Outcomes from intracerebral hemorrhage among patients pre-treated with statins

Statins on Spontaneous Intracerebral Hemorrhage: A Meta-Analysis

Objective

In order to explore whether the application of statins can improve the prognosis of patients with intracerebral hemorrhage.

Methods

Studies of patients with intracerebral hemorrhage taking statins published in English until December 2021 were searched based on limited search terms, the retrieved literature was screened out based on inclusion and exclusion criteria, and the quality assessment and data extraction were carried out independently by two investigators. The extracted clinical data were then meta-analyzed.

Results

A total of 17 literatures were included in this study, with a sample size of 16,988 cases, including 3,001 cases in the statin group and 13,487 cases in the control group. MRS score of mortality was used as the prognostic index to evaluate cerebral hemorrhage. According to the Newcastle-Ottawa Scale (NOS), the score of literature quality evaluation scale was 6-8, indicating good literature quality. Meta-analysis of clinical data extracted from the literature showed that the statin group reduced overall mortality after intracerebral hemorrhage compared with the nonstatin group (P < 0.01). In terms of improving functional prognosis, the statin group improved functional prognosis 90 days after intracerebral hemorrhage (P=0.01). There was no significant difference between the statin and nonstatin groups in reducing the number of intracerebral hematomas.

Conclusions

Statins can reduce the total mortality after ICH and improve the survival rate (90 d), without increasing the amount of hematoma.

Association of Statins With Functional Outcome and 30-Day Mortality in Patients With Intracerebral Hemorrhage

Aim

The effect of statins is well established in cardiac and cerebrovascular diseases. However, its impact on intracerebral hemorrhage (ICH) is unclear. We aim to identify an association of pre-ICH statin treatment and statin use during admission for ICH with functional outcome at discharge and 30-day mortality.

Material and methods

A retrospective cohort study was held in patients with ICH admitted to our stroke unit over a year period. Demographic characteristics, risk factors and cardiovascular diseases, Glasgow Coma Scale (GCS), National Institutes of Health Stroke Score (NIHSS), systolic blood pressure (SBP) at admission, cholesterol levels and radiologic findings were analyzed to explore the association between pre-ICH and inpatient statin use with outcomes. The primary endpoint was functional outcome defined as modified Rankin Score (mRS) at discharge and 30-day mortality. We performed a univariate analysis and the variables with statistical significance were included in a multivariate analysis to control for confounding covariates.

Results

The study included 78 patients, 33 (42.31%) had previous statin intake history, of which 13 (39.39%) maintained statin intake during hospitalization. Regarding functional outcome we did not report a statistically significant difference between groups. In the “pre-ICH statin use” group a decreased 30-day mortality (6.06%, p = 0.009) was observed. In this group it was also noted higher antiplatelet medication use (33.33%, p = 0.006), higher GCS at admission (13-15: 84.38%, p = 0.018) and deep ICH (81.82%, p = 0.030). However, 30-day mortality had no impact in multivariate regression (Odds ratio (OR) 4.535, 95% Confidence Interval (CI) = 0.786-26.173, p = 0.091). In the group that maintained statin treatment during hospitalization no deaths were registered (p = 0.020) and there was no association with functional status. Multivariate regression analysis was not performed due to sample size.

Conclusion

The only association demonstrated in this study was lower 30-day mortality with pre-ICH statin use and continued statin treatment during admission. However, this was not confirmed by multivariate regression analysis. There were no differences between groups concerning cholesterol values, results that can be explained by the pleiotropic and immunomodulatory effect of statins. However, prospective studies are needed to prove the benefit of the statins in ICH.

Association between Serum Lipid and Hematoma Expansion after Spontaneous Intracerebral Hemorrhage in Chinese Patients

OBJECTIVES

Although several studies have shown that interventions to lower blood lipid concentration may reduce the risk of coronary arterial disease and ischemic stroke, the correlation between serum lipid levels and hemorrhagic stroke remains controversial. To clarify any possible association between serum lipid and hematoma expansion, we examined various serum lipid indices in patients with and without early hematoma expansion.

