Poor outcome in primary intracerebral haemorrhage: results of a matched comparison

The Impact of Stroke Subtype on Recovery and Functional Outcome after Inpatient Rehabilitation: A Retrospective Analysis of Factors

The aims of this study were to compare inpatient rehabilitation outcomes between acute stroke subtypes of Cerebral Infarction (CI) and Intracerebral Hemorrhage (ICH), and to determine the predictors of discharge outcomes. A retrospective study of stroke inpatients was carried out using the discharge Functional Independence Measure (FIM) as the primary outcome measure. Relationships between stroke subtype, rehabilitation impairments, and medical complications on FIM -gain were analyzed. Altogether, 280 datasets including 211 (75.4%) CI and 69 (24.6%) ICH were analyzed. ICH patients were significantly younger than CI patients (55 years ICH vs. 64.0 years CI years, p < 0.001), had a 10-fold higher proportion needing ICU admission (ICH 82.6% vs. CI 7.6%, p < 0.001), and had significantly lower total admission FIM scores (67 points ICH vs. 74 CI points, p = 0.006), with lower motor-FIM scores in particular (38 points ICH vs. 48 points CI, p = 0.003). Significant functional improvements after inpatient rehabilitation, i.e., FIM gain, occurred regardless of stroke subtype (FIM-ICH Δ 27 vs. FIM-CI Δ 21, p = 0.05). Despite significantly worse initial stroke severity, ICH patients achieved similar functional gains, independence levels, and return-home rates compared with their CI counterparts after inpatient rehabilitation.

Comparison of risk of serious cardiovascular events after haemorrhagic versus ischaemic stroke: a population-based study

BACKGROUND

Patients with ischaemic stroke are considered a very-high risk population for subsequent cardiovascular events and guidelines recommend intensive preventive strategies. In contrast, there is no clear recommendation that patients with haemorrhagic stroke should also be regarded as a very-high cardiovascular risk population.

OBJECTIVE

To compare the risk of subsequent cardiovascular morbidity/mortality between patients with incident haemorrhagic versus ischaemic stroke.

METHODS

Patients aged >18 years with incident haemorrhagic or ischaemic stroke between 1998-2017, and no prior history of serious vascular event were identified from UK Clinical Practice Research Datalink (CPRD-GOLD) linked to Hospital Episode Statistics (HES) data.

RESULTS

The cohort included 32,091 patients with an overall follow-up of 381,237 person-years (median: 11.8 years). After adjusting for potential confounders, patients with incident haemorrhagic stroke had no significantly different risk of subsequent cardiovascular morbidity compared with patients with incident ischaemic stroke - CHD [HR:0.86, 95%CI:0.56-1.32], recurrent stroke [HR:0.92, 95%CI:0.83-1.02], PVD [HR:1.15, 95%CI:0.56-2.38], or heart failure [HR:1.03, 95%CI:0.61-1.74]. Patients with incident haemorrhagic stroke had significantly higher risk of subsequent CVD-related mortality [HR:2.35, 95%CI:2.04-2.72] and all-cause mortality [HR:2.16, 95%CI: 1.94-2.41]. Propensity-score matched analysis of 1,039 patients with haemorrhagic stroke and 1,039 with ischaemic stroke showed similar risk in subsequent cardiovascular morbidity - CHD [stratified hazard ratio (sHR):0.92, 95%CI:0.55-1.54], recurrent stroke [sHR:0.93, 95%CI:0.82-1.02)], PVD [sHR:1.04 95%CI:0.45-2.41], or heart failure [HR:0.71, 95%CI:0.39-1.27].

CONCLUSIONS

The risk of subsequent cardiovascular events is similar between patients with incident haemorrhagic or ischaemic stroke. Patients with previous haemorrhagic stroke should be regarded as a population at very-high risk of subsequent CVD.

