Recurrent Intracerebral Hemorrhage: Associations with Comorbidities and Medicine with Antithrombotic Effects

Race, Ethnicity, and Gender Disparities in the Management and Outcomes of Critically Ill Adults with Acute Stroke

Racial, ethnicity and sex disparities are pervasive in the evaluation and acute care of ischemic stroke patients. Administration of intravenous thrombolysis and mechanical thrombectomy are the most critical steps in ischemic stroke treatment but compared to White patients, ischemic stroke patients from minority racial and ethnic groups are less likely to receive these potentially life-saving interventions. Sex and racial disparities in intracerebral hemorrhage or subarachnoid hemorrhage treatment have not been well studied.

Temporal and Spatial Clustering of Intracerebral Hemorrhage in Cerebral Amyloid Angiopathy

OBJECTIVES

Cerebral amyloid angiopathy (CAA)-associated lobar intracerebral hemorrhage (ICH) has a high risk of recurrence, but the underlying mechanisms remain uncertain. We, therefore, aimed to characterize patterns of recurrent ICH.

METHODS

We investigated early recurrent ICH (≥1 recurrent ICH event within 90 days of the index event) and ICH clusters (≥2 ICH events within 90 days at any time point) in 2 large cohorts of consecutive patients with first-ever ICH and available MRI.

RESULTS

In 682 included patients (median age 68 years, 40.3% female, median follow-up time 4.1 years), 18 (2.6%) had an early recurrent ICH, which was associated with higher age and CAA. In patients with probable CAA, the risk of early recurrent ICH was increased 5-fold within the first 3 months compared with during months 4-12 (hazard ratio 5.41, 95% CI 2.18-13.4) while no significant difference was observed in patients without CAA. In patients with an ICH cluster, we observed spatial clustering (recurrent ICH within close proximity of index ICH in 63.0%) and a tendency for multiple sequential hemorrhages (≥3 ICH foci within 3 months in 44.4%).

DISCUSSION

Our data provide evidence of both temporal and spatial clustering of ICH in CAA, suggesting a transient and localized active bleeding-prone process.

Statin use and long-term risk of recurrent intracerebral haemorrhage: the MUCH-Italy

BACKGROUND

Whether statin use after spontaneous intracerebral haemorrhage (ICH) increases the risk of recurrent ICH is uncertain.

METHODS

In the setting of the Multicentric Study on Cerebral Haemorrhage in Italy we followed up a cohort of 30-day ICH survivors, consecutively admitted from January 2002 to July 2014, to assess whether the use of statins after the acute event is associated with recurrent cerebral bleeding.

RESULTS

1623 patients (mean age, 73.9±10.3 years; males, 55.9%) qualified for the analysis. After a median follow-up of 40.5 months (25th to 75th percentile, 67.7) statin use was not associated with increased risk of recurrent ICH either in the whole study group (adjusted HR, 0.99; 95% CI 0.64 to 1.53) or in the subgroups defined by haematoma location (deep ICH, adjusted HR, 0.74; 95% CI 0.35 to 1.57; lobar ICH, adjusted HR, 1.09; 95% CI 0.62 to 1.90), intensity of statins (low-moderate intensity statins, adjusted HR, 0.93; 95% CI 0.58 to 1.49; high-intensity statins, adjusted HR, 1.48; 95% CI 0.66 to 3.31) and use of statins before the index event (adjusted HR, 0.66; 95% CI 0.38 to 1.17).

CONCLUSIONS

Statin use appears to be unrelated to the risk of ICH recurrence.

Effect of statin therapy patterns on readmission and mortality in patients with intracerebral hemorrhage

There is limited and inconsistent evidence for the association of statin therapy and statin treatment patterns with the risk of recurrent intracerebral hemorrhage (ICH) in patients with prior ICH. To assess the association of statin therapy and its intensity, type, initiation time, and discontinuation with the risk of recurrent ICH and mortality in Chinese patients with ICH. Patients with newly diagnosed ICH in the Beijing Employee Medical Claims Data database from 2010 to 2017 were included. Post-ICH statin users (post-diagnosis only) and nonusers (never), statin discontinuers (pre-diagnosis only) and continuers (pre- and post-diagnosis) were matched on a 1:1 propensity score, respectively. Adjusted Cox proportional risk models were used to estimate the risk ratios for ICH readmission and mortality under various statin patterns. A total of 2668 post-ICH statin users and 2668 nonusers without a history of statin use were enrolled. Post-ICH statin users had a lower risk of ICH readmission (HR, 0.57; 95% CI 0.48, 0.69) and all-cause death (0.56: 0.49, 0.63) than nonusers. Low/moderate-intensity treatment was associated with a 63% lower risk of recurrent ICH compared with nonusers (0.37: 0.29, 0.46), whereas high-intensity treatment did not reduce the risk (0.93: 0.74, 1.16). Both low/moderate-intensity (0.42: 0.36, 0.48) and high-intensity statins (0.57: 0.48, 0.69) were associated with a lower risk of all-cause mortality. The risk of ICH readmission was 53% (0.47: 0.30, 0.74) lower with adherence to rosuvastatin than with atorvastatin. Only starting medication within 30 days of the first diagnosis of ICH reduced the risk of ICH readmission (0.49: 0.40, 0.60). Among patients with a history of statin use, 1807 discontinuing and 1,807 continuing users of statins were included. The risk of ICH readmission (4.00: 3.32, 4.80) and the risk of all-cause death (4.01: 3.57, 4.50) were substantially increased in statin discontinuation compared with continued statin use. Statin therapy after ICH was associated with lower risks for ICH readmission and all-cause mortality compared with non-statin therapy, especially at low/moderate intensity and early initiation of statins after ICH. Adherence to rosuvastatin was associated with a lower risk of recurrence of ICH than atorvastatin. Among patients with a statin history prior to ICH, discontinuation of statins after ICH was associated with increased risk of ICH recurrence and death.

Association of Statin Use With Risk of Stroke Recurrence After Intracerebral Hemorrhage

BACKGROUND AND OBJECTIVES

Survivors of spontaneous intracerebral hemorrhage (ICH) may have indications for statin therapy. The effect of statins on the risk of subsequent hemorrhagic and ischemic stroke (IS) in this setting is uncertain. We sought to determine the risk of any stroke (ischemic stroke, IS or recurrent ICH), IS, and recurrent ICH associated with statin use among ICH survivors.

