Association of statins and statin discontinuation with poor outcome and survival after intracerebral hemorrhage

The double-edged sword of statins in intracerebral hemorrhage patients: a systematic review and meta-analysis

Background

This meta-analysis aimed to investigate the effect of statins on the prognosis of patients with intracerebral hemorrhage (ICH).

Methods

We conducted a systematic search using the keywords "statin" and "intracerebral hemorrhage" across four electronic databases (PubMed, Cochrane Library, Web of Science, and Embase) from their inception to October 31, 2023, to identify studies comparing the effects of statins on the prognosis of patients with ICH. The primary outcome was total mortality after ICH. This meta-analysis was registered online (PROSPERO ID: CRD42023493063).

Results

Our initial search identified 5,543 studies. After applying inclusion criteria, 30 studies with a total of 42,298 patients were included in the final analysis. Our meta-analysis showed that statins significantly reduced overall mortality in patients with ICH (OR: 0.61; 95% CI: 0.51-0.73; I 2 = 87%; p < 0.01). Subgroup analyses further demonstrated lower mortality in ICH patients treated with statins compared to those not treated, including in the propensity score matching (PSM) group (OR: 0.59; 95% CI: 0.48-0.74; I 2 = 90%; p < 0.01), the prospective cohort study (PCS) group (OR: 0.56; 95% CI: 0.40-0.77; I 2 = 89%, p < 0.01), and the retrospective cohort study (RCS) group (OR: 0.64; 95% CI: 0.51-0.81; I 2 = 87%, p < 0.01).

Conclusion

Our meta-analysis of 30 studies suggests that statin use may be associated with improved mortality and functional outcomes in patients with intracerebral hemorrhage (ICH).

Systematic Review Registration

https://www.crd.york.ac.uk/PROSPERO/, CRD42023493063.

Discontinuation versus continuation of statins: A systematic review

BACKGROUND

Clinicians and patients often face a decision to continue or discontinue statins. We examined the impact of discontinuation of statins compared with continuation on clinical outcomes (all-cause mortality, cardiovascular [CV] mortality, CV events, and quality of life).

METHODS

We conducted a systematic review. Randomized controlled trials (RCTs), cohort studies, case-control studies, and quasi-randomized studies among people ≥18 years were eligible. We searched MEDLINE, Embase, and Cochrane Central Registry (inception to August 2023). Two independent reviewers performed screening and extracted data. Quality assessment was performed by one author and verified by another. We summarized results narratively, performed meta-analysis for a subset of studies, and used GRADE to assess certainty of evidence. We summarized findings in the subgroup of persons ≥75 years.

RESULTS

We retrieved 8369 titles/abstracts; 37 reports from 36 studies were eligible. This comprised 35 non-randomized studies (n = 1,708,684) and 1 RCT (n = 381). The 1 RCT was conducted among persons with life expectancy <1 year and showed there is probably no difference in 60-day mortality (risk difference = 3.5%, 90% CI -3.5 to 10.5) for statin discontinuation compared with continuation. Non-randomized studies varied in terms of population and setting, but consistently suggested that statin discontinuation might be associated with a relative increased risk of mortality (hazard ratio (HR) 1.92, 95% CI 1.52 to 2.44, nine studies), CV mortality (HR 1.63, 95% CI 1.27 to 2.10, five reports), and CV events (HR 1.31, 95% CI 1.23 to 1.39, eight reports). Findings in people ≥75 years were consistent with main results. There was a high degree of uncertainty in findings from non-randomized studies due to methodological limitations.

CONCLUSIONS

Statin discontinuation does not appear to affect short-term mortality near end-of-life based on one RCT. Outside of this population, findings from non-randomized studies consistently suggested statin discontinuation may be associated with worse outcomes, though this is uncertain.

Statins for neuroprotection in spontaneous intracerebral haemorrhage (STATIC): protocol for a multicentre, prospective and randomised controlled trial

INTRODUCTION

Intracerebral haemorrhage (ICH) is a neurological emergency with high morbidity and mortality, and current treatment is limited. Emerging evidence has reported that statins can exert neuroprotective effects in cerebrovascular diseases. However, most of the published clinical studies are retrospective. Therefore, it is important to conduct a prospective randomised controlled trial to further validate the efficacy and safety of statins in patients with ICH.

METHODS AND ANALYSIS

The present study is performed at Xuan Wu Hospital Capital Medical University, Beijing Fengtai You'anmen Hospital and Shunping County Hospital, Hebei Province. The target number of patients is 98. Eligible patients are randomly assigned in a 1:1 ratio to the statins group or the control group. The primary outcome is the perihaemorrhagic oedema to haematoma ratio at 7 days. Secondary outcomes include mortality at 30 days, haematoma resolution rate at 7 days, National Institute of Health stroke scale (NIHSS) score at 7 days or discharge, ordinal distribution of modified Rankin scale (mRS) score at 90 days, the proportion of patients with an mRS score of 0-2 on day 90, the proportion of patients with an mRS score of 0-3 on day 90, absolute haematoma volume changes between initial and 7-day follow-up CT scan, absolute perihaematomal oedema changes between initial and 7-day follow-up CT scan.

ETHICS AND DISSEMINATION

The trial has been approved by the ethics committees of Xuan Wu Hospital Capital Medical University, Beijing Fengtai You'anmen Hospital and Shunping County Hospital, Hebei Province. The results will be disseminated in a peer-reviewed journal and in conference reports.

TRIAL REGISTRATION NUMBER

NCT04857632.

Rationale and Design of the Statin Use in Intracerebral Hemorrhage Patients (SATURN) Trial

INTRODUCTION

The benefits and risks of HMG-CoA reductase inhibitor (statin) drugs in survivors of intracerebral hemorrhage (ICH) are unclear. Observational studies suggest an association between statin use and increased risk of lobar ICH, particularly in patients with apolipoprotein-E (APOE) ε2 and ε4 genotypes. There are no randomized controlled trials addressing the effects of statins after ICH leading to uncertainty as to whether statins should be used in patients with lobar ICH who are at high risk for ICH recurrence. The SATURN trial aims to evaluate the effects of continuation versus discontinuation of statin on the risk of ICH recurrence and ischemic major adverse cerebro-cardio-vascular events (MACCEs) in patients with lobar ICH. Secondary aims include the assessment of whether the APOE genotype modifies the effects of statins on ICH recurrence, functional and cognitive outcomes, and quality of life.