Frequency, Risk Factors, and Outcomes of Unplanned Readmission to the Neurological Intensive Care Unit after Spontaneous Intracerebral Hemorrhage

BACKGROUND

Unplanned readmission to the neurological intensive care unit (ICU) is an underinvestigated topic in patients admitted after spontaneous intracerebral hemorrhage (ICH). The purpose of this study is to investigate the frequency, clinical risk factors, and outcome of bounce back to the neurological ICU in a cohort of patients admitted after ICH.

METHODS

This is a retrospective observational study inspecting bounce back to the neurological ICU in patients admitted with spontaneous ICH over an 8-year period. For each patient, demographics, medical history, clinical presentation, length of ICU stay, unplanned readmission to neurological ICU, cause of readmission, and mortality were reviewed. Bounce back to the neurological ICU was defined as an unplanned readmission to the neurological ICU from a general floor service during the same hospitalization. A multivariable analysis was used to define independent variables associated with bounce back to the neurological ICU as well as association between bounce back to the neurological ICU and mortality. The significance level was set at p < 0.05.

RESULTS

A total of 221 patients were included. Among those, 20 (9%) had a bounce back to the neurological ICU. Respiratory complications (n = 11) was the most common reason for bounce back to the neurological ICU, followed by neurological (n = 5) and cardiological (n = 4) complications. In a multivariable logistic regression, location of hemorrhage in the basal ganglia (odds ratio [OR]: 3.0, 95% confidence interval [CI]: 1.0-8.9, p = 0.03) and dysphagia at the time of transfer (OR: 3.9, 95% CI: 1.0-15.4, p = 0.04) were significantly associated with bounce back to the neurological ICU. After we controlled for ICH score, readmission to the ICU was also independently associated with higher mortality (OR: 14.1, 95% CI: 2.8-71.7, p < 0.01).

CONCLUSIONS

Bounce back to the neurological ICU is not an infrequent complication in patients with spontaneous ICH and is associated with higher hospital length of stay and mortality. We identified relevant and potentially modifiable risk factors associated with bounce back to the neurological ICU. Future prospective studies are necessary to develop patient-centered strategies that may improve transition from the neurological ICU to the general floor.

Comparison between Ischemic and Hemorrhagic Strokes in Functional Outcome at Discharge from an Intensive Rehabilitation Hospital

Comparison studies on recovery outcomes in ischemic (IS) and hemorrhagic strokes (HS) have yielded mixed results. In this retrospective observational study of consecutive IS and HS patients, we aimed at evaluating functional outcomes at discharge from an intensive rehabilitation hospital, comparing IS vs. HS, analyzing possible predictors. Modified Rankin Scale (mRS) at discharge was the main outcome. Out of the 229 patients included (mean age 72.9 ± 13.9 years, 48% males), 81 had HS (35%). Compared with IS (n = 148), HS patients were significantly younger (75 ± 12.5 vs. 68.8 ± 15.4 years, p = 0.002), required longer hospitalizations both in acute (23.9 ± 36.7 vs. 35.2 ± 29.9 days, p = 0.019) and rehabilitation hospitals (41.5 ± 31.8 vs. 77.2 ± 51.6 days, p = 0.001), and had more severe initial clinical deficit (mean number of neurological impairments: 2.0 ± 1.1 vs. 2.6 ± 1.4, p = 0.001) and mRS scores at admission (p = 0.046). At discharge, functional status change, expressed as mRS, was not significantly different between IS and HS (F = 0.01, p = 0.902), nor was the discharge destination (p = 0.428). Age and clinical severity were predictors of functional outcome in both stroke types. On admission in an intensive rehabilitation hospital, HS patients presented a worse functional and clinical status compared to IS. Despite this initial gap, the two stroke types showed an overlapped trajectory of functional recovery, with age and initial stroke severity as the main prognostic factors.

