Heavy Alcohol Use Linked to ICH at Younger Age

Pauline Anderson

September 10, 2012

September 10, 2012 — Among patients who sustain an intracerebral hemorrhage (ICH), heavy alcohol users were about 14 years younger on average than non–heavy drinkers, a new study shows.

ICH in heavy consumers of alcohol was also more likely to occur in deep areas of the brain, suggesting the involvement of small-vessel disease, researchers speculate. Of note, the heavy drinkers not only were relatively young — about 60 years old — but they had not been severely ill before.

"While the fact that they were young was interesting, what really struck me as a doctor was that there was no previous indication that something was going to be very wrong with them," said study author Charlotte Cordonnier, MD, PhD, professor of neurology, Lille University Hospital, France, told Medscape Medical News.

However, if these patients survive the acute phase of their stroke, they're as likely to have a good long-term outcome as those who don't drink as much, said Dr. Cordonnier. "So it's really worth investing a lot of energy in trying to save their lives."

The study is published in the September 11 issue of Neurology.

PITCH Study

The Prognosis of InTra-Cerebral Hemorrhage (PITCH) study included 540 patients (median age, 71 years) admitted to the emergency department of the Lille University Hospital with parenchymal hemorrhage confirmed by computed tomography.

As well as demographic information, medical history and cognitive status, researchers collected self-reported data on alcohol consumption. Heavy alcohol intake was defined as regularly consuming more than 300 g per week (the equivalent of more than 3 drinks per day). This cutoff is in line with the known effect of alcohol on cognition as well as on stroke and morbidity, said Dr. Cordonnier.

By this definition, 25% of the study patients were heavy alcohol drinkers. This, said Dr. Cordonnier, reflects a high prevalence of alcoholism in northern France as well as many northern European countries. However, she stressed that the study group was not the general population but rather people sustaining an ICH.

Heavy drinkers were often dependent before their ICH, the authors noted. Many had multiple falls, peripheral neuropathies, depression, chronic fatigue, and other effects.

Both groups had similar length of hospital stay and rates of complications, such as the need for intubation, neurosurgery, early epileptic seizures, and infections.

The study found that among survivors, the median age of heavy drinkers was 60 years compared with 74 years for non–heavy drinkers (P < .0001). Heavy drinkers were less likely to have a history of ischemic heart disease and more likely to smoke.

Coagulation Problems

Although still within the normal range, the platelet counts (P = .01) and prothrombin ratio (P = .017) were significantly lower among heavy alcohol drinkers, which, according to Dr. Cordonnier, suggests a link with early-stage small-vessel disease. As well as increasing risks for hypertension and making the small and fragile vessels deep within the brain more leaky, heavy alcohol use can create coagulation problems, she said.

The patients who drank heavily were more likely to have nonlobar ICHs (odds ratio [OR], 1.71; 95% confidence interval [CI], 1.05 - 2.77) and less likely to have leukoariosis (OR, 0.76 per 1-step increase; 95% CI, 0.62 - 0.73). This is further evidence that alcohol has an effect in areas deep in the brain, said Dr. Cordonnier.

As for survival, heavy drinking was predictive of mortality at 2 years only among those younger than age 60 years with a nonlobar ICH (hazard ratio, 1.96; 95% CI, 1.06 - 3.63).

Also at the 2-year follow-up, 61% of the heavy alcohol drinking group were dependent versus 70% among the nondrinkers, although this difference was not statistically significant.

The brain of a 60-year-old shouldn't be the same as the brain of a 70-year-old, so this shows that alcohol was already having an effect on the brain.

The groups had a similar mean brain atrophy score. Brain atrophy has been consistently linked to heavy alcohol use and could be a marker for small-vessel disease. "The brain of a 60-year-old shouldn't be the same as the brain of a 70-year-old, so this shows that alcohol was already having an effect on the brain," said Dr. Cordonnier.

A limitation of the study is that it relied on self-report, but this may have resulted in a slight underestimation of the influence of heavy alcohol intake.

The authors stressed that conclusions about whether alcohol causes ICH can't be drawn on the basis of these data. "It's probably not alcohol itself, but alcohol with probably a slight degree of high blood pressure, and probably a slight degree of coagulation disorders, but these are mediated by a strong input of alcohol," said Dr. Cordonnier.

Quality of Life

Asked to comment, Pierre Fayad, MD, professor of neurology and director, Stroke Center, Nebraska Medical Center, University of Nebraska Medical Center, Omaha, and member of the American Academy of Neurology, said the study echoed earlier research, much of which looked at the effect of alcohol on both ischemic and hemorrhagic stroke.

"Here we're missing part of the ischemic stroke equation, but we gain more information on the hemorrhage side," he told Medscape Medical News.

Dr. Fayad questioned the quality of life of heavy drinkers who survive an ICH, especially because many appear already to be dependent.

"Certainly they can survive; the question is, are they going to be functioning part of society? Are they going to stop drinking after the bleed or continue drinking? Are they going to quit smoking and what are they going to do about their other lifestyle factors?"

He also noted that the study did not include information about drug use.

"They don't mention anything about screening subjects for drugs and whether that played a part. If you're alcoholic and a heavy smoker, it's possible that you may also be using drugs," such as cocaine or methamphetamine, he said.

Dr. Cordonnier was an investigator in drug trials of sanofi-aventis (BOREALIS), Photothera (NEST3), and Brainsgate (Impact-24); honoraria were paid to ADRINORD. For disclosures of other authors, see original paper. Dr. Fayad has disclosed no relevant financial relationships.

Neurology. 2012;79:1109-1115. Abstract

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