score ◽  
Antihypertensive Treatment ◽  
White Matter Hyperintensity ◽  
Risk Of Death ◽  
Increased Risk

Background and Purpose— It remains unknown that whether white matter hyperintensity (WMH) severity influences the effect of antihypertensive treatment in acute ischemic stroke. We aimed to investigate the effects of early antihypertensive treatment on death and disability among patients with acute ischemic stroke according to WMH severities. Methods— This study was a secondary analysis of the data from CATIS (China Antihypertensive Trial in Acute Ischemic Stroke). Severity of WMH was evaluated using Fazekas rating scale score among 303 participants with available magnetic resonance imaging data and was categorized into none-mild WMH (Fazekas score 0–2) and moderate-severe WMH (Fazekas score 3–6). Functional outcome was death or major disability (modified Rankin Scale score of ≥3) at 14 days or hospital discharge and within 3 months. Results— WMH severity was significantly associated with an increased risk of death or major disability. Each 1 score increase in Fazekas score was associated with an adjusted odds ratio (95% CI) of 1.25 (1.03–1.51) for 14 days or hospital discharge and 1.39 (1.12–1.72) for 3-month functional outcome. There were no significant interactions between antihypertensive treatment and WMH severity (both P >0.1) on functional outcome at 14 days or hospital discharge and within 3 months. The neutral effects of immediate antihypertensive treatment were observed both in patients with moderate-severe WMH and none-mild WMH. Conclusions— Participants with higher WMH burden had increased risk of death or major disability after acute ischemic stroke. Early antihypertensive treatment had a neutral effect on clinical outcomes among acute ischemic stroke patients with a variety of WMH severities. Registration— URL: https://www.clinicaltrials.gov ; Unique identifier: NCT01840072.

scholarly journals Blood Pressure Level and Variability During Long-Term Prasugrel or Clopidogrel Medication After Stroke

Stroke ◽  
2021 ◽  
Vol 52 (4) ◽  
pp. 1234-1243
Author(s):  
Kazunori Toyoda ◽  
Hiroshi Yamagami ◽  
Kazuo Kitagawa ◽  
Takanari Kitazono ◽  
Takehiko Nagao ◽  
...  
Keyword(s):  
Blood Pressure ◽  
Ischemic Stroke ◽  
Hemorrhagic Stroke ◽  
Recurrent Stroke ◽  
Hazard Ratio ◽  
Observational Period ◽  
Bleeding Events ◽  
Increased Risk ◽  
Ischemic Events

Background and Purpose: High blood pressure increases bleeding risk during treatment with antithrombotic medication. The association between blood pressure levels and the risk of recurrent stroke during long-term secondary stroke prevention with thienopyridines (particularly prasugrel) has not been well studied. Methods: This was a post hoc analysis of the randomized, double-blind, multicenter PRASTRO-I trial (Comparison of Prasugrel and Clopidogrel in Japanese Patients With Ischemic Stroke-I). Patients with noncardioembolic stroke were randomly assigned (1:1) to receive prasugrel 3.75 mg/day or clopidogrel 75 mg/day for 96 to 104 weeks. Risks of any ischemic or hemorrhagic stroke, combined ischemic events, and combined bleeding events were determined based on the mean level and visit-to-visit variability, including successive variation, of systolic blood pressure (SBP) throughout the observational period. These risks were also compared between quartiles of mean SBP level and successive variation of SBP. Results: A total of 3747 patients (age 62.1±8.5 years, 797 women), with a median average SBP level during the observational period of 132.5 mm Hg, were studied. All the risks of any stroke (146 events; hazard ratio, 1.318 [95% CI, 1.094–1.583] per 10-mm Hg increase), ischemic stroke (133 events, 1.219 [1.010–1.466]), hemorrhagic stroke (13 events, 3.247 [1.660–6.296]), ischemic events (142 events, 1.219 [1.020–1.466]), and bleeding events (47 events, 1.629 [1.172–2.261]) correlated with increasing mean SBP overall. Similarly, an increased risk of these events correlated with increasing successive variation of SBP (hazard ratio, 3.078 [95% CI, 2.220–4.225] per 10-mm Hg increase; 3.051 [2.179–4.262]; 3.276 [1.172–9.092]; 2.865 [2.042–4.011]; 2.764 [1.524–5.016], respectively). Event rates did not differ between the clopidogrel and prasugrel groups within each quartile of SBP or successive variation of SBP. Conclusions: Both high mean SBP level and high visit-to-visit variability in SBP were significantly associated with the risk of recurrent stroke during long-term medication with either prasugrel or clopidogrel after stroke. Control of hypertension would be important regardless of the type of antiplatelet drugs. Registration: URL: https://www.clinicaltrials.jp ; Unique identifier: JapicCTI-111582.