Excessive antibiotics use increased in-hospital mortality in intracerebral hemorrhage patients with stroke-associated infection

Intracerebral hemorrhage (ICH) is associated with higher incidence of stroke-associated infection (SAI) as well as antibiotic use. However, there were few methods for judging proper antibiotic use in clinical manner. We introduce an index of antibiotic use, called personal antibiotic use density (PAUD), to evaluate the relation between antibiotic use and prognosis of ICH patients with SAI. A total of 162 in 570 ICH patients were observed to diagnose as SAI. Comparing with the survival patients, PAUD, ICH volume, National Institutes of Health Stroke Scale (NIHSS) score and ICH score were significantly higher among those who died, while the Glasgow Coma Scale score and the length of stay were significantly lower (P < 0.05). PAUD was identified as an independent risk factor of in-hospital death (OR 2.396, 95% CI 1.412-4.067, P = 0.001). In-hospital mortality was significantly lower in the low (P = 0.027) and intermediate PAUD (P < 0.001) groups than that in the high PAUD group. Cumulative in-hospital survival was significantly higher in low and intermediate PAUD groups (log rank test, P < 0.001). PAUD correlated positively with NIHSS score (r = 0.224, P < 0.001) and in-hospital mortality (r = 0.268, P = 0.001). The study indicated that PAUD is closely related to in-hospital prognosis of ICH patients with SAI. Higher PAUD may not be associated with better prognosis, but instead, higher risk of death.

Blood Pressure Variability and Outcome in Patients with Acute Nonlobar Intracerebral Hemorrhage following Intensive Antihypertensive Treatment

Background:

Blood pressure (BP) variability has been associated with stroke risk. We elucidated the association between systolic BP (SBP) variation and outcomes in patients with nonlobar intracerebral hemorrhage (ICH) following intensive antihypertensive treatment upfront.

Methods:

We screened consecutive patients with spontaneous ICH who underwent intensive antihypertensive treatments targeting BP <140 mmHg between 2008 and 2016. SBPs were monitored hourly during the acute period (≤7 days after symptom onset) in the intensive care unit. SBP variability was determined in terms of range, standard deviation (SD), coefficient of variation (CoV), and mean absolute change (MAC). The primary outcomes included hematoma growth and poor clinical outcome at 3 months (modified Rankin Scale [mRS] score ≥3. The secondary outcome was an ordinal shift in mRS at 3 months.

Results:

A total of 104 individuals (mean age, 63.0 ± 13.5 years; male, 57.7%) were included in this study. In multivariable model, MAC (adjusted odds ratio [OR], 1.11; 95% confidence interval [CI]: 1.02–1.21; P = 0.012) rather than the range of SD or CoV, was significantly associated with hematoma growth even after adjusting for mean SBP level. Sixty-eight out of 104 patients (65.4%) had a poor clinical outcome at 3 months. SD and CoV of SBP were significantly associated with a 3-month poor clinical outcome even after adjusting for mean SBP. In addition, in multivariable ordinal logistic models, the MAC of SBP was significantly associated with higher shift of mRS at 3 months (adjusted OR, 1.08; 95% CI: 1.02–1.15; P = 0.008).

Conclusions:

The MAC of SBP is associated with hematoma growth, and SD and COV are correlated with 3-month poor outcome in patients with supratentorial nonlobar ICH. Therefore, sustained SBP control, with a reduction in SBP variability is essential to reinforce the beneficial effect of intensive antihypertensive treatment.

Upper extremity recovery after ischaemic and haemorrhagic stroke: Part of the SALGOT study

Introduction

The purpose was to explore if there are differences in extent of change in upper extremity motor function and activity capacity, in persons with ischaemic versus haemorrhagic stroke, during the first year post stroke.

Patients and methods

One hundred seventeen persons with stroke (ischaemic n = 98, haemorrhagic n = 19) and reduced upper extremity function 3 days after onset were consecutively included to the Stroke Arm Longitudinal Study at the University of Gothenburg (SALGOT) from a stroke unit. Upper extremity motor function (Fugl-Meyer Assessment Scale for Upper Extremity (FMA-UE)) and activity capacity (Action Research Arm Test (ARAT)) were assessed at 6 assessments during the first year; age and initial stroke severity were recorded. Differences between groups in extent of change over time of upper extremity motor function and activity capacity were analysed with mixed models repeated measurements method.

