Heavy alcohol consumption — three or more drinks a day — is linked to earlier and more severe intracerebral hemorrhage (ICH), a new study showed.

Heavy drinkers experienced ICH about 11 years sooner than nonheavy drinkers, with significantly larger hematoma size and imaging features consistent with more advanced cerebral small vessel disease (cSVD), including a greater burden of white matter hyperintensities.

“While heavy drinking has been linked in previous studies to an increased risk of stroke, our findings suggest that it doesn’t just increase the severity of a bleeding stroke, it may also accelerate long-term harm to the brain’s small vessels,” study investigator Edip Gurol, MD, associate professor of neurology at the Harvard Medical School and stroke neurologist at the Mass General Brigham Hospital, both in Boston, said in a news release.

The study was published online on November 5 in Neurology.

‘A Lethal Condition’

Acute ICH is considered the most deadly type of stroke, comprising an estimated 10%-15% of annual strokes in the US. It is most often caused by cerebral cSVD, a progressive condition linked to hypertension and aging. Modifiable risk factors for cSVD include high blood pressure, smoking, and alcohol use.

However, although heavy alcohol use has been associated with an increased risk for ICH, few studies have examined its effect on hemorrhage severity and cSVD burden.

To address this knowledge gap, the investigators looked at whether chronic heavy drinking accelerates microvascular injury through sustained hypertension, endothelial dysfunction, and impaired hemostasis, potentially leading to earlier and more severe ICH.

For the study, the researchers analyzed data from 1600 patients (53% male; median age, 75 years) admitted to the Massachusetts General Hospital for ICH. Patient alcohol consumption was reported by the patient or the person with them.

Heavy alcohol use was defined as consuming three or more drinks per day. Participants were categorized as heavy drinkers (three or more drinks per day) or nonheavy drinkers (fewer than three or no drinks per day).

CT scans were used to assess brain bleed volume, location, and spread. MRI scans were used to evaluate damage to blood vessels, based on markers including white matter hyperintensities, cerebral microbleeds, cortical superficial siderosis, and lacunes.

Models were adjusted for covariates including age, sex, race, smoking, hypertension, diabetes, hyperlipidemia, and previous stroke risks.

Hemorrhage location or hematoma volume models were further adjusted for medication use and the time from ICH to CT scan.

Minimizing Risk

Among those with ICH, 7% were heavy drinkers. The heavy drinkers were 11 years younger than the nonheavy drinkers’ group at the time of ICH (median age, 64 years vs 75 years; P < .001).

Heavy drinkers had larger brain bleeds (1.7 fold increase; P = .005). They were twice as likely to have bleeding in deep brain regions (P = .021) and to have bleeding spread to the brain’s ventricular system (P = .045).

After adjustment for baseline covariates, heavy drinking was significantly associated with severe white matter hyperintensities, indicative of small blood vessel damage (adjusted odds ratio, 3.04; P = .004).

In addition, the heavy drinkers had a lower platelet number and higher blood pressure, which could be contributing factors to stroke risk, the investigators noted.

“Minimizing or stopping alcohol use is an important step to lower that risk. Even for people at relatively low brain bleeding risk, limiting alcohol consumption to no more than three drinks per week may be an effective measure to protect against all types of stroke and to preserve both brain and cardiovascular health,” Gurol said.

Limitations of the study were that alcohol use was self-reported, the influence of other substances was not fully assessed, and only patients from a single hospital were included.

See article for full list of author disclosures. This study was funded by National Institutes of Health (NINDS/NIA R01NS114526, NS 083711).