METHODS

The SATURN trial is a multi-center, pragmatic, prospective, randomized, open-label, phase III clinical trial with blinded end-point assessment. A planned total of 1,456 patients with lobar ICH will be recruited from 140 sites in the USA, Canada, and Spain. Patients presenting within 7 days of a spontaneous lobar ICH that occurred while taking a statin will be randomized (1:1) to continuation (control) versus discontinuation (intervention) of the same statin drug and dose that they were using at ICH onset. The primary outcome is the time to recurrent symptomatic ICH within a 2-year follow-up period. The primary safety outcome is the occurrence of ischemic MACCE.

CONCLUSION

The results will help to determine the best strategy for statin use in survivors of lobar ICH and may help to identify if there is a subset of patients who would benefit from or be harmed by statins.

INTRODUCTION

The benefits and risks of HMG-CoA reductase inhibitor (statin) drugs in survivors of intracerebral hemorrhage (ICH) are unclear. Observational studies suggest an association between statin use and increased risk of lobar ICH, particularly in patients with apolipoprotein-E (APOE) ε2 and ε4 genotypes. There are no randomized controlled trials addressing the effects of statins after ICH leading to uncertainty as to whether statins should be used in patients with lobar ICH who are at high risk for ICH recurrence. The SATURN trial aims to evaluate the effects of continuation versus discontinuation of statin on the risk of ICH recurrence and ischemic major adverse cerebro-cardio-vascular events (MACCEs) in patients with lobar ICH. Secondary aims include the assessment of whether the APOE genotype modifies the effects of statins on ICH recurrence, functional and cognitive outcomes, and quality of life.

METHODS

The SATURN trial is a multi-center, pragmatic, prospective, randomized, open-label, phase III clinical trial with blinded end-point assessment. A planned total of 1,456 patients with lobar ICH will be recruited from 140 sites in the USA, Canada, and Spain. Patients presenting within 7 days of a spontaneous lobar ICH that occurred while taking a statin will be randomized (1:1) to continuation (control) versus discontinuation (intervention) of the same statin drug and dose that they were using at ICH onset. The primary outcome is the time to recurrent symptomatic ICH within a 2-year follow-up period. The primary safety outcome is the occurrence of ischemic MACCE.

CONCLUSION

The results will help to determine the best strategy for statin use in survivors of lobar ICH and may help to identify if there is a subset of patients who would benefit from or be harmed by statins.

How to Use Statins in Secondary Prevention of Atherosclerotic Diseases: from the Beneficial Early Initiation to the Potentially Unfavorable Discontinuation

Statins, a class of lipid-lowering drugs, reduce morbidity and mortality in patients with established atherosclerosis-related cardiovascular disease. Early initiation of statin therapy after admission for acute coronary syndromes (ACS), stroke, or transient ischemic attack (TIA) is associated with improved cardiovascular outcomes. Moreover, high-dose statin treatment prior to coronary or carotid revascularization has been shown to reduce cardiovascular events in these patients. However, many patients may be undertreated, and a residual cardiovascular risk remains in current clinical practice. Despite the beneficial role of statins, their discontinuation rate among patients is still elevated leading to severe adverse cardiovascular events due to atherosclerotic plaque destabilization. In this review, we summarized the impact of statin treatment among patients, focusing on the initiation time-points as well as the potential harm derived by their discontinuation.

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.

Cardiovascular medications and long-term mortality among stroke survivors in the Brazilian Study of Stroke Mortality and Morbidity (EMMA)

AIM

To investigate the association between medication use and long-term all-cause mortality in a Brazilian stroke cohort.

METHODS

Both ischemic and hemorrhagic stroke were evaluated. Medication use was assessed as: never, only pre-stroke, only post-stroke, and continuous use. We evaluated anti-hypertensives, anti-diabetics, lipid-lowering drugs, anti-platelets, and anti-coagulants. Cox regression models were adjusted for sociodemographic and cardiovascular risk factors.

RESULTS

Among 1173 incident stroke cases (median age: 68; 86.8% were ischemic, 70% first-ever stroke), medication use was low (overall: 17.5% pre-stroke, 26.4% post-stroke, and 40% were under continuous use). Anti-hypertensives and anti-platelets (aspirin) were the continuous cardiovascular medications used most often, at 83.5% and 72%, respectively, while statins (39.7%) and anti-diabetics (31.3%) were the least used. Medication use (pre-stroke, post-stroke and continuous use) was associated with a reduction in all-cause mortality risk, particularly among those under continuous use (multivariable hazard ratio, 0.52; 95% confidence interval (CI), 0.46-0.66) compared with never-users. Among ischemic stroke patients, this effect was similar (multivariable hazard ratio, 0.52; 95% CI, 0.40-0.68). No significant associations were evident among hemorrhagic stroke patients.

CONCLUSIONS

The risk of all-cause mortality was reduced by 48% among those with ischemic stroke under continuous use of medications. Secondary prevention should be emphasized more strongly in clinical practice. Geriatr Gerontol Int 2022; ••: ••-••.

Prior statin and short-term outcomes of primary intracerebral hemorrhage: From a large-scale nationwide longitudinal registry

Introduction

The relationship between statins and intracerebral hemorrhage outcomes is unclear.

Aim

We aimed to compare the in‐hospital mortality and evacuation of intracranial hematoma rates in patients with primary intracerebral hemorrhage between prior statin users and nonusers.

Results

The final study population included 66,263 patients. Multivariable logistics analyses showed that prior statin use was not associated with in‐hospital mortality for primary intracerebral hemorrhage (adjusted odd ratio 0.78, 95% CI 0.61–1.01), but reduced the proportion of patients undergoing evacuation of intracranial hematoma (adjusted odd ratio 0.70, 95% CI 0.61–0.82). Propensity score matching analyses yielded similar results.

Conclusion

Prior statin use was not associated with in‐hospital mortality but did reduce evacuation of intracranial hematoma rates.

Risk Factor Analysis of the Conservative Treatment in Chronic Subdural Hematomas: A Substudy of the ATOCH Trial

INTRODUCTION

The objective of the study was to analyze the risk factors for worsening of the disease progression in patients with chronic subdural hematomas (CSDH) during wait-and-observation treatment regimen and conservative treatment with atorvastatin.

METHODS

A total of 196 patients with CSDH were recruited (98 in the atorvastatin group and 98 in the blank placebo group). Receiver operating characteristic (ROC) curve analysis was used to identify the optimal cutoff for the hematoma volume by testing surgical and nonsurgical outcomes. Other measures, including univariate and multivariate analyses, were performed to identify the potential significant factors indicative of the outcome of therapeutic efficacy of conservative treatment through the characteristics of the baseline indicators at enrollment.