Results

Significant improvements were found in function and activity in both groups within the first month (p = 0.001). Higher age and more severe stroke had a negative impact on recovery in both groups. Larger improvements of function and activity were seen in haemorrhagic stroke compared to ischaemic, both from 3 days to 3- and 12 months, and from 1 month to 3 months. Both groups reached similar levels of function and activity at 3 months post stroke.

Conclusion

Although persons with haemorrhagic stroke had initially lower scores than those with ischaemic stroke, they had a larger improvement within the first 3 months, and thereafter both groups had similar function and activity.

Recovery and Rehabilitation after Intracerebral Hemorrhage

About half of patients survive intracerebral hemorrhage (ICH), but most are left with significant disability. Rehabilitation after ICH is the mainstay of treatment to reduce impairment, improve independence in activities, and return patients to meaningful participation in the community. The authors discuss the neuroplastic mechanisms underlying recovery in ICH, preclinical and clinical interventional studies to augment recovery, and the rehabilitative and medical management of post-ICH patients.

Blood Pressure Management in Intracranial Hemorrhage: Current Challenges and Opportunities

OPINION STATEMENT

Non-traumatic intracranial hemorrhage (i.e. intracerebral hemorrhage [ICH] and subarachnoid hemorrhage [SAH]) are more life threatening and least treatable despite being less common than ischemic stroke. Elevated blood pressure (BP) is a strong predictor of poor outcome in both ICH and SAH. Data from a landmark clinical trial INTERACT 2, wherein 2839 participants enrolled with spontaneous ICH were randomly assigned to receive intensive (target systolic BP <140 mmHg) or guideline recommended BP lowering therapy (target systolic BP <180 mmHg), showed that intensive BP lowering was safe, and more favorable functional outcome and better overall health-related quality of life were seen in survivors in the intensive treatment group. These results contributed to the shift in European and American guidelines towards more aggressive early management of elevated BP in ICH. In contrast, the treatment of BP in SAH is less well defined and more complex. Although there is consensus that hypertension needs to be controlled to prevent rebleeding in the acute setting, induced hypertension in the later stages of SAH has questionable benefits.

Derivation and Validation of a Novel Prognostic Scale (Modified–Stroke Subtype, Oxfordshire Community Stroke Project Classification, Age, and Prestroke Modified Rankin) to Predict Early Mortality in Acute Stroke

Background and Purpose—

The stroke subtype, Oxfordshire Community Stroke Project classification, age, and prestroke modified Rankin (SOAR) score is a prognostic scale proposed for early mortality prediction after acute stroke. We aimed to evaluate whether including a measure of initial stroke severity (National Institutes of Health Stroke Scale and modified-SOAR [mSOAR] scores) would improve the prognostic accuracy.

Methods—

Using Anglia Stroke and Heart Clinical Network data, 2008 to 2011, we assessed the performance of SOAR and mSOAR against in-hospital mortality using area under the receiver operating curve statistics. We externally validated the prognostic utility of SOAR and mSOAR using an independent cohort data set from Glasgow. We described calibration using Hosmer–Lemeshow goodness-of-fit test.

Results—

A total of 1002 patients were included in the derivation cohort, and 105 (10.5%) died as inpatients. The area under the receiver operating curves for outcome of early mortality derived from the SOAR and mSOAR scores were 0.79 (95% confidence interval, 0.75–0.84) and 0.83 (95% confidence interval, 0.79–0.86), respectively ( P =0.001). The external validation data set contained 1012 patients with stroke; of which, 121 (12.0%) patients died within 90 days. The mSOAR scores identified the risk of early mortality ranging from 3% to 42%. External validation of mSOAR score yielded an area under the receiver operating curve of 0.84 (95% confidence interval, 0.82–0.88) for outcome of early mortality. Calibration was good ( P =0.70 for the Hosmer–Lemeshow test).

Conclusions—

Adding National Institutes of Health Stroke Scale data to create a modified-SOAR score improved prognostic utility in both derivation and validation data sets. The mSOAR may have clinical utility by using easily available data to predict mortality.

