Objective To evaluate the influence of intracerebral haemorrhage (ICH) location on stroke outcomes.
Methods We included patients recruited to a UK hospital-based, multicentre observational study of adults with imaging confirmed spontaneous ICH. The outcomes of interest were occurrence of a cerebral ischaemic event (either stroke or transient ischaemic attack) or a further ICH following study entry. Haematoma location was classified as lobar or non-lobar.
Results All 1094 patients recruited to the CROMIS-2 (Clinical Relevance of Microbleeds in Stroke) ICH study were included (mean age 73.3 years; 57.4% male). There were 45 recurrent ICH events (absolute event rate (AER) 1.88 per 100 patient-years); 35 in patients presenting with lobar ICH (n=447, AER 3.77 per 100 patient-years); and 9 in patients presenting with non-lobar ICH (n=580, AER 0.69 per 100 patient-years). Multivariable Cox regression found that lobar ICH was associated with ICH recurrence (HR 8.96, 95% CI 3.36 to 23.87, p<0.0001); similar results were found in multivariable completing risk analyses. There were 70 cerebral ischaemic events (AER 2.93 per 100 patient-years); 29 in patients presenting with lobar ICH (AER 3.12 per 100 patient-years); and 39 in patients with non-lobar ICH (AER 2.97 per 100 patient-years). Multivariable Cox regression found no association with ICH location (HR 1.13, 95% CI 0.66 to 1.92, p=0.659). Similar results were seen in completing risk analyses.
Conclusions In ICH survivors, lobar ICH location was associated with a higher risk of recurrent ICH events than non-lobar ICH; ICH location did not influence risk of subsequent ischaemic events.
Trial registration number NCT02513316.
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Twitter @DrGargiBanerjee, @BleedingStroke, @UCLStrokeRes
Collaborators The CROMIS-2 collaborators: Louise Shaw, MD; Kirsty Harkness MD; Jane Sword, MD; Azlisham Mohd Nor, MD; Pankaj Sharma, PhD; Deborah Kelly, MD; Frances Harrington, MD; Marc Randall, MD; Matthew Smith, MD; Karim Mahawish, MD; Abduelbaset Elmarim, MD; Bernard Esisi, MD; Claire Cullen, MD; Arumug Nallasivam, MD; Christopher Price, MD; Adrian Barry, MD; Christine Roffe, MD: John Coyle, MD; Ahamad Hassan, MD; Caroline Lovelock, DPhil; Jonathan Birns, MD; David Cohen, MD; L Sekaran, MD; Adrian Parry-Jones, PhD; Anthea Parry, MD; David Hargroves, MD; Harald Proschel, MD; Prabel Datta, MD; Khaled Darawil, MD; Aravindakshan Manoj, MD; Mathew Burn, MD; Chris Patterson, MD; Elio Giallombardo, MD; Nigel Smyth, MD; Syed Mansoor, MD; Ijaz Anwar, MD; Rachel Marsh, MD; Sissi Ispoglou, MD; Dinesh Chadha, MD; Mathuri Prabhakaran, MD; Sanjeevikumar Meenakishundaram, MD; Janice O’Connell, MD; Jon Scott, MD; Vinodh Krishnamurthy, MD; Prasanna Aghoram, MD; Michael McCormick, MD; Paul O’Mahony, MD; Martin Cooper, MD; Lillian Choy, MD; Peter Wilkinson, MD; Simon Leach, MD; Sarah Caine, MD; Ilse Burger, MD; Gunaratam Gunathilagan, MD; Paul Guyler, MD; Hedley Emsley, MD; Michelle Davis, MD; Dulka Manawadu, MD; Kath Pasco, MD; Maam Mamun, MD; Robert Luder, MD; Mahmud Sajid, MD; Ijaz Anwar, MD; James Okwera, MD; Julie Staals, PhD; Elizabeth Warburton, MD; Kari Saastamoinen, MD; Timothy England, MD; Janet Putterill, MD; Enrico Flossman, MD; Michael Power, MD; Krishna Dani, MD; David Mangion, MD; Appu Suman, MD; John Corrigan, MD; Enas Lawrence, MD; and Djamil Vahidassr, MD.
Contributors GB contributed to the design of the project, analysed the data and drafted and revised the manuscript. DW had a major role in the acquisition of data and revised the manuscript for intellectual content. GA contributed to the statistical analysis and interpretation of the data and revised the manuscript for intellectual content. ICH, CS and HH had a major role in the acquisition of data and revised the manuscript for intellectual content. HC, TAY, RA-SS, GL, KM, MMB and HRJ were involved in the design and execution of the CROMIS-2 study (as members of the Study Steering Committee) and revised the manuscript for intellectual content. DJW designed and conceptualised the study, and revised the manuscript for intellectual content.
Funding The CROMIS-2 study is funded by the Stroke Association and British Heart Foundation. GB holds a National Institute for Health Research (NIHR) Academic Clinical Fellowship and received funding from the Rosetrees Trust. GA receives funding from the National Institute for Health Research University College London Hospitals (UCLH) Biomedical Research Centre. MMB’s Chair in Stroke Medicine is supported by the Reta Lila Weston Trust for Medical Research. DJW receives research support from the Stroke Association, the British Heart Foundation and the Rosetrees Trust. This work was undertaken at University College London Hospitals and Univeristy College London, which receives a proportion of funding from the Department of Health’s NIHR Biomedical Research Centres funding scheme.
Competing interests HC has received institutional research support from Bayer; honoraria for lectures and an Advisory Board from Bayer, diverted to a local charity; and travel/accommodation expenses for participation in scientific meetings covered by Bayer. GL acts as a consultant for Bayer/Janssen, BMS/Pfizer, Medtronic, Boehringer Ingelheim, Novartis, Verseon and Daiichi-Sankyo, and as a speaker for Bayer, BMS/Pfizer, Medtronic, Boehringer Ingelheim and Daiichi-Sankyo; no fees are directly received personally. DJW has received honoraria for consultancy and lectures from Bayer, Portola and Alnylam. The remaining authors report no disclosures or conflicts of interest relevant to the manuscript.
Patient consent for publication Not required.
Ethics approval The study was approved by the National Research Ethics Service (IRAS reference 10/H0716/61).
Provenance and peer review Not commissioned; externally peer reviewed.
Data availability statement Data are available on reasonable request. Analyses for the CROMIS-2 study are ongoing; once all of these analyses are completed, the CROMIS-2 Steering Committee will consider applications from other researchers for access to anonymised source data.
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