{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,6,13]],"date-time":"2026-06-13T04:56:30Z","timestamp":1781326590370,"version":"3.54.1"},"reference-count":25,"publisher":"MDPI AG","issue":"6","license":[{"start":{"date-parts":[[2026,6,8]],"date-time":"2026-06-08T00:00:00Z","timestamp":1780876800000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":["IJERPH"],"abstract":"<jats:p>Objective: On 28 February 2026, Israel entered direct large-scale hostilities with Iran under Operation Roaring Lion. The opening phase was characterized by repeated missile alerts, civilian protected-space instructions, and rapid reorganization of hospital activity into protected areas. We observed an apparent increase in strict spontaneous intracerebral hemorrhage admissions during March 2026 within our linked neurology\/neurosurgery services dataset. The aim of this preliminary single-center study was to determine whether March 2026 was temporally associated with a higher proportional burden of strict spontaneous intracerebral hemorrhage admissions compared with March cohorts from the preceding decade and whether this pattern was also observed for acute ischemic stroke or non-traumatic subarachnoid hemorrhage. Methods: We performed a retrospective observational cohort study of all unique March admissions captured within a linked neurology\/neurosurgery services dataset from 2016 through 2026. Hospitalizations were deduplicated by admission number. March 2026 was treated as the first full March occurring after the onset of direct Israel\u2013Iran hostilities on 28 February 2026. Strict spontaneous ICH was defined using diagnosis-text phenotyping that included intraparenchymal or intracerebral hemorrhage terminology while excluding trauma, subarachnoid hemorrhage, subdural hematoma, aneurysm, arteriovenous malformation, tumor-related hemorrhage, cavernoma, venous sinus thrombosis, dissection, and other clearly secondary etiologies. Comparator phenotypes included acute ischemic stroke and non-traumatic subarachnoid hemorrhage (SAH). Results: Across 3855 unique March admissions, 68 met criteria for strict spontaneous ICH. In March 2026, 9 of 223 admissions (4.0%) were classified as strict spontaneous ICH, compared with 59 of 3632 admissions (1.6%) across March 2016\u20132025, yielding a rate ratio of 2.48 (95% CI 1.25\u20134.94; p = 0.015). Patients with strict spontaneous ICH in March 2026 were older (mean age 72.3 vs. 65.8 years), and 7 of 9 cases (77.8%) occurred in patients aged \u226570 years compared with 25 of 59 (42.4%) historically (p = 0.073). Acute ischemic stroke did not increase in March 2026 (7.6% vs. 9.4%; p = 0.475), and non-traumatic SAH showed only a non-significant numerical increase (2.7% vs. 1.4%; p = 0.147). Sensitivity analyses showed a directionally consistent but statistically non-significant increase when March 2026 was compared with March 2025 alone (4.0% vs. 1.2%; rate ratio 3.36, 95% CI 0.92\u201312.27; p = 0.076) and with a rolling 3-year March baseline from 2023 through 2025 (4.0% vs. 2.1%; rate ratio 1.93, 95% CI 0.88\u20134.23; p = 0.143). In-hospital mortality among strict spontaneous ICH patients was 1 of 9 (11.1%) in March 2026 versus 4 of 59 (6.8%) in March 2016\u20132025. Conclusions: In this preliminary single-center neurology\/neurosurgery services cohort, March 2026 showed a higher proportional burden of strict spontaneous intracerebral hemorrhage admissions than March cohorts from the preceding decade, while acute ischemic stroke did not increase. Sensitivity analyses using March 2025 alone and a rolling 3-year March baseline were directionally consistent but did not reach statistical significance. These findings should therefore be interpreted as a hypothesis-generating temporal association rather than evidence of causality or population-level incidence. Wartime-related psychological stress, sleep disruption, altered healthcare access, blood pressure dysregulation, and medication nonadherence are biologically plausible contributors, but individual-level blood pressure, medication exposure, body mass index, time-to-admission, direct stress exposure, and detailed outcome data were not available in the present dataset. Multicenter, hospital-wide, and registry-based validation with seasonal and systems-level sensitivity analyses is required.