Regular Physical Activity Leads to Reduced Hematoma Volumes in Intracerebral Hemorrhage

Katharina Stibrant Sunnerhagen, MD, PhD

A recently published longitudinal study in the journal of Stroke and Vascular Neurology showed that patients who engaged in light physical activity prior to experiencing an intracerebral haemorrhage (ICH) had reduced hematoma volumes in deep and lobar locations. These findings suggest that prestroke physical activity may decrease admission hematoma volume, improve recovery, and prevent mortality in primary ICH.¹

Physical activity prestroke for at least 4 hours a week was associated with 36% smaller hematoma volumes in deep ICH (β=−0.36; SE=0.09; P <.001) and 23% smaller hematoma volumes in lobar ICH (β=−0.23; SE=0.09; P = .016). Notably, patients who were physically active more often presented with mild stroke severity at admission (57% vs 26%), good functional status after 1 week (54% vs 19%), and had higher rates of survival at 90 days (92% vs 66%) compared patients who were inactive.

Lead author Adam Viktorisson, a PhD student in clinical neuroscience at Sahlgrenska Academy, University of Gothenburg, and doctor in general practice at Sahlgrenska University Hospital, said in a statement, “We found that individuals who engage in regular physical activity had, on average, bleeding volumes that were 50 percent smaller upon arriving to the hospital. A similar connection has previously been seen in animal studies, but no prior study has demonstrated this in humans.”²

Of 686 primary ICH cases in the study between 2014 and 2019, 349 were deep, 240 lobar, and 97 infratentorial, all from Sahlgrenska University Hospital. Enrolled patients were considered physically active if they performed light physical activity for at least 4 hours a week the year before they had a stroke, which included walking, cycling, swimming, gardening, or dancing. Using multivariate linear and logistic regression models, adjusted associations were estimated. The hematoma volume was investigated as mediator to the potential association between prestroke physical activity and mild stroke severity, a good 1-week functional status, and 90-day survival. Also, average direct effects (ADE) and average causal mediation effects (ACME) were analyzed.

The average age of the participants in the study was 73 years old (SD,14), 320 (47%) patients were women, and 235 (38%) were physically active. There was only 1 patient that performed vigorous physical activity, and 31 patients who did moderate physical activity before their stroke. Authors noted that the inactive patients were predominately older women who had more comorbid conditions with a higher frequency of antihypertensive treatment and anticoagulation.

Additional findings showed that smaller hematoma volumes were associated with longer time to scan (β=−0.046; SE=0.02; P = .002), active physical activity (β = −0.313; SE = 0.06; P <0.001) and higher education levels (β = −0.175; SE = 0.07; P = 0.008). Conversely, larger hematoma volumes were associated with an increasing International Normalized Ratio, a measure of blood clotting time (β = 0.117; SE = 0.06; P = 0.048).

The study also showed that hematoma volume partially mediated the relationship between physical activity and stroke severity (ADE, 0.08, P = .004; ACME, 0.10, P <.001), 1-week functional status (ADE, 0.07, P = 0.03; ACME, 0.10, P <.001) and 90-day survival (ADE, 0.14, P <.001; ACME, 0.05, P <.001). There was no significance observed between physical activity and infratentorial hematoma volume after accounting for other factors (β = −0.29; SE = 0.19; P = .114).

“In cases of major intracerebral hemorrhages, there is a risk of increased pressure within the skull that can potentially lead to fatal outcomes” coauthor Thomas Skoglund, MD, PhD associate professor of neurosurgery at the University of Gothenburg, neurosurgeon at the University Hospital said in a statement.²

Authors noted several limitations in the study, including a small sample size of patients with infratentorial ICH which may have affected the detection of significant differences. Another limitation was the use of self-reported and retrospective assessments of prestroke physical activity, which could have introduced biases. The lack of automated software for accurate quantification of ICH volume and the nonrandomized design of the study also posed as a limitation. The study also did not investigate the relationship between prestroke physical activity and hematoma expansion as well as factors including pain, fatigue, and emotional distress following ICH.

“We hope that our findings contribute to a deeper understanding of intracerebral hemorrhages and aid in the development of more effective preventive measures” senior author Katharina Stibrant Sunnerhagen, MD, PhD professor of rehabilitation medicine at the University of Gothenburg and senior consultant physician at Sahlgrenska University Hospital said in a statement.²

REFERENCES
1. Viktorisson A, Buvarp D, Danielsson A, Skoglund T, S Sunnerhagen K. Prestroke physical activity is associated with admission haematoma volume and the clinical outcome of intracerebral haemorrhage. Stroke Vasc Neurol. 2023;svn-2023-002316. doi:10.1136/svn-2023-002316
2. Exercise seems to protect against major brain hemorrhage. News Release. University of Gothenburg. Published May 22, 2023. Accessed May 24, 2023. https://www.gu.se/en/news/exercise-seems-to-protect-against-major-brain-hemorrhage