METHODS

Using the Danish Stroke Registry, we identified all patients admitted to a hospital in Denmark (population 5.8 million) with a first-ever ICH between January 2003 and December 2021 who were aged 50 years or older and survived >30 days. Patients were followed up until August 2022. Within this cohort, we conducted 3 nested case-control analyses for any stroke, IS, and recurrent ICH. We matched controls for age, sex, time since first-ever ICH, and history of prior IS. The primary exposure was statin use before or on the date of subsequent stroke or the equivalent date in matched controls. Using conditional logistic regression, we calculated adjusted odds ratios (aORs) and corresponding 95% confidence intervals (CIs) for any stroke, IS, and recurrent ICH associated with statin exposure.

RESULTS

We identified 1,959 patients with any stroke (women 45.3%; mean [SD] age, 72.6 [9.7] years) who were matched to 7,400 controls; 1,073 patients with IS (women 42.0%; mean [SD] age, 72.4 [10.0] years) who were matched to 4,035 controls and 984 patients with recurrent ICH (women 48.7%; mean [SD] age, 72.7 [9.2] years) who were matched to 3,755 controls. Statin exposure was associated with a lower risk of both any stroke (cases 38.6%, controls 41.1%; aOR 0.88; 95% CI 0.78-0.99) and IS (cases 39.8%, controls 41.8%, aOR 0.79; 95% CI 0.67-0.92), but was not associated with recurrent ICH risk (cases 39.1%, controls 40.8%, aOR 1.05; 95% CI 0.88-1.24).

DISCUSSION

Exposure to statins was not associated with an increased risk of recurrent ICH but was associated with a lower risk of any stroke, largely due to a lower risk of IS. Confirmation of these findings in randomized trials is needed.

CLASSIFICATION OF EVIDENCE

This study provides Class III evidence that statin use in patients with ICH is associated with a lower risk of any stroke and IS and not with increased risk of recurrent ICH.

Early Antiplatelet Resumption and the Risks of Major Bleeding After Intracerebral Hemorrhage

BACKGROUND

The appropriate timing of resuming antithrombotic therapy after intracerebral hemorrhage (ICH) remains unclear. The aim of this study was to compare the risks of major bleeding between early and late antiplatelet resumption in ICH survivors.

METHODS

Between 2008 and 2017, ICH patients were available in the National Health Insurance Research Database. Patients with a medication possession ratio of antiplatelet treatment ≥50% before ICH and after antiplatelet resumption were screened. We excluded patients with atrial fibrillation, heart failure, under anticoagulant or hemodialysis treatment, and developed cerebrovascular events or died before antiplatelet resumption. Finally, 1584 eligible patients were divided into EARLY (≤30 days) and LATE groups (31-365 days after the index ICH) based on the timing of antiplatelet resumption. Patients were followed until the occurrence of a clinical outcome, end of 1-year follow-up, death, or until December 31, 2018. The primary outcome was recurrent ICH. The secondary outcomes included all-cause mortality, major hemorrhagic events, major occlusive vascular events, and ischemic stroke. Cox proportional hazard model after matching was used for comparison between the 2 groups.

RESULTS

Both the EARLY and LATE groups had a similar risk of 1-year recurrent ICH (EARLY versus LATE: 3.12% versus 3.27%; adjusted hazard ratio [AHR], 0.967 [95% CI, 0.522-1.791]) after matching. Both groups also had a similar risk of each secondary outcome at 1-year follow-up. Subgroup analyses disclosed early antiplatelet resumption in the patients without prior cerebrovascular disease were associated with lower risks of all-cause mortality (AHR, 0.199 [95% CI, 0.054-0.739]) and major hemorrhagic events (AHR, 0.090 [95% CI, 0.010-0.797]), while early antiplatelet resumption in the patients with chronic kidney disease were associated with a lower risk of ischemic stroke (AHR, 0.065 [95% CI, 0.012-0.364]).

CONCLUSIONS

Early resumption of antiplatelet was as safe as delayed antiplatelet resumption in ICH patients. Besides, those without prior cerebrovascular disease or with chronic kidney disease may benefit more from early antiplatelet resumption.

Association of Long-term Statin Use With the Risk of Intracerebral Hemorrhage: A Danish Nationwide Case-Control Study

BACKGROUND AND OBJECTIVES

A causal relationship between long-term statin use and the risk of intracerebral hemorrhage (ICH) remains uncertain. We investigated the association with statin use before hospital admission for ICH in a Danish population-based, nationwide case-control study.

METHODS

We used the Danish Stroke Registry to identify all patients aged 45 years or older with a first-ever ICH between 2005 and 2018. Patients with ICH were matched for age, sex, and calendar year to controls selected from the general population. A medication registry with information on all dispensed prescriptions at community pharmacies in Denmark since 1995 was used to ascertain previous statin exposure that was classified for recency, duration, and intensity. Using conditional regression and adjusting for potential confounders, we calculated adjusted odds ratios (aORs) and corresponding 95% CIs for the risk of ICH.

RESULTS

The study population consisted of 16,235 patients with ICH and 640,943 controls. Current statin use (cases 25.9% vs controls 24.5%; aOR 0.74, 95% CI, 0.71-0.78) and a longer duration of current statin use (<1 year: aOR 0.86; 95% CI, 0.81-0.92; ≥1 to <5 years: aOR 0.72; 95% CI, 0.68-0.76; ≥5 to <10 years: aOR 0.65; 95% CI, 0.60-0.71; ≥10 years of use, 0.53; 95% CI 0.45-0.62; p for trend <0.001) were associated with a lower risk of ICH. Similar treatment duration relationships were found in analyses stratified by statin use intensity (high-intensity therapy: <1 year of use: aOR 0.78; 95% CI, 0.66-0.93; ≥10 years of use: aOR 0.46; 95% CI 0.33-0.65; p for trend 0.001).

DISCUSSION

We found that a longer duration of statin use was associated with a lower risk of ICH.

CLASSIFICATION OF EVIDENCE

This study provides Class II evidence that current statin use and a longer duration of statin use are each associated with a lower risk of ICH.

Cardiovascular Events After Intracerebral Hemorrhage

Cardiovascular events after primary intracerebral hemorrhage (ICH) have emerged as a leading cause of poor functional outcomes and mortality during the long-term recovery after an ICH. These events encompass arterial ischemic events such as ischemic stroke and myocardial infarction, arterial hemorrhagic events that include recurrent ICH, and venous thrombotic events such as venous thromboembolism. The purpose of this review is to summarize the cardiovascular complications after ICH, epidemiology and associated risk factors, and their impact on ICH outcomes. Additionally, we will highlight possible pathophysiological mechanisms to explain the short- and long-term increased risks of ischemic and hemorrhagic events after ICH. Finally, we will highlight potential secondary stroke and venous thrombotic prevention strategies often not considered after ICH, balanced against the risk of ICH recurrence.