<\/jats:p>","DOI":"10.3390\/ijerph23060772","type":"journal-article","created":{"date-parts":[[2026,6,9]],"date-time":"2026-06-09T00:43:54Z","timestamp":1780965834000},"page":"772","update-policy":"https:\/\/doi.org\/10.3390\/mdpi_crossmark_policy","source":"Crossref","is-referenced-by-count":0,"title":["Temporal Increase in Strict Spontaneous Intracerebral Hemorrhage Admissions During the First March Following Direct Israel\u2013Iran Hostilities: Preliminary Single-Center Findings from a Decade-Referenced Neuroscience Services Cohort"],"prefix":"10.3390","volume":"23","author":[{"ORCID":"https:\/\/orcid.org\/0009-0001-2637-8517","authenticated-orcid":false,"given":"Paz","family":"Kelmer","sequence":"first","affiliation":[{"name":"Department of Neurosurgery, Sheba Medical Center, Ramat Gan 6997801, Israel"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0003-3411-6266","authenticated-orcid":false,"given":"Shachar Zion","family":"Shemesh","sequence":"additional","affiliation":[{"name":"Department of Neurosurgery, Sheba Medical Center, Ramat Gan 6997801, Israel"},{"name":"Gray Faculty of Medicine, Tel Aviv University, Tel Aviv 6997801, Israel"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-2797-7861","authenticated-orcid":false,"given":"Jose","family":"Asprilla","sequence":"additional","affiliation":[{"name":"Department of Neurosurgery, Sheba Medical Center, Ramat Gan 6997801, Israel"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Omri","family":"Cohen","sequence":"additional","affiliation":[{"name":"Department of Neurosurgery, Sheba Medical Center, Ramat Gan 6997801, Israel"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Zvi R.","family":"Cohen","sequence":"additional","affiliation":[{"name":"Department of Neurosurgery, Sheba Medical Center, Ramat Gan 6997801, Israel"},{"name":"Gray Faculty of Medicine, Tel Aviv University, Tel Aviv 6997801, Israel"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0009-0002-7799-7323","authenticated-orcid":false,"given":"Lior","family":"Ungar","sequence":"additional","affiliation":[{"name":"Department of Neurosurgery, Sheba Medical Center, Ramat Gan 6997801, Israel"},{"name":"Dina Recanati School of Medicine, Reichman University, Herzeliya 4610101, Israel"},{"name":"Pain Center, Sheba Medical Center, Ramat Gan 6997801, Israel"}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"1968","published-online":{"date-parts":[[2026,6,8]]},"reference":[{"key":"ref_1","unstructured":"Israel Democracy Institute (2026, March 30). Declaration of a Special Home Front Situation: Legal and Operational Implications of Operation Roaring Lion. Available online: https:\/\/en.idi.org.il\/articles\/63607."},{"key":"ref_2","unstructured":"Horovitz, D. (2026, March 30). IDF Launches Operation Roaring Lion Against Iran: Opening Strikes and Missile Barrages. The Jerusalem Post. Available online: https:\/\/www.jpost.com\/middle-east\/iran-news\/article-888415."},{"key":"ref_3","unstructured":"World Health Organization (2026, March 30). Conflict Deepens Health Crisis Across Middle East: WHO Situation Report No. 1, Eastern Mediterranean Region. Available online: https:\/\/www.who.int\/news\/item\/11-03-2026-conflict-deepens-health-crisis-across-middle-east--who-says."