Outcome of Intensive Care Unit-Dependent, Tracheotomized Patients with Cerebrovascular Diseases

BACKGROUND

Outcome studies in intensive care unit -dependent, tracheotomized, and mechanical ventilated patients with cerebrovascular disease (CVD) are scarce.

METHODS

In a retrospective approach, we analyzed the outcome of 143 patients with ischemic stroke (IS), primary intracerebral hemorrhage (PICH), and subarachnoid hemorrhage (SAH). To measure the potential benefit of in-patient rehabilitation, we used the Functional Independence Measure (FIM). In addition, weaning and rehabilitation duration, duration of mechanical ventilation (MV) in the acute care hospital (preweaning), and mortality rates were assessed.

RESULTS

Approximately 50% of all patients were transferred home. These patients were fully independent or under nursing support. We found no differences regarding weaning and rehabilitation durations, or FIM scores in between each entity. Log-regression analyses showed that every day on MV generates a 3.2% reduction of the possibility to achieve a beneficial outcome (FIM ≥ 50 points [only moderate assistance necessary]), whereas every day in-patient rehabilitation without MV increases the chance for favorable outcome by 1.9%. Mortality rates were 5% for IS and 10% for PICH and SAH, respectively.

CONCLUSIONS

This study shows that even severely affected, tracheotomized patients with CVD benefit from early in-patient rehabilitation, irrespective of the etiology of vascular brain injury. Mortality rates of early rehabilitation in CVD are low. Until no validated outcome predictors are available, all efforts should be undertaken to enable in-patient rehabilitation, even in severe cases of CVD to improve outcome and to prevent accommodation in long-time-care facilities.

The clinical effect of deferoxamine mesylate on edema after intracerebral hemorrhage

Background and Purpose

It has been shown that 3 days of 62 mg/kg/day deferoxamine infusion (maximum dose not to exceed 6000 mg/day) is safe and tolerated by intracerebral hemorrhage (ICH) patients. The aim of this study was to investigate the efficacy of deferoxamine mesylate for edema resolution and hematoma absorption after ICH.

Methods

From February 2013 to May 2014, spontaneous ICH patients diagnosed by computed tomography (CT) within 18 hours of onset were evaluated. Patients were randomly divided into two groups: an experimental group and a control group. The treatment of the two groups was similar except that the experimental group received deferoxamine mesylate. Patients were evaluated by CT and neurology scale at the time of admission, and on the fourth, eighth, and fifteenth day (or at discharge) after admission. Patients were followed up for the first 30 days and clinical data of the two groups were compared.

Results

Forty-two patients completed 30 days of follow-up by May 2014; 21 cases in the experimental group and 21 cases in the control group. The control group’s relative edema volume on the fifteenth day (or discharge) was 10.26 ± 17.54, which was higher than the experimental group (1.91 ± 1.94; P < 0.05). The control group’s 1–8 day and 8–15 day relative hematoma absorption were greater than the experimental group (P < 0.05).The control group’s relative edema volume on the fourth, eighth, and fifteenth day (or discharge) was higher than the experimental group (P < 0.05). Neurological scores between the two groups were not statistically different on the fifteenth day (or discharge) or on the thirtieth day.

Conclusions

Deferoxamine mesylate may slow hematoma absorption and inhibit edema after ICH, although further investigation is required to form definitive conclusions.

Trial Registration

Chinese Clinical Trial Registry ChiCTR-TRC-14004979

Are Patients with Intracerebral Haemorrhage Disadvantaged in Hospitals?

Background and Aims

Providing evidence-based clinical care reduces disability and mortality rates following stroke. We examined if compliance with evidence-based processes of care were different for patients with intracerebral haemorrhage when compared with ischemic stroke and sought to describe differences in health outcomes during hospitalization and at time of discharge for these stroke subtypes.

Methods

The New South Wales acute stroke dataset was used. This included data from 50–100 consecutively admitted patients' medical records collected from 32 New South Wales hospitals between 2003 and 2010. Multivariable logistic regression analyses were conducted taking into account patient factors and clustering of patients by hospital.