CT-Visible Convexity Subarachnoid Hemorrhage Predicts Early Recurrence of Lobar Hemorrhage

Background and Purpose

Convexity subarachnoid hemorrhage (cSAH) may predict an increased recurrence risk in cerebral amyloid angiopathy (CAA)-related intracerebral hemorrhage (ICH) survivors. We aimed to investigate whether cSAH detected on CT was related to early recurrence in patients with ICH related to CAA.

Methods

We analyzed data from consecutive lobar ICH patients diagnosed as probable or possible CAA according to the Boston criteria using the method of cohort study. Demographic and clinical data, ICH recurrence at discharge and within 90 days were collected. The association between cSAH detected on CT and early recurrent ICH was analyzed using multivariable logistic regression.

Results

A total of 197 cases (74 [66–80] years) were included. cSAH was observed on the baseline CT of 91 patients (46.2%). A total of 5.1% (10/197) and 9.5% (17/179) of patients experienced ICH recurrence within 2 weeks and 90 days, respectively. The presence of cSAH was related to recurrence within 2 weeks (OR = 5.705, 95%CI 1.070–30.412, P = 0.041) after adjusting for hypertension, previous symptomatic ICH and anticoagulant use. The presence of cSAH was related to recurrence within 90 days (OR 5.473, 95%CI 1.425–21.028, P = 0.013) after adjusting for hypertension, previous symptomatic ICH and intraventricular hemorrhage. The similar results were obtained in other models using different methods to select adjusting variables.

Conclusion

In patients with lobar ICH related to CAA, 5.1% and 9.5% of them experienced ICH recurrence within 2 weeks and 90 days, respectively. CT-visible cSAH was detected in 46.2% of patients and indicates an increased risk for early recurrent ICH.

Validity of Simple Algorithms to Identify Recurrence of Intracerebral Hemorrhage in Two Danish Nationwide Registries

Purpose

Danish registries could be an attractive resource for studies of recurrent intracerebral hemorrhage (re-ICH). We developed and validated algorithms to identify re-ICH in the Danish Stroke Registry (DSR) and the Danish National Patient Registry (DNPR).

Patients and Methods

Using multiple sources, we followed-up an inception cohort with verified first-ever spontaneous ICH (n = 2528) for their first re-ICH in 2009-2018 (study period). We used verified cases of re-ICH (n = 124) as the gold standard to assess the performance of register-based algorithms for identifying re-ICH. For each cohort member, we traced events of re-ICH (ICD-10-code I61) in the study period according to DSR and DNPR, respectively. For each registry, we tested algorithms with a blanking period (BP) - ie, a period immediately following the index ICH during which outcome events were ignored - of varying length (7 days-360 days). The algorithm with the shortest BP that returned a positive predictive value (PPV) of ≥80% was considered optimal. We also calculated negative predictive value (NPV), sensitivity, and specificity of each algorithm and [95% confidence intervals] for all proportions.

Results

The optimal algorithm for DSR (BP 30 days) had a PPV of 89.5% [82.2-94.0], NPV 98.8% [98.2-99.1], sensitivity 75.8% [67.6-82.5], and specificity 99.5% [99.2-99.7]. The optimal algorithm for DNPR (BP 120 days) had a PPV of 80.6% [71.7-87.2], NPV 98.1% [97.5-98.6], sensitivity 63.7% [55.0-71.6], and specificity 99.2% [98.8-99.5].

Conclusion

Simple algorithms accurately identified re-ICH in DSR and DNPR. Compared with DNPR, DSR achieved higher PPV and sensitivity with a shorter BP. The proposed algorithms could facilitate valid use of DSR and DNPR for studies of re-ICH.

Safety considerations for prescribing SSRI antidepressants to patients at increased cardiovascular risk

INTRODUCTION

With the development of selective serotonin reuptake inhibitors (SSRI), a relatively uncomplicated treatment of depression and a safer alternative to tricyclic antidepressants was introduced. Any medical treatment has potential safety risks, however, and these risks should also be considered when prescribing SSRIs.

AREAS COVERED

The present review focuses on safety considerations when prescribing SSRIs to patients with previous stroke and myocardial infarction, as depression, and the need for antidepressant treatment, is common in these patients. At the same time, patients with stroke and myocardial infarction may be at increased risk of developing adverse events due to higher age, comorbidity, and co-medication. Specifically, the evidence of the risk of QT prolongation and bleeding versus thrombotic events will be discussed in the present review.

EXPERT OPINION

No medical treatment comes without risk and SSRIs are no exception. Depression, a common complication after vascular events, is a potentially life-threatening condition in itself and relevant and sufficient treatment is imperative. SSRIs are often the first medical treatment choice in the ambulatory setting, also in patients at increased cardiovascular risk. Relevant comorbidity and co-medication, however, should always be taken into account when initiating treatment and when choosing a specific SSRI.

Atherosclerotic event risk and risk reduction therapies among Ghanaian hemorrhagic stroke survivors

BACKGROUND

Intracerebral hemorrhage (ICH) stroke constitute up to 40% of incident strokes in Africa. While ICH patients are at high risk for atherosclerotic events, the risk-benefit of anti-atherosclerotic therapies in this patient population is uncertain.

PURPOSE

To assess whether utility of statins and/or antithrombotic agents after surviving an ICH correlates with atherosclerotic risk of an observational cohort.

METHODS

We analyzed data in a stroke registry prospectively collected on consecutively encountered stroke survivors seen at an out-patient clinic in Ghana between January 2018 and March 2020. We collected baseline demographic and clinical details, including diagnosis of ICH, co-morbidities, and key atherosclerotic risk reduction therapies (statins and anti-platelet drugs). We computed ischemic vascular risk using the Framingham Risk Score (FRS) to classify patients into low, intermediate and high vascular risk.

