Most patients with Severe Intracerebral Hemorrhage who die in hospital do so after the decision is made to withdraw life support measures.
The prediction of future recovery, thanks to the inclusion of previous hospital events, pre-existing conditions, and responses to model therapies. Photo: Shutterstock.
New and better expectations for those survivors of Severe Intracerebral Hemorrhage (HIC) and intraventricular hemorrhage (HIV) that initially appeared to have poor long-term functional outcomes now
Researchers analyzed functional outcome trajectories in more than 700 survivors of ICH or HIV, who had shown very poor functional outcomes at day 30 post-incident.
Hence, it was possible to identify that more than 40% of these patients achieved favorable results after one year, one third being more functional and independent; so too after one year, almost two thirds had returned home and quality of life scores showed a significant upward trajectory.
One of the best results is due to the prediction of future recovery, thanks to the inclusion of previous hospital events, pre-existing conditions, and responses to model therapies.
“The main take-home message from this study is that the approach of many ICH patients needs to change,” said study senior author Wendy Ziai, MD, MPH, medical director of the neurovascular laboratory and professor of neurology. from Johns Hopkins Hospital, Baltimore, Maryland. She also confirmed that “the data support longer evaluation periods for ICH patients with in-hospital observation of events and response to therapy to provide a better understanding of the long term recovery“.
Historically, ICH prognosis is done at admission, and most models predict short-term outcomes. Most studies also do not describe the long term recovery among people with initial severe disability.
Most prognostic models include baseline ICH severity factors but do not take into account comorbidities, hospital interventions, and complications, whereas IVH classification scales typically incorporate only baseline IVH volume, but not the expansion, volume reduction or hydrocephalus of IVH, which “can also affect recovery,” he said.
“The majority of ICH patients who die in hospital do so after the decision is made to withdraw life support measures, due to providers’ perception of a high probability of poor long-term outcomes,” he said. , Dr. Ziai.
“These decisions may result in a self-fulfilling prophecy of poor outcomes,” he continued, saying, “even do-not-resuscitate orders are associated with an increased risk of mortality and may reduce the likelihood of a favorable functional outcome when instituted early.”
To assess outcome trajectories 1 year after ICH, the investigators performed a post hoc longitudinal analysis of the 500 patients with spontaneous obstructive IVH randomized to intraventricular alteplase or placebo in the CLEAR-III trial and 499 patients with supratentorial ICH large spontaneous without obstructive IVH. HIV randomized to stereotactic thrombolysis or standard care in the MISTIE trial.
Both trials were neutral for the primary endpoint of improved functional outcome, but found significant reductions in mortality in the active treatment groups at 180 days and 1 year, respectively.
The final pooled cohort included 715 patients who survived to day 30 with a modified Rankin scale (mRS) score of 4 (29.5%) or 5 (69.5%). Their median age was 60.3 years, 58% were male, 68.6% white, 24.3% black, and 13.7% Hispanic.
Baseline characteristics included age, gender, race, ethnicity, stroke-related comorbidities, Glasgow Coma Scale score, and National Institutes of Health Stroke Scale score ( NIHSS), as well as hematoma volumes (measured at admission, at ICH stability, and, IVH, at end of treatment and at day 30 from enrollment in both trials).
The primary outcome measure was 1-year mRS, with assessments performed in both trials at days 30, 180, and 365.
Patients were divided into two groups based on a 1-year outcome of “good” (mRS 0 – 3) and “poor” (mRS 4 – 6).
Secondary outcomes were 1-year mortality, withdrawal of life-sustaining treatment, discharge home, and European Visual Analogue Scale quality of life score.
Avoid early withdrawal of life-sustaining therapies
At 1 year, 18% of participants had died, 43% had achieved mRS scores of 0 to 3, and 64.6% of survivors had returned home at a median of 98 (52 to 302) subsequent days.
Among the 308 patients who recovered with a good outcome at 1 year, 95.4% returned home. Additionally, the 41% who had a persistently poor outcome at 1 year were also able to return home.
In models adjusted for the pooled cohort, the factors in the following table at day 30 were associated with lack of recovery.
Graphic, taken from MedScape.
On the other hand, resolution of ICH (Possibility of Occurrence aOR, 1.82; 95% CI, 1.08 – 3.04) and IVH (aOR, 2.19; 95% CI, 1.02 – 4.68) at day 30 was associated with good recovery. Leave.
Additional factors associated with poor outcome included cerebral perfusion pressure less than 60 mm, sepsis, prolonged mechanical ventilation, and the need to monitor intracranial pressure.
Thirty-day event-based models “strongly predicted” the 1-year outcome (AUC, 0.87; 95% CI, 0.83 – 0.90), with “significantly improved discrimination” compared with using baseline severity factors alone (AUC, 0.76; 95% CI, 0.71-0.80), the authors report.
“Although there are as yet no proven interventions for patients with ICH that definitively improve outcomes, effective hematoma volume reduction, as studied in these clinical trials, was significantly associated with a better ability to discriminate between patients who achieved functional recovery. end after 1 year and those that don’t,” Ziai said.
The findings “highlight the importance of promoting aggressive treatment and avoiding early withdrawal of life-sustaining therapies in the acute phase after ICH,” he said.
Magdy Selim, MD, PhD, a professor of neurology at Beth Israel Deaconess Medical Center in Boston, Massachusetts, said the study results have “practice-changing implications,” recovery after ICH is “slow, but many patients are likely to recover with aggressive care and time,” he said.
Patients and families “should be informed that the effects of aggressive measures may not be apparent in the short term and that patients with ICH require patience from their providers and caregivers,” said Selim, who was not involved in the study.
He noted that most deaths after ICH are the result of early withdrawal of care “due to perceptions of poor long-term outcome by treating physicians and family.” The study’s findings “clearly point out that clinicians and families should exercise caution before limiting aggressive care early on, to maximize patients’ chances of recovery.”
Source consulted here.