RESULTS

Over a median treatment duration of 2 months, lower total cholesterol, higher hematoma volume, and more midline shift were independent risk factors for worse outcomes of atorvastatin treatment for CSDH, and only a higher hematoma volume was an independent risk factor for spontaneous absorption in the placebo group. ROC analysis of all of the data showed that the optimal threshold of hematoma volume was 68.5 ml (sensitivity 73.5%, specificity 74%) in response to the greatest chance of switching to surgery.

CONCLUSIONS

Critical independent predictors of atorvastatin monotherapy treatment success included higher total cholesterol, lower hematoma volume, and less midline shift in atorvastatin monotherapy, and higher hematoma volume was the only independent risk factor in close follow-up observation patients without any pharmacotherapy. Initial hematoma volume more than 68.5 ml may help clinicians to determine individual risk assessments and to make optimal treatment decisions.

TRIAL REGISTRATION

http://www.

CLINICALTRIALS

gov . Identifier NCT02024373.

Management of Dyslipidaemia for the Prevention of Stroke: Clinical Practice Recommendations from the Lipid Association of India

Stroke is the second most common cause of death worldwide. The rates of stroke are increasing in less affluent countries predominantly because of a high prevalence of modifiable risk factors. The Lipid Association of India (LAI) has provided a risk stratification algorithm for patients with ischaemic stroke and recommended low density lipoprotein cholesterol (LDL-C) goals for those in very high risk group and extreme risk group (category A) of <50 mg/dl (1.3 mmol/l) while the LDL-C goal for extreme risk group (category B) is ≤30 mg/dl (0.8 mmol/l). High intensity statins are the first-line lipid lowering therapy. Nonstatin therapy like ezetimibe and proprotein convertase subtilisin kexin type 9 (PCSK9) inhibitors may be added as an adjunct to statins in patients who do not achieve LDL-C goals with statins alone. In acute ischaemic stroke, high intensity statin therapy improves neurological and functional outcomes regardless of thrombolytic therapy. Although conflicting data exist regarding increased risk of intracerebral haemorrhage (ICH) with statin use, the overall benefit risk ratio favors long-term statin therapy necessitating detailed discussion with the patient. Patients who have statins withdrawn while being on prior statin therapy at the time of acute ischaemic stroke have worse functional outcomes and increased mortality. LAI recommends that statins be continued in such patients. In patients presenting with ICH, statins should not be started in the acute phase but should be continued in patients who are already taking statins. ICH patients, once stable, need risk stratification for atherosclerotic cardiovascular disease (ASCVD).

Lower low-density lipoprotein cholesterol levels are associated with an increased risk of hematoma expansion and ensuing mortality in acute ICH patients

BACKGROUND AND PURPOSE

The relationship between lipid levels and the prognosis of acute intracerebral hemorrhage (ICH) remains controversial. Thus, we aimed to investigate whether lower low-density lipoprotein cholesterol (LDL-C) levels increased the risk of adverse outcomes, as well as the current situation of statin treatment in acute ICH patients with premorbid lipid-lowering therapy.

METHODS

From August 1, 2015, to July 31, 2019, a total of 73,098 ICH patients were included in our study from the Chinese Stroke Center Alliance program. Patients were grouped by LDL-C levels of < 1.4 mmol/L, 1.4-1.8 mmol/L, 1.8-2.6 mmol/L, and > 2.6 mmol/L. Logistic regression was used to assess the association between LDL-C levels and the composite risk of hematoma expansion (HE) or in-hospital death. Moreover, statin treatment in ICH patients with cardio-cerebrovascular diseases was analyzed.

RESULTS

In total, 6368 (8.7%) patients were identified as a composite of HE or in-hospital death with a mean LDL-C level of 2.9 ± 1.7 mmol/L. In the univariate analysis, patients who achieved lower LDL-C concentrations under 1.4 mmol/L had a 36% higher risk of adverse outcomes compared with the ≥ 2.6 mmol/L group (OR 1.36, 95%CI 1.23-1.51). Similar results were obtained in multivariate analyses, especially for patients with GCS scores of 9-15. For acute ICH patients with concomitant atherosclerotic disease, statin treatment was discontinued in the majority of Chinese population.

CONCLUSIONS

Lower LDL-C levels (< 1.4 mmol/L) are associated with an increased risk of HE and ensuing mortality in acute ICH patients. Maintaining an optimal LDL-C range may have therapeutic potential against HE which merits further investigation.

Statins for the Prevention of Post-Stroke Seizure and Epilepsy Development: A Systematic Review and Meta-Analysis

OBJECTIVES

Cerebrovascular disease is the leading cause of seizures and incident epilepsy of known etiology in older adults. Statins have increasingly garnered attention as a potential preventive strategy due to their pleiotropic effects beyond lipid-lowering, which may include neuroprotective and anti-epileptogenic properties. We aim to assess the evidence on statin use for prevention of post-stroke early-onset seizures and post-stroke epilepsy.

MATERIALS AND METHODS

We conducted a systematic review and meta-analysis in accordance with PRISMA guidelines, which was prospectively registered with PROSPERO (CRD42019144916). PubMed and Embase were searched from database inception to 05/2020 for English-language, full-text studies examining the association between statin use in adults and development of early-onset seizures (≤7 days post-stroke) or post-stroke epilepsy. Pooled analyses were based on random-effects models using the inverse-variance method.

RESULTS

Of 182 citations identified, 175 were excluded due to duplication or ineligibility. The 7 eligible publications were all cohort studies from East Asia or South America, with a total of 53,579 patients. Pre-stroke statin use was not associated with post-stroke epilepsy (3 studies pooled: OR 1.14, CI 0.91-1.42). However, post-stroke statin use was associated with lower risk of both early-onset seizures (3 studies pooled: OR 0.36, CI 0.25-0.53), and post-stroke epilepsy (6 studies pooled: OR 0.64, CI 0.46-0.88).

CONCLUSIONS

Review of 7 cohort studies suggested post-stroke, but not pre-stroke, statin use may be associated with reduced risk of early-onset seizures and post-stroke epilepsy. Further research is warranted to validate these findings in broader populations and better parse the temporal components of the associations.

A Systematic Review and Meta-Analysis of Statins in Animal Models of Intracerebral Hemorrhage

BACKGROUND

Intracerebral hemorrhage (ICH) is a severe form of stroke with limited treatment options. Statins have shown promise as a therapy for ICH in animal and human studies. We systematically reviewed and assessed the quality of preclinical studies exploring statin-use after ICH to guide clinical trial decision-making and design.

