Early Do-Not-Resuscitate Orders and Outcome After Intracerebral Hemorrhage

Artificial Intelligence and Machine Learning Applications in Critically Ill Brain Injured Patients

The utilization of Artificial Intelligence (AI) and Machine Learning (ML) is paving the way for significant strides in patient diagnosis, treatment, and prognostication in neurocritical care. These technologies offer the potential to unravel complex patterns within vast datasets ranging from vast clinical data and EEG (electroencephalogram) readings to advanced cerebral imaging facilitating a more nuanced understanding of patient conditions. Despite their promise, the implementation of AI and ML faces substantial hurdles. Historical biases within training data, the challenge of interpreting multifaceted data streams, and the "black box" nature of ML algorithms present barriers to widespread clinical adoption. Moreover, ethical considerations around data privacy and the need for transparent, explainable models remain paramount to ensure trust and efficacy in clinical decision-making.This article reflects on the emergence of AI and ML as integral tools in neurocritical care, discussing their roles from the perspective of both their scientific promise and the associated challenges. We underscore the importance of extensive validation in diverse clinical settings to ensure the generalizability of ML models, particularly considering their potential to inform critical medical decisions such as withdrawal of life-sustaining therapies. Advancement in computational capabilities is essential for implementing ML in clinical settings, allowing for real-time analysis and decision support at the point of care. As AI and ML are poised to become commonplace in clinical practice, it is incumbent upon health care professionals to understand and oversee these technologies, ensuring they adhere to the highest safety standards and contribute to the realization of personalized medicine. This engagement will be pivotal in integrating AI and ML into patient care, optimizing outcomes in neurocritical care through informed and data-driven decision-making.

Code ICH: A Call to Action

Intracerebral hemorrhage is the most serious type of stroke, leading to high rates of severe disability and mortality. Hematoma expansion is an independent predictor of poor functional outcome and is a compelling target for intervention. For decades, randomized trials aimed at decreasing hematoma expansion through single interventions have failed to meet their primary outcomes of statistically significant improvement in neurological outcomes. A wide range of evidence suggests that ultra-early bundled care, with multiple simultaneous interventions in the acute phase, offers the best hope of limiting hematoma expansion and improving functional recovery. Patients with intracerebral hemorrhage who fail to receive early aggressive care have worse outcomes, suggesting that an important treatment opportunity exists. This consensus statement puts forth a call to action to establish a protocol for Code ICH, similar to current strategies used for the management of acute ischemic stroke, through which early intervention, bundled care, and time-based metrics have substantially improved neurological outcomes. Based on current evidence, we advocate for the widespread adoption of an early bundle of care for patients with intracerebral hemorrhage focused on time-based metrics for blood pressure control and emergency reversal of anticoagulation, with the goal of optimizing the benefit of these already widely used interventions. We hope Code ICH will endure as a structural platform for continued innovation, standardization of best practices, and ongoing quality improvement for years to come.

Patient and hospital characteristics associated with do-not-resuscitate/do-not-intubate orders: a cross-sectional study based on the Taiwan stroke registry

BACKGROUND

Previous studies of do-not-resuscitate (DNR) or do-not-intubate (DNI) orders in stroke patients have primarily been conducted in North America or Europe. However, characteristics associated with DNR/DNI orders in stroke patients in Asia have not been reported.

METHODS

Based on the Taiwan Stroke Registry, this nationwide cross-sectional study enrolled hospitalized stroke patients from 64 hospitals between 2006 and 2020. We identified characteristics associated with DNR/DNI orders using a two-level random effects model.

RESULTS

Among the 114,825 patients, 5531 (4.82%) had DNR/DNI orders. Patients with acute ischemic stroke (AIS) had the highest likelihood of having DNR/DNI orders (adjusted odds ratio [aOR] 1.76, 95% confidence interval [CI] 1.61-1.93), followed by patients with intracerebral hemorrhage (ICH), and patients with subarachnoid hemorrhage (SAH) had the lowest likelihood (aOR 0.53, 95% CI 0.43-0.66). From 2006 to 2020, DNR/DNI orders increased in all three types of stroke. In patients with AIS, women were significantly more likely to have DNR/DNI orders (aOR 1.23, 95% CI 1.15-1.32), while patients who received intravenous alteplase had a lower likelihood (aOR 0.74, 95% CI 0.65-0.84). Patients with AIS who were cared for by religious hospitals (aOR 0.55, 95% CI 0.35-0.87) and patients with SAH who were cared for by medical centers (aOR 0.40, 95% CI 0.17-0.96) were significantly less likely to have DNR/DNI orders.

CONCLUSIONS

In Taiwan, DNR/DNI orders increased in stroke patients between 2006 and 2020. Hospital characteristics were found to play a significant role in the use of DNR/DNI orders.

