What are the risk factors for Intracerebral Hemorrhage (ICH)?

From the Guidelines

The main risk factors for Intracerebral Hemorrhage (ICH) include hypertension, advanced age, anticoagulant or antiplatelet medication use, cerebral amyloid angiopathy, and prior stroke history, as identified in the most recent study 1.

Risk Factors for ICH

The following are key risk factors for ICH:

• Older age, especially age ≥75 years
• Number of antithrombotic drugs: twofold increase in risk with each additional drug
• Previous stroke or transient ischaemic attack: up to twofold increase in risk
• Intracranial aneurysm and other vascular malformations
• High systolic blood pressure
• Diabetes mellitus
• Atrial fibrillation
• Chronic pulmonary disease
• End-stage renal disease: one of the strongest predictors of ICH, with a 3.5-fold increase in risk
• Dementia: cerebral amyloid angiopathy is associated with ICH, cognitive impairment and dementia in older patients
• Cerebral amyloid angiopathy
• Use of vitamin K antagonist (VKA): associated with a twofold increase in the risk of ICH, in contrast to the use of direct oral anticoagulants

Management and Prevention

Controlling modifiable risk factors, particularly maintaining blood pressure below 130/80 mmHg and careful monitoring of anticoagulant therapy, is essential for ICH prevention, as supported by guidelines 1. Additional considerations for management and prevention include:

• Lifestyle modifications, such as avoidance of alcohol use, tobacco use, and illicit drug use
• Treatment of underlying conditions, such as obstructive sleep apnea
• Avoidance of long-term anticoagulation with warfarin in patients with nonvalvular atrial fibrillation and a history of lobar ICH
• Consideration of anticoagulation after nonlobar ICH and antiplatelet monotherapy after any ICH, particularly when there are strong indications for these agents.

From the Research

Risk Factors for Intracerebral Hemorrhage (ICH)

The risk factors for ICH can be categorized into modifiable and non-modifiable factors.

• Modifiable risk factors include:
  • Blood pressure: High blood pressure is the most important risk factor for ICH 2, 3, 4
  • Smoking
  • Alcohol consumption
  • Lipid profiles
  • Use of anticoagulants, antiplatelet agents, and sympathomimetic drugs 5, 4, 6
• Non-modifiable risk factors include:
  • Old age: The incidence of ICH increases exponentially with age, and old age is a major predictor of mortality independent of ICH severity 4
  • Male gender
  • Asian ethnicity: Asian populations have a higher incidence of ICH compared to white Americans 4
  • Cerebral amyloid angiopathy (CAA): CAA is a degenerative vasculopathy that is classically associated with lobar intracerebral or sulcal hemorrhage 5, 3
  • Cerebral microbleed
  • Chronic kidney disease

Other Factors Associated with ICH

• History of cardiovascular disease, arthritis, or high cholesterol level: These factors are associated with a reduced risk of ICH 2
• Being moderately overweight or using hormone replacement therapy: These factors are also associated with a reduced risk of ICH 2
• Drinking coffee: Drinking coffee is associated with a reduced risk of ICH 2
• Use of aspirin-like drugs: The use of aspirin-like drugs is not associated with an increased risk of ICH 2
• Previous use of antiplatelet agents: Previous use of antiplatelet agents is a predictor of hematoma enlargement in patients with ICH treated with rapid administration of antifibrinolytic agents and blood pressure control 6