METHODS

We identified preclinical trials assessing the efficacy of statins in ICH via a systematic review of the literature according to PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. In total, 16 studies were identified that described statin use in an animal model of ICH and assessed histological outcomes, behavioral scores, or both. Design characteristics were analyzed using Stroke Therapy Academic Industry Roundtable (STAIR) criteria modified for ICH. Meta-analysis was performed using a random effects model.

RESULTS

Behavioral outcomes were assessed in 12 of the studies with 100% (n = 12) reporting that statins significantly improved ICH recovery. Histologic hematoma volume and brain water content outcomes were analyzed in 10 of the studies, with 50% (n = 5) reporting significant improvement. The ratio of means between experimental and control cases for modified Neurological Severity Score was 0.63 (95% confidence interval 0.49-0.82). The ratio of means between experimental and control cases for hemorrhagic volume was 0.85 (95% confidence interval 0.70-1.03). There was heterogeneity between studies (P < 0.0001) but no evidence of publication bias (P = 0.89, P = 0.59, respectively).

CONCLUSIONS

Behavioral outcomes in ICH were found to consistently improve with administration of statins in preclinical studies suggesting that statin therapy may be suitable for randomized clinical trials in humans. In addition, the STAIR criteria can be modified to effectively evaluate preclinical studies in ICH.

Neuroprotective Therapies for Spontaneous Intracerebral Hemorrhage

Patients who survive the initial ictus of spontaneous intracerebral hemorrhage (ICH) remain vulnerable to subsequent injury of the perilesional parenchyma by molecular and cellular responses to the hematoma. Secondary brain injury after ICH, which contributes to long-term functional impairment and mortality, has emerged as an attractive therapeutic target. This review summarizes preclinical and clinical evidence for neuroprotective therapies targeting secondary injury pathways following ICH. A focus on therapies with pleiotropic antiinflammatory effects that target thrombin-mediated chemotaxis and inflammatory cell migration has led to studies investigating statins, anticholinergics, sphingosine-1-phosphate receptor modulators, peroxisome proliferator activated receptor gamma agonists, and magnesium. Attempts to modulate ICH-induced blood-brain barrier breakdown and perihematomal edema formation has prompted studies of nonsteroidal antiinflammatory agents, matrix metalloproteinase inhibitors, and complement inhibitors. Iron chelators, such as deferoxamine and albumin, have been used to reduce the free radical injury that ensues from erythrocyte lysis. Stem cell transplantation has been assessed for its potential to enhance subacute neurogenesis and functional recovery. Despite promising preclinical results of numerous agents, their outcomes have not yet translated into positive clinical trials in patients with ICH. Further studies are necessary to improve our understanding of the molecular events that promote damage and inflammation of the perihematomal parenchyma after ICH. Elucidating the temporal and pathophysiologic features of this secondary brain injury could enhance the clinical efficacy of neuroprotective therapies for ICH.

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.

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.

Early in-hospital exposure to statins and outcome after intracerebral haemorrhage - Results from the Virtual International Stroke Trials Archive

Introduction

Recent data suggest that statin use after intracerebral haemorrhage might be beneficial. However, data on the effects of early in-hospital statin exposure are lacking. Therefore, we sought to assess whether (1) early statin exposure during the acute phase after intracerebral haemorrhage and (2) early continuation of prevalent statin use are associated with favourable functional outcome.

Patients and methods

Data were obtained from the Virtual International Stroke Trials Archive. Patients were categorised according to use patterns of statins during this early in-hospital phase (continuation, discontinuation or new initiation of statins). Univariate and multivariable analyses were conducted to explore the association between early statin exposure and functional outcome.

Results

A total of 919 patients were included in the analysis. Early in-hospital statin exposure (n = 89, 9.7%) was associated with better functional outcome (modified Rankin Scale ≤ 3) compared with 790 patients without statin exposure before or early after the event (66% versus 47%, adjusted OR 2.1, 95% confidence interval 1.3-3.6). Compared with patients without exposure to statins before and early after the event, early continuation of statin therapy (n = 57) was associated with favourable functional outcome (adjusted odds ratio 2.6, 95% confidence interval 1.3-5.2). The association between early continuation of statins and outcome remained robust in sensitivity analyses restricted to patients able to take oral medication within 72 h and one-week survivors.

Discussion

It is possible that part of the observed associations are not due to a protective effect of statins but are confounded by indication bias.

Conclusion

Statin exposure and continuation of prevalent statin therapy early after intracerebral haemorrhage are associated with favourable functional outcome after 90 days.

Effect of initiating statin therapy on long-term outcomes of patients with dyslipidemia after intracerebral hemorrhage

BACKGROUND AND AIMS

Intracerebral hemorrhage (ICH) has a higher mortality than ischemic stroke. Statin is beneficial for stroke, but high potency statin treatment has been associated with the risk of hemorrhagic stroke. The aim of this study was to assess the impact of initiating statin therapy after ICH on cardiovascular outcomes.

METHODS

Dyslipidemic patients were retrieved from the ICH population from the National Health Insurance Research Database in Taiwan. We retrospectively compared patients prescribed with and without statin treatment after ICH. Outcomes of interest were mortality, myocardial infarction, ischemic stroke, and hemorrhagic stroke during 5 years of follow-up.

RESULTS

Of 17,980 adult patients with ICH and dyslipidemia, 8927 were eligible for analysis over the study period, including 1613 patients receiving statin therapy and 7314 patients not taking statins. After propensity score matching, the mean age was 61.2 ± 12.2 years in the statin group and 61.6 ± 13.0 years in the non-statin group. Hypertension was dominant, followed by diabetes mellitus, and the mean estimated NIHSS score was 12.9. The patients who received statin therapy were associated with lower risks of all-cause mortality (12.7% vs. 21.3%; hazard ratio [HR], 0.54; 95% confidence interval [CI], 0.45-0.65), cardiovascular death (4.0% vs. 7.1%; HR, 0.54; 95% CI, 0.39-0.75) and ICH (5.4% vs. 8.5%; HR, 0.62; 95% CI, 0.46-0.83) compared to those who did not receive statins.

CONCLUSIONS

Initiating statin therapy after ICH was associated with a decreased risk of recurrent ICH and mortality for dyslipidemia patients.

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.

Discontinuing or continuing statin following intracerebral hemorrhage from the view of a national cohort study

BACKGROUND AND AIMS

Statins improve clinical outcomes in patients with ischemic stroke but there is no evidence of the effect of continuing long-term statin therapy in patients with intracerebral hemorrhage (ICH). The aim of this study was to evaluate the impact of continuing statin after ICH.