RESULTS

Of 1101 stroke survivors seen during the period, 244 (22.2%) had ICH. Vascular risk profiles were low (n = 86; 35.2%), intermediate (n = 71; 29.1%) and high (n = 87; 35.7%). Utility of statin use was 76.7% (low risk), 84.5% (intermediate risk), and 87.4% (high risk), p = 0.16 while antiplatelet use trended with atherosclerotic risk being 9.3% (low risk), 25.4% (intermediate risk), and high risk (34.5%), p = 0.0004. Independent factors associated with statin use were hypertension (OR 8.80; 95% CI: 2.34-33.11) and cigarette smoking (OR 0.29; 95% CI: 0.09-0.89) while antiplatelet drug use was associated with age (OR 1.43; 95% CI: 1.06-1.92) and time from index stroke (OR: 1.02; 95% CI: 1.01-1.02).

CONCLUSION

Approximately two-thirds of ICH survivors in this African sample had intermediate to high risk of future atherosclerotic events. Clinical trials on the timing, safety, and efficacy of statins and antiplatelet drugs among ICH survivors could help better guide risk mitigation in this population.

Risk Factors and Neurologic Outcomes in Patients with Traumatic Brain Injury and Coagulopathy Within 72 h After Surgery

OBJECTIVE

The purpose of this study was to explore the effect of coagulopathy in patients with traumatic brain injury (TBI) during the early postoperative period.

METHODS

The baseline characteristics, intraoperative management, and follow-up data of 462 patients with TBI between January 2015 and June 2019 were collected and retrospectively analyzed by multivariate logistic regression. Coagulopathy was defined as activated partial thromboplastin time > 40 s, international normalized ratio > 1.4, or platelet counts < 100×10⁹/L.

RESULTS

Multivariate logistic regression analysis revealed that the Glasgow Coma Scale (GCS) on admission, Injury Severity Score (ISS) on admission, pupil mydriasis, duration of surgery, intraoperative blood loss, and intraoperative crystalloid resuscitation were independent risk factors for patients who developed coagulopathy after surgery. There were statistical differences in mortality (p = 0.049), the Glasgow Outcome Scale-Extended (GCS-E; p = 0.024), and the modified Rankin Scale (p = 0.043) between the patients with and without coagulopathy 1 week after surgery. Coagulopathy within 72 h after surgery revealed the higher mortality at 1 week (66.7%), 3 months (71.4%), and 6 months (76.2%). Coagulopathy within 72 h after surgery in patients with a TBI predicted worse disease progression and unfavorable neurologic outcomes.

CONCLUSION

Taking practical and reasonable measures to manage these risk factors may protect patients with TBI from postoperative coagulopathy.

Effectiveness and Safety of Restarting Oral Anticoagulation in Patients with Atrial Fibrillation after an Intracranial Hemorrhage: Analysis of Medicare Part D Claims Data from 2010-2016

BACKGROUND

In patients with atrial fibrillation (AF) who survive an anticoagulant-related intracranial hemorrhage (ICH), the benefits of restarting oral anticoagulation (OAC) remain unclear.

OBJECTIVE

In this study, we sought to determine the effectiveness and safety associated with resumption of OAC in atrial fibrillation patients who survive an ICH.

METHODS

Using 2010-2016 Medicare claims data, we identified patients with non-valvular AF who experienced an OAC-related ICH and survived at least 6 weeks after the ICH (n = 1502). The primary outcomes included the composite of ischemic stroke and transient ischemic attack (TIA), thromboembolism (TE), a composite of ischemic stroke/TIA and TE, recurrent ICH, and all-cause mortality. We constructed Cox proportional hazard models to evaluate the association between post-ICH OAC resumption, which was measured in a time-dependent manner, and the risk of primary outcomes, while controlling for a comprehensive list of covariates.

RESULTS

Among patients who survived an ICH, 69% reinitiated OAC within 6 weeks of the event, and among those who resumed OAC, 83% restarted warfarin. There was no significant difference in the risk of ischemic stroke/TIA (hazard ratio [HR] 0.87, 95% confidence interval [CI] 0.62-1.21), TE (HR 0.85, 95% CI 0.55-1.32), and ischemic stroke/TIA/TE (HR 0.81, 95% CI 0.61-1.07) between post-ICH OAC use and non-use. Post-ICH OAC use was associated with a lower risk of recurrent ICH (HR 0.62, 95% CI 0.41-0.95) and all-cause mortality (HR 0.48, 95% CI 0.37-0.62) compared with non-OAC use.

CONCLUSIONS

In AF patients who survived an ICH, restarting OAC was not associated with a greater risk of recurrent ICH. Evidence from randomized controlled studies is needed to further clarify the clinical benefit of restarting OAC in this high-risk population. Further evaluation of which individuals benefit from restarting OAC is also needed to provide more clinical guidance.

Long-term prognosis after intracerebral haemorrhage

Introduction

The aim of this study was to determine the risk of recurrent intracerebral haemorrhage (ICH), ischaemic stroke, all stroke, any vascular event and all-cause mortality in 30-day survivors of ICH, according to age and sex.

Patients and methods

We linked national hospital discharge, population and cause of death registers to obtain a cohort of Dutch 30-day survivors of ICH from 1998 to 2010. We calculated cumulative incidences of recurrent ICH, ischaemic stroke, all stroke and composite vascular outcome, adjusted for competing risk of death and all-cause mortality. Additionally, we compared survival with the general population.

Results

We included 19,444 ICH-survivors (52% male; median age 72 years, interquartile range 61–79; 78,654 patient-years of follow-up). First-year cumulative incidence of recurrent ICH ranged from 1.5% (95% confidence interval 0.9–2.3; men 35–54 years) to 2.4% (2.0–2.9; women 75–94 years). Depending on age and sex, 10-year risk of recurrent ICH ranged from 3.7% (2.6–5.1; men 35–54 years) to 8.1% (6.9–9.4; women 55–74 years); ischaemic stroke 2.6% to 7.0%, of all stroke 9.9% to 26.2% and of any vascular event 15.0% to 40.4%. Ten-year mortality ranged from 16.7% (35–54 years) to 90.0% (75–94 years). Relative survival was lower in all age-groups of both sexes, ranging from 0.83 (0.80–0.87) in 35- to 54-year-old men to 0.28 (0.24–0.32) in 75- to 94-year-old women.

Discussion

ICH-survivors are at high risk of recurrent ICH, of ischaemic stroke and other vascular events, and have a sustained reduced survival rate compared to the general population.

Conclusion

The high risk of recurrent ICH, other vascular events and prolonged reduced survival-rates warrant clinical trials to determine optimal secondary prevention treatment after ICH.

