Heavy Alcohol Use Tied to More-Severe Intracerebral Hemorrhages

Consuming at least three alcoholic drinks per day is associated with increased severity of acute intracerebral hemorrhage (ICH) and signs of more advanced cerebral small vessel disease, researchers report.

When heavy drinkers presented with ICH, they were significantly younger, had larger hematoma volumes, and had greater odds of a deep hemorrhage location and intraventricular extension compared with those who drank less or abstained completely, according to researchers led by Mette Foldager Hindsholm, MD (Mass General Brigham and Harvard Medical School, Boston).

In addition, heavy alcohol users were more likely to have severe white matter hyperintensities (WMHs) and hypertensive or mixed-location cerebral small vessel disease on MRI and had higher blood pressure and lower platelet counts when admitted to the hospital.

The findings, published online this week in Neurology, “suggest that heavy alcohol use may exacerbate acute ICH severity and accelerate long-term cerebral small vessel pathology,” the authors write, adding that “future studies should clarify alcohol-related mechanisms underlying cerebral small vessel disease progression and ICH severity and inform prevention strategies.”

Senior author M. Edip Gurol, MD (Mass General Brigham and Harvard Medical School), said there are markers, including cerebral microbleeds, severe white matter disease, and superficial siderosis, that can identify individuals with an increased risk for ICH. And patients who have one ICH have a greater risk of another one.

To prevent hemorrhagic strokes, patients are advised to follow general preventive measures like keeping their blood pressure under control, not smoking, and avoiding strong anticoagulants, Gurol told TCTMD, but there are no specific interventions meant to cut the risk of ICH. In that scenario, it’s important to understand how to manage other risk factors, such as alcohol consumption, he said.

Based on these results, “I will tell my patients who already sustained a brain bleed to really, really minimize alcohol intake, and when I say minimize, I mean not taking more than a glass of alcohol only a few times per year,” Gurol said. “I will essentially ask them to stop using alcohol or to take very little.”

The same advice would apply to patients deemed to have a high risk of a first ICH—for example, those with brain microbleeds, severe resistant hypertension, or obstructive sleep apnea, he added.

For the rest of the population without a higher-than-usual risk of hemorrhagic stroke, Gurol said his recommendation is to drink no more than three servings of alcohol per week because consuming more is associated with greater risks of atrial fibrillation and other vascular problems.

Possible Drivers: High BP, Platelet Function

Though prior studies have linked alcohol consumption to a greater risk of ICH, the potential influence of drinking on the severity of acute ICH and cerebral small vessel disease is unclear.

For this study, investigators performed a cross-sectional analysis of prospectively collected data on 1,600 patients (median age 75 years; 53% men) admitted to Massachusetts General Hospital with spontaneous, nontraumatic ICH between 2003 and 2019. Overall, 7% met criteria for heavy alcohol use, defined as regular consumption of at least three drinks per day. That level of drinking has been previously associated with elevated BP, platelet dysfunction, and vascular damage.

Compared with patients who drank less than three drinks per day or didn’t consume any alcohol, heavy drinkers were significantly younger at ICH onset (median age 64 vs 75 years; P < 0.001). CT scans also showed larger hematoma volumes (median 28.7 vs 17.0 mL; P = 0.002) and greater odds of having a deep hemorrhage location (adjusted OR 2.01; 95% CI 1.11-3.64) and intraventricular extension (adjusted OR 1.94; 95% CI 1.02-3.71).

A history of heavy alcohol use also was tied to lower platelet counts (P = 0.021) and higher mean arterial pressure (P = 0.047) at admission. Those who drank the most had a longer median hospital stay (11 vs 7 days; P = 0.006) and a greater likelihood of transitioning from being independent before ICH to dependent after the event (adjusted OR 1.92; 95% CI 1.12-3.31), despite the lack of a difference between groups in admission Glasgow Coma Scale scores or in-hospital mortality.

“This apparent paradox,” the authors say, “may be partly explained by the younger age and lower burden of cardiovascular comorbidities in the heavy alcohol use group, potentially conferring greater physiologic resilience during the acute phase.”

About three-quarters of the cohort underwent brain MRI a median of 2 days after ICH onset, and these scans revealed greater odds of severe WMHs (adjusted OR 3.04; 95% CI 1.43-6.49) and of hypertensive or mixed-location cerebral small vessel disease (adjusted OR 1.82; 95% CI 1.04-3.20) in the heavy drinkers compared with the other patients.

Collectively, the findings indicate that heavy alcohol use possibly influences the severity of acute ICH and cerebral small vessel disease through mechanisms related to chronic high BP and impaired platelet function, Gurol said, suggesting that “alcohol decreases the coagulation pathway.”

He wishes he could run a randomized trial to confirm these results, but since that’s not possible, Gurol said, a larger, community-based study that includes brain MRIs could provide important insights into the effects of consuming alcohol, as well as the impact of either reducing intake or stopping altogether.

For now, this study “underscores excessive alcohol consumption as a modifiable cerebrovascular risk factor with significant public health implications,” the investigators write.

For instance, they say, “from a preventive neurology perspective, reducing heavy alcohol consumption may not only decrease the risk of ICH but also slow the progression of cerebral small vessel disease, with potential downstream benefits in reducing stroke recurrence, cognitive decline, and long-term disability.”