METHODS

Data on patients with ICH was retrieved from the National Health Insurance Research Database of Taiwan. The final population was separated into two groups according to those who continued and those who discontinued statin treatment. All-cause mortality and cardiovascular outcomes were analyzed after a 3 year follow-up after propensity score matching (PSM).

RESULTS

Of the 114,101 patients with ICH, who were initially enrolled, 2468 patients with dyslipidemia and ICH were included. After PSM, the benefit of statin therapy on mortality appeared from 1 year to the end of the 3-year follow-up period after discharge (statin group versus non-statin group: 4.9% vs.12.3% at 1 year (hazard ratio [HR], 0.38; 95% confidence interval [CI], 0.26-0.57) and 12.9% vs. 25.3% at the end of the 3 year follow-up period (HR, 0.45; 95% CI, 0.35-0.58). Compared with the patients using lipophilic statins, those using hydrophilic statins had a significantly lower incidence of all-cause mortality (HR = 0.65, 95% CI = 0.43-0.99). There were no differences between those prescribed moderate-intensity statins and those prescribed high-intensity statins in terms of stroke and all-cause mortality (HR = 0.76; 95% CI = 0.40-1.46).

CONCLUSIONS

There was a lower risk of all-cause mortality following ICH in patients who continued statin treatment compared with those without statin treatment, especially in those treated with hydrophilic statins.

The increasing impact of cerebral amyloid angiopathy: essential new insights for clinical practice

Cerebral amyloid angiopathy (CAA) has never been more relevant. The last 5 years have seen a rapid increase in publications and research in the field, with the development of new biomarkers for the disease, thanks to advances in MRI, amyloid positron emission tomography and cerebrospinal fluid biomarker analysis. The inadvertent development of CAA-like pathology in patients treated with amyloid-beta immunotherapy for Alzheimer's disease has highlighted the importance of establishing how and why CAA develops; without this information, the use of these treatments may be unnecessarily restricted. Our understanding of the clinical and radiological spectrum of CAA has continued to evolve, and there are new insights into the independent impact that CAA has on cognition in the context of ageing and intracerebral haemorrhage, as well as in Alzheimer's and other dementias. While the association between CAA and lobar intracerebral haemorrhage (with its high recurrence risk) is now well recognised, a number of management dilemmas remain, particularly when considering the use of antithrombotics, anticoagulants and statins. The Boston criteria for CAA, in use in one form or another for the last 20 years, are now being reviewed to reflect these new wide-ranging clinical and radiological findings. This review aims to provide a 5-year update on these recent advances, as well as a look towards future directions for CAA research and clinical practice.

Early Use of Statin in Patients Treated with Alteplase for Acute Ischemic Stroke

Studies have reported that statin usage before stroke can increase the incidence of intracerebral hemorrhage after thrombolytic treatment. However, whether the administration of statin at an early stage of ischemic stroke increases hemorrhage occurrence is unknown. The aim of this study was to assess the effect of statin on neurological imaging and functional outcomes after intravenous alteplase treatment, within 24 h of acute ischemic stroke attack. A total of 119 consecutive acute ischemic stroke patients treated by intravenous alteplase were recruited, of which 71 patients (59.7 %) were given statin therapy within 24 h of stroke onset. The physiological parameters, including demography, vascular risk factors, and clinical characteristics were recorded. The occurrence of intracerebral hemorrhage (ICH), symptomatic intracerebral hemorrhage (sICH), 90-day functional outcomes, and mortality in the patients were further analyzed. There were 24 occurrences of ICH after alteplase treatment (20.2 %) and there was no difference when patients were treated with statin (p = 0.280). Multivariate logistic regression analysis showed no significant correlation between the administration of statin and the occurrence of ICH (p = 0.230) or sICH (p = 0.949). There was a trend toward better neurological function with higher statin dose. The use of statin in the early stage of ischemic stroke is safe and does not increase the risk of intracerebral hemorrhage after alteplase treatment, suggesting that a clinical trial of early statin treatment on a large scale following thrombolysis is needed for further evaluation.

Association between patient outcomes and key performance indicators of stroke care quality: A systematic review and meta-analysis

Purpose

Translating research evidence into clinical practice often uses key performance indicators to monitor quality of care. We conducted a systematic review to identify the stroke key performance indicators used in large registries, and to estimate their association with patient outcomes.

Method

We sought publications of recent (January 2000-May 2017) national or regional stroke registers reporting the association of key performance indicators with patient outcome (adjusting for age and stroke severity). We searched Ovid Medline, EMBASE and PubMed and screened references from bibliographies. We used an inverse variance random effects meta-analysis to estimate associations (odds ratio; 95% confidence interval) with death or poor outcome (death or disability) at the end of follow-up.

Findings

We identified 30 eligible studies (324,409 patients). The commonest key performance indicators were swallowing/nutritional assessment, stroke unit admission, antiplatelet use for ischaemic stroke, brain imaging and anticoagulant use for ischaemic stroke with atrial fibrillation, lipid management, deep vein thrombosis prophylaxis and early physiotherapy/mobilisation. Lower case fatality was associated with stroke unit admission (odds ratio 0.79; 0.72-0.87), swallow/nutritional assessment (odds ratio 0.78; 0.66-0.92) and antiplatelet use for ischaemic stroke (odds ratio 0.61; 0.50-0.74) or anticoagulant use for ischaemic stroke with atrial fibrillation (odds ratio 0.51; 0.43-0.64), lipid management (odds ratio 0.52; 0.38-0.71) and early physiotherapy or mobilisation (odds ratio 0.78; 0.67-0.91). Reduced poor outcome was associated with adherence to swallowing/nutritional assessment (odds ratio 0.58; 0.43-0.78) and stroke unit admission (odds ratio 0.83; 0.77-0.89). Adherence with several key performance indicators appeared to have an additive benefit.

Discussion

Adherence with common key performance indicators was consistently associated with a lower risk of death or disability after stroke.

Conclusion

Policy makers and health care professionals should implement and monitor those key performance indicators supported by good evidence.

Use of Statins and Outcomes in Intracerebral Hemorrhage Patients

BACKGROUND AND PURPOSE

Statin use may be associated with improved outcome in intracerebral hemorrhage patients. However, the topic remains controversial. Our analysis examined the effect of prior, continued, or new statin use on intracerebral hemorrhage outcomes using the ERICH (Ethnic/Racial Variations of Intracerebral Hemorrhage) data set.

