Rates and risk factors for major adverse cardiovascular and cerebrovascular events after stroke due to intracerebral hemorrhage: Systematic review and study-level meta-analysis.

2026-02-25
International journal of stroke : official journal of the International Stroke Society 21(6)
- Vega Pratiwi Putri
- Neshika Samarasekera
- Tom J Moullaali
- Saketh Jampana
- Joseph Aked
- Signild Åsberg
- Sam Schulman
- Georgios Tsivgoulis
- Maria Pikilidou
- Hsin-Hsi Tsai
- Li-Kai Tsai
- Phyo Kyaw Myint
- Tiberiu A Pana
- Charlotte Cordonnier
- Barbara Casolla
- David Gaist
- Alessandro Pezzini
- Pol Camps-Renom
- Catharina J M Klijn
- Michele Romoli
- Arnstein Tveiten
- Ming Liu
- Mangmang Xu
- Bo Wu
- David Werring
- Philip S Nash
- Gargi Banerjee
- Linxin Li
- Rustam Al-Shahi Salman

PubMed: 41605872
DOI: 10.1177/17474930261416692

Study Design

Type: Meta-Analysis
Population: 198,289 ICH survivors
Methods: Systematic search of Medline, Embase, and trial registries in April 2024; random-effects meta-analysis; QUIPS risk of bias assessment.

Background

Intracerebral hemorrhage (ICH) survivors are at increased risk of major adverse cardiovascular and cerebrovascular events (MACE) compared with population controls; however, little is known about the annual rates and risk factors for MACE.

Methods

We searched Medline, Embase, and trial registries systematically in April 2024 for studies of adults with ICH, reporting either a MACE composite outcome or both ischemic and hemorrhagic outcomes, with at least one year of follow-up. We excluded studies limited to secondary ICH or isolated non-ICH intracranial hemorrhages. We used the QUIPS tool to assess studies' risk of bias. The primary outcome was the rate of MACE. We used a random-effects meta-analysis to estimate the annual event rate (per 100 person-years, expressed as %) for each outcome. We conducted subgroup analyses and meta-regression to explore heterogeneity.

Results

We included 26 studies, involving 198,289 ICH survivors. Individual studies' reported annual rate of MACE ranged 4.2-14.6%. The pooled annual rate of recurrent ICH was 2.1% (95% confidence interval (CI) = 1.7-2.6; 26 studies; I² = 94%) and of ischemic stroke was 2.0% (95% CI = 1.5-2.7; 24 studies; I² = 95%). Meta-regression analyses identified one statistically significant association between a higher prevalence of atrial fibrillation and an increased risk of ischemic stroke.

Discussion

The rates of recurrent ICH and ischemic stroke were comparable among ICH survivors, but evidence about other MACE outcomes remains limited. An individual participant data meta-analysis is needed to investigate the predictors of MACE outcomes, which may help inform risk stratification and prognosis among ICH survivors.