# Functional outcome, five-year survival and burden of disease after size- and location-matched hemorrhagic versus ischemic stroke

## TL;DR

Hemorrhagic strokes lead to worse recovery and higher disease burden than ischemic strokes of the same size and location, despite similar long-term survival.

## Contribution

The study compares outcomes of matched hemorrhagic and ischemic strokes, isolating the effect of stroke type on disability and disease burden.

## Key findings

- Hemorrhagic stroke patients had worse functional outcomes compared to ischemic stroke patients.
- ICH resulted in higher Disability-Adjusted Life Years (DALYs) than AIS, due to greater years lived with disability and years of life lost.
- Five-year survival rates were similar between the two stroke types after matching for lesion size and location.

## Abstract

Worse functional outcome has been reported after hemorrhagic compared to ischemic stroke, yet it remains unclear whether the lesion size, location, or stroke etiology itself results in different degrees of disability. This study compares outcomes in ischemic vs. hemorrhagic stroke patients with matched lesion size and location.

Data from the longitudinal cohort study on intracerebral hemorrhage (ICH) care (2006–2015) and a retrospective registry on acute ischemic stroke (AIS) (2011–2015), both conducted at the university hospital Erlangen, were used to investigate patients with a single stroke lesion in the middle cerebral artery territory. Patient characteristics, lesion size and affected brain location according to the Alberta Stroke Program Early CT Score (ASPECTS) regions were balanced using propensity score matching. Functional outcomes (ordinal shift of modified Rankin scale (mRS) at 3 months), 5-year survival (Kaplan–Meier, Cox regression), and burden of disease (Disability-Adjusted Life Years [DALYs] = Years of Life Lost [YLL] + Years Lived with Disability [YLD]) were compared.

After propensity score matching, we analyzed 194 patients, divided equally into AIS or ICH cases. We observed a shift in mRS distribution towards better functional outcomes in favor of AIS over ICH (OR: 1.69, 95% CI: 1.02–2.79, p = 0.04), especially in younger patients (age < 75 years, OR: 3.23, 95% CI: 1.58–6.59, p < 0.01) and smaller lesion volumes (< 15 mL, OR: 4.48, 95% CI: 1.85–10.89, p < 0.01). The 5-year survival did not differ between groups (log-rank 0.63). Mean number of DALYs was higher following ICH compared to AIS in general (8.39 ± 5.18 vs. 5.90 ± 4.61, p < 0.001) and per milliliter of parenchymal lesion volume (0.31[0.14–0.81] vs. 0.24[0.10–0.41], p = 0.04). The higher number of DALYs is attributable to the higher number of YLDs (ICH, 3.49 ± 3.3 vs. AIS, 2.31 ± 2.86, p < 0.01) and YLLs (ICH, 4.90 ± 3.27 vs. AIS, 3.59 ± 3.08, p < 0.01) in matched patients following ICH compared to AIS.

For stroke lesions of matched size and location, patients with hemorrhagic stroke had worse functional outcome, greater disease burden in total and per ml, yet comparable long-term survival rates compared to those with ischemic stroke.