scholarly journals Non-vitamin K oral anticoagulants (NOACs) in patients with stroke and atrial fibrillation

2020 ◽  
Vol 70 (5) ◽  
pp. 269-283
Author(s):  
Dejana Jovanović
Keyword(s):  
Atrial Fibrillation ◽  
Ischemic Stroke ◽  
Intracerebral Hemorrhage ◽  
Vitamin K ◽  
Hemorrhagic Stroke ◽  
Small Vessel Disease ◽  
Oral Anticoagulants ◽  
Stroke Recurrence ◽  
Ischemic Attack

Patients with atrial fibrillation who had a previous transient ischemic attack or ischemic stroke had a significantly high risk of stroke recurrence and the introduction of oral anticoagulants should be mandatory. However, the long-term use of oral anticoagulants increases the risk of developing all types of intracranial hemorrhages. The advantages of non-vitamin K oral anticoagulants (NOACs) compared to warfarin are that they have a significantly lower risk for hemorrhagic stroke. They are preferred in elderly patients, those with small vessel disease, or those with previous intracerebral hemorrhage. The time of NOACs introduction after an ischemic stroke depends on its severity and the rule "1-3-6-12" days should be applied. The reintroduction of NOACs in patients with atrial fibrillation and previous intracerebral hemorrhage depends on its etiology and should be after about 4-8 weeks if the cardioembolic risk is high and the risk for intracranial hemorrhage small.

White matter hyperintensity load on stroke recurrence and mortality at 1 year after ischemic stroke

Neurology ◽  
2019 ◽  
Vol 93 (6) ◽  
pp. e578-e589 ◽  
Author(s):  
Wi-Sun Ryu ◽  
Dawid Schellingerhout ◽  
Keun-Sik Hong ◽  
Sang-Wuk Jeong ◽  
Min Uk Jang ◽  
...  
Keyword(s):  
Ischemic Stroke ◽  
White Matter ◽  
Proportional Hazards Model ◽  
Recurrent Stroke ◽  
Absolute Risk ◽  
Cox Proportional Hazards ◽  
Cox Proportional Hazards Model ◽  
White Matter Hyperintensity ◽  
Stroke Recurrence ◽  
The Absolute

ObjectiveTo define the role and risks associated with white matter hyperintensity (WMH) load in a stroke population with respect to recurrent stroke and mortality after ischemic stroke.MethodsA total of 7,101 patients at a network of university hospitals presenting with ischemic strokes were followed up for 1 year. Multivariable Cox proportional hazards model and competing risk analysis were used to examine the independent association between quartiles of WMH load and stroke recurrence and mortality at 1 year.ResultsOverall recurrent stroke risk at 1 year was 6.7%/y, divided between 5.6%/y for recurrent ischemic and 0.5%/y for recurrent hemorrhagic strokes. There was a stronger association between WMH volume and recurrent hemorrhagic stroke by quartile (hazard ratio [HR] 7.32, 14.12, and 33.52, respectively) than for ischemic recurrence (HR 1.03, 1.37, and 1.61, respectively), but the absolute incidence of ischemic recurrence by quartile was higher (3.8%/y, 4.5%/y, 6.3%/y, and 8.2%/y by quartiles) vs hemorrhagic recurrence (0.1%/y, 0.4%/y, 0.6%/y, and 1.3%/y). All-cause mortality (10.5%) showed a marked association with WMH volume (HR 1.06, 1.46, and 1.60), but this was attributable to nonvascular rather than vascular causes.ConclusionsThere is an association between WMH volume load and stroke recurrence, and this association is stronger for hemorrhagic than for ischemic stroke, although the absolute risk of ischemic recurrence remains higher. These data should be helpful to practitioners seeking to find the optimal preventive/treatment regimen for poststroke patients and to individualize risk-benefit ratios.

Abstract WMP104: Associations Between Lobar Microbleed and PiB Negative Intracerebral Hemorrhage.

Stroke ◽  
2017 ◽  
Vol 48 (suppl_1) ◽  
Author(s):  
Hsin-Hsi Tsai ◽  
Li-Kai Tsai ◽  
Ya-Fang Chen ◽  
Sung-Chun Tang ◽  
Ruoh-Fang Yen ◽  
...  
Keyword(s):  
White Matter ◽  
Intracerebral Hemorrhage ◽  
Small Vessel Disease ◽  
Standardized Uptake Value ◽  
Amyloid Deposition ◽  
White Matter Hyperintensity ◽  
Amyloid Angiopathy ◽  
Potential Marker ◽  
Positron Emission ◽  
Magnetic Resonance Imaging Mri