Mortality Following Diagnosis of Nontraumatic Intracerebral Hemorrhage Within an Integrated "Hub-and-Spoke" Neuroscience Care Model: Is Spoke Presentation Noninferior to Hub Presentation?

BACKGROUND

Practice guidelines recommend that patients with intracerebral hemorrhage (ICH) be treated in units with acute neuroscience care experience. However, most hospitals in the United States lack this degree of specialization. We sought to examine outcome differences for patients with nontraumatic ICH presenting to centers with and without advanced neuroscience care specialization.

METHODS

This was a retrospective study of adult patients presenting with nontraumatic ICH between 1/1/2011 and 9/30/2020 across 21 medical centers within Kaiser Permanente Northern California, an integrated care system that employs a "hub-and-spoke" model of neuroscience care in which two centers service as neuroscience "hubs" and the remaining 19 centers service as referral "spokes." Patients presenting to spokes can receive remote consultation (including image review) by neurosurgical or neurointensive care specialists located at hubs. The primary outcome was 90-day mortality. We used hierarchical logistic regression, adjusting for ICH score components, comorbidities, and demographics, to test a hypothesis that initial presentation to a spoke medical center was noninferior to hub presentation [defined as an odds ratio (OR) with an upper 95% confidence interval (CI) limit of 1.24 or less].

RESULTS

A total of 6978 patients were included, with 6170 (88%) initially presenting to spoke medical centers. The unadjusted 90-day mortality for patients initially presenting to spoke versus hub medical centers was 32.2% and 32.7%, respectively. In adjusted analysis, presentation to a spoke medical center was neither noninferior nor inferior for 90-day mortality risk (OR 1.21, 95% CI 0.84-1.74). Sensitivity analysis excluding patients admitted to general wards or lacking continuous health plan insurance during the follow-up period trended closer to a noninferior result (OR 0.99, 95% CI 0.69-1.44).

CONCLUSIONS

Within an integrated "hub-and-spoke" neuroscience care model, the risk of 90-day mortality following initial presentation with nontraumatic ICH to a spoke medical center was not conclusively noninferior compared with initial presentation to a hub medical center. However, there was also no indication that care for selected patients with nontraumatic ICH within medical centers lacking advanced neuroscience specialization resulted in significantly inferior outcomes. This finding may support the safety and efficiency of a "hub-and-spoke" care model for patients with nontraumatic ICH, although additional investigations are warranted.

Factors Associated with Early Withdrawal of Life-Sustaining Treatments After Out-of-Hospital Cardiac Arrest: A Subanalysis of a Randomized Trial of Prehospital Therapeutic Hypothermia

BACKGROUND

The objective of this study is to describe incidence and factors associated with early withdrawal of life-sustaining therapies based on presumed poor neurologic prognosis (WLST-N) and practices around multimodal prognostication after out-of-hospital cardiac arrest (OHCA).

METHODS

We performed a subanalysis of a randomized controlled trial assessing prehospital therapeutic hypothermia in adult patients admitted to nine hospitals in King County with nontraumatic OHCA between 2007 and 2012. Patients who underwent tracheal intubation and were unconscious following return of spontaneous circulation were included. Our outcomes were (1) incidence of early WLST-N (WLST-N within < 72 h from return of spontaneous circulation), (2) factors associated with early WLST-N compared with patients who remained comatose at 72 h without WLST-N, (3) institutional variation in early WLST-N, (4) use of multimodal prognostication, and (5) use of sedative medications in patients with early WLST-N. Analysis included descriptive statistics and multivariable logistic regression.

RESULTS

We included 1,040 patients (mean age was 65 years, 37% were female, 41% were White, and 44% presented with arrest due to ventricular fibrillation) admitted to nine hospitals. Early WLST-N accounted for 24% (n = 154) of patient deaths and occurred in half (51%) of patients with WLST-N. Factors associated with early WLST-N in multivariate regressions were older age (odds ratio [OR] 1.02, 95% confidence interval [CI]: 1.01-1.03), preexisting do-not-attempt-resuscitation orders (OR 4.67, 95% CI: 1.55-14.01), bilateral absent pupillary reflexes (OR 2.4, 95% CI: 1.42-4.10), and lack of neurological consultation (OR 2.60, 95% CI: 1.52-4.46). The proportion of patients with early WLST-N among all OHCA admissions ranged from 19-60% between institutions. A head computed tomography scan was obtained in 54% (n = 84) of patients with early WLST-N; 22% (n = 34) and 5% (n = 8) underwent ≥ 1 and ≥ 2 additional prognostic tests, respectively. Prognostic tests were more frequently performed when neurological consultation occurred. Most patients received sedating medications (90%) within 24 h before early WLST-N; the median time from last sedation to early WLST-N was 4.2 h (interquartile range 0.4-15).