METHODS

Data of 572 intracerebral hemorrhage (ICH) patients from the cerebral small vessel disease cohort of Peking Union Medical College Hospital were retrospectively analyzed. Patients who finished the baseline brain computed tomography (CT) examination within 6 h post-ictus and the follow-up CT within 48 h after initial CT were included in the study. Hematoma expansion was delimited as an enlargement of hemorrhage volume over 33% or 12.5 mL between baseline and subsequent CT. Both uni- and multivariate logistic regression analyses were conducted to explore the association between early hematoma growth and various serum lipid indices, including triglycerides, total cholesterol (TC), high-density lipoprotein cholesterol (HDL-C), low-density lipoprotein cholesterol (LDL-C), non-HDL-C, ratios of LDL-C/HDL-C and LDL-C/TC, as well as other demographic and clinical features.

RESULTS

Out of 157 patients included in the analysis, hematoma growth occurred in 45 (28.7%). Only higher baseline systolic blood pressure was found to be correlated with an increased risk of hematoma growth based on both univariate (odds ratio [OR] 1.014, 95% confidence interval [CI]: 1.002-1.026, P = .024) and multivariate logistic regression analyses (OR 1.022, 95%CI: 1.008-1.037, P = .003). No associations were detected between the various serum lipid indices examined and other clinical features with a likelihood of early hematoma growth between groups or within various subgroups defined by different characteristics including age, gender, baseline Glasgow Coma Scale score, systolic blood pressure, intraventricular extension, and hematoma location.

CONCLUSIONS

No association between various indices of serum lipid and hematoma growth was identified among patients and subgroups with spontaneous ICH in the Chinese population; these findings may help to guide lipid management after ICH. However, further multi-centered, larger scale studies are expected to verify our results.

The Benefits and Risks of Statin Therapy in Ischemic Stroke: A Review of the Literature

Statins are effective cholesterol-lowering drugs for reducing the risks of mortality and morbidity of cardiovascular diseases. Increasing evidence has shown that statin use is associated with a significant beneficial effect in patients with ischemic stroke. Both pre-stroke and post-stroke statin use has been found to be beneficial in ischemic stroke. Furthermore, good adherence is associated with a better clinical outcome, and statin withdrawal is associated with a poor functional outcome in patients with ischemic stroke. High-intensity statin therapy is advocated for the treatment of ischemic stroke. However, there are concerns regarding the adverse effects associated with statin use in ischemic stroke such as intracranial hemorrhage. In this review, we summarize the beneficial effect of statin use in ischemic stroke and discuss the potential risks associated with statin therapy.

Statins for neuroprotection in spontaneous intracerebral hemorrhage

Statins, a common drug class for treatment of dyslipidemia, may be neuroprotective for spontaneous intracerebral hemorrhage (ICH) by targeting secondary brain injury pathways in the surrounding brain parenchyma. Statin-mediated neuroprotection may stem from downregulation of mevalonate and its derivatives, targeting key cell signaling pathways that control proliferation, adhesion, migration, cytokine production, and reactive oxygen species generation. Preclinical studies have consistently demonstrated the neuroprotective and recovery enhancement effects of statins, including improved neurologic function, reduced cerebral edema, increased angiogenesis and neurogenesis, accelerated hematoma clearance, and decreased inflammatory cell infiltration. Retrospective clinical studies have reported reduced perihematomal edema, lower mortality rates, and improved functional outcomes in patients who were taking statins before ICH. Several clinical studies have also observed lower mortality rates and improved functional outcomes in patients who were continued or initiated on statins after ICH. Subgroup analysis of a previous randomized trial has raised concerns of a potentially elevated risk of recurrent ICH in patients with previous hemorrhagic stroke who are administered statins. However, most statin trials failed to show an association between statin use and increased hemorrhagic stroke risk. Variable statin dosing, statin use in the pre-ICH setting, and selection biases have limited rigorous investigation of the effects of statins on post-ICH outcomes. Future prospective trials are needed to investigate the association between statin use and outcomes in ICH.

