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Original Investigation
August 2017

Association Between Cirrhosis and Stroke in a Nationally Representative Cohort

Author Affiliations
  • 1Clinical and Translational Neuroscience Unit, Feil Family Brain and Mind Research Institute, New York, New York
  • 2Department of Neurology, Weill Cornell Medicine, New York, New York
  • 3Division of Gastroenterology and Hepatology, Weill Cornell Medicine, New York, New York
JAMA Neurol. 2017;74(8):927-932. doi:10.1001/jamaneurol.2017.0923
Key Points

Questions  Do patients with cirrhosis experience an increased risk of stroke, and does the risk differ by stroke type?

Findings  In this cohort study of 1 618 059 Medicare beneficiaries, patients with cirrhosis faced an increased risk of stroke, and associations appeared stronger for hemorrhagic stroke than for ischemic stroke.

Meaning  Patients with cirrhosis face an increased risk of stroke, particularly hemorrhagic stroke. These findings in a vascular bed that is independent of portal hypertension may reflect the clinical implications of the mixed coagulopathy observed in cirrhosis.


Importance  Cirrhosis is associated with hemorrhagic and thrombotic extrahepatic complications. The risk of cerebrovascular complications is less well understood.

Objective  To investigate the association between cirrhosis and various stroke types.

Design, Setting, and Participants  We performed a retrospective cohort study using inpatient and outpatient Medicare claims data from January 1, 2008, through December 31, 2014, for a random 5% sample of 1 618 059 Medicare beneficiaries older than 66 years.

Exposures  Cirrhosis, as defined by a validated diagnosis code algorithm.

Main Outcomes and Measures  The primary outcome was stroke, and secondary outcomes were ischemic stroke, intracerebral hemorrhage, and subarachnoid hemorrhage as defined by validated diagnosis code algorithms.

Results  Among 1 618 059 beneficiaries, 15 586 patients (1.0%) had cirrhosis (mean [SD] age, 74.1 [6.9] years; 7263 [46.6%] female). During a mean (SD) of 4.3 (1.9) years of follow-up, 77 268 patients were hospitalized with a stroke. The incidence of stroke was 2.17% (95% CI, 1.99%-2.36%) per year in patients with cirrhosis and 1.11% (95% CI, 1.10%-1.11%) per year in patients without cirrhosis. After adjustment for demographic characteristics and stroke risk factors, patients with cirrhosis had a higher risk of stroke (hazard ratio [HR], 1.4; 95% CI, 1.3-1.5). The magnitude of association appeared to be higher for intracerebral hemorrhage (HR, 1.9; 95% CI, 1.5-2.4) and subarachnoid hemorrhage (HR, 2.4; 95% CI, 1.7-3.5) than for ischemic stroke (HR, 1.3; 95% CI, 1.2-1.5).

Conclusions and Relevance  In a nationally representative sample of Medicare beneficiaries, cirrhosis was associated with an increased risk of stroke, particularly hemorrhagic stroke. A potential explanation of these findings implicates the mixed coagulopathy observed in cirrhosis.