METHODS

We analyzed ERICH (a multicenter study designed to examine ethnic variations in the risk, presentation, and outcomes of intracerebral hemorrhage) to explore the association of statin use and hematoma growth, mortality, and 3-month disability. We computed subset analyses with respect to 3 statin categories (prior, continued, or new use).

RESULTS

Two thousand four hundred and fifty-seven enrolled cases (mean age, 62 years; 42% females) had complete data on mortality and 3-month disability (modified Rankin Scale). Among those, 1093 cases were on statins (prior, n=268; continued, n=423; new, n=402). Overall, statin use was associated with reduced mortality and disability without any effect on hematoma growth. This association was primarily driven by continued/new statin use. A multivariate analysis adjusted for age and major predictors for poor outcome showed that continued/new statins users had good outcomes compared with prior users. However, statins may have been continued/started more frequently among less severe patients. When a propensity score was developed based on factors that could influence a physician's decision in prescribing statins and used as a covariate, continued/new statin use was no longer a significant predictor of good outcome.

CONCLUSIONS

Although statin use, especially continued/new use, was associated with improved intracerebral hemorrhage outcomes, this effect may merely reflect the physician's view of a patient's prognosis rather than a predictor of survival.

Neuroprotective strategies following intraparenchymal hemorrhage

Intracerebral hemorrhage and, more specifically, intraparenchymal hemorrhage, are devastating disease processes with poor clinical outcomes. Primary injury to the brain results from initial hematoma expansion while secondary hemorrhagic injury occurs from blood-derived products such as hemoglobin, heme, iron, and coagulation factors that overwhelm the brains natural defenses. Novel neuroprotective treatments have emerged that target primary and secondary mechanisms of injury. Nonetheless, translational application of neuroprotectants from preclinical to clinical studies has yet to show beneficial clinical outcomes. This review summarizes therapeutic agents and neuroprotectants in ongoing clinical trials aimed at targeting primary and secondary mechanisms of injury after intraparenchymal hemorrhage.

Statin discontinuation and mortality in an older adult population with traumatic brain injury: A four-year, multi-centre, observational cohort study

INTRODUCTION

Statin discontinuation has been investigated in a wide range of diseases and injuries, but there is a paucity of data in the older adult population with traumatic brain injury (TBI). The purpose of this study was to re-examine the extent to which early discontinuation of pre-injury statin (PIS) therapy increases the risk of poor patient outcomes in older adult patients suffering a TBI.

METHODS

This was a retrospective observational cohort study of adult trauma patients with a blunt TBI across three trauma centres over four years. Patients were excluded because of no PIS use, age <55years, or a hospital length of stay (LOS) less than three days. Patients found to be intentionally discontinued from statin therapy within 48h of hospital admission for injury-related reasons were excluded. The primary and secondary outcomes were in-hospital mortality and a hospital LOS ≥1 week. Outcomes were analysed using logistic regression.

RESULTS

There were 266 patients in the continuation group, and 131 in the discontinuation group. The statin discontinuation group had a significantly higher proportion of patients with a moderate or severe head injury, intubation in emergency department (ED), and disposition to the intensive care unit or operating room. Overall, 23 (6%) patients died while in the hospital. After adjusting for ED Glasgow coma scale, the odds of dying in the hospital were not significantly larger for patients having been discontinued from PIS, compared to those who were continued (OR=1.75, 95%CI=0.71-4.31, p=0.22). Among patients who received an in-hospital statin, the median (interquartile range) time between hospital admission and first administration of statin medication did not differ between patients who died and those who survived (22.8h [10.96-28.91] vs. 22.9h [11.67-39.80], p=0.94). There were no significant differences between study groups in the proportion of patients with a hospital length of stay >1 week (continuation=29% vs. discontinuation=36%, p=0.19).

CONCLUSION

We did not observe a significantly increased odds of in-hospital mortality following PIS discontinuation, compared to PIS continuation, in an older adult population with TBI. It remains to be seen whether statin discontinuation is a proxy variable for injury severity, or whether it exerts deleterious effects after injury.

Low cholesterol level associated with severity and outcome of spontaneous intracerebral hemorrhage: Results from Taiwan Stroke Registry

The relationship between cholesterol level and hemorrhagic stroke is inconclusive. We hypothesized that low cholesterol levels may have association with intracerebral hemorrhage (ICH) severity at admission and 3-month outcomes. This study used data obtained from a multi-center stroke registry program in Taiwan. We categorized acute spontaneous ICH patients, based on their baseline levels of total cholesterol (TC) measured at admission, into 3 groups with <160, 160–200 and >200 mg/dL of TC. We evaluated risk of having initial stroke severity, with National Institutes of Health Stroke Scale (NIHSS) >15 and unfavorable outcomes (modified Rankin Scale [mRS] score >2, 3-month mortality) after ICH by the TC group. A total of 2444 ICH patients (mean age 62.5±14.2 years; 64.2% men) were included in this study and 854 (34.9%) of them had baseline TC <160 mg/dL. Patients with TC <160 mg/dL presented more often severe neurological deficit (NIHSS >15), with an adjusted odds ratio [aOR] of 1.80; 95% confidence interval [CI], 1.41–2.30), and 3-month mRS >2 (aOR, 1.41; 95% CI, 1.11–1.78) using patients with TC >200 mg/dL as reference. Those with TC >160 mg/dL and body mass index (BMI) <22 kg/m² had higher risk of 3-month mortality (aOR 3.94, 95% CI 1.76–8.80). Prior use of lipid-lowering drugs (2.8% of the ICH population) was not associated with initial severity and 3-month outcomes. A total cholesterol level lower than 160 mg/dL was common in patients with acute ICH and was associated with greater neurological severity on presentation and poor 3-month outcomes, especially with lower BMI.

Statin Adherence and the Risk of Stroke: A Dose-Response Meta-Analysis

BACKGROUND

Statins are one of the most common medications for stroke prevention. Increasing evidence indicates that the effect of statins against stroke may depend on the optimal adherence of the patients to the long-term therapies. However, the magnitude of the association between statin adherence and the risk of stroke has not been determined.

OBJECTIVE

We conducted a dose-response meta-analysis to investigate the association between statin adherence and the risk of stroke.

METHODS

The Medline and Embase databases were systematically searched to identify relevant observational studies that evaluated the association between statin adherence and stroke risk. Statin adherence was primarily quantified by the proportion of days covered by prescribed statins. Studies in which relative risks (RRs) with 95% confidence intervals (CIs) for the association between statin adherence and stroke risk were reported or could be estimated were included in this meta-analysis.

