Effects of Heavy Alcohol Use on Acute Intracerebral Hemorrhage and Cerebral Small Vessel Disease

BACKGROUND AND OBJECTIVES: Heavy alcohol use (HAU) is a modifiable risk factor that may influence intracerebral hemorrhage (ICH) severity and cerebral small vessel disease (cSVD), but its role remains insufficiently understood. We aimed to investigate how HAU is associated with acute ICH characteristics and cSVD burden. METHODS: In this cross-sectional study, we analyzed prospectively collected data from consecutive patients admitted with spontaneous, nontraumatic ICH to Massachusetts General Hospital between 2003 and 2019. HAU was defined as regular alcohol consumption of ≥3 drinks per day. Multivariable regression models assessed associations between HAU and acute ICH clinical and radiologic features and MRI markers of cSVD. RESULTS: Among 1,600 patients (851 male patients [53%]; median age 75 [interquartile range 64-82] years), 104 (7%) met criteria for HAU. Compared with the non-HAU cohort, patients with HAU were significantly younger at ICH onset (median 64 vs 75 years; p < 0.001) and had larger hematoma volume (1.7-fold increase, p = 0.005) and greater odds of deep hemorrhage location (adjusted odds ratio [aOR] 2.01; 95% CI 1.11-3.64; p = 0.021) and intraventricular extension (aOR 1.95; 95% CI 1.02-3.70; p = 0.045). Among 1,195 patients with MRI (75%), analysis of markers of cSVD showed that HAU was independently associated with severe white matter hyperintensities (aOR 3.04; 95% CI 1.43-6.49; p = 0.004) and a hypertensive cSVD pattern (aOR 1.82; 95% CI 1.04-3.20; p = 0.035). No other MRI markers of cSVD were associated with HAU. HAU was also associated with lower platelet counts (β = -17.73; 95% CI -32.75 to -2.72; p = 0.021) and higher admission blood pressure (β = 4.81; 95% CI 0.06-9.56; p = 0.047). DISCUSSION: HAU is associated with younger age at ICH onset, larger hematoma size, and imaging features consistent with more advanced hypertensive cSVD, including a greater burden of white matter hyperintensities. These findings suggest that HAU may exacerbate acute ICH severity and accelerate long-term cerebral small vessel pathology. Study limitations include the cross-sectional design, MRI availability restricted to a subset, and lack of detailed lifetime alcohol exposure. Future studies should clarify alcohol-related mechanisms underlying cSVD progression and ICH severity and inform prevention strategies.