Association of Selective Serotonin Reuptake Inhibitor Use After Intracerebral Hemorrhage With Hemorrhage Recurrence and Depression Severity

IMPORTANCE

Selective serotonin reuptake inhibitors (SSRIs) are widely used to treat poststroke depression but are associated with increased incidence of first-ever intracerebral hemorrhage (ICH) in the general population. The decision to treat ICH survivors with SSRIs must therefore balance potential risks of ICH recurrence with presumed benefits on depressive symptoms.

OBJECTIVE

To determine whether SSRI use among survivors of primary ICH was associated with ICH recurrence and decreased severity of depressive symptoms.

DESIGN, SETTING, AND PARTICIPANTS

Longitudinal ICH cohort study at a tertiary care center enrolling from January 2006 to December 2017, with follow-up for a median of 53.2 months (interquartile range, 42.3-61.2 months). The study included 1279 consenting individuals (1049 White, 89 Black, 77 Hispanic, and 64 other race/ethnicity) of 1335 eligible patients presenting with primary ICH and who were discharged alive from initial hospitalization for stroke.

MAIN OUTCOMES AND MEASURES

We conducted univariable and multivariable analyses for ICH recurrence risk and depression severity, including subset analyses for patients with 1 or more of the following characteristics associated with high ICH recurrence risk: (1) lobar ICH; (2) presence of the apolipoprotein ε2/ε4 gene variants; (3) prior history of ICH/TIA/ischemic stroke; and (4) Black or Hispanic race/ethnicity.

RESULTS

Mean age of study participants was 71.3 years, with 602 women (47%); of the 1279 participants, 1049 were White, 89 were Black, 77 were Hispanic, and 64 were other race/ethnicity. SSRI exposure was associated with both ICH recurrence (subhazard ratio [SHR], 1.31; 95% CI, 1.08-1.59) and resolution of post-ICH depression (SHR, 1.53; 95% CI, 1.12 2.09). Among those individuals at high risk for recurrent ICH, SSRIs were associated with further elevation in risk for ICH recurrence (SHR, 1.79; 95% CI, 1.22-2.64) compared with all other survivors of ICH (SHR, 1.20; 95% CI, 1.01-1.42; P = .008 for comparison of effect sizes). The association of SSRI with reduced depressive symptoms did not differ between high those at high risk for recurrent ICH and all other ICH survivors.

CONCLUSIONS AND RELEVANCE

Selective serotonin reuptake inhibitor exposure after ICH is associated with both improvement in depressive symptoms and increased risk of recurrent hemorrhagic stroke. Clinical history, neuroimaging data, and genetic biomarkers may help to identify survivors of ICH more likely to safely tolerate SSRI use.

Recurrent intracerebral hemorrhages due to central nervous system vasculitis: A neuropsychological case report

OBJECTIVE

Primary angiitis of the central nervous system (PACNS) is a rare and devastating form of vasculitis that destroys the vessels of the brain and spinal cord, resulting in progressive and debilitating neurologic symptoms. The objective of the present study was to detail the diagnostic process of a case of a patient with PACNS who suffered from six intracerebral hemorrhages (ICHs).

METHOD

The patient was an African American woman with a history of recurrent ICHs of unclear etiology who received serial neuropsychological evaluations over the course of a 5-year period. Two comprehensive neuropsychological evaluations are included, as well as an overview of her clinical course, including differential diagnostic considerations and treatment planning.

RESULTS

Neuropsychological assessment revealed marked deficits in visuospatial abilities and processing speed associated with her underlying neuropathology. Integrated review of her medical records indicated a probable diagnosis of PACNS as the likely etiology of her recurrent ICHs.

CONCLUSIONS

This study demonstrates the importance of differential diagnosis of low base-rate conditions, functional neuroanatomy and neurobehavioral phenomenology, serial assessment, and cognitive reserve in clinical neuropsychological practice.

Nationwide patterns of hemorrhagic stroke among patients hospitalized with brain metastases: influence of primary cancer diagnosis and anticoagulation

Brain metastases can contribute to a decreased quality of life for patients with cancer, often leading to malaise, neurologic dysfunction, or death. Intracerebral hemorrhage (ICH) is an especially feared complication in patients with brain metastases given the potential for significant morbidity and mortality. We aim to characterize patients with cancer and brain metastases admitted to hospitals nationwide and identify factors associated with ICH. The 2016 Healthcare Cost and Utilization Project Nationwide Inpatient Sample (HCUP-NIS) was queried for all patients with cancer hospitalized with a diagnosis of brain metastases. Admissions with a primary or secondary diagnosis of ICH were further identified. Baseline differences in demographic, clinical, socioeconomic, and hospital-related characteristics between patients with and without ICH were assessed by chi-square, Mann–Whitney U, and ANOVA testing. Multivariable logistic regression was used to identify factors associated with ICH. Weighted frequencies were used to create national estimates for all data analysis. In 2016, a total 145,225 hospitalizations were associated with brain metastases, of which 4,145 (2.85%) had a concurrent diagnosis of ICH. Patients with ICH were more likely to have a longer length of stay (median 5 days vs 4 days, p < 0.001) and a higher cost of stay (median $14,241.14 vs $10,472.54, p  < 0.001). ICH was found to be positively associated with having a diagnosis of melanoma (odds ratio [OR] 5.01; 95% Confidence Interval [CI] 3.50–7.61) and kidney cancer (OR 2.50; 95% CI 1.69–3.72). Patients on long-term anticoagulation had a higher risk of ICH (OR 1.49; CI 1.15–1.91). Approximately 3% of patients hospitalized with brain metastases also had a diagnosis of ICH, which was significantly associated with longer length of stay and cost. Patients with melanoma, kidney cancer, and on long-term anticoagulation had a higher risk of ICH. Physicians should consider the risks of anticoagulation carefully for patients with brain metastases, especially those with melanoma and kidney cancer.

Incidence and prognostic factors for recurrence of intracerebral hemorrhage in patients with and without atrial fibrillation: A cohort study

BACKGROUND

Intracerebral hemorrhage is a devastating vascular event. Clinical factors prognostic of recurrence facilitating individualized post-bleeding patient management are sparsely described. We aimed to describe incidence of recurrence of intracerebral hemorrhage and explore the prognostic value of 25 clinical characteristics in patients with and without atrial fibrillation.

METHODS

Cohort study of patients with incident intracerebral hemorrhage diagnosed from 2003 to 2016 identified using nationwide Danish administrative registries. Results reported as cumulative incidence of intracerebral recurrence accounting for competing risk of death. Univariate and multivariate prognostic factors for recurrence estimated using Cox regression (hazard ratios [HRs], 95% confidence intervals [CI]).

