Sex-specific hemoglobin thresholds and longitudinal trajectories in intracerebral hemorrhage outcomes: a multicenter cohort study

Does anything here get survivors recovered? NO? So, useless!

Sex-specific hemoglobin thresholds and longitudinal trajectories in intracerebral hemorrhage outcomes: a multicenter cohort study

• Yu-jia Jin, 
• Guo-shen Yu, 
• Li-li Tang, 
• Jia-wen Li, 
• Qing Lin, 
• Jian Wu, 
• Zai-jun Song, 
• Hong-na An, 
• Xiang-hua Ye, 
• Cheng-jia Liu, 
• Feng Gao & 
• Lu-sha Tong 

BMC Neurology volume 25, Article number: 287 (2025) Cite this article

Abstract

Background

We aim to investigate the association between admission hemoglobin and outcomes after primary intracerebral hemorrhage (ICH), including 3-month outcome and long-term survival and recurrence.

Methods

Utilizing a multicenter stroke registry database, we retrospectively analyzed patients with spontaneous ICH confirmed within 48 h of symptom onset who had admission hemoglobin measurements and baseline neuroimaging. Cox proportional hazards regression models were employed to evaluate associations between admission hemoglobin levels and risks of all-cause mortality and ICH recurrence during follow-up. Nonlinear relationships were assessed using threshold effect models with inflection point determination. Sensitivity analyses were restricted to patients who underwent repeated routine blood testing during hospitalization to examine whether increased hemoglobin levels during hospitalization correlated with improved clinical outcomes.

Results

The cohort comprised 2,407 patients (mean age 64 ± 14 years; 65.1% male) with spontaneous ICH, followed for a median duration of 2.0 years (IQR 0.8–3.2). Threshold analysis revealed a nonlinear L-shaped association between admission hemoglobin and mortality. Below 14.3 g/dL, hemoglobin elevation correlated with reduced mortality risk (adjusted HR 0.88 per 1-g/dL increase, 95% CI 0.81–0.95). Above this threshold, no significant association was observed (HR 1.13, 95% CI 0.98–1.31). Lower admission hemoglobin was independently associated with higher ICH recurrence risk (HR 0.88 per 1-g/dL decrease, 95% CI 0.775–0.998). In sensitivity analyses of 954 patients with serial hemoglobin measurements, improved 3-month functional outcomes and reduced long-term mortality were observed in patients with longitudinal elevation during hospitalization.

Conclusions

Admission hemoglobin demonstrates a L-shaped association with post-ICH mortality, with inflection point observed near 14.3 g/dL. Lower hemoglobin independently predicts higher hemorrhage recurrence risk. Longitudinal hemoglobin elevation during hospitalization correlates with improved functional outcomes and survival.

Trial registration

Clinical trials NCT06548737 (retrospectively registered)

Key points

What is already known on this topic

Prior studies in general acute stroke (ischemic or hemorrhagic stroke) populations describe a U-shaped association between hemoglobin levels and mortality. However, thresholds specific to ICH outcomes remain undefined, particularly in sex-specific contexts.

What this study adds

Based on a multi-center cohort with 2.0 (IQR 0.8–3.2) years of follow-up, we found a baseline hemoglobin level of at least 14.3 g/dL was associated with better prognosis (3-month outcome, and long-term survival and ICH prevention) of patients. Improved 3-month functional outcomes and reduced long-term mortality were observed in patients with longitudinal elevation during hospitalization.

How this study might affect research, practice or policy

Managing the hemoglobin level in the acute phase after ICH could be a possible treatment therapy.