Results

Ischemic stroke and intracerebral haemorrhage cases had similar demographic features (ischemic stroke n = 3467, mean age 74 years [standard deviation 13], 50% female; intracerebral haemorrhage n = 275, mean age 74 years [standard deviation 13], 48% female). Following multivariable analyses patients with intracerebral haemorrhage were less likely to be admitted to a stroke unit (adjusted odds ratio 0·65; 95% confidence interval 0·45–0·94) or receive an assessment from allied health (adjusted odds ratio 0·54; 95% confidence interval 0·33–0·89) than patients with ischemic stroke. Patients with intracerebral haemorrhage are also less likely to be independent (adjusted odds ratio 0·36; 95% confidence interval 0·3–0·5) at time of hospital discharge and had a greater odds of dying in hospital (adjusted odds ratio 2·1; 95% confidence interval 1·3–3·5). Patients that were admitted to a stroke unit had a greater odds of being independent (modified Rankin Score 0–2) at day 7–10 irrespective of stroke type or severity on admission (adjusted odds ratio 1·3; 95% confidence interval 1·01–1·66).

Conclusions

Following intracerebral haemorrhage, patients were less likely to be admitted to an acute stroke unit and receive allied health interventions. Admission to stroke units improved the likelihood of being independent at days 7–10 and, therefore, more should be done to encourage evidence-based care for intracerebral haemorrhage.

Dysphagia as a predictor of outcome and transition to palliative care among middle cerebral artery ischemic stroke patients

BACKGROUND

Middle Cerebral Artery (MCA) territory strokes can be disabling and may leave patients unable to swallow safely. Decisions regarding artificial nutrition and goals of care often arise in patients with severe strokes leading to dysphagia. This study determined some predictors of early transition to palliative level of care among patients with acute ischemic MCA stroke with dysphagia.

METHODS

This is a retrospective cohort study. Demographic and clinical data of patients presenting to Hartford Hospital with an acute ischemic stroke between January 2005-December 2010 were gathered utilizing the Stroke Center at Hartford Hospital Database. The 236 patients included were divided into "early transition" and "not transitioned" to palliative care cohorts. Primary outcome was transition to palliative care. Factors that were significantly associated with an early transition to palliative level of care in univariate analysis were then entered into a multivariate logistic regression analysis to identify potential independent predictors of early transition to palliative level of care. The significance level was set at p < 0.05.

RESULTS

79 patients (34%) were transitioned to palliative level of care after failing the first swallow evaluation within a median of 3 days. Factors predictive of an early transition to palliative level of care after multivariate logistic regression analysis included advancing age (p < 0.001; OR: 1.10; 95% CI :1.056-1.155) , left MCA infarct (p = 0.039; OR: 0.417; 95% CI:0.182-0.956), a high NIHSS score on admission (p = 0.017; OR: 3.038; 95% CI: 1.22-7.555), administration of intra-arterial tPA (p < 0.001; OR: 7.106; 955 CI 2.541-19.873) and the inability to be assessed on the 1(st) swallow evaluation (p < 0.001; OR 0.053; 95% CI 0.022-0.131).

CONCLUSIONS

The severity of dysphagia influences early transition to palliative level of care in acute stroke patients. Independent predictors of an early transition to palliative level of care among patients with an acute MCA territory stroke and dysphagia included advancing age, a left MCA infarct, a high NIHSS score on admission, administration of intra-arterial tPA and the inability to be assessed on the 1(st) swallow evaluation. This information may guide discussions with families of patients with MCA territory strokes regarding artificial nutrition and goals of care.

Comparison of outcomes after intracerebral hemorrhage and ischemic stroke

BACKGROUND

Intracerebral hemorrhage (ICH) is associated with a greater average initial stroke severity, higher mortality, and poorer long-term neurologic outcomes than ischemic stroke. The purpose of this study was to determine whether the poorer prognosis of ICH is independent of initial stroke severity.