Is nontraumatic intracerebral hemorrhage different between young and elderly patients?

Only a few studies have reported nontraumatic intracerebral hemorrhage in young patients notwithstanding its fatal and devastating characteristics. This study investigated the clinical characteristics and outcome of nontraumatic intracerebral hemorrhage in young patients in comparison to those of the elderly. A retrospective review of consecutive patients admitted at the department of neurosurgery of two tertiary care medical centers presenting with first-ever nontraumatic intracerebral hemorrhage was performed. We identified and compared the demographics, etiologies, risk factors, and laboratory, radiological, and clinical findings between elderly and young patients. Additionally, logistic regression analyses of independent prognostic factors associated with 1-month mortality and favorable functional outcome were performed. Altogether, 247 patients including 69 young patients and 178 elderly patients were enrolled. On multivariate analysis, young patients exhibited significantly more often an infratentorial hematoma location, excessive alcohol consumption, and high body mass index (BMI), but less frequent systemic hypertension. There was no statistical difference between the two groups in 1-month mortality (17.46% and 18.01% for young and elderly patients, respectively), but the favorable functional outcome based on modified Rankin scale score of 0 or 1 was significantly different between the two groups (favorable outcome in 51.79% and 29.93% of patients, respectively). Predictors of 1-month mortality was the presence of herniation in the young group, and lower Glasgow Coma Scale score, renal or heart disease, and leukocytosis (WBC > 10,000) in the elderly group. Lower National Institutes Health Stroke Scale score was associated with favorable functional outcome in both groups. Nontraumatic intracerebral hemorrhage in younger patients appears to be associated with excessive alcohol consumption and high BMI. Younger patients had similar short-term mortality but more favorable functional outcome than the elderly.

Meta-analysis of Statin Use for the Acute Therapy of Spontaneous Intracerebral Hemorrhage

BACKGROUND

Growing evidence demonstrates the neuroprotective effects of statins, and the risk to develop an intracerebral hemorrhage (ICH) using statins has been refuted. However, some controversy remains regarding their role in the acute phase after ICH onset. Therefore, we performed a systematic review to investigate this issue.

METHODS

We searched in MEDLINE, Web of Knowledge, and Scopus databases for studies examining the outcome in patients with spontaneous ICH and statin use. The analysis was performed for short-term (≤3 months) and long-term outcome (≥6 months) and a further subanalysis considered studies seeking for the effects of the discontinuation of statin after ICH onset. A random-effect model was applied, and country was used as a cofactor for meta-regression; odds ratios (ORs) with 95% confidence intervals (CIs) are offered.

RESULTS

A total of 17 studies were included, only 1 pseudo cohort trial assessed the new use of statin after ICH onset and 3 studies evaluated the suspension of statin after ICH onset, the rest of the studies focused on the effect of the regular use of statin before ICH onset. The number of patients with an ICH exposed and not exposed to statins were 3455 and 11,821, respectively. The absolute short-term mortality was 27.3% in statin users and 33% in nonusers that represented a significant risk reduction of mortality (OR, .73; 95% CI, .54-.97). For long-term mortality, the effect was less evident (OR, .71; 95% CI, .43-1.15). The analysis of the 3 studies assessing the discontinuation of statins suggested a reduction of mortality risk by continuing statin (OR, .14; 95% CI, .1-.20).

CONCLUSIONS

The current evidence suggests that continuing statin after ICH onset might be highly related to improvement of the outcome of patients with ICH. Despite this strong suggestion, randomized controlled trials should be performed to further investigate this association.