RESULTS

A total of 15 studies with 710,504 participants were included. The pooled RR of total stroke for the categories with the highest compared with the lowest adherence to statins was 0.72 (95% CI 0.65-0.79). Stratified by stroke subtype, the pooled RR for ischemic stroke (IS) was 0.83 (95% CI 0.74-0.92) and for hemorrhagic stroke was 0.75 (95% CI 0.51-1.09). The dose-response analysis indicated that an improvement in statin adherence of 20% was associated with an 8% lower risk of total stroke (RR 0.92; 95% CI 0.89-0.94). In the subgroup analysis for IS, an improvement in statin adherence of 20% was associated with a 7% lower risk of IS (RR 0.93; 95% CI 0.88-0.99).

CONCLUSION

Improved adherence to statins was associated with a lower risk of stroke, particularly of IS.

Intracerebral Hemorrhage: Perihemorrhagic Edema and Secondary Hematoma Expansion: From Bench Work to Ongoing Controversies

Intracerebral hemorrhage (ICH) is a medical emergency, which often leads to severe disability and death. ICH-related poor outcomes are due to primary injury causing structural damage and mass effect and secondary injury in the perihemorrhagic region over several days to weeks. Secondary injury after ICH can be due to hematoma expansion (HE) or a consequence of repair pathway along the continuum of neuroinflammation, neuronal death, and perihemorrhagic edema (PHE). This review article is focused on PHE and HE and will cover the animal studies, related human studies, and clinical trials relating to these mechanisms of secondary brain injury in ICH patients.

The Role of Statin Therapy in Hemorrhagic Stroke

The 3-hydroxy-3-methylglutaryl coenzyme A reductase inhibitors (statins) are the most widely utilized class of cholesterol-lowering agents, carrying multiple indications for both primary and secondary cardiovascular risk reduction. Concern was raised by previously published post hoc analyses and observational studies that noted an increased risk of hemorrhagic stroke in patients receiving a statin. Subsequent studies have demonstrated conflicting results regarding the role of statin therapy on hemorrhagic stroke risk and patient outcomes. New evidence suggests that statins taken prior to or continued during admission for intracerebral hemorrhage (ICH) may be associated with positive outcomes. Evidence also suggests deleterious outcomes resulting from the abrupt discontinuation of statins upon hospital admission for multiple disease states including ICH. Conflicting data also exist for the use of statins following aneurysmal subarachnoid hemorrhage (aSAH). Recent evidence suggests statins started during admission for aSAH confer no additional benefit in reducing delayed ischemic neurologic deficits despite initial positive results. Larger scale evaluation of the role of statin therapy following hemorrhagic stroke is warranted. The available literature is reviewed to provide guidance for therapeutic decision making.

Statin use after intracerebral hemorrhage: a 10-year nationwide cohort study

INTRODUCTION

Although statin therapy is beneficial to patients with ischemic stroke, statin use, and intracerebral hemorrhage (ICH) remain a concern. ICH survivors commonly have comorbid cardiovascular risk factors that would otherwise warrant cholesterol-lowering medication, thus emphasizing the importance of assessing the characteristics of statin therapy in this population.

METHODS

We performed a cohort study by using 10 years of data collected from the National Health Insurance Research Database in Taiwan. We enrolled 726 patients admitted for newly diagnosed ICH from January 1, 2001 to December 31, 2010. The patients were categorized into high- (92), moderate- (545), and low-intensity (89) statin groups, and into hydrophilic (295) and lipophilic (431) statin groups. The composite outcomes included all-cause mortality, recurrent ICH, ischemic stroke, transient ischemic attack, and acute coronary events.

RESULTS

The patients in the low-intensity group did not differ significantly from the patients in the high-intensity group in risk of all-cause mortality (adjusted hazard ratio [aHR] = 0.65, 95% confidence interval [CI] = 0.28-1.55) and recurrent ICH (aHR = 0.66, 95% CI = 0.30-1.44). In contrast, the patients in the hydrophilic group had a significantly lower risk of recurrent ICH than did those in the lipophilic group (aHR = 0.69, 95% CI = 0.48-0.99). We determined no significant differences in other composite endpoints between hydrophilic and lipophilic statin use.

CONCLUSION

Hydrophilic statin therapy is associated with a reduced risk of recurrent ICH in post-ICH patients. The intensity of statin use had no significant effect on recurrent ICH or other components of the composite outcome. Additional studies are required to clarify the biological mechanisms underlying these observations.

Guidelines for Management of Hyperlipidemia: Implications for Treatment of Patients with Stroke Secondary to Atherosclerotic Disease

After careful review of randomized cardiovascular outcomes trial data, the 2013 ACC/AHA cholesterol guideline focused on using the appropriate intensity of statin therapy to reduce atherosclerotic cardiovascular disease (ASCVD) risk and moved away from recommending specific low-density lipoprotein cholesterol (LDL-C) treatment targets. In patients who have had a stroke or other clinical ASCVD event, a high-intensity statin should be initiated up to age 75 years unless there are safety concerns, including a history of hemorrhagic stroke. A moderate-intensity statin is recommended if there are safety concerns or age is greater than 75 years. Atorvastatin 40-80 mg and rosuvastatin 20-40 mg are considered high-intensity statins. These new guidelines avoid unnecessary usage of non-statins to achieve specific LDL-C values, thus avoiding potential adverse effects or use of an inadequate statin intensity in patients who are "at goal." When non-statins are considered for additional LDL-C lowering, ezetimibe is the only non-statin clearly shown to further reduce ASCVD risk when added to background statin therapy.

Management of intracerebral hemorrhage--use of statins

Intracerebral hemorrhage (ICH) is a neurologic injury resulting in significant morbidity and mortality. Statins play a significant role in primary and secondary prevention of cardiovascular and cerebrovascular ischemic events. Despite clear benefits of statins in ischemic stroke, post hoc analyses of some studies suggest there may be a link between statin therapy and development of ICH. Direct pharmacologic effects of decreased serum levels of total cholesterol and low-density lipoproteins in conjunction with pleiotropic effects are thought to be linked to this possible increase in ICH risk. In the face of the potential of statins to increase the risk of ICH, recent evidence suggests that statins may also have beneficial effects on patient outcomes when continued or initiated following an ICH. This discordance in findings and the overall lack of well-designed prospective clinical trials increase the complexity of clinical decision making when utilizing statin therapy in patients with, or at risk for, ICH. This review evaluates the pharmacologic effects of statin therapy and describes how these effects translate to both risks and benefits in ICH. The current literature regarding the effects of statin therapy on clinical outcomes in ICH is evaluated to help guide clinicians with decisions regarding initiation, continuation, or discontinuation of statin therapy in patients with ICH.