METHODS

We analyzed data from the Glycine Antagonist in Neuroprotection (GAIN) Americas trial, in which 1604 non-obtunded patients with acute stroke were treated within 6 hours of symptom onset irrespective of hemorrhagic (N = 237) versus ischemic (N = 1367) subtype. Multiple logistic regression analysis was performed to evaluate predictors of mortality and neurologic outcome (modified Rankin scale [mRS] score of 0-1 v 2-6 at 3 months) adjusting for baseline National Institutes of Health Stroke Scale score, stroke risk factors, clinical and demographic characteristics, and gavestinel treatment group. Multiple linear regression techniques were used to assess the impact of various predictors on the full mRS score at 3 months.

RESULTS

ICH significantly increased the odds of a poor neurologic outcome (odds ratio 1.94, 95% confidence interval 1.23-3.06) and was independently associated with a mean 0.25-point increase in the 3-month mRS score (P = .04). ICH had no effect on mortality compared with ischemic stroke (odds ratio 1.01, 95% confidence interval .68-1.49) after adjusting for initial stroke severity (National Institutes of Health Stroke Scale score) and other baseline characteristics.

CONCLUSIONS

Among conscious stroke patients, ICH is an independent predictor of poor neurologic outcome, nearly doubling the odds of long-term disability. However, ICH is not associated with higher mortality compared with ischemic stroke after adjusting for initial stroke severity and other baseline characteristics.

Do stroke patients with intracerebral hemorrhage have a better functional outcome than patients with cerebral infarction?

OBJECTIVE

To compare the functional outcome of stroke patients with cerebral infarction (CI) and intracerebral hemorrhage (ICH) after rehabilitation.

DESIGN

Review of a prospectively maintained database of all stroke patients admitted to a rehabilitation unit during a 9.5-year period.

SETTING

Rehabilitation unit in a university hospital in Australia.

PATIENTS

A total of 718 consecutive stroke admissions (589 CI and 129 ICH) who met the inclusion criteria.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASUREMENTS

Functional Independence Measure (FIM) gain, FIM efficiency, Motor Assessment Scale (MAS) change, gait velocity, and discharge destination.

RESULTS

Patients who had ICH were more severely disabled on admission compared with patients who had CI and achieved a greater functional improvement with rehabilitation, ie, a greater FIM efficiency and a greater MAS change. Admission FIM score, admission MAS score, and length of stay were significant explanatory variables for the discharge FIM and FIM gain in both ICH and CI patients. On general linear model analyses, stroke type remained a significant explanatory factor for FIM gain, after adjusting for admission FIM, length of stay, age, and days from stroke onset to rehabilitation admission, ie, stroke patients with ICH obtained a better functional outcome than patients with CI. Admission motor FIM, admission MAS, younger age, and increasing length of stay were independent predictors for FIM gain and discharge FIM for both CI and ICH groups. Admission cognitive FIM score predicted discharge FIM for both the CI and ICH groups and FIM gain in the ICH group but was not a predictor of FIM gain for the CI group. The majority of patients in both groups went home at discharge.

CONCLUSIONS

Although patients with ICH had a greater level of disability on admission to rehabilitation, they achieved significantly greater gains in function than patients with CI after rehabilitation. This was found regardless of the severity of disability on admission.

Analysis of risk factors, localization and 30-day prognosis of intracerebral hemorrhage