Statin use in spontaneous intracerebral hemorrhage: a systematic review and meta-analysis

BACKGROUND

Nonrandomized observational studies have been conducted to evaluate the effects of statins on clinical outcomes in patients with intracerebral hemorrhage. Several studies on the effects of statin administration in patients with intracerebral hemorrhage have been published recently, but the findings are inconsistent.

AIM

To evaluate the effects of statins administered prior to hospital admission and during hospitalization on mortality and functional outcomes in patients with intracerebral hemorrhage.

SUMMARY OF REVIEW

We searched for relevant literature using multiple comprehensive databases and performed a systematic review and meta-analysis. Sixteen studies met our selection criteria. Preintracerebral hemorrhage statin use was not associated with mortality (odds ratio: 0·90, 95% confidence interval: 0·63-1·28). However, patients who used statins prior to intracerebral hemorrhage had a decreased risk of mortality at three-months following symptom onset (odds ratio: 0·47, 95% confidence interval: 0·32-0·68) and an increased probability of good functional outcomes (odds ratio: 1·49, 95% confidence interval: 1·01-2·19), as compared with those who did not. In-hospital use of statins was associated with a low risk of mortality (odds ratio: 0·34, 95% confidence interval: 0·26-0·44) irrespective of preadmission statin use or postadmission time-points. Additionally, we were unable to pool the data on statin withdrawal because of differences in study methodologies.

CONCLUSIONS

Although careful interpretation is necessary due to several study limitations, we have demonstrated that statin use in patients with intracerebral hemorrhage is likely associated with improved mortality and functional outcomes.

Intracerebral hemorrhage at young age: long-term prognosis

BACKGROUND AND PURPOSE

Intracerebral hemorrhage (ICH) is a devastating disorder associated with dismal outcomes. The long-term mortality and functional outcome of ICH in young patients was studied - areas so far poorly investigated.

METHODS

A follow-up study was performed on a cohort of patients. Clinical and imaging data on ICH patients aged 16-49 were retrospectively obtained and linked with a nationwide cause-of-death register. The modified Rankin Scale (mRS) was evaluated for 30-day survivors at a visit 9.7 (7.0-12.0) years after ICH onset. Independent factors associated with mortality and unfavorable functional outcome (mRS 2-5) were sought by multivariate analysis.

RESULTS

Amongst the 268 1-month survivors, 1-year survival was 98.1% [95% confidence interval (CI) 96.2%-100%], 5-year survival 93.2% (89.3%-97.1%) and 10-year survival 88.8% (84.9%-92.7%). After adjustment for age and intraventricular hematoma extension, male sex [odds ratio (OR) 3.36, 95% CI 1.28-8.80] and diabetes (OR 2.64, 1.01-6.89) were associated with increased mortality. Unfavorable functional outcome emerged in 49%. After adjustment for confounders, age (OR 1.09 per 1 year, 95% CI 1.03-1.15), initial stroke severity (1.17 per one National Institutes of Health Stroke Scale score point, 1.08-1.27) and intraventricular hemorrhage (3.26, 1.11-9.55) were associated with unfavorable functional outcome.

CONCLUSIONS

Of every 10 survivors of acute phase ICH at a young age, one died within 10 years after onset, male sex and diabetes being associated with increased mortality. Half the survivors did not achieve a favorable functional outcome, which was predicted by increasing age, initial stroke severity and intraventricular hemorrhage.

Association between statin use and intracerebral hemorrhage: a systematic review and meta-analysis

BACKGROUND AND PURPOSE

Accumulating evidence suggests that statins exert neuroprotective effects, but whether their use affects the outcomes of intracerebral hemorrhage (ICH) remains controversial. Therefore, we performed a systematic review and meta-analysis to investigate whether statin use before spontaneous ICH affects unfavorable functional outcome or mortality.

METHODS

We searched the Cochrane Library, MEDLINE, EMBASE and China National Knowledge Infrastructure databases for studies examining the effects of pre-ICH statin use on unfavorable functional outcome, mortality or neuroimaging outcomes in consecutively recruited patients with spontaneous ICH, regardless of the duration or dose of statin treatment.