CONCLUSIONS

Nearly one quarter of deaths after OHCA were due to early WLST-N. The presence of concerning neurological examination findings appeared to impact early WLST-N decisions, even though these are not fully reliable in this time frame. Lack of neurological consultation was associated with early WLST-N and resulted in underuse of guideline-concordant multimodal prognostication. Sedating medications were often coadministered prior to early WLST-N and may have further confounded the neurological examination. Standardizing prognostication, restricting early WLST-N, and a multidisciplinary approach including neurological consultation might improve outcomes after OHCA.

Functional Outcomes and Mortality in Patients With Intracerebral Hemorrhage After Intensive Medical and Surgical Support

BACKGROUND AND OBJECTIVES

Despite decades of increasingly sophisticated neurocritical care, patient outcomes after spontaneous intracerebral hemorrhage (ICH) remain dismal. Whether this reflects therapeutic nihilism or the effects of the primary injury has been questioned. In this contemporary cohort, we determined the 30- and 90-day mortality, cause-specific mortality, functional outcome, and the effect of surgical intervention in a culture of aggressive medical and surgical support.

METHODS

This was a retrospective cohort study of consecutive adult patients with spontaneous ICH admitted to a tertiary neurocritical care unit. Patients with secondary ICH and those subject to limitation of care before 72 hours were excluded. For each ICH score, mortality at 30- and 90-days, and the modified Rankin Scale (mRS) within 1-year were examined. The effect of craniotomy/craniectomy ± hematoma evacuation on the outcome of supratentorial ICH was determined using propensity score matching. Median patient follow-up after discharge was 2.2 (interquartile range [IQR] 0.4-4.4) years.

RESULTS

Among 319 patients with spontaneous ICH (median age was 69 [IQR 60-77] years, 60% male), 30- and 90-day mortality were 16% and 22%, respectively, and unfavorable functional outcome (mRS score 4-6) was 50% at a median 3.1 months after ICH. Admission predictors of mortality mirrored those of the original ICH score. Unfavorable outcomes for ICH scores 3 and 4 were 73% and 86%, respectively. The most common adjudicated primary causes of mortality were direct effect or progression of ICH (54%), refractory cerebral edema (21%), and medical complications (11%). In matched analyses, lifesaving surgery for supratentorial ICH did not significantly alter mortality or unfavorable functional outcome in patients overall. In subgroup analyses restricted to (1) surgery with hematoma evacuation and (2) ICH score 3 and 4 patients, the odds of 30-day mortality were reduced by 71% (odds ratio [OR] 0.29, 95% CI 0.09-0.9, p = 0.032) and 80% (OR 0.2, 95% CI 0.04-0.91, p = 0.038), respectively, but no difference was observed for 90-day mortality or unfavorable functional outcome.

DISCUSSION

This study demonstrates that poor outcomes after ICH prevail despite aggressive treatment. Unfavorable outcomes appear related to direct effects of the primary injury and not to premature care limitations. Lifesaving surgery for supratentorial lesions delayed mortality but did not alter functional outcomes.

Predictors of do-not-attempt-resuscitation decisions in patients with infratentorial or large supratentorial intracerebral hemorrhages and consequences thereafter: a register-based, longitudinal study in Sweden

OBJECTIVES

Do-not-attempt-resuscitation (DNAR) decisions for patients with infratentorial or large supratentorial intracerebral hemorrhages (ICHs) pose clinical and ethical challenges. We aimed to investigate factors associated with DNAR decisions in patients with infratentorial or large (≥30 mL) supratentorial ICH, and differences in complications, treatment, and mortality.

MATERIALS & METHODS

This longitudinal, observational study comprised all patients treated for ICH at three stroke units in Gothenburg, Sweden, between November 2014 and June 2019. Patients were identified in the local stroke register, and additional data were collected from medical records and national registries. Mortality rates were followed 1 year after incident ICHs. Factors associated with DNAR decisions, and one-year mortality were explored.

RESULTS

Of 307 included patients, 164 received a DNAR decision. Most (75%) decisions were made within 24 h. DNAR decisions were associated with higher age, pre-stroke dependency, stroke severity, and intraventricular hemorrhage. Patients without DNAR decisions received thrombosis prophylaxis, oral antibiotics, and rehabilitative evaluations more frequently. The one-year survival probability was 0.16 (95% confidence interval [CI] 0.11-0.23) in patients with DNAR decisions, and 0.87 (95% CI 0.81-0.92) in patients without DNAR decision. DNAR decisions, higher age, stroke severity, hematoma volume, and comorbidities were associated with increased one-year mortality. Thrombosis prophylaxis and living alone were associated with a lower hazard.