Intracerebral hemorrhage is the deadliest, most disabling and least treatable form of stroke despite progression in medical science. The aim of the study was to analyze the frequency, risk factors, localization and 30-day prognosis in patients with intracerebral hemorrhage. We analyzed 352 patients with intracerebral hemorrhage (ICH) hospitalized at the Department of Neurology Tuzla during a three-year follow up. The following data were collected for all patients in a computerized database: age, sex, risk factors (hypertension, heart diseases, diabetes and smoking) and CT findings. Stroke severity was estimated with Scandinavian Stroke Scale, ICH topography was specified by CT, and outcome at 1st month after onset included information on vital status and disability (modified Rankin Scale, mRS). The most frequent risk factors were hypertension (84%), heart diseases (31%), cigarette smoking (28%) and diabetes mellitus (14%). The most frequent localization of ICH was multilobar (38%), internal capsule/basal ganglia region (36%) and lobar (17%). Within first month died 147 patients (42%). The highest mortality rate was in patients with brain stem (83%) and multilobar hemorrhage (64%). Factors independently associated with mortality were age (odds ratio 1,05 (95% confidence interval 1,02 to 1,08); p=0,001), stroke severity (OR 0,93 (0,92 to 0,95); p<0,0001), multilobar hemorrhage (OR 5,4 (3,0 to 9,6); p<0,0001) and intraventricular hemorrhage (OR 3,9 (2,2 to 7,1); p<0,0001). Favorable outcome at first month (mRS < or = 2) had 45% of the surviving patients with ICH. The best outcome was for the patients with cerebellar hemorrhage (63%), while only 40% of the patients with hemorrhage in internal capsule/basal ganglia region had Rankin scale 2 or less. Hypertension is the most frequent risk factor in patients with ICH. ICHs are mainly localized in lobar and internal capsule/basal ganglia regions. Independent predictors of mortality following ICH are age, hypertension, intraventricular blood extension and stroke severity. Mortality, as well as good outcome at 1 month, is related to the localization of bleeding.

Disparities in Outcomes Among Patients With Stroke Associated With Insurance Status

Background and Purpose— Despite well-documented discrepancies in many clinical conditions across insurance groups, limited research has examined insurance-related disparities for patients with stroke. This study examined the relationship between insurance status and hospital care for patients with stroke.

Methods— Discharges with intracerebral hemorrhage and acute ischemic stroke were abstracted from the 2002 National Inpatient Sample. Neurologic impairment status and mortality were examined.

Results— Compared with privately insured patients, uninsured patients had a higher level of neurologic impairment, a longer average length of hospital stay, and higher mortality risk. For patients with intracerebral hemorrhage and acute ischemic stroke, mortality risk of uninsured patients was approximately 24% and 56% higher, respectively, than that of their privately insured peers.

Conclusions— Policy should promote access to outpatient and preventive care for uninsured patients so risk factors such as hypertension can be detected and treated during early, asymptomatic stages. Further research is needed to evaluate the extent to which differences in outcomes are attributable to differences in severity level on admission.

Intracerebral Hemorrhage: Outcomes and Eligibility for Factor VIIa Treatment in a National Stroke Registry

BACKGROUND

Intracerebral hemorrhage (ICH) is a devastating form of stroke for which the lack of treatment options, high mortality rate, and the tendency to severely disable result in high social and economic burden.

METHODS

We analyzed data in the Registry of the Canadian Stroke Network (RCSN). We sought to: (1) provide a descriptive analysis of ICH; (2) determine the proportion of ICH patients that might have been eligible for treatment with recombinant activated factor VII (rFVIIa) using criteria from a recent phase II trial; (3) compare 6-month outcomes of ICH patients with those of ischemic stroke patients, matched for gender, age, and stroke severity.

RESULTS

In the RCSN, 11% of all strokes were nontraumatic ICH. The median Canadian Neurological Scale score was 7. A minority (33%) of patients arrived to the emergency department in less than 3 h from onset. In this cohort, in-hospital mortality was 15%. At 6 months, a further 9% of patients had died and 58% had a slight to no disability (Stroke Impact Scale-16 score > or = 75). Approximately 20% of ICH patients would have been eligible for rFVIIa treatment. Compared to ischemic stroke, ICH showed a trend towards increased mortality at discharge (OR: 1.96, CI: 0.99-3.87). At 6-month follow-up, ICH showed increased mortality (OR: 2.27, CI: 1.29-3.97), yet functional outcomes were not significantly different.

CONCLUSION

ICH patients had a higher case-fatality rate when compared to acute ischemic stroke, but survivors had similar functional outcomes. In Canada, about one fifth of ICH patients might potentially benefit from rFVIIa if it is approved, with the major exclusion factor being time.