RESULTS

A total of 12 studies were included that examined the effects of pre-ICH statin use on post-ICH outcomes in 1652 subjects in the favors pre-statin group and 5309 in the favors no pre-ICH statin group. Meta-analysis of 11 studies suggested that pre-ICH statin use did not significantly affect mortality across all three time points tested [in-hospital, 30 days, 90 days; odds ratio (OR) 0.85, 95% confidence interval (CI) 0.70-1.03]. However, meta-analysis of seven studies showed that pre-ICH statin use did significantly decrease 90-day mortality (OR 0.72, 95% CI 0.59-0.88). Meta-analysis of six studies showed that pre-ICH statin use was not associated with significant changes in unfavorable functional outcome. Moreover, pre-ICH statin use did not significantly affect admission hematoma volume (standardized mean difference 7.75, 95% CI -5.59 to 21.09).

CONCLUSION

Available evidence suggests that statin use before spontaneous ICH does not increase short-term mortality, unfavorable functional outcome or post-ICH hematoma volume at admission.

Long-term improvement in outcome after intracerebral hemorrhage in patients treated with statins

BACKGROUND

Intracerebral hemorrhage (ICH) is a severe type of stroke for which there is currently no specific medical therapy. We hypothesized that statins reduce immediate inflammatory injury and improve long-term recovery from increased neurogenesis and angiogenesis. We conducted a large retrospective cohort study to assess the influence of statin therapy on patient death and disability at 12 months after ICH.

METHODS

This was a retrospective analysis of a prospectively collected database at a tertiary care medical center. Patients were grouped based on statin use, and poor outcome was assessed as dead or alive with dependency (modified Barthel Index≤14).

RESULTS

We compared outcomes in 190 patients exposed to statins to 236 patients who were not exposed to statins. Univariate analysis found that statin use was associated with decreased mortality in-hospital and at 12 months (P=.001). Multivariable analysis found that statin use was associated with a decreased odds of death or disability at 12 months after ICH (odds ratio 0.44; 95% confidence interval 0.21-0.95).

CONCLUSIONS

Statin use is associated with improved long-term outcome at 12 months after ICH. This finding supports previous clinical studies that have shown the short-term benefits of statin therapy. In addition, this study correlates with animal studies supporting the possible long-term recovery benefits of statins.

Association of prestroke statin use and lipid levels with outcome of intracerebral hemorrhage

BACKGROUND AND PURPOSE

It is unclear whether blood lipid profiles and statin use before intracerebral hemorrhage (ICH) are associated with its outcome.

METHODS

The Helsinki ICH Study, a single-center observational registry of consecutive ICH patients, was used to study the associations between premorbid statin use, baseline lipid levels, and clinical outcome.

RESULTS

The registry includes 964 ICH patients. Statin users (n=187; 19%) were significantly older, had more frequent comorbidities and medication, lower lipid levels, and higher admission Glasgow Coma Scale compared with nonusers. Modified Rankin Scale at discharge or mortality did not differ between statin users and nonusers. Compared with survivors, significantly lower total cholesterol and low-density lipoprotein cholesterol levels were observed in patients who died in hospital (median, 4.1 mmol/L [interquartile range, 3.6-4.4] versus 4.5 [3.8-5.1]; P<0.01; 1.9 mmol/L [1.4-2.5] versus 2.4 [1.8-3.0]; P<0.001, respectively), at 3 or 12 months. After adjusting for known ICH prognostic factors based on univariate analysis that is, age, National Institutes of Health Stroke Scale, Glasgow Coma Scale, ICH volume, and intraventricular location, lower low-density lipoprotein levels were independently associated with in-hospital mortality (odds ratio, 0.54 [95% confidence interval, 0.31-0.93]; P=0.028).

CONCLUSIONS

Premorbid statin use did not affect the outcome of ICH, but lower low-density lipoprotein levels were associated with higher in-hospital mortality.