RESULTS

We identified 9255 patients with incident intracerebral hemorrhage (median age 73 years, 46.6% females, 16% with atrial fibrillation). Five-year risks of recurrence of intracerebral hemorrhage were approximately 10% in the study population, although slightly higher for patients without atrial fibrillation. Prognostic factors for recurrence were broadly similar for patients with and without atrial fibrillation. Age in categories <60 years (reference), age 60-70 years (HR 1.29, 95% CI 1.02-1.64), age 70-80 years (HR 1.59, 95% CI 1.26-2.00), age >80 years (HR 1.19, 95% CI 0.91-1.55), nursing home residency (HR 1.48, 95% CI 1.02-2.13), and Scandinavian Stroke Scale score ('mild' versus 'moderate' (HR 1.40, 95% CI 1.13-1.72) and 'severe' (HR 1.96, 95% CI 1.61-2.39)) were the strongest prognostic factors.

CONCLUSION

Risk of recurrence of intracerebral hemorrhage after five years was approximately 10%. Clinical characteristics associated with recurrence were few and broadly similar for patients with and without atrial fibrillation, with age and measure of incident bleeding severity, as reflected by Scandinavian Stroke Scale score, being the most important.

Chronic Kidney Disease and Clinical Outcomes in Patients with Intracerebral Hemorrhage

BACKGROUND AND PURPOSE

The influence of chronic kidney disease (CKD) on functional outcome in intracerebral hemorrhage (ICH) is scarcely investigated and reported findings are conflicting mostly because of nonaccounting for imbalances. Aim of the present study was to determine the impact of CKD on functional long-term outcome in ICH-patients.

METHODS

In this observational cohort study of spontaneous ICH-patients admitted to our Department of Neurology between 2006 and 2015 we investigated retrospectively as primary outcome the dichotomized functional status (modified-Rankin-Scale = 0-3-versus-4-6) at 12 months according to renal function (CKD versus non-CKD), including categorial estimates of the glomerular filtration rate subanalyses. Confounding was addressed by propensity-score(ps)-matching and adjusted multivariable regression analyses.

RESULTS

We identified 1076 eligible ICH-patients, of which 131 (12.2%) suffered from CKD on hospital admission. Confounders associated with CKD consisted of hypertension (P = .023), Diabetes mellitus (P = .001), prior ischemic stroke and/or transitory ischemic attack (TIA) (P = .021), congestive heart failure (P < .01), impaired liver function (P < .01), antiplatelet therapy (P = .01), poorer premorbid functional status (P < .01), and deep ICH-location (P = .006). After balancing for confounding, patients with CKD showed a significantly decreased rate of favorable functional outcome at 12 months (CKD:29 of 111(26.1%)-versus-non-CKD:78 of 206 (37.9%); P = .035). Subanalyses showed that stages of CKD were evenly associated with mortality at 12 months (GFR category G3a, OR:2.811; CI (1.130-6.994); P = .026; GFR category G3b, OR:1.874; CI (.694-5.058); P = .215; GFR category G4, OR:10.316; CI (1.976-53.856); P = .006; GFR category G5, OR:8.989; CI (1.900-42.518); P = .006).

CONCLUSIONS

As compared to ICH-patients without CKD, those with CKD show increased rates of mortality and worse functional outcomes even after statistical correction for imbalanced baseline characteritsics. This finding is presumably linked to comorbidity and warrants further investigation in prospective studies.

Statins and Risk of Intracerebral Hemorrhage in Individuals With a History of Stroke

Background and Purpose—

It has been suggested that statins increase the risk of intracerebral hemorrhage in individuals with a history of stroke, which has led to a precautionary principle of avoiding statins in patients with prior intracerebral hemorrhage. However, such prescribing reticence may be unfounded and potentially harmful when considering the well-established benefits of statins. This study is so far the largest to explore the statin-associated risk of intracerebral hemorrhage in individuals with prior stroke.

Methods—

We conducted a population-based, propensity score–matched cohort study using information from Danish national registers. We included all individuals initiating statin treatment after a first-time stroke diagnosis (intracerebral hemorrhage, N=2728 or ischemic stroke, N=52 964) during 2002 to 2016. For up to 10 years of follow-up, they were compared with a 1:5 propensity score–matched group of statin nonusers with the same type of first-time stroke. The difference between groups was measured by adjusted hazard ratios for intracerebral hemorrhage calculated by type of first-time stroke as a function of time since statin initiation.

Results—

Within the study period, 118 new intracerebral hemorrhages occurred among statin users with prior intracerebral hemorrhage and 319 new intracerebral hemorrhages in users with prior ischemic stroke. The risk of intracerebral hemorrhage was similar for statin users and nonusers when evaluated among those with prior intracerebral hemorrhage, and it was reduced by half in those with prior ischemic stroke. These findings were consistent over time since statin initiation and could not be explained by concomitant initiation of other medications, by dilution of treatment effect (due to changes in exposure status over time), or by healthy initiator bias.

Conclusions—

This large study found no evidence that statins increase the risk of intracerebral hemorrhage in individuals with prior stroke; perhaps the risk is even lower in the subgroup of individuals with prior ischemic stroke.

Net clinical benefit of anticoagulation for atrial fibrillation following intracerebral hemorrhage

Following an anticoagulation-associated intracerebral hemorrhage (ICH), whether and when to resume anticoagulation is controversial. Patient-level recurrence risk is difficult to predict with accuracy, but time-based recurrence risk may be more predictable. To better inform clinical decisions, we set out to estimate the net clinical benefit of anticoagulation over time among patients with atrial fibrillation. Using a large administrative dataset with 5339 index ICH hospitalizations and 132 readmissions for ICH, we created a two-stage prediction model, first predicting patient-level risk of recurrence and then predicting timing, conditional on recurrence. A log-normal survival function best explained the declining risk of recurrent ICH over time. We then compared risk of recurrent ICH over time against ischemic stroke risk, weighting the two outcomes to compute the net clinical benefit on each day following an index discharge. Using a bootstrapping approach, we identified the first day following discharge on which anticoagulation would lead to net benefit rather than net harm. Anticoagulation remains harmful for at least 11 days following index discharge and, depending on desired confidence level and assumptions, may remain harmful for as long as 62 days after discharge. Results were sensitive to the overall ICH recurrence risk. Although patient-level risk of recurrent ICH is difficult to predict accurately, recurrence risk declines rapidly over time. The survival function presented herein can inform decision-analytic models regarding when patients should resume anticoagulation following ICH.