Statins in Intracerebral Hemorrhage

While statins play an indisputable role in primary and secondary prevention of ischemic cardiovascular and cerebrovascular disease, a concern exists regarding a possible association between low lipoprotein levels and statin use on the risk of intracerebral hemorrhage (ICH). While these data may incline physicians to discontinue statins after ICH, an increasing amount of preclinical and clinical evidence suggests that statins might have a beneficial effect on outcome and recovery in this context that goes beyond lipid lowering effects. Different etiologies of ICH and the related risk of recurrence should also be taken into account when deciding about statin use/avoidance in patients with high risk of ICH. The problem is compounded by paucity of data from randomized controlled trials and well-designed prospective observational studies. This review will discuss the existing evidence on potential interactions between statins and risk of ICH as well as outcomes in order to provide practical recommendations for clinical decision-making.

Blood lipid levels, statin therapy and the risk of intracerebral hemorrhage

Dyslipidemia has been proven to play an important role in the occurrence and development of the ischemic stroke and lipid-lowering therapy could significantly decrease the risk of the ischemic stroke. However, the association between lipid levels, lipid-lowering therapy and the risk of intracerebral hemorrhage (ICH) is not clear. Studies have shown that low serum levels of total cholesterol might be associated with increasing risk of ICH, whereas the SPARCL study, a large prospective, randomized, placebo-controlled trial, demonstrated an increased risk of hemorrhagic stroke during high-dose statin therapy among the patients with previous stroke. The relationship between lipid-lowering therapy and ICH has become a hot topic in the recent years. We searched PubMed for articles published in English to review the existing evidence on the association of lipid levels, statin therapy and risk of ICH as well as the underlying mechanisms in order to provide practical recommendations for clinical decision-making and a foundation for further researches.

Molecular, Cellular and Clinical Aspects of Intracerebral Hemorrhage: Are the Enemies Within?

Hemorrhagic stroke is a disease with high incidence and mortality rates. In addition to the mass lesions that result from hemorrhagic stroke, substances such as the blood-derived products (BDP) (hemoglobin (Hb), heme and iron) induce a potent inflammatory response and exert direct toxic effects on neurons, astrocytes, and microglia. In the present review, we discuss the mechanisms of brain injury secondary to hemorrhagic stroke, focusing on the involvement of BDP as major players of cellular redox imbalance, inflammation, and glutamate excitotoxicity. Potential natural mechanisms of protection against free Hb and heme such as haptoglobin and hemopexin, respectively, are highlighted. We finally discuss the experimental and clinical trials targeting free iron and heme scavenging as well as inflammation, as potential new therapies to minimize the devastating effects of hemorrhagic stroke on brain structure and function.

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.

Potential role of statins in the intracerebral hemorrhage and subarachnoid hemorrhage

Statins are used in primary and secondary prevention of cardiovascular episodes. Most of recent studies regard ischemic stroke. There are more emerging results of studies suggesting usefulness of these drugs in the other types of stroke e.g. intracerebral hemorrhage (ICH) and subarachnoid hemorrhage (SAH). Searching for new methods of treatment is important, because both ICH and SAH lead to poor prognosis and severe psychomotor disability. The unquestionable role of inflammatory factors in the pathogenesis of these disorders justifies considering statin treatment. Previous results are contradictory, thus in present study we review results of studies and try to explain the potential pathomechanism of statin use in hemorrhagic strokes.

Perihematoma cerebral blood flow is unaffected by statin use in acute intracerebral hemorrhage patients

Statin therapy has been associated with improved cerebral blood flow (CBF) and decreased perihematoma edema in animal models of intracerebral hemorrhage (ICH). We aimed to assess the relationship between statin use and cerebral hemodynamics in ICH patients. A post hoc analysis of 73 ICH patients enrolled in the Intracerebral Hemorrhage Acutely Decreasing Arterial Pressure Trial (ICH ADAPT). Patients presenting <24 hours from ICH onset were randomized to a systolic blood pressure target <150 or <180 mm Hg with computed tomography perfusion imaging 2 hours after randomization. Cerebral blood flow maps were calculated. Hematoma and edema volumes were measured planimetrically. Regression models were used to assess the relationship between statin use, perihematoma edema and cerebral hemodynamics. Fourteen patients (19%) were taking statins at the time of ICH. Statin-treated patients had similar median (IQR Q25 to 75) hematoma volumes (21.1 (9.5 to 38.3) mL versus 14.5 (5.6 to 27.7) mL, P=0.25), but larger median (IQR Q25 to 75) perihematoma edema volumes (2.9 (1.7 to 9.0) mL versus 2.2 (0.8 to 3.5) mL, P=0.02) compared with nontreated patients. Perihematoma and ipsilateral hemispheric CBF were similar in both groups. A multivariate linear regression model revealed that statin use and hematoma volumes were independent predictors of acute edema volumes. Statin use does not affect CBF in ICH patients. Statin use, along with hematoma volume, are independently associated with increased perihematoma edema volume.

Use of statin during hospitalization improves the outcome after intracerebral hemorrhage

AIMS

To examine the relationship between statin use in Chinese patients with intracerebral hemorrhage (ICH) during their hospitalization and the outcomes.

METHODS

Data were collected from the China National Stroke Registry. Good functional outcome was defined by a modified Rankin Scale score between 0-2. Functional outcome and rate of mortality at 3 months and 1 year were compared between ICH patients on statin and those without it during their hospitalization. Odds ratios (ORs) with 95% confidence intervals (CI) were calculated using the multivariable logistic regression model adjusted for baseline risk factors.

RESULTS

Among 3218 consecutive ICH patients from 2007 to 2008, 220 (6.8%) were on statin during their hospitalization. Compared with those without statin, patients on statin were younger, had more stroke risk factors but lower stroke severity. ICH patients on statin had better functional outcome at 3 months (OR 2.24, 95% CI 1.49-3.36) and at 1 year (OR 2.04, 95% CI 1.37-3.06). They also had lower rate of mortality at 3 months (OR 0.44, 95% CI 0.22-0.87) and 1 year (OR 0.49, 95% CI 0.27-0.86).

CONCLUSIONS

In-hospital statin use in ICH patients is associated with better functional outcome and lower mortality at 3 months and 1 year.

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.