Background and Purpose: Cerebral microbleed (CMB) in the lobar region is regarded as an image marker for cerebral amyloid angiopathy (CAA), but it is sometimes encountered in patients with intracerebral hemorrhage (ICH) owing to hypertension or other small vessel disease (SVD). Recently, enlarged perivascular space (EPVS) in white matter and deep region was suggested to be another potential marker for SVD. Knowledge of CMB location and EPVS in patients with ICH in relation to amyloid deposition might help us understand its heterogeneous pathophysiology. Methods: Fifty-seven primary, spontaneous ICH patients underwent magnetic resonance imaging (MRI) with susceptibility-weighted imaging (SWI) to analyze the CMB, the EPVS in basal ganglia (BG) and centrum semiovale (CSO), and the overall white matter hyperintensity (WMH). 11 C-Pittsburgh Compound B (PiB) positron emission tomography was also performed to measure the global amyloid deposition and was quantified as standardized uptake value ratio (SUVR) using cerebellum as the reference. Results: Twenty-six patients with lobar ICH and 31 patients with deep ICH were included. Positive PiB scan (SUVR >1.13) was found in 37% of patients (11 lobar ICH, 10 deep ICH). Presence of lobar CMB was found in 65% of patients irrespective of PiB scan status (p=0.084), but PiB (+) had higher number of lobar CMB (14.6 ± 16.9 vs. 5.4± 10.1, p=0.014) compared with PiB (-) patients. In PiB (-) patients, the number of lobar CMB is positively correlated with the number of deep CMB (p<0.001, r=0.773). The presence of lobar CMB in PiB (-) patients is also associated with severe EPVS in BG (70% vs. 31%, p=0.042), but not in CSO (p=0.073). Conclusions: Lobar CMB can be found in more than half of ICH patients irrespective of PiB scan status, but higher number of lobar CMB is seen in PiB (+) ICH patients. In PiB (-) patients, the presence of lobar CMB is associated with higher deep CMB number and EPVS in BG, suggesting the contribution of hypertensive angiopathy instead of amyloid angiopathy.

scholarly journals Differences in risk factors for 3 types of stroke

Neurology ◽  
2018 ◽  
Vol 90 (4) ◽  
pp. e298-e306 ◽  
Author(s):  
Alison J. Price ◽  
F. Lucy Wright ◽  
Jane Green ◽  
Angela Balkwill ◽  
Sau Wan Kan ◽  
...  
Keyword(s):  
Risk Factors ◽  
Ischemic Stroke ◽  
Subarachnoid Hemorrhage ◽  
Intracerebral Hemorrhage ◽  
Cox Regression ◽  
Related Factors ◽  
Stroke Incidence ◽  
Relative Risks ◽  
Increased Risk ◽  
Meta Analyses

ObjectiveTo compare associations of behavioral and related factors for incident subarachnoid hemorrhage and intracerebral hemorrhage and ischemic stroke.MethodsA total of 712,433 Million Women Study participants without prior stroke, heart disease, or cancer reported behavioral and related factors at baseline (1999–2007) and were followed up by record linkage to national hospital admission and death databases. Cox regression yielded adjusted relative risks (RRs) by type of stroke. Heterogeneity was assessed with χ2 tests. When appropriate, meta-analyses were done of published prospective studies.ResultsAfter 12.9 (SD 2.6) years of follow-up, 8,128 women had an incident ischemic stroke, 2,032 had intracerebral hemorrhage, and 1,536 had subarachnoid hemorrhage. In women with diabetes mellitus, the risk of ischemic stroke was substantially increased (RR 2.01, 95% confidence interval [CI] 1.84–2.20), risk of intracerebral hemorrhage was increased slightly (RR 1.31, 95% CI 1.04–1.65), but risk of subarachnoid hemorrhage was reduced (RR 0.43, 95% CI 0.26–0.69) (heterogeneity by stroke type, p < 0.0001). Stroke incidence was greater in women who rated their health as poor/fair compared to those who rated their health as excellent/good (RR 1.36, 95% CI 1.30–1.42). Among 565,850 women who rated their heath as excellent/good, current smokers were at an increased risk of all 3 stroke types, (although greater for subarachnoid hemorrhage [≥15 cigarettes/d vs never smoker, RR 4.75, 95% CI 4.12–5.47] than for intracerebral hemorrhage [RR 2.30, 95% CI 1.94–2.72] or ischemic stroke [RR 2.50, 95% CI 2.29–2.72]; heterogeneity p < 0.0001). Obesity was associated with an increased risk of ischemic stroke and a decreased risk of hemorrhagic stroke (heterogeneity p < 0.0001). Meta-analyses confirmed the associations and the heterogeneity across the 3 types of stroke.ConclusionClassic risk factors for stroke have considerably different effects on the 3 main pathologic types of stroke.

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