Absence of Microbleeds Reduces the Risk for Recurrent Intracerebral Hemorrhage

BACKGROUND

Many known risk factors, including hypertension and hyperlipidemia cause intracerebral hemorrhage (ICH). Recently, microbleeds have been identified as one of the factors leading to ICH. While some patients have been found to have recurrent ICH, risk factors for recurrent ICH are scarcely reported. We conducted an observational study on the risk-factors of recurrent ICH, comparing stroke patients with a single hemorrhagic episode and those with recurrent ICH.

METHODS

A retrospective analysis of a single-center database was performed to analyze the clinical presentation and characteristics of patients with a single and recurrent ICH. From January 2016 to December 2017, a total of 317 patients were analyzed based on suspected factors including patients' sex, age, medical history, antiplatelet therapy use, and presence of microbleeds on images.

RESULTS

Of the 317 patients, 36 patients (11.4%) developed a second episode of cerebral hemorrhage. Brain magnetic resonance imaging (MRI) of the patients without microbleeds, predicted reduced risk of recurrence. This is the first report strongly associating the presence of microbleeds with the possibility of a recurrent ICH. Other factors under study did not show an apparent association with recurrent ICH probably because of the high statistical significance obtained with the presence of microbleeds.

CONCLUSION

Our findings revealed that the absence of microbleeds on images is a factor that strongly predicts a reduced risk for recurrent ICH and that the detection of microbleeds on MRI performed in patients with a single hemorrhagic episode, is useful in defining further therapeutic management. These findings may benefit physicians treating stroke patients.

Racial/ethnic disparities in the risk of intracerebral hemorrhage recurrence

OBJECTIVE

To estimate the risk of intracerebral hemorrhage (ICH) recurrence in a large, diverse, US-based population and to identify racial/ethnic and socioeconomic subgroups at higher risk.

METHODS

We performed a longitudinal analysis of prospectively collected claims data from all hospitalizations in nonfederal California hospitals between 2005 and 2011. We used validated diagnosis codes to identify nontraumatic ICH and our primary outcome of recurrent ICH. California residents who survived to discharge were included. We used log-rank tests for unadjusted analyses of survival across racial/ethnic groups and multivariable Cox proportional hazards regression to determine factors associated with risk of recurrence after adjusting for potential confounders.

RESULTS

We identified 31,355 California residents with first-recorded ICH who survived to discharge, of whom 15,548 (50%) were white, 6,174 (20%) were Hispanic, 4,205 (14%) were Asian, and 2,772 (9%) were black. There were 1,330 recurrences (4.1%) over a median follow-up of 2.9 years (interquartile range 3.8). The 1-year recurrence rate was 3.0% (95% confidence interval [CI] 2.8%-3.2%). In multivariable analysis, black participants (hazard ratio [HR] 1.22; 95% CI 1.01-1.48; p = 0.04) and Asian participants (HR 1.29; 95% CI 1.10-1.50; p = 0.001) had a higher risk of recurrence than white participants. Private insurance was associated with a significant reduction in risk compared to patients with Medicare (HR 0.60; 95% CI 0.50-0.73; p < 0.001), with consistent estimates across racial/ethnic groups.

CONCLUSIONS

Black and Asian patients had a higher risk of ICH recurrence than white patients, whereas private insurance was associated with reduced risk compared to those with Medicare. Further research is needed to determine the drivers of these disparities.

Does statin increase the risk of intracerebral hemorrhage in stroke survivors? A meta-analysis and trial sequential analysis

BACKGROUND

It remains debatable whether statin increases the risk of intracerebral hemorrhage (ICH) in poststroke patients.

METHODS

We systematically searched PubMed, EMBASE, and CENTRAL for randomized controlled trials. Trial sequential analysis (TSA) was conducted to assess the reliability and conclusiveness of the available evidence in the meta-analysis. To evaluate the overall effectiveness, the net composite endpoints were derived by totaling ischemic stroke, hemorrhagic stroke, transient ischemic attack (TIA), myocardial infarction, and cardiovascular mortality.

RESULTS

A total of 17 trials with 11,576 subjects with previous ischemic stroke, TIA, or ICH were included, in which statin therapy increased the risk of hemorrhagic stroke (risk ratio [RR], 1.42; 95% confidence interval [CI], 1.07-1.87), but reduced the risk of ischemic stroke (RR, 0.85; 95% CI, 0.75-0.95). For the net composite endpoints, statin therapy was associated with a 17% risk reduction (95% CI, 12-21%; number needed to treat = 6). With a control event rate 2% and RR increase 40%, the TSA suggested a conclusive signal of an increased risk of hemorrhagic stroke in stroke survivors taking statin. However, with the sensitivity analysis by changing assumptions, the conclusions about hemorrhagic stroke risk were less robust.

CONCLUSIONS

Statin therapy in poststroke patients increased the risk of hemorrhagic stroke but effectively reduced ischemic stroke risk. Weighing the benefits and potential harms, statin has an overall beneficial effect in patients with previous stroke or TIA. However, more studies are required to investigate the conclusiveness of the increased hemorrhagic stroke risk revealed in our study.

A Narrative Review of Cardiovascular Abnormalities After Spontaneous Intracerebral Hemorrhage

BACKGROUND

The recommended cardiac workup of patients with spontaneous intracerebral hemorrhage (ICH) includes an electrocardiogram (ECG) and cardiac troponin. However, abnormalities in other cardiovascular domains may occur. We reviewed the literature to examine the spectrum of observed cardiovascular abnormalities in patients with ICH.

METHODS

A narrative review of cardiovascular abnormalities in ECG, cardiac biomarkers, echocardiogram, and hemodynamic domains was conducted on patients with ICH.

RESULTS

We searched PubMed for articles using MeSH Terms "heart," "cardiac," hypertension," "hypotension," "blood pressure," "electro," "echocardio," "troponin," "beta natriuretic peptide," "adverse events," "arrhythmi," "donor," "ICH," "intracerebral hemorrhage." Using Covidence software, 670 articles were screened for title and abstracts, 482 articles for full-text review, and 310 extracted. A total of 161 articles met inclusion and exclusion criteria, and, included in the manuscript. Cardiovascular abnormalities reported after ICH include electrocardiographic abnormalities (56% to 81%) in form of prolonged QT interval (19% to 67%), and ST-T changes (19% to 41%), elevation in cardiac troponin (>0.04 ng/mL), and beta-natriuretic peptide (BNP) (>156.6 pg/mL, up to 78%), echocardiographic abnormalities in form of regional wall motion abnormalities (14%) and reduced ejection fraction. Location and volume of ICH affect the prevalence of cardiovascular abnormalities. Prolonged QT interval, elevated troponin-I, and BNP associated with increased in-hospital mortality after ICH. Blood pressure control after ICH aims to preserve cerebral perfusion pressure and maintain systolic blood pressure between 140 and 179 mm Hg, and avoid intensive blood pressure reduction (110 to 140 mm Hg). The recipients of ICH donor hearts especially those with reduced ejection fraction experience increased early mortality and graft rejection.