},{"key":"ref_4","unstructured":"Radio Free Europe\/Radio Liberty (2026, March 30). Inside Israel\u2019s Largest Hospital as Doctors Work Underground Amid Iran War. Available online: https:\/\/www.rferl.org\/a\/underground-hospital-israel-war\/33706639.html."},{"key":"ref_5","doi-asserted-by":"crossref","unstructured":"Wang, S., Zou, X.L., Wu, L.X., Zhou, H.F., Xiao, L., Yao, T., Zhang, Y., Ma, J., Zeng, Y., and Zhang, L. (2022). Epidemiology of intracerebral hemorrhage: A systematic review and meta-analysis. Front. Neurol., 13.","DOI":"10.3389\/fneur.2022.915813"},{"key":"ref_6","doi-asserted-by":"crossref","first-page":"e282","DOI":"10.1161\/STR.0000000000000407","article-title":"2022 guideline for the management of patients with spontaneous intracerebral hemorrhage: A guideline from the American Heart Association\/American Stroke Association","volume":"53","author":"Greenberg","year":"2022","journal-title":"Stroke"},{"key":"ref_7","doi-asserted-by":"crossref","first-page":"14","DOI":"10.1038\/s41572-023-00424-7","article-title":"Intracerebral haemorrhage","volume":"9","author":"Puy","year":"2023","journal-title":"Nat. Rev. Dis. Prim."},{"key":"ref_8","doi-asserted-by":"crossref","unstructured":"Baig, E., Tannous, J., Potter, T., Pan, A., Prince, T., Britz, G., Vahidy, F.S., and Bako, A.T. (2023). Seasonal variation in the incidence of primary intracerebral hemorrhage: A 16-year nationwide analysis. Front. Neurol., 14.","DOI":"10.3389\/fneur.2023.1179317"},{"key":"ref_9","doi-asserted-by":"crossref","first-page":"563","DOI":"10.1080\/07420528.2016.1278223","article-title":"Seasonal variation in spontaneous intracerebral hemorrhage in northern Israel","volume":"34","author":"Telman","year":"2017","journal-title":"Chronobiol. Int."},{"key":"ref_10","doi-asserted-by":"crossref","first-page":"460","DOI":"10.1177\/23969873231223031","article-title":"Age-dependent seasonality in the incidence of stroke: A 21-year population-based study","volume":"9","author":"Libruder","year":"2024","journal-title":"Eur. Stroke J."},{"key":"ref_11","doi-asserted-by":"crossref","first-page":"565","DOI":"10.1016\/j.jocn.2012.02.052","article-title":"Seasonal variation in spontaneous intracerebral hemorrhage frequency in Chengdu, China, is independent of conventional risk factors","volume":"20","author":"Wang","year":"2013","journal-title":"J. Clin. Neurosci."},{"key":"ref_12","doi-asserted-by":"crossref","unstructured":"Zheng, D., Arima, H., Sato, S., Gasparrini, A., Heeley, E., Delcourt, C., Lo, S., Huang, Y., Wang, J., and Stapf, C. (2016). Low ambient temperature and intracerebral hemorrhage: The INTERACT2 study. PLoS ONE, 11.","DOI":"10.1371\/journal.pone.0149040"},{"key":"ref_13","doi-asserted-by":"crossref","unstructured":"Czernych, R., Kozera, G., Badyda, A.J., Bieniaszewski, L., and Zagozdzon, P. (2024). Air pollution increases risk of occurrence of intracerebral haemorrhage but not of subarachnoid haemorrhage: Time-series cross-sectional study. Biomedicines, 12.","DOI":"10.3390\/biomedicines12071562"},{"key":"ref_14","doi-asserted-by":"crossref","unstructured":"Khalifa, M.A., Alardhi, A.S., Alharbi, G.F.S., Mousa, M., Alzahrani, A., Taqi, B.A., Alsalman, F.S., Basher, G., Albalawi, M., and Alzahrani, S.A. (2025). Psychosocial stress and stroke risk: Meta-analysis of observational studies. Front. Neurol., 16.","DOI":"10.3389\/fneur.2025.1669925"},{"key":"ref_15","doi-asserted-by":"crossref","first-page":"614","DOI":"10.1007\/s00415-012-6687-z","article-title":"Seasonal and meteorological determinants of aneurysmal subarachnoid hemorrhage: A systematic review and meta-analysis","volume":"260","author":"Algra","year":"2013","journal-title":"J. Neurol."