CONCLUSION

The majority of DNAR decisions for patients with infratentorial or large supratentorial ICH were made within 48 h. Higher age, pre-stroke dependency, high stroke severity, and intraventricular hemorrhage predicted receiving a DNAR decision. DNAR decisions were strongly associated with increased short- and long-term mortality.

Medical management of cerebral edema in large hemispheric infarcts

Acute ischemic stroke confers a high burden of morbidity and mortality globally. Occlusion of large vessels of the anterior circulation, namely the intracranial carotid artery and middle cerebral artery, can result in large hemispheric stroke in ~8% of these patients. Edema from stroke can result in a cascade effect leading to local compression of capillary perfusion, increased stroke burden, elevated intracranial pressure, herniation and death. Mortality from large hemispheric stroke is generally high and surgical intervention may reduce mortality and improve good outcomes in select patients. For those patients who are not eligible candidates for surgical decompression either due timing, medical co-morbidities, or patient and family preferences, the mainstay of medical management for cerebral edema is hyperosmolar therapy. Other neuroprotectants for cerebral edema such as glibenclamide are under investigation. This review will discuss current guidelines and evidence for medical management of cerebral edema in large hemispheric stroke as well as discuss important neuromonitoring and critical care management targeted at reducing morbidity and mortality for these patients.

The intersection of prognostication and code status in patients with severe brain injury

Accurately estimating the prognosis of brain injury patients can be difficult, especially early in their course. Prognostication is important because it largely determines the care level we provide, from aggressive treatment for patients we predict could have a good outcome to withdrawal of treatment for those we expect will have a poor outcome. Accurate prognostication is required for ethical decision-making. However, several studies have shown that prognostication is frequently inaccurate and variable. Overly optimistic prognostication can lead to false hope and futile care. Overly pessimistic prognostication can lead to therapeutic nihilism. Overlapping is the powerful effect that cognitive biases, in particular code status, can play in shaping our perceptions and the care level we provide. The presence of Do Not Resuscitate orders has been shown to be associated with increased mortality. Based on a comprehensive search of peer-reviewed journals using a wide range of key terms, including prognostication, critical illness, brain injury, cognitive bias, and code status, the following is a review of prognostic accuracy and the effect of code status on outcome. Because withdrawal of treatment is the most common cause of death in the ICU, a clearer understanding of this intersection of prognostication and code status is needed.

Multicenter Validation of the max-ICH Score in Intracerebral Hemorrhage

OBJECTIVE

Outcome prognostication unbiased by early care limitations (ECL) is essential for guiding treatment in patients presenting with intracerebral hemorrhage (ICH). The aim of this study was to determine whether the max-ICH (maximally treated ICH) Score provides improved and clinically useful prognostic estimation of functional long-term outcomes after ICH.

METHODS

This multicenter validation study compared the prognostication of the max-ICH Score versus the ICH Score regarding diagnostic accuracy (discrimination and calibration) and clinical utility using decision curve analysis. We performed a joint investigation of individual participant data of consecutive spontaneous ICH patients (n = 4,677) from 2 retrospective German-wide studies (RETRACE I + II; anticoagulation-associated ICH only) conducted at 22 participating centers, one German prospective single-center study (UKER-ICH; nonanticoagulation-associated ICH only), and 1 US-based prospective longitudinal single-center study (MGH; both anticoagulation- and nonanticoagulation-associated ICH), treated between January 2006 and December 2015.

RESULTS

Of 4,677 included ICH patients, 1,017 (21.7%) were affected by ECL (German cohort: 15.6% [440 of 2,377]; MGH: 31.0% [577 of 1,283]). Validation of long-term functional outcome prognostication by the max-ICH Score provided good and superior discrimination in patients without ECL compared with the ICH Score (area under the receiver operating curve [AUROC], German cohort: 0.81 [0.78-0.83] vs 0.74 [0.72-0.77], p < 0.01; MGH: 0.85 [0.81-0.89] vs 0.78 [0.74-0.82], p < 0.01), and for the entire cohort (AUROC, German cohort: 0.84 [0.82-0.86] vs 0.80 [0.77-0.82], p < 0.01; MGH: 0.83 [0.81-0.85] vs 0.77 [0.75-0.79], p < 0.01). Both scores showed no evidence of poor calibration. The clinical utility investigated by decision curve analysis showed, at high threshold probabilities (0.8, aiming to avoid false-positive poor outcome attribution), that the max-ICH Score provided a clinical net benefit compared with the ICH Score (14.1 vs 2.1 net predicted poor outcomes per 100 patients).

INTERPRETATION

The max-ICH Score provides valid and improved prognostication of functional outcome after ICH. The associated clinical net benefit in minimizing false poor outcome attribution might potentially prevent unwarranted care limitations in patients with ICH. ANN NEUROL 2021;89:474-484.