CONCLUSIONS

Various cardiovascular abnormalities are common after spontaneous ICH. The workup of patients with spontaneous ICH should involve 12-lead ECG, cardiac troponin-I, as well as BNP, and echocardiogram to evaluate for heart failure. Blood pressure control with preservation of cerebral perfusion pressure is a cornerstone of hemodynamic management after ICH. The perioperative implications of hemodynamic perturbations after ICH warrant urgent further examination.

The impact of selective serotonin reuptake inhibitors on the risk of intracranial haemorrhage: A systematic review and meta-analysis

Introduction

Observational studies have suggested increased risk of intracranial haemorrhage (ICrH) in patients receiving selective serotonin reuptake inhibitors (SSRIs). We sought to clarify the impact of SSRIs on ICrH, accounting for study methodology.

Patients and methods

A comprehensive search of Medline, Embase and the Cochrane Library from 1960 to December 2017 identified studies comparing SSRIs with control. The outcomes (first-ever and recurrent ICrH) were meta-analysed using a random effects model.

Results

Twenty-four observational studies and three randomised trials were available for meta-analysis, totalling 4,844,090 patient-years of follow-up. Those receiving SSRIs were more likely to be female (p = 0.01) and have depression (p < 0.001). Compared to controls, SSRI users had a significantly increased risk of ICrH (relative risk (RR) 1.26, 95%CI 1.11-1.42). Although SSRI use was associated with increased ICrH risk in those without previous ICrH (RR 1.31, 95%CI 1.15-1.48), this was not the case in those with previous ICrH (RR 0.95, 95%CI 0.83-1.09). Sensitivity analysis according to the bleeding definition reported demonstrated that although 'haemorrhagic stroke' was associated with SSRIs (RR 1.40, 95%CI 1.13-1.72), intracerebral haemorrhage was not (RR 1.11, 95%CI 0.86-1.42). Additional sensitivity analyses demonstrated a stronger association between SSRIs and ICrH in studies with a high (p < 0.001) compared to low risk of bias (p = 0.09) and with retrospective (p < 0.001) compared to prospective (p=0.31) study designs.

Discussion

Although SSRIs are associated with an increased risk of ICrH, the association is partly accounted for by important biases and other methodological limitations in the available observational data.

Conclusion

Our findings suggest there is insufficient high-quality data to advise restriction of SSRIs because of concern regarding ICrH risk.

Statins and the risk of intracerebral haemorrhage in patients with stroke: systematic review and meta-analysis

OBJECTIVE

Whether statins increase the risk of intracerebral haemorrhage (ICH) in patients with a previous stroke remains uncertain. This study addresses the evidence of statin therapy on ICH and other clinical outcomes in patients with previous ischaemic stroke (IS) or ICH.

METHODS

A systematic literature review and meta-analysis was performed in conformity with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines to assess observational and randomised studies comparing statin therapy with control (placebo or no treatment) in patients with a previous ICH or IS. The risk ratios (RR) for the primary outcome (ICH) and secondary outcomes (IS, any stroke, mortality and function) were pooled using random effects meta-analysis according to stroke subtype.

RESULTS

Forty-three studies with a combined total of 317 291 patient-years of follow-up were included. In patients with previous ICH, statins had no significant impact on the pooled RR for recurrent ICH (1.04, 95% CI 0.86 to 1.25; n=23 695); however, statins were associated with significant reductions in mortality (RR 0.49, 95% CI 0.36 to 0.67; n=89 976) and poor functional outcome (RR 0.71, 95% CI 0.67 to 0.75; n=9113). In patients with previous IS, statins were associated with a non-significant increase in ICH (RR 1.36, 95% CI 0.96 to 1.91; n=103 525), but significantly lower risks of recurrent IS (RR 0.74, 95% CI 0.66 to 0.83; n=53 162), any stroke (RR 0.82, 95% CI 0.67 to 0.99; n=55 260), mortality (RR 0.68, 95% CI 0.50 to 0.92; n=74 648) and poor functional outcome (RR 0.83, 95% CI 0.76 to 0.91; n=34 700).

CONCLUSIONS

Irrespective of stroke subtype, there were non-significant trends towards future ICH with statins. However, this risk was overshadowed by substantial and significant improvements in mortality and functional outcome among statin users.

TRIAL REGISTRATION NUMBER

CRD42017079863.

Overexpression of GRP75 inhibits inflammation in a rat model of intracerebral hemorrhage

Glucose‑regulated protein 75 (GRP75) is a member of the heat shock protein 70 family and previous studies have demonstrated that GRP75 is involved in diseases of the central nervous system. However, the biological function of GRP75 in intracerebral hemorrhage (ICH) remains to be clarified. Thus, the aim of the present study was to evaluate the effects of GRP75 in a rat model of ICH. Western blotting was used to detect the protein expression of GRP75, active caspase‑3, Bax, Bcl‑2, p‑Akt and Akt in brain tissues following ICH. The levels of tumor necrosis factor‑α (TNF‑α) and interleukin (IL)‑1β were evaluated using ELISA assay. Expression of GRP75 mRNA and protein was demonstrated to be reduced in the brain tissues of rats with ICH compared with sham‑operated rats. In addition, overexpression of GRP75 in brain tissues with ICH significantly inhibited the production of the inflammatory cytokines TNF‑α and IL-1β and increased Bcl‑2/decreased Bax levels compared with ICH alone. Furthermore, overexpression of GRP75 in brain tissues with ICH resulted in significantly increased phosphorylation of Akt compared with ICH alone. Therefore, the present study demonstrated, for the first time to the best of our knowledge, significantly reduced GRP75 expression in brain tissues following ICH, and that overexpression of GRP75 inhibits inflammation and potentially inhibits neuronal apoptosis in a rat model of ICH. GRP75 may, therefore, represent a promising target in the treatment of ICH.