Brain Bleeds on Steady Trend Upward

Intracerebral hemorrhage (ICH) has become increasingly common in recent decades, driven by events in older people, according to an analysis of the Framingham Heart Study.

The incidence of ICH increased steadily from 25 cases per 100,000 person-years in 1948-1986 (period 1) to 73 cases per 100,000 person-years in 2000-2016 (period 3), reported a team led by Vasileios-Arsenios Lioutas, MD, of Beth Israel Deaconess Medical Center and Harvard Medical School.

Altogether, people 75 years and older had ICH reach 176 cases per 100,000 person-years in 2000-2016 (up from 88 per 100,000 in 1948-1986) in the study published online in JAMA Neurology.

Importantly, the incidence trend differed depending on age:

  • Remained low in the group ages 45-74 years (not exceeding 25 cases per 100,000 person-years over time)
  • Increased slightly in people ages 75-84 years (from 96 to 113 cases per 100,000 person-years between periods 1 and 3)
  • Jumped substantially in the group 85 years and older (from 39 to 287 cases per 100,000 person-years between periods 1 and 3)

This increase coincided with increased use of statins and anticoagulant medications, Lioutas and colleagues noted.

“These findings, in conjunction with the expected increase in life expectancy, suggest that the absolute number of individuals who experience an ICH event, particularly at an older age, will likely continue to increase despite improvements in primary and secondary preventive interventions. Such a trend has already been documented in other high-income countries,” they concluded.

Adjusted for age, ICH incidence showed an initial increase followed by a dip between 1987-1999 (51 cases per 100,000 person-years) and 2000-2016 (46 cases per 100,000 person-years), such that it was no higher during period 3 compared to period 1.

“This finding was likely associated with improvements in primary and secondary preventive practices, which is reflected in the well-documented decrease in the prevalence of risk factors in the Framingham Heart Study cohort; both hypertension prevalence and BP levels, which are the most important ICH risk factors, decreased steadily,” according to Lioutas and team.

Their analysis drew upon 10,333 Framingham participants (originally enrolled in 1948) and their children. Of this cohort, 129 (55.8% women, age 77 on average) had an ICH over 68 years. After applying exclusion criteria, 99 ICH patients were matched 1:4 by age and sex to controls.

Overall, ICH risk was comparable between men and women. Both deep ICH and lobar ICH grew in incidence with advancing age.

Predictors of deep ICH were higher systolic and diastolic blood pressure and statin medication use. Factors associated with lobar ICH were higher systolic blood pressure and apolipoprotein E ε4 allele homozygosity.

The Framingham cohort was nearly all white, the authors cautioned, limiting the generalizability of the results to other populations. Another limitation of the study was that the investigators did not have data on antiplatelet use.

Last Updated June 09, 2020

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    Nicole Lou is a reporter for MedPage Today, where she covers cardiology news and other developments in medicine. Follow


The study was supported by grants from the National Institute of Neurological Disorders and Stroke; the National Institute on Aging; and the National Heart, Lung, and Blood Institute.

Lioutas disclosed receiving personal fees from Qmetis.