Even Mild Baseline Anemia Predicts Poor Outcomes After Intracerebral Hemorrhage

Daniel M. Keller, PhD

November 03, 2016

HYDERABAD, INDIA — Anemia at admission for intracerebral hemorrhage predicts a poor outcome, a study shows. Almost one in five patients in the study presented with anemia, and those patients as a group had a 50% greater likelihood of a poor outcome at 90 days.

In a presentation here at the World Stroke Congress (WSC) 2016, Nikola Sprigg, MBChB, DM, associate professor of stroke medicine at Nottingham University in the United Kingdom, reported these findings from the ongoing Tranexamic Acid for Hyperacute Primary Intracerebral Hemorrhage (TICH-2) trial.

Of 1648 patients in the trial, 300 (18.2%) were anemic, defined as having a baseline hemoglobin level of less than 13 g/dL for men or less than 12 g/dL for women. For the patients overall, the mean hemoglobin levels were 14.3 ± 1.6 g/dL for men and 13.2 ± 1.4 g/dL for women.

Compared with the stroke patients who did not have anemia, the anemic patients were older (77 vs 69 years) and had worse modified Rankin Scale (mRS), National Institutes of Health Stroke Scale (NIHSS), and Glasgow Coma Scale scores (0.9 vs 0.5, 14.7 vs 12.7, and 12.9 vs 13.6, respectively). The anemic patients also had a greater history of receiving antiplatelet agents, having a stroke or transient ischemic attack, diabetes, and statin use.

"When we followed these patients up, we found that they had a much worse modified Rankin, so [they were] much more likely to be dead or dependent," Dr Sprigg told participants in a poster walk.

Adjusting for baseline mRS score, NIHSS score, and age, logistic regression analysis showed that mRS score at 90 days was worse for patients with anemia at baseline (odds ratio, 1.50; 95% confidence interval, 1.16 - 1.94; P = .002).

Also worse for patients with anemia than those without were serious adverse events (P = .018), early deaths (P = .002), and time to death (P = .002).

These findings were independent of the fact that the anemic patients were older and had more severe strokes. Dr Sprigg said baseline anemia is a marker of frailty, and, as such, "these patients that have got frailty or anemia need closer monitoring to try to prevent serious adverse events."

Poster walk moderator Sunil Gajre, MBBS, MD, DM, head of his own clinic in Jalgaon, Maharashtra, India, asked Dr Sprigg what would be the outcome for patients with more severe vs less severe levels of anemia.

She said she suspects that those with a greater degree of anemia would fare worse, but so far, the investigators have not stratified results according to the hemoglobin level. Rather, they have only dichotomized them by "anemia" or "no anemia"; there were very few patients with severe anemia because patients had to be fairly well physically and independent before the stroke. Nonetheless, worse outcomes were apparent even for patients with milder degrees of anemia.

"Your correlation is what we see clinically in these patients — the lower the hemoglobin levels versus the outcome," Dr Gajre commented. He speculated that as brain hematomas expand, the brain oxygen levels decrease in anemic patients, and that is probably why these patients have more morbidity and more mortality.

Dr Sprigg replied that such an explanation would probably apply in the case of severe anemia, but there was only a small proportion of patients with hemoglobin levels less than 8 g/dL in the study.

Asked by Medscape Medical News whether anemia is merely a marker of frailty or if it directly contributes to the worse outcomes, Dr Sprigg said that in the latter case "if they have very severe anemia, you could give them a transfusion," thereby correcting the anemia and possibly ameliorating the outcomes.

There was no commercial funding for the study. Dr Sprigg and Dr Gajre have disclosed no relevant financial relationships.

World Stroke Congress (WSC) 2016. Abstract 183. Presented October 28, 2016.

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