},{"key":"ref_16","doi-asserted-by":"crossref","first-page":"e16413","DOI":"10.1111\/ene.16413","article-title":"Diagnostic accuracy and radiological validation of intracerebral hemorrhage diagnosis in the Swedish Stroke Register (Riksstroke)","volume":"31","author":"Sultani","year":"2024","journal-title":"Eur. J. Neurol."},{"key":"ref_17","doi-asserted-by":"crossref","first-page":"12","DOI":"10.1038\/jhh.2008.74","article-title":"Does psychosocial stress cause hypertension? A systematic review of observational studies","volume":"23","author":"Sparrenberger","year":"2009","journal-title":"J. Hum. Hypertens."},{"key":"ref_18","doi-asserted-by":"crossref","first-page":"215","DOI":"10.1038\/nrcardio.2017.189","article-title":"Effects of stress on the development and progression of cardiovascular disease","volume":"15","author":"Steptoe","year":"2018","journal-title":"Nat. Rev. Cardiol."},{"key":"ref_19","first-page":"467","article-title":"Acute stress and subsequent risk of ischaemic stroke and spontaneous intracerebral haemorrhage: A cohort study using individual-level linked data","volume":"27","author":"Jarden","year":"2020","journal-title":"Eur. J. Prev. Cardiol."},{"key":"ref_20","doi-asserted-by":"crossref","first-page":"833","DOI":"10.1161\/01.HYP.0000217362.34748.e0","article-title":"Short sleep duration as a risk factor for hypertension: Analyses of the first National Health and Nutrition Examination Survey","volume":"47","author":"Gangwisch","year":"2006","journal-title":"Hypertension"},{"key":"ref_21","doi-asserted-by":"crossref","first-page":"610","DOI":"10.1097\/HJH.0b013e328342ca97","article-title":"Better compliance to antihypertensive medications reduces cardiovascular risk","volume":"29","author":"Corrao","year":"2011","journal-title":"J. Hypertens."},{"key":"ref_22","doi-asserted-by":"crossref","first-page":"e127","DOI":"10.1016\/j.jacc.2017.11.006","article-title":"2017 ACC\/AHA\/AAPA\/ABC\/ACPM\/AGS\/APhA\/ASH\/ASPC\/NMA\/PCNA guideline for the prevention, detection, evaluation, and management of high blood pressure in adults","volume":"71","author":"Whelton","year":"2018","journal-title":"J. Am. Coll. Cardiol."},{"key":"ref_23","doi-asserted-by":"crossref","first-page":"1309","DOI":"10.1001\/jamaneurol.2019.2167","article-title":"Effect of standard vs intensive blood pressure control on the risk of recurrent stroke: A randomized clinical trial and meta-analysis","volume":"76","author":"Kitagawa","year":"2019","journal-title":"JAMA Neurol."},{"key":"ref_24","doi-asserted-by":"crossref","first-page":"26","DOI":"10.1016\/j.ctim.2017.07.008","article-title":"Transcendental meditation for lowering blood pressure: An overview of systematic reviews and meta-analyses","volume":"34","author":"Ooi","year":"2017","journal-title":"Complement. Ther. Med."},{"key":"ref_25","doi-asserted-by":"crossref","first-page":"169","DOI":"10.1037\/a0018555","article-title":"The effect of mindfulness-based therapy on anxiety and depression: A meta-analytic review","volume":"78","author":"Hofmann","year":"2010","journal-title":"J. Consult. Clin. Psychol."}],"container-title":["International Journal of Environmental Research and Public Health"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/www.mdpi.com\/1660-4601\/23\/6\/772\/pdf","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2026,6,13]],"date-time":"2026-06-13T04:13:58Z","timestamp":1781324038000},"score":1,"resource":{"primary":{"URL":"https:\/\/www.mdpi.com\/1660-4601\/23\/6\/772"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2026,6,8]]},"references-count":25,"journal-issue":{"issue":"6","published-online":{"date-parts":[[2026,6]]}},"alternative-id":["ijerph23060772"],"URL":"https:\/\/doi.org\/10.3390\/ijerph23060772","relation":{},"ISSN":["1660-4601"],"issn-type":[{"value":"1660-4601","type":"electronic"}],"subject":[],"published":{"date